Recommendations range from universal masking to more flexible approaches.
Healthcare facilities should continue to have masking policies despite the fact that the crisis phase of the coronavirus pandemic has passed, according to a new journal article.
Universal masking in healthcare facilities was adopted during the pandemic based on research that indicates masking could reduce the risk of respiratory viral transmission. Many healthcare organizations have lifted universal masking requirements since the end of the COVID-19 public health emergency earlier this year.
The new journal article, which was published this week in Annals of Internal Medicine, calls on healthcare facilities to continue masking requirements either universally or under specific circumstances. "In our view, the ongoing disease burden among persons at highest risk for severe COVID-19, the large proportion of transmission from asymptomatic and presymptomatic cases, uncertainty about the future course of the pandemic, and the effects of post-COVID-19 conditions merit integration of lessons learned from the pandemic into healthcare precautions and policies," the new journal article's co-authors wrote.
The new journal article's co-authors agree with another journal article published in Annals of Internal Medicine in June that calls for healthcare facilities to adopt one of four approaches to masking:
Require masking in healthcare settings year-round
Require masking in targeted settings with high-risk patients such as transplant, oncology, and geriatric units
Require masking during specified months of the local respiratory viral season
Require masking when the community burden of respiratory viruses is at a critical threshold as determined by "appropriate metrics"
Healthcare facilities should not go back to limited masking policies that were in place before the pandemic, the new journal article's co-authors wrote. "Our appreciation and understanding of both patient and healthcare system impacts associated with SARS-CoV-2 and other respiratory viruses have been reshaped as a result of the COVID-19 pandemic. We should be mindful of continuing areas of uncertainty while integrating the lessons learned into our hospital-based practices to prevent harm to vulnerable patients rather than reverting to suboptimal pre-pandemic behaviors."
There are several reasons why healthcare facilities should continue masking, the lead author of the new journal article told HealthLeaders.
"First and foremost, COVID-19 continues to circulate in our communities and there continues to be uncertainty about the future course of the pandemic. This is especially true as new variants emerge. We also know that hospitalizations and deaths, while lower than at other periods during the pandemic, are still occurring and disproportionately impact people at higher risk for severe disease. This includes people who are older and people who have chronic conditions. No. 2, we are only beginning to learn more about post-COVID-19 conditions also known as long COVID. We know that people of all ages are at risk for post-COVID-19 conditions. Even people with asymptomatic or mild acute COVID-19 are at risk for post-COVID-19 conditions," said Eric Chow, MD, MS, MPH, chief of Communicable Disease and Immunization for Public Health at Seattle and King County, clinical assistant professor of epidemiology at University of Washington, and clinical assistant professor of Medicine-Allergy and Infectious Disease at University of Washington Medicine.
Masking is also needed to safeguard healthcare workers, he said. "Masking protects healthcare workers. Many health systems are desperately trying to maintain their healthcare workforce capacity and implementing masking in healthcare facilities will help prevent infections and outbreaks among healthcare workers. This can help mitigate additional shortages of healthcare workers."
Universal masking in hospitals may be the safest option, Chow said. "This is one of the approaches we have recommended in our article, and it avoids having a patchwork of policies within a hospital system. It also acknowledges that masking reduces the risk of infection not only in patient encounters but also between and among healthcare workers, which is another source of infection. Targeted masking policies are implemented in units where there are high-risk patients, but this is a less perfect approach because there are high-risk patients who are admitted to different parts of a hospital."
Improving communication while masked is a consideration for healthcare providers, he said. "There is a need to provide safe care and to improve communication while wearing masks. Some approaches include discussing with individuals about their own preferred approach to improving communication. Healthcare providers can allow for extra time for patient encounters, choose a quiet location for patient encounters, and speak clearly and slow down their talking speed. Other approaches could include alternative forms of communication such as written communication or assistive technology to maximize understanding."
Staffing company says nurse practitioners have led employment searches for three consecutive years.
Recruiting incentives for physicians and advanced practice providers (APPs) have increased significantly over the past year, according to a new report from the staffing company AMN Healthcare.
The employment market for physicians and APPs is as tight as it has ever been. Traditional healthcare providers such as hospitals and physician practices are competing to employ physicians and APPs with market disruptors such as retail chains, urgent care centers, and telemedicine platforms.
The new report, "2023 Review of Physician and Advanced Practitioner Recruiting Incentives," was produced by AMN Healthcare Physician Solutions (formerly Merritt Hawkins). The report is based on a representative sample of the 2,676 permanent physician and APP search engagements AMN Healthcare Physician Solutions had ongoing or conducted from April 1, 2022, to March 31, 2023.
The report has several key findings.
Nurse practitioners (NPs) were the No.1 requested provider search for the third consecutive year
Average starting salary offerings for NPs increased 9% year-over-year
AMN Healthcare conducted more searches for APPs than for primary care physicians, which reflects a patient shift away from primary care practices to retail chains, urgent care centers, and telemedicine platforms
Although demand for primary care physicians has flattened, family physicians were still the second most requested search engagement in the new report
Most of AMN Healthcare's search engagements (64%) were for physician specialists, with radiologists ranking third in the company's requested search engagements
Obstetricians/Gynecologists ranked fourth on the list of AMN Healthcare's most requested search engagements, with starting salaries for OB/GYN's up 10.5% year-over-year
Psychiatrists fell from fourth on the list of search engagements last year to sixth on this year's list, which likely reflects the shortage of psychiatrists and healthcare organizations turning to psychologists and APPs to fill behavioral health provider positions
Average starting salary offers for many specialists increased, with starting salaries for dermatologists up 22% year-over-year, starting salaries for psychiatrists up 19% year-over-year, and starting salaries for orthopedic surgeons up 12% year-over-year
Average starting salary offers for primary care specialties were flat year-over-year, with family physician starting salaries up 2% year-over-year, pediatrician starting salaries up less than 1%, and starting salaries for internal medicine physicians unchanged
Orthopedic surgeons posted the highest average starting salary for physicians ($633,000)
Pediatricians posted the lowest average starting salary for physicians ($233,000)
The average signing bonus for physicians increased sharply from 2022 to 2023, rising from $31,000 to more than $37,000
Interpreting the data
Market disruptors are driving the demand for NPs, Leah Grant, MBA, president of AMN Healthcare Physician Solutions, told HealthLeaders. "Demand for NPs is being driven by the spread and increase of convenient care. We are seeing expansion of convenient care such as retail clinics, urgent care centers, and telemedicine—all of which are expanding using their APP staffing model, while before they depended on physicians."
NPs are also a cost-effective alternative to hiring physicians, she says. "APPs can provide many of the services that a physician can provide, and the number of states where they can practice autonomously keeps on growing. We are seeing more healthcare organizations take advantage of NPs than in the past because they often do not need to be paired with a physician. Now, nurse practitioners are the pillar of rural healthcare in many states."
The "Seven Ps" are driving demand for physician specialists, Grant says.
"First, there is population growth—the U.S. population is projected to grow from 332 million people today to 423 million by 2050. Second, population aging is a significant piece to the demand for physician specialists. By 2034, there will be more seniors over the age of 65 than children 17 years old or younger. Third is provider aging. While we are seeing the general population aging, we are also seeing providers aging. About 30% of physicians in active patient care are 60 or older. Fourth, we are dealing with provider burnout, with about 58% of physicians feeling burned out. Fifth, there is pervasive ill health. About 6 in 10 of American adults have a chronic medical condition such as diabetes, and about 4 in 10 have two or more chronic conditions. Sixth, there are pipeline problems. Federal funding for physician training was capped in 1997. So, we will continually see the effects of that as the years go on in terms of supply and demand. Seventh is changing practice styles. Many physicians are embracing different practice styles that reduce full-time equivalence with locum tenens work and part-time hours. Population aging is probably the most important piece in the demand for specialists."
A couple of factors account for the flat starting salary offers in primary care, she says. "They are just not as much in demand as they were several years ago, when everyone was setting up primary care networks or buying primary care practices. Family medicine is our No. 2 search, and I foresee that to continue. However, there is a ceiling for primary care salaries as opposed to specialists. The main reason for that is specialists can generate more revenue. Our physician billing report shows that an orthopedic surgeon can bill more than $9 million a year to commercial payers, while a primary care physician is going to generate half as much billing."
The No. 1 reason for the steep increase in physician signing bonuses is the demand for physicians, Grant says. "The demand for physicians has continued to increase. With that demand, a lot of healthcare organizations are trying to figure out how to be more competitive and how to get a provider in the door faster. The faster you can get a physician into your clinic or hospital, the more revenue you are going to generate. You can also decrease patient wait times, which are a concern in the market. Decreased wait times can make you stand out in the market as a preferred provider."
Market disruptors such as retail chains, urgent care centers, and telemedicine platforms are not only driving the market for APPs but also changing the healthcare landscape, she says. "The wait times to see a primary care provider have grown 24% since 2004. So, the market disruptors saw an opportunity presented by the physician shortage and the long appointment wait times associated with the physician shortage. There has also been a societal shift toward convenient care. The disruptors have realized that the healthcare market is increasingly about customer experience. If you are able to provide a better experience, you are going to have an advantage. Now, hospitals are moving to outpatient care and trying to compete with the disruptors."
Given the employment market conditions, offering recruitment incentives beyond starting salaries is becoming the norm, Grant says. "Signing bonuses are no longer a perk—they are an expectation. Nine times out of 10, the return on offering incentives such as continuing medical education allowances, relocation allowances, and medical education loan forgiveness is above and beyond the financial value of the incentives."
To pursue administrative roles, physicians should seek out a mentor, the chief medical officer of West Penn Hospital says.
Before taking on an administrative role, physicians should consult with physician executives about their challenges, their keys to success, and the pros and cons of administration, says Beth Prairie, MD, MPH, chief medical officer (CMO) of West Penn Hospital.
Prairie has been CMO of the Pittsburgh-based hospital, which is part of Allegheny Health Network (AHN), since April 2021. She also has served as medical operations officer for AHN's Women's Institute.
HealthLeaders recently talked with Prairie about a range of issues, including the challenges of serving as CMO at West Penn Hospital, her main learnings from serving as a CMO during the coronavirus pandemic, and how her clinical background in obstetrics and gynecology helped prepare her for the CMO role. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of West Penn Hospital?
Beth Prairie: Coming in as chief medical officer during the coronavirus pandemic represented a specific set of challenges both for myself as a leader and for the hospital, the patients, and the health system. Coming out of the public health emergency and emerging into a world of an even worse nursing shortage and a general staffing shortage moved us into a second set of challenges that are ongoing.
HL: How are you rising to the staffing challenge?
Prairie: As a chief medical officer, I am responsible for overseeing the clinical quality of the care that we provide in the hospital. Under those auspices, I think of chief medical officers as being the head physician for the hospital. So, I think a lot about my physician workforce.
For physicians and advanced practice providers, we need to make sure we are addressing their needs from an employment perspective. We need to acknowledge the significant toll that the pandemic took on all of our frontline clinicians, including physicians. We need to support them as we move into a post-pandemic world.
We need to make sure that we are a hospital that is committed to patients and families first. We need to think about them first in every action that we take and every strategy that we implement, which will make us attractive for clinicians to come work with us.
Along the lines of quality and collaboration, all of us know that growing your own talent and supporting your own talent is the best way forward—certainly for recruitment and often for retention. I am fortunate to be at a teaching hospital, where we train the next generation of physicians. Nothing is a greater sign of success than when we can recruit our own residents and fellows to stay with us. We focus on making sure that we understand their needs and that they are supported in their education and clinical work. We try to have an environment of collegial collaboration that any physician would feel lucky to join.
Another thing that we often do not talk enough about is making sure that we do not leave anybody behind in our recruitment efforts. Part of being a collegial and collaborative healthcare environment is making sure that we treat each other with respect and that all people regardless of their characteristics are equally welcome to come to the table.
Beth Prairie, MD, MPH, chief medical officer of West Penn Hospital. Photo courtesy of Allegheny Health Network.
HL: You became CMO of West Penn Hospital in the middle of the pandemic. What were your main learnings from this experience?
Prairie: I learned to have flexibility in all things except ethics. We faced an unprecedented crisis in modern times, and it required us to be flexible. We needed to be flexible in thinking both as individuals and groups caring for patients. We needed to be flexible as a hospital and a network organization. The capacity to assess a problem and think of new ways to solve a problem was also critical to our success.
I also learned the importance of continuing to be kind to each other as we went through an unbelievably stressful situation.
Finally, I learned the importance of communication—communicating with each other, communicating with our patients, and communicating with our communities about risks and how to mitigate them.
HL: You have a clinical background in obstetrics and gynecology. How has this clinical background helped you serve in the CMO role?
Prairie: Part of West Penn Hospital's function in the community is that we provide the full range of women's healthcare services. More than 50% of the patients who are cared for at West Penn Hospital are here for something related to gynecology or obstetrics. It is important and useful to have physicians at the executive level who have a broad and deep understanding of how we provide care to women. For West Penn Hospital, it is important to have an OB/GYN leader who can communicate with our physicians and who understands all of the aspects of the care that we need to provide—from gynecologic surgery all the way through obstetrics.
HL: What advice would you offer to other female physicians who may be interested in an administrative leadership role such as CMO?
Prairie: The advice I always give to everyone who asks about being a physician executive or pursuing more of an administrative role is to talk with other people who have walked that path. Find out what their challenges have been. Find out what they feel gave them success in that pursuit. Find out about some of the downsides of pivoting from a primarily clinical role to a primarily administrative role. Like all things, there are pros and cons. You need to think about who you are as a physician—why you get up every day to do the work and how an administrative role will best serve you, patients, colleagues, and your community.
It is always helpful to have a mentor. Mentors can be hard to find, but if you have one, use them and talk with them. If you are interested in being mentored, seek a mentor out. It is helpful to have someone you can bounce ideas off of and someone you trust to reflect back to you honestly about your strengths, weaknesses, areas of opportunity for growth, and how the next step in your career path could be served best.
HL: How are physicians involved in administrative leadership at Allegheny Health Network?
Prairie: Allegheny Health Network is committed to being a clinician- and physician-run organization. For example, our hospital presidents are physicians. Our hospital presidents still see patients as do the chief medical officers. It is our belief that having physicians who are still active participants in patient care lead us as an organization informs our decision-making with the ethos of being a physician at the forefront.
Going back to recruitment and retention, you must be able to grow that bench. If you are committed to physician leaders, you must have structures in place to help interested or promising physicians to have the opportunity to try on administrative hats.
In each of our institutes, which function similar to clinical departments, there are officer roles for physicians to have the opportunity to both perform vital administrative functions in their home departments as well as at the network level. For example, I was the medical operations officer and the information technology officer for the Women's Institute prior to becoming chief medical officer at West Penn Hospital.
We also have a medical staff officer structure, which is an important part of how physicians take care of ourselves as professionals and operate on the hospital level.
So, there are multiple ways for physicians to get involved from a leadership perspective and learn multiple parts of the organization.
Researchers find widespread COVID-19 misinformation by physicians on social media across more than two dozen medical specialties.
The most common theme of COVID-19 misinformation from physicians on social media was discouraging people from getting coronavirus vaccines, a new research article found.
About one-third of COVID-19-related deaths in the United States were considered preventable if public health recommendations had been followed, the new research article says. Misinformation about COVID-19 by physicians is alarming because physicians are widely considered as trusted sources of information about public health recommendations.
The new study is based on searches of five high-use social media platforms—Twitter, Facebook, Instagram, Parler, and YouTube—as well as two media outlets—The New York Times and National Public Radio. Data was collected about COVID-19 misinformation by 52 U.S. physicians from January 2021 to December 2022. The study was published by JAMA Network Open.
The study generated several key findings.
Misinformation categories included vaccines, medications, masks, and "other" such as conspiracy theories
Vaccine misinformation was most common at 42 physicians (80.8%), followed by "other" misinformation at 28 physicians (53.8%) and medication misinformation at 27 physicians (51.9%)
Forty physicians (76.9%) posted misinformation in more than one category
The physicians who engaged in misinformation represented 28 medical specialties and misinformation was most common among primary care physicians
Nearly one-third (16 of 52) the physicians were linked to groups with a history of spreading medical misinformation such as America's Frontline Doctors
Twitter was the most commonly used social media platform among the physicians (37 of 52 physicians), with the physicians having a median of 67,400 followers
Some of the misinformation made unsubstantiated claims that vaccines were ineffective at limiting the spread of COVID-19
Some of the misinformation made unsubstantiated claims that COVID-19 vaccines were harmful such as causing infertility and immune system damage
Many of the physicians promoted the use of untested or non-Food and Drug Administration (FDA) approved drugs for COVID-19, most notably ivermectin and hydroxychloroquine
Many of the physicians made unsubstantiated claims about mask wearing, either claiming mask wearing was ineffective or harmful
The research found significant COVID-19 misinformation by physicians, the study's co-authors wrote. "In this mixed-methods study of U.S. physician propagation of COVID-19 misinformation on social media, results suggest widespread, inaccurate, and potentially harmful assertions made by physicians across the country who represented a range of subspecialties."
Interpreting the data
Organizations that have been linked to medical misinformation in the past played a large role in medical misinformation during the coronavirus pandemic, the study's co-authors wrote.
"Some of the physicians identified belonged to organizations that have been propagating medical misinformation for decades, but these organizations became more vocal and visible in the context of the pandemic's public health crisis, political divisiveness, and social isolation. Understanding the motivation for misinformation propagation is beyond the scope of this study, but it has become an increasingly profitable industry within and outside of medicine. For example, America's Frontline Doctors implemented a telemedicine service that charged $90 per consult, primarily to prescribe hydroxychloroquine and ivermectin for COVID-19 to patients across the country, profiting at least $15 million from the endeavor," they wrote.
The absence of policies and laws against medical misinformation make it likely that the problem will continue to be a concern, the study's co-authors wrote. "Twitter's elimination of safeguards against misinformation and the absence of federal laws regulating medical misinformation on social media platforms suggest that misinformation about COVID-19 and other medical misinformation is likely to persist and may increase. Deregulation of COVID-19 misinformation on social media platforms may have far-reaching implications because consumers may struggle to evaluate the accuracy of the assertions made."
Many physicians who engage in medical misinformation are likely to escape discipline, the study's co-authors wrote. "National physicians' organizations, such as the American Medical Association, have called for disciplinary action for physicians propagating COVID-19 misinformation, but stopping physicians from propagating COVID-19 misinformation outside of the patient encounter may be challenging. Although professional speech may be regulated by courts and the FDA has been called on to address medical misinformation, few physicians appear to have faced disciplinary action. Factors such as licensing boards' lack of resources available to dedicate toward monitoring the internet and state government officials' challenges to medical boards' authority to discipline physicians propagating misinformation may limit action."
The study has revealing findings on COVID-19 misinformation by physicians and the research should help efforts to combat medical misinformation, the study's co-authors wrote.
"Results of this mixed-methods study of the propagation of COVID-19 misinformation by US physicians on social media suggest that physician-propagated misinformation has reached many people during the pandemic and that physicians from a range of specialties and geographic regions have contributed to the 'infodemic.' High-quality, ethical healthcare depends on inviolable trust between healthcare professionals, their patients, and society. Understanding the degree to which the misinformation about vaccines, medications, masks, and conspiracy theories spread by physicians on social media influences behaviors that put patients at risk for preventable harm, such as illness or death, will help to guide actions to regulate content or discipline physicians who participate in misinformation propagation related to COVID-19 or other conditions."
There were 309 ongoing drug shortages at the end of the second quarter of 2023, which is near the all-time high of 320 shortages.
Drug shortages are near a 10-year high, according to the American Society of Health-System Pharmacists (ASHP).
Drug shortages can have an impact on patient care, including drug rationing, delays in care, and cancellation of treatment. Drug shortages also affect pharmacy costs in terms of labor expenses and drug purchasing costs.
Based on quarterly drug shortage statistics from the University of Utah Drug Information Service, there were 309 ongoing drug shortages at the end of the second quarter of 2023. This figure is near the all-time high of 320 shortages.
ASHP has released the findings of a new survey on drug shortages. The survey, which was conducted from June 23 to July 14, features data collected from more than 1,000 ASHP members.
The survey includes several key findings.
More than 99% of survey respondents said they were experiencing drug shortages
32% of survey respondents said their drug shortages were critically impactful, which means they are having drug rationing, delays in care, or canceling of treatments or procedures
57% of survey respondents said they had critically impactful shortages of chemotherapy drugs
73% of survey respondents said that drug shortages had caused increases in their drug budgets by 6% to 20%
87% of survey respondents who were involved in purchasing decisions said manufacturer and product quality were very important
59% of survey respondents who were involved in purchasing decisions said they would prefer to buy products from manufacturers who meet a predefined quality standard
Survey respondents who reported using clinical management strategies to address drug shortages said they had taken the following actions: changed to therapeutic alternatives (97%), implemented rationing criteria (85%), converted to different dosage forms (84%), changed order sets or protocols (75%), and delayed or canceled treatments or procedures (42%)
Drug shortages are reaching a historical high, Michael Ganio, PharmD, MS, senior director of pharmacy practice and quality at ASHP, told HealthLeaders. "We are at a high point for the number of active, ongoing shortages since 2014. The shortages have been steadily increasing. What is different is that if you look at the number of newly reported shortages from 2012 to this year, there is a slight downward trend in the number of new shortages each year. However, this can be deceiving. When you look at the number of active shortages, the number keeps increasing. What that tells us is that shortages are not resolving as quickly as they are happening."
Active shortages are concerning, he said. "Some of the drug shortages we have been following have been ongoing for five to 10 years. Regarding the current trend, while the number of new shortages may not look like an impressive number, the number of active shortages is nearing an all-time high."
Impact of drug shortages
The costs of managing drug shortages are significant, Ganio said. "We know from a 2019 report that was conducted by one of the group purchasing organizations that there was an estimated $359 million in annual healthcare labor expenses in managing drug shortages. The new survey results do not give an actual dollar amount, but we wanted to get percentages of how much more pharmacies are spending on personnel and their drug budgets. What we found was that there is between a 5% to 20% increase in baseline spending for personnel and drug budgets."
Clinical management strategies can be effective in responding to drug shortages, he said. "Often, we can manage a drug shortage within the pharmacy department, so there is no impact on patients. We can buy drugs from alternative suppliers. We can buy different package sizes or concentrations, then repackage the drugs and make sure whoever is administering the drug is aware that it looks different, and it is going to be a different amount that will be administered. Those strategies result in the patient receiving the exact same drug."
However, sometimes clinical management strategies have a negative impact on patients, Ganio said. "When we look at certain classes of drugs such as chemotherapy drugs, the survey found there is almost 60% rationing drugs, delaying treatment, or canceling treatment. That is not sustainable. We cannot and should not accept that as a fact of life for our patients."
Substituting drugs has a downside, he said. "When we treat a patient, we have a drug of choice. There is a first line of treatment for a reason. It is either optimally effective, has fewer side effects, or there is some sort of cost benefit to the treatment. When that treatment is not available, and we have to go to a second-line treatment, we are compromising one or more of the benefits of first-line treatment or you are introducing risk for a medication error."
The drug shortage forecast for the rest of 2023 and into 2024 is uncertain, but Ganio is pessimistic. "The reality is that there are multiple factors that contribute to shortages. A good case in point is the tornado that damaged a Pfizer facility in North Carolina. We are still waiting to see the impact from that event. Pfizer has released some information about what we might expect, but so far there is no definitive measure of how impactful that event will be. However, if we follow the current trends, I expect things will get worse before they get better."
If healthcare worker burnout and mental health problems are not addressed, people leaving the profession could worsen widespread workforce shortages.
Exercise can reduce depressive symptoms, burnout, and sick days for healthcare workers (HCWs), according to a new research article.
Burnout and mental health problems among HCWs spiked during the coronavirus pandemic. For example, earlier research found that physicians reporting at least one burnout symptom rose from 38.2% in 2020 to 62.8% in 2021. If HCW burnout and mental health problems are not addressed, people leaving the profession could worsen widespread workforce shortages.
The new research article, which was published by JAMA Psychiatry, is based on data collected from nearly 300 HCWs who were split evenly between an intervention group and a control group. The intervention group was asked to exercise in four 20-minute sessions per week for 12 weeks. The intervention group was given a free, one-year subscription to the Down Dog suite of apps, which included body weight interval training, yoga, barre, and running apps.
The study generated several key findings for the intervention group.
The treatment effect on depressive symptoms ranged from small to medium by the end of the 12-week trial
There was a significant reduction in the cynicism and emotional exhaustion burnout measures, but only a very small improvement in the professional efficacy burnout measure
There was a small reduction in healthcare worker sick days
Adherence to the 80-minute per week of exercise requirement declined during the 12-week trial, falling from 54.9% of participants in the first week to 23.2% of participants in week 12
The positive impact of exercise was greatest for intervention group participants who exercised at least 80 minutes per week
There was no significant impact on depressive symptoms, burnout, or sick days for intervention group participants who exercised less than 20 minutes per week
"Although exercise was able to reduce depressive symptoms among HCWs, adherence was low toward the end of the trial. Optimizing adherence to exercise programming represents an important challenge to help maintain improvements in mental health among HCWs," the study's co-authors wrote.
Interpreting the data
Providing HCWs with exercise apps can have a positive impact as long as HCWs continue to use the apps, the study's co-authors wrote. "Our results suggest that at-home exercise can have meaningful effects on HCWs' well-being and absenteeism when they are given free access to mobile-based exercise apps, provided they continue using these apps."
Exercise adherence is critical, they wrote. "Even though all the participants volunteered and were generally willing, ready, and able to start exercising with the apps at home (and most did so in the first few weeks), adherence was suboptimal among some participants, with older adults more likely to use the apps. While we ruled out baseline depressive symptoms or burnout as causal factors of adherence, it is likely that stressors at home or at work, not measured in the present study, interfered with adherence."
The success of exercise programs in improving HCW well-being likely requires professional support for particular individuals, the study's co-authors wrote. "In our efficacy trial, we sought to support mental health at the individual level, and determined that at-home, app-based exercise improves mental health with some success. The challenge at the individual level, then, is to determine not only for whom providing free apps is effective in promoting new engagement and maintenance of exercise, but also who—based on demographics and baseline characteristics— needs additional behavioral (eg, health coaches trained in motivational interviewing to increase exercise levels) or psychological (eg, psychiatric and/or psychological professionals) supports."
Large-scale trials to gauge the impact of exercise among HCWs has the potential to develop a cost-effective way to boost well-being, they wrote. "Scaled-up effectiveness trials are needed whereby all HCWs from an organization are provided longer opportunities to access the suite of apps to determine interest, uptake, adherence, and mental, physical, and economic effects. Such trials may reveal a potential low-cost, high-reward opportunity for healthcare networks to use at large, embedded within wellness programs, to reduce healthcare's growing mental health crisis."
One patient safety initiative at Sentara Northern Virginia Medical Center has been to establish a masking protocol in the wake of the coronavirus pandemic.
Patient safety at hospitals is not only a concern for clinical staff, but also for other team members such as environmental services and facilities management, the chief medical officer (CMO) of Sentara Northern Virginia Medical Center says.
Alice Tang, DO, MPH, MBA, has been CMO of the Woodbridge, Virginia-based hospital since August 2021. She has been a practicing emergency medicine physician at Norfolk, Virginia-based Sentara Health since March 2017. Tang's leadership experience includes serving as chairman of the Emergency Medicine Department at Sentara Northern Virginia Medical Center.
HealthLeaders recently talked with Tang about a range of issues, including her top challenges as CMO, patient safety, and care quality. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Sentara Northern Virginia Medical Center?
Alice Tang: Sentara is a large health system in the Mid-Atlantic and Southeast regions. The health system includes 12 hospitals in Virginia and North Carolina. Sentara Northern Virginia Medical Center is the northern-most site. It is a 183-bed hospital that provides a range of healthcare services, including emergency care, surgical specialty services, and women's health services.
One challenge is matching the medical staff to care for our patients given the constantly evolving healthcare landscape. Now more than ever, there are many ways to consume healthcare ranging from traditional hospital-based care to telemedicine to retail clinics. So, it is important to be aware of how the healthcare environment is changing for our patients and for our healthcare workers. You need to understand patients as consumers.
Equally important is to monitor the implications of these changes for the practices of our medical staff. Establishing and maintaining strong connections with key stakeholders is important. You need to put all the pieces of the puzzle together. You need to find a strategy to meet the patients and the healthcare providers where they are.
Currently, we are on a transformation journey to find ways to provide healthcare that is seamless, personal, and simple, so we can bridge healthcare gaps in our community.
Another challenge has been to promote retention and recruitment efforts, especially after the pandemic, which has changed the employment landscape. With increased burnout among healthcare workers and market competition, we recognize that efforts to retain employees are of high importance. For example, in 2022 we implemented a 5% pay increase, and we added enhanced benefits such as increased paid time off, paid parental leave, and increased tuition reimbursement.
HL: How do you rise to the challenge of bridging healthcare gaps and keeping pace with changes in the healthcare environment?
Tang: We need to be aware of healthcare market intel and use our resources to address where we can impact healthcare the most. For example, we need to identify key social determinants of health and how they impact our community and patients receiving healthcare and accessing healthcare. We need to focus on those key, high-impact items, then direct efforts to target those social determinants of health.
HL: You became CMO of the medical center during the coronavirus pandemic in 2021. What were your main learnings from this experience?
Tang: I learned that healthcare workers are resilient and that their dedication to provide the best care to patients superseded any fear of the virus or fear caused by confusion surrounding prevention and treatment guidelines that changed constantly. Our healthcare providers worked through the uncertainty and put their health at risk during the pandemic. However, they put those fears aside to come to work every day and stay late on many occasions to care for their patients.
I also learned how the pandemic has changed how patients access healthcare, especially with telemedicine. Even though the worst of the pandemic is over, we have learnings such as telemedicine to increase access for patients. Telemedicine is a practice that is here to stay.
Alice Tang, DO, MPH, MBA, chief medical officer of Sentara Northern Virginia Medical Center. Photo courtesy of Sentara Health.
HL: What is your approach to patient safety at the medical center?
Tang: Patient safety requires a team approach. Measures such as hand hygiene and sepsis management take every healthcare provider and team member to prioritize the safety of patients in every daily task. This responsibility is not limited to our clinical staff—it includes other team members such as environmental services and facilities management. Every job and every team member contributes to maintaining patient safety.
HL: Give an example of a patient safety initiative at the medical center since you became CMO.
Tang: Related to the pandemic and coming out of the pandemic, we have transitioned practices that were pandemic-centric to keep patients and employees safe. We have transitioned from wearing a mask at all times in clinical settings to directing our patients and staff on when to wear a mask. In the very beginning of the pandemic, mask management was confusing, and it evolved. Now, it is at a place where patients, family members, and staff members feel safe.
The current protocol for masking is to observe personal protective equipment precautions such as wearing a mask if a patient is receiving an aerosolizing procedure. Masks are required when patients and staff members are in clinical areas where they are at risk for respiratory droplets. That is not limited to COVID patients—it applies to patients with the flu, pneumonia, and other respiratory illnesses.
HL: What is your approach to quality at the medical center?
Tang: The main approach to driving quality is education and messaging the "why" and clinical importance for each quality initiative. This approach can help team members become knowledgeable about quality and be able to share about quality with patients and other team members on our various clinical quality efforts. This approach also allows us to meaningfully execute the things that are needed to improve quality.
For example, sepsis management has been important at Sentara over the past year. We have been focusing on the front-end care such as early goal-directed therapies otherwise known as the SEP-1 bundle, which has been escalated in priority and importance in our health system. We have increased our SEP-1 bundle compliance and have experienced a decrease in sepsis mortality. That took a lot of education about sepsis, about the bundle, and about how to effectively implement the bundle.
There is a constant commitment to educate our team members about quality initiatives through different channels. We use methods such as computer-based training, daily huddles, and simulations. We focus on the "why" and how to execute these initiatives.
HL: What advice would you offer to other female physicians who might be interested in top administrative roles such as CMO?
Tang: My advice would be to not be afraid and to know your purpose. Knowing your purpose, even as a clinician, helps drive advocacy and high standards for patients. Having the courage to provide the best care for your patients and recruiting help from your team to do so is not always easy, especially in an administrative role. Many female physicians and advanced practice providers are comfortable functioning within their clinical scope, and clinical knowledge can be powerful in driving change at an administrative level. But if a clinician has a purpose to drive positive change at a local level or beyond, I encourage them to pursue a career in administration and challenge themselves to make changes materialize.
Female physicians do not have a huge footprint in administration nationwide, but we definitely have the voice and the ability to serve in administration.
HL: How can female physicians develop the voice and abilities to serve in roles such as CMO?
Tang: You need to seek out leadership opportunities at multiple levels, whether it is at the departmental level, hospital level, or health system level. That is what I have done. It is also vital for female physicians and advanced practice providers to have a sponsor who is either outside of their facility or inside their facility. A sponsor not only fosters and encourages opportunities for leadership but also can help with facilitating those opportunities.
The Centers for Medicare & Medicaid Services make SEP-1 sepsis care bundle a pay-for-performance measure.
The inclusion of the Severe Sepsis and Septic Shock Management Bundle (SEP-1) into Medicare's Hospital Value-Based Purchasing Program (VBP) is a significant advancement for sepsis care, the chair of the Sepsis Alliance Board of Directors says.
Sepsis is an extreme reaction to infection that can be life-threatening. According to the Centers for Disease Control and Prevention, about 1.7 million American adults develop sepsis annually and about 1 out of 3 hospital patients who die during their hospitalization had sepsis.
"CMS has finalized the inclusion of SEP-1 in the VBP program in recognition of the importance of improving sepsis care, a leading cause of morbidity and mortality. The SEP-1 measure has been included in the Hospital Inpatient Quality Reporting Program since FY 2017. Since the inclusion of the measure, the national average measure performance has increased 8%. In order to continue to drive improvement on outcomes of this critical condition, we finalized adding the measure into the VBP program to link performance on the measure to hospital payment," the spokesperson said.
A research article published by Spartan Medical Research Journal summarizes the SEP-1 protocols. "There are two bundles included in the SEP-1 measure: the severe sepsis bundle and the septic shock bundle. The severe sepsis bundle requires lactate measurements, blood cultures and broad-spectrum antibiotics administration within three hours of sepsis identification followed by repeat lactate measurements within six hours if the initial lactate level is elevated. The septic shock bundle adds three additional requirements: 1. 30 mL/kg of IV fluids within three hours; 2. vasopressors within five hours for persistent hypertension; and 3. repeat volume assessment within six hours."
The inclusion of SEP-1 in the VBP program makes SEP-1 a pay-for-performance measure, says Steven Simpson, MD, professor of medicine at the University of Kansas and chair of the Sepsis Alliance Board of Directors.
"For several years, there have been financial penalties if your hospital was not participating in reporting how well they were doing with the various care measures that are part of SEP-1. It is believed by CMS and others, including the Sepsis Alliance, that if you do these things in your care of sepsis patients the outcomes will be better. If you are a hospital larger than a critical access hospital, you were required to report your SEP-1 activities or you would experience a Medicare reimbursement penalty. When CMS adopts SEP-1 as part of the Hospital Value-Based Purchasing program, you will not only have to report but also meet standards for performance. If you do not meet those standards, you will have to forfeit a small percentage of your Medicare reimbursement," he says.
Including SEP-1 in the VBP program gives hospitals an incentive to improve their sepsis care, Simpson says. "With a reporting-only standard for SEP-1, there is no requirement that you get better at taking care of sepsis patients. Under the Hospital Value-Based Purchasing program, hospitals will be required to meet standards for how often they comply with the SEP-1 bundle in order to achieve full payment. It is going to be an incentive to perform better. It comes down to dollars. Many hospitals operate on relatively thin margins of 1% to 2%, so losing any of your Medicare reimbursement is important. For many hospitals, Medicare is the largest payer, so this becomes a financial incentive for hospitals to do better."
Compliance with SEP-1 saves lives, he says. "CHEST published a paper on the impact of SEP-1 on Medicare beneficiaries last year, and they found that the bundle reduced sepsis mortality by about 5 percentage points. So, if you are compliant with SEP-1 compared to if you are not compliant, you have better outcomes and lower mortality. In the Medicare research, mortality was reduced from about 27% to about 22%."
Hospitals can take several steps to improve SEP-1 compliance, Simpson says. "One of the things that hospitals need to do is to have a physician champion who cares deeply about improving sepsis care. Some doctors do not understand that following the SEP-1 bundle requirements makes a difference, so you must educate doctors about the SEP-1 bundle. You must educate doctors and nurses to work as a team, to identify sepsis early, and to know when to trigger the sepsis bundle appropriately so patients get early treatment. It also helps if a hospital can assign particular individuals to monitor compliance with the SEP-1 bundle—you need to have data collection in place if you want to improve."
Read the Top 10 HealthLeaders burnout and well-being stories since 2021.
Addressing healthcare worker burnout and well-being are key elements of improving healthcare andrising to the challenge of widespread workforce shortages at health systems, hospitals, and physician practices.
In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
HealthLeaders has been following healthcare worker burnout and well-being developments for years. The 10 stories listed below have been popular with HealthLeaders readers.
Study Identifies Interventions Physicians and Nurses Want to Address Burnout: To address burnout, physicians and nurses prefer actions to boost nurse staffing, increase clinician control over workload, and improve work environments rather than wellness programs and resilience training, a research article found.
Battling Burnout: ANA Arms Nurses With an Effective Weapon: The program, developed by SE Healthcare, a healthcare data analytics provider, gives nurses on-demand access to more than 190 "bite-size" videos on real-world challenges faced by nurses, with topics such as Building a Better Day Off; Delegation—What a Revelation; Shared Governance; and Ethical Dilemmas.
Expert: Healthcare Worker Burnout Trending in Alarming Direction: Healthcare worker burnout has reached crisis proportions and urgent action is required to turn the tide, according to Bernadette Melnyk, PhD, RN, APRN-CNP. Melnyk is chief wellness officer of The Ohio State University and dean of the university's College of Nursing. She is a nationally recognized leader on healthcare worker burnout and well-being.
Nurses, Other Healthcare Workers Experience Reduced Stress and Burnout Through Mindfulness Program: An 8-week mindfulness program created by researchers at The Ohio State University Wexner Medical Center and The Ohio State University College of Medicine significantly reduced burnout and perceived stress for nurses and other healthcare staff, while increasing resilience and work engagement, a study found.
Researchers find that unfair treatment of parents and children in healthcare settings is linked to care disruptions such as delayed or foregone care.
Black parents are about twice as likely as parents who are White, Hispanic/Latinx, or of other races to experience unfair treatment in healthcare settings, according to a new study.
Earlier research has documented discrimination or unfair treatment based on race, ethnicity, and other personal characteristics. In healthcare settings, discrimination or unfair treatment has been linked to negative consequences for healthcare access, healthcare quality, trust in the healthcare system, and treatment adherence.
The new study, which was conducted by the Urban Institute, is based on data collected from parents with children under the age of 19. The data was drawn from the June 2022 Urban Institute Health Reform Monitoring Survey. That survey had a sample size of 9,494 adults.
The study features several key findings:
13% of parents said they were treated unfairly in healthcare settings based on race or ethnicity, language, health insurance type, weight, income, disability, or other characteristics
22% of Black parents said they were treated unfairly in healthcare settings, which was 10 percentage points higher than unfair treatment reported by parents who were White, Hispanic/Latinx, or additional races
3% of all parents said that their children were treated unfairly in healthcare settings because of the parent's or child's race, ethnicity, country of origin, or primary language
9% of Black parents said that their children were treated unfairly in healthcare settings because of the parent's or child's race, ethnicity, country of origin, or primary language
71% of parents who reported unfair treatment said they experienced disruptions in their healthcare
40% of Black parents and 30% of Hispanic/Latinx parents said they were concerned that they or a family member would be treated unfairly in healthcare settings in the future because of race, ethnicity, or primary language
Black parents were more likely than White parents to be treated unfairly based on health insurance type (9% versus 4%); weight (8% versus 5%); gender, gender identity, or sexual orientation (9% versus 4%); income level (6% versus 3%); or disability or health condition (5% versus 3%)
Interpreting the data
Healthcare organizations should find the research alarming, Dulce Gonzalez, a research associate at the Urban Institute's Health Policy Center and co-author of the study, told HealthLeaders. "It is a concern because all people regardless of their background and regardless of their personal characteristics deserve access to respectful and high-quality care. It is concerning to us that not everybody—particularly people of color—is getting that kind of treatment in healthcare. It points to systemic issues in the healthcare system, including both implicit and explicit systemic biases as well as policies that are systemic to the healthcare system that allow for racism, classism, and ablism."
The findings are "striking," she said. "People of color and especially Black parents reported feeling treated unfairly at much higher rates than White parents. Among Black patients, the rates of unfair treatment among children specifically are much higher than those of other races and ethnicities. Notably, rates of unfair treatment for parents with the youngest children are just as high as parents with older children. That is significant because young children are going through an intense period of development, and exposure to negative experiences in healthcare early on in life is particularly concerning."
Unfair treatment has negative consequences for patients, Gonzalez said. "It is concerning that these experiences of unfair treatment have the potential to affect healthcare access generally. When people told us that they experienced unfair treatment, many people reported they also experienced disruptions to care such as delayed or foregone needed care, switching providers, and not following providers' recommendations, which speaks to the breakage of trust between patient and provider. Based on prior research, we know that unfair treatment can be associated with higher levels of stress and adverse mental health outcomes."
These care disruptions have short-term and long-term effects on patients, she said. "It is possible that if people are not getting needed healthcare that they are also not able to get preventive care, routine care, or primary condition management care in the short-term. It is also possible that not getting these kinds of care could have a negative effect on health in the long-term."
Addressing unfair treatment of patients
Several steps can be taken to reduce the unfair treatment of patients based on personal characteristics, Gonzalez said. "You can uncover and address the implicit and explicit bias that exists among providers and their front-office staff. You can also make broader changes to the healthcare system to improve the experiences of people of color such as diversifying the healthcare workforce along race, ethnicity, and other dimensions to help build trust between providers and their patients. Another avenue is expanding on community programs, which can leverage community expertise to help bridge communication and trust gaps for people of color."
A pair of government programs should be focal points in efforts to address unfair treatment of parents and their children based on personal characteristics, she said. "You could leverage Medicaid and the Children's Health Insurance Program, with the acknowledgement that these programs serve a large number of children. Being able to leverage those programs to reward providers who are excelling at providing high-quality and respectful care could be a powerful incentive to promote better treatment of patients."
Beth Prairie, MD, MPH, chief medical officer of West Penn Hospital. Photo courtesy of Allegheny Health Network.
