The initiative harnesses data, strengthens community partnerships, and provides key information to grieving families.
In a trend across the country, many hospital morgues have been overrun since the first surge of the coronavirus pandemic. Increased decedent release time not only creates a burden for families but also poses an operational challenge for hospitals, which are forced to supplement their morgues with refrigerated trucks.
Average decedent release times have increased from about three days before the pandemic to as long as two weeks since the pandemic, according to Komal Bajaj, MD, chief quality officer at NYC Health + Hospitals/Jacobi | North Central Bronx, which is a two-campus hospital.
To combat this issue, Jacobi | North Central Bronx hospital has launched a program to improve decedent release time.
Jacobi | North Central Bronx hospital's Compassion for the Community: Continuing Care After Death program has reduced average decedent holding time from 13 days to five days.
"First and foremost, there are implications for the loved ones of the individual who was lost; it impacts their grieving process and their journey," Bajaj says. "It also has significant operational consequences. Being able to release decedents in a timely fashion means that our community partners such as funeral homes can do the work that they need to do."
The Compassion for the Community: Continuing Care after Death program has three primary elements.
Data infrastructure: The hospitals built the capacity to track data in real-time to have a clear understanding of decedent hold time.
Strengthening community partnerships: The hospitals worked more closely with community partners such as funeral homes and places of worship to co-design processes that were more efficient.
Information resource: The hospitals created an informational packet that includes information on funeral homes in the area, resources for supporting funeral costs, and phone numbers that families can call at Jacobi | North Central Bronx hospital for help.
Through a multipronged effort, there has been a substantial reduction in decedent release time.
"There are certain things that healthcare delivery organizations require. There are certain things that funeral homes require," Bajaj says. "We have put this information in one place, and we have served as a guide for people on how to navigate the process."
The program is reducing delays in the decedent release time process, according to Bajaj. First, the program has reduced delays by giving families a clear understanding of the paperwork and other steps required with the passing of a loved one.
"With that understanding, the paperwork and steps are more likely to be completed in an efficient way," Bajaj says. "A process that previously took three or four days can be shortened to a day-and-a-half."
Improving coordination with community partners has also reduced delays, Bajaj explains.
"For example, if a funeral home is sending out a truck to pick up a decedent, and we know another family has decided to have a decedent go to the same funeral home, we can ensure that the truck can take both decedents at the same time," Bajaj says.
Komal Bajaj, MD, is chief quality officer for NYC Health + Hospitals/Jacobi | North Central Bronx hospital. Photo courtesy of NYC Health + Hospitals.
Taking a team approach
The Compassion for the Community: Continuing Care after Death program is operated by an interdisciplinary team, which includes staff from pathology, care experience, admitting, and finance.
"The department of pathology oversees the morgue, so they are the subject matter experts in operational processes and challenges in decedent release time," Bajaj says. "They are also experts in potential solutions."
Care experience teams and social workers have expertise in thinking about partnering with patients and their families.
"They support families through their grieving process," Bajaj says.
Admitting and finance staff have a good handle on how patients are flowing through the hospital.
"Working with them to understand the data parameters that were available was hugely important," Bajaj says.
The primary elements of effective medical staff governance include shared decision making, harnessing data, and strong physician leadership, according to this new CMO.
Michael Fiorina, DO, was announced as the CMO of Independence Health System on June 10. He joined the health system's administrative team in 2021. Prior to being named CMO, Fiorina served as vice president of medical education and associate CMO of Butler Memorial Hospital and Clarion Hospital.
There are six essential elements to succeeding in medical staff governance, according to Fiorina.
Strong physician leadership: This starts with engaged physician leaders who understand clinical, operational, and strategic priorities. These leaders must be identified, cultivated, and developed in a coordinated and intentional fashion.
Shared decision making: Physicians must be engaged in the decision-making process through committees, councils, and valuing their input.
Clear roles, accountability, and ownership: The goals of the work assigned to physicians need to be clearly defined and communicated. There must be ownership for the outcomes, particularly in areas such as quality and safety.
Effective communication: Frequent and transparent communication is critical to building trust and facilitating effective problem solving.
Harnessing data: Clinical data and performance metrics should be used to guide decisions to make meaningful and measurable improvements.
Interprofessional collaboration: There must be collaboration across disciplines, not just physicians, to get a comprehensive view of the challenges and solutions.
Michael Fiorina, DO, is CMO of Independence Health System. Photo courtesy of Independence Health System.
Succeeding in community-based care
CMOs and other healthcare leaders face barriers in providing community-based care, particularly in rural settings, according to Fiorina.
"This is a real challenge, given the evidence that many rural areas are struggling to provide care for the people in their communities," Fiorina says.
A primary strategy to provide community-based care is to build strong partnerships with community-based organizations. For example, Butler Memorial Hospital is a member of the Butler County Growth Collaborative, which is a group of political, educational, and business leaders who meet regularly to discuss their challenges and build strategies for serving members of the community. The hospital also involves care teams in community events.
"This puts faces to names and allows us to interact with the people who are our patients," Fiorina says.
Butler Memorial Hospital also shares its achievements with the community, Fiorina explains.
"When we win a quality award or have a provider achieve a new certification, we announce it to the public," Fiorina says. "We need to be our own greatest advocate."
Establishing residency programs
Securing the support of a health system's top leadership is essential in building residency programs, according to Fiorina.
"Our president and CEO was the one who originally approached me with the idea, and we had wholehearted support of the board of trustees," Fiorina says. "Without this foundational support, the concept could not have become a reality."
It is also crucial to gain the support of key stakeholders, Fiorina explains.
"It was vital to get the support of the medical staff through effective communication via the department chairs, who served as key liaisons to the broader medical staff," Fiorina says. "It was also imperative to communicate the goals of the residency program to the other disciplines that would interact with the residents such as nursing and physical therapy."
Next, a health system must build the infrastructure required for accreditation such as hiring faculty and staff to support a residency program, according to Fiorina. Without the proper infrastructure in place, accrediting bodies won't consider an organization a viable site.
"We also utilized relationships built with medical schools to assist us in the application process," Fiorina says. "These institutions are invested in having high-quality residency sites to send their graduates and are very interested in partnering with hospitals."
CMOs can learn from these two healthcare organizations that have different approaches to providing second opinions in cancer care.
A second opinion in any profession is the best practice.
That's why Karmanos Cancer Institute implemented a streamlined process to provide patients with second opinions within seven days of an initial diagnosis.
At Karmanos, a second opinion results in a revised treatment plan or even a new diagnosis up to 20% of the time, according to George Yoo, MD, CMO of the comprehensive cancer center.
"The second opinion allows for a more comprehensive and expert review by a multidisciplinary team of doctors who specialize in a cancer type," Yoo says. "This review includes reviewing the pathology slides and the radiology images."
Providing a second opinion also boosts the patient's peace of mind, according to Yoo.
"A second opinion can confirm and validate the treatment plan that the patient has been given," Yoo says. "This reassures the patient that they have made the right choice."
When a patient receives a cancer diagnosis, getting a second opinion is beneficial, according to David Peter, MD, MBA, CMO of The Clinic by Cleveland Clinic, which specializes in virtual second opinions.
"Cancer is a complex and, of course, life-changing condition," Peter says. "If you've received a cancer diagnosis, it's important to confirm your diagnosis promptly and ensure you're on the right path for your treatment. You owe it to yourself to leave no stone unturned."
Regardless of the result of a second opinion in cancer care, the patient benefits, Peter explains.
"A recommended change to your diagnosis or treatment plan can set you on a promising path," Peter says. "Alternatively, confirmation that you're already doing everything you should can help clear your doubts about the next steps in your journey."
George Yoo, MD, is CMO of Karmanos Cancer Institute. Photo courtesy of Karmanos Cancer Institute.
How Karmanos provides second opinions
Karmanos has implemented a four-step process to facilitate providing rapid second opinions.
First, Karmanos has made it easy for patients to contact the comprehensive cancer center for second opinions. Patients can either call 1-800-KARMANOS or fill out a form online.
Second, Karmanos has trained specialized oncology navigators who guide patients through every step of receiving a second opinion—getting records, arranging insurance coverage, and setting up appointments. The oncology navigators relieve stress for the patients and make the process easier.
Third, there is a pre-intake appointment involving a nurse practitioner, who calls the patient and makes sure all information has been gathered.
Fourth, the patient has an on-site appointment with an oncologist who specializes in the patient's type of cancer. The work of the oncology navigator and the nurse practitioner tees up the appointment with the oncologist, so it is easy for the doctor to communicate with the patient.
"We have a rapid process keyed by the oncology navigator gathering all the information," Yoo says. "We have a pre-appointment intake, where a nurse practitioner will talk with the patient and organize all the information. We make sure we have open appointment slots with our specialized oncologists, so patients can get in within seven days."
For cancer centers interested in replicating Karmanos' second opinion model, having oncology navigators is crucial, according to Yoo.
"You need to train your oncology navigators to focus on the information that is important to treat an oncology patient," Yoo says. "The navigators should be empowered to advocate for the patients."
David Peter, MD, MBA, is CMO of The Clinic by Cleveland Clinic. Photo courtesy of The Clinic by Cleveland Clinic.
The Clinic's approach
The Clinic by Cleveland Clinic makes it easy for cancer patients to receive a second opinion from an expert physician quickly and from the comfort of home, according to Peter. After a brief online registration, patients can quickly schedule a video visit with a nurse. During that intake visit, their nurse gets an understanding about their diagnosis, treatment plan, concerns, and questions.
"With the patient's consent, we then do the work of collecting their medical records and any relevant imaging or pathology on their behalf, which can save the patient significant hassle and anxiety," Peter says.
In the next step, The Clinic by Cleveland Clinic's clinical team identifies the cancer specialist at Cleveland Clinic who is best suited for the patient's particular case. That physician then reviews all of the relevant information to provide a thorough second opinion report, which is delivered typically a few days after records are collected.
"If the cancer specialist is licensed in the patient's state, the patient has the option to have a video call with the physician," Peter says. "Patients also have the opportunity to ask follow-up questions after their opinion is delivered."
In particularly complex cases, the cancer specialist assigned to the patient may determine the need to re-interpret the patient's pathology or consult with advanced subspecialists for additional insight.
"While not every case requires it, the opportunity for a deeper and multidisciplinary review can provide greater clarity and certainty about a patient’s diagnosis and treatment options," Peter says.
The National Association for Healthcare Quality has set national standards for quality and safety.
The National Association for Healthcare Quality (NAHQ) has published a new report that includes ways healthcare organizations can generate return on investment from quality efforts.
Boosting care quality is one of the top responsibilities for CMOs and other healthcare leaders. Quality improvement is linked to patient safety and financial considerations such as generating revenue from pay-for-performance incentive programs.
A core element of NAHQ's work is the Healthcare Quality Competency Framework. The framework features eight domains: regulatory and accreditation, patient safety, performance and process improvement, health data analytics, quality review and accountability, quality leadership and integration, professional engagement, and population health and care transitions.
One of the primary strategies for quality improvement included in the new report is using the NAHQ Healthcare Quality Competency Framework to provide clarity in the field of healthcare quality.
"Before NAHQ created a quality competency framework, nothing existed in the industry to guide quality leaders and quality programs to achieve results through their people," says Stephanie Mercado, CEO and executive director of NAHQ. "As quality improvement was born in the industry, it was set up and structured at the local level. It was put together organically at the site-by-site level. Each one of the hospitals had their own homegrown quality system."
The healthcare industry has standards in many areas such as standards of practice and standards of care, but NAHQ has filled a gap in standards for quality and safety, according to Mercado.
"Until NAHQ developed the Healthcare Quality Competency Framework, we did not have a standard for setting up and structuring the work of quality and safety," Mercado says.
NAHQ's approach to helping healthcare organizations improve quality and safety is a step-by-step program aided by a NAHQ navigator that systematically helps healthcare organizations understand the level of work and type of work that their employees are doing, Mercado explains.
"We help healthcare organizations to visualize their competency-based performance through an assessment," Mercado says.
The next step is a peer-to-peer benchmarking analysis so a health system can see how their staff compares to each other, such as staff at hospitals within a health system. This benchmarking analysis also includes comparing a health system's staff to staff at other health systems.
The third step is helping a healthcare organization set goals for better quality performance, according to Mercado.
"We set a target for them to be at higher ground; and once we set that target, we deploy coaching, mentoring, and upskilling methods," Mercado says. "Then we reassess to see whether their people are working at higher levels. We want their work to be less variable."
Claire Lauzon-Vallone, RN, MBA, is vice president of quality and safety at CHRISTUS Health. Photo courtesy of CHRISTUS Health.
Generating results
CHRISTUS Health has made significant gains from working with NAHQ.
"What we saw in terms of return on investment was increased patient safety and quality of care as well as reduction of harm," says Claire Lauzon-Vallone, RN, MBA, vice president of quality and safety at CHRISTUS Health. "We saw mitigation of risk. We helped our people understand what they should be looking for."
Working with NAHQ has resulted in empowerment of CHRISTUS Health's quality professionals, according to Lauzon-Vallone.
"When you train them and provide professional enhancement and engagement, they feel more confident and engaged to make decisions locally," Lauzon-Vallone says.
Participating in NAHQ programs has generated financial gains, including more than $15 million generated annually from pay-for-performance incentive programs. The health system has also achieved a 50% reduction in serious safety event rates.
"We have seen cost avoidance as a return on investment," Lauzon-Vallone says. "We have had lower catheter-associated infections and lower central line infections. We have had less mortality and shorter length of stay. We have had penalty reductions in government programs."
CHRISTUS Health's hospitals have posted improvements in patient safety, according to Lauzon-Vallone. For example, with Leapfrog, the health system only had one hospital out of 28 that had an A grade. Now, it has 14 hospitals with an A grade.
"We started out with a lot of our national benchmarks not being where they needed to be," Lauzon-Vallone says. "Working with NAHQ has helped us kickstart our hospitals to get better performance for safety."
Women with high-risk pregnancies often need management of chronic medical conditions after childbirth such as high blood pressure and cardiovascular disease.
Adverse outcomes in maternal health are a national concern.
The maternal mortality rate in the United States is significantly higher than the maternal mortality rate in other high-income countries, according to a report published by The Commonwealth Fund.
Scripps Health's Fourth Trimester Continuum of Care program provides optimized care for new moms with high-risk pregnancies, particularly women with chronic medical conditions.
The "fourth trimester" is a critically important time period for new moms, according to Sean Daneshmand, MD, medical director of the Scripps Clinic Maternal-Fetal Medicine Program.
"We think of pregnancy as having three trimesters—three consecutive blocks of time that are three months each," Daneshmand says. "However, there is also an important block of time for moms after they deliver, which is what we refer to as the fourth trimester."
Launched last fall, the Fourth Trimester Continuum of Care program focuses on women who have high-risk pregnancies. Many of these women have chronic medical conditions such as high blood pressure, diabetes, and cardiovascular disease. Daneshmand describes the program as more of a continuum of care than a clinic.
"This program involves setting up a new system and streamlined process to identify at-risk moms before they give birth," Daneshmand says. "We help high-risk moms receive the care that they need from their primary care physician in a timely fashion shortly after they deliver."
In the United States, most new moms get two visits with their obstetrician-gynecologist after delivering their baby. Particularly for new moms with chronic medical conditions, two postpartum OB/GYN visits are insufficient to provide quality care, Daneshmand explains.
"The Fourth Trimester Continuum of Care puts more structure and focus on care, so we can be more proactive on how we take care of our high-risk new moms," Daneshmand says. "The goal is faster care and as many doctor visits as needed after delivery to get new moms on the right track. These visits can be provided virtually or in-person."
The Fourth Trimester Continuum of Care program identifies high-risk new moms and connects them with care. The patients are flagged in the EMR as needing proactive follow-up from their primary care physicians soon after delivery.
"During a baby's pediatrician visits, the pediatrician proactively asks the mom about her health, which helps new moms get the care they need faster," Daneshmand says. "There is close collaboration between my division, maternal-fetal medicine, and primary care."
Although most medical services offered through the Fourth Trimester Continuum of Care program are provided by primary care physicians, some new moms are referred to specialists such as cardiologists and endocrinologists, Daneshmand explains.
It is too soon to have data showing the impact of the Fourth Trimester Continuum of Care program, but the primary goal is reducing chronic medical conditions experienced by new moms, according to Daneshmand.
"By addressing chronic health conditions such as hypertension, we can help reduce co-morbidities in future pregnancies such as the development of preeclampsia," Daneshmand says.
Ghazala Sharieff, MD, MBA, is executive senior vice president and chief medical and operations officer of acute care at Scripps Health. Photo courtesy of Scripps Health.
CMO perspective
CMOs should be concerned about the continuum of care for pregnant women, according to Ghazala Sharieff, MD, MBA, executive senior vice president and chief medical and operations officer of acute care at Scripps Health.
"We need to think about pre-pregnancy because if women are going to plan pregnancies, we want them to be as healthy as possible," Sharieff says. "Then if we have high-risk pregnancies, we want those moms to meet with specialists such as Dr. Daneshmand, so we can manage high-risk pregnancies."
At Scripps Health, hospital caregivers are focused on providing quality care to new moms with chronic medical conditions, Sharieff explains.
"When a pregnant woman comes into a hospital with a chronic condition, if they need a hospitalist to co-manage their condition, we can provide that kind of care," Sharieff says. "Some of our moms end up in the ICU, so we have our ICU staff work hand-in-hand with Dr. Daneshmand."
CMOs should also focus on the fourth trimester, according to Sharieff.
"There is good reason for CMOs to start thinking more proactively—not just during a pregnancy but also after delivery, so we can get moms feeling as good as they can feel," Sharieff says.
Innovation initiatives help hospitals to improve the quality of care, this new chief medical executive says.
In the hospital setting, frontline staff should be leaders in innovation, the new chief medical executive of a Sutter Health hospital says.
Anup Singh, MD, became chief medical executive of California Pacific Medical Center this month. He was previously chief medical executive at another Sutter Health hospital, Sutter Santa Rosa Regional Hospital.
"The first key driver of innovation in the hospital setting is relying on frontline leaders and physicians for innovation rather than the C-suite," Singh says. "You need to reach out to frontline team members to ask for suggestions. When you ask them questions, you will get significant innovative answers from them."
In addition to relying on frontline staff for innovation initiatives, ideas can come from outside a hospital, Singh explains.
"Leaders should look across their health system and across the country to see who is performing best in terms of metrics and how they are doing it," Singh says. "You need to learn from others about best practices and innovations."
To promote innovation, CMOs and other hospital leaders need to be open to new ideas, according to Singh.
"If you are not open to new ideas and if you are not flexible, people will not have the psychological safety to come to you to talk about innovations," Singh says.
Singh gave an example of an innovation initiative at Sutter Santa Rosa Regional Hospital.
"We had an innovation initiative for congestive heart failure patient readmissions," Singh says. "We did not have enough outpatient physicians or cardiologists to see the patients. We could not see patients quickly enough."
The initiative focused on enlisting pharmacists to engage patients.
"We had our pharmacy team call these patients within 48 hours of discharge as well as connect patients with home health services," Singh says. "We were able to talk with patients and adjust medications to improve their care."
Anup Singh, MD, is chief medical executive of California Pacific Medical Center. Photo courtesy of Sutter Health.
Improving care quality
Hospital readmission is a key quality metric, according to Singh.
When Singh became chief medical executive of Sutter Santa Rosa Medical Center in 2023, one out of six congestive heart failure (CHF) and heart failure patients were being readmitted to the hospital within 30 days. The hospital took several actions to reduce these readmissions.
The hospital was able to reduce the amount of time it took for CHF and heart failure patients to get follow-up appointments with cardiologists. Patient engagement was improved with the pharmacy and transitional care teams. The hospital worked more closely with the home health team, which engaged with patients and helped to manage medications.
"By the end of the year, we were able to decrease readmissions from 16% to around 9%," Singh says.
Patient experience is another crucial quality metric, Singh explains.
"When you talk about patient experience, it is not only about care, but also knowing the patient as a person," Singh says.
Hospitals should take a team-based approach to improving patient experience, according to Singh.
"It is not only the physician—it is the nurses and the rest of the care team," Singh says. "When we talk with a patient, we talk with them not only as a patient but also as a human being. We need to know them and what they like such as their hobbies."
Communication is pivotal in patient experience, Singh explains.
"We want to narrate the care in a way that the patient understands," Singh says. "We want them to be aware of what is happening in their care."
Improving care coordination
Health systems need to focus on patient engagement to improve care coordination, according to Singh.
"We need to take care of the patient with continuous care, not just care when they are in a clinic or a hospital," Singh says. "We should be in touch with the patient in way where we are taking care of them even when they are not in a healthcare setting."
CMOs and other healthcare leaders need to ask themselves pointed questions to provide good care coordination, Singh explains.
"How are we taking care of a patient? How safe are we providing care to the patient? How are we connecting with the patient once they are at home?" Singh says. "We need to be providing follow-up appointments to patients, so they are not coming back to the hospital, and we need to provide care to patients once they have gone home."
Care teams in various settings need to work together to boost care coordination. According to Singh, CMOs need to have outpatient teams coordinating with inpatient teams as well as home health teams.
"When we have patients go home from the hospital, home health staff connect with these patients, so there is a continuous connection with the patients," Singh says. "Our home health team works on the same electronic medical record as our hospitals, Epic, so documentation is visible to outpatient physicians."
Having care teams on the same EMR is essential for care coordination, Singh explains.
"When the home health team goes to the patient in the home, they are collecting data, and they are talking with the patient," Singh says. "If problems arise that require intervention, our home health staff has the option to send messages to the outpatient team, whether that is a primary care physician or a specialist."
When patient safety concerns arise in a non-punitive workplace, the emphasis is on improving processes rather than blaming individuals.
Establishing a non-punitive workplace culture is a cornerstone of patient safety, a trio of top clinical leaders say.
Patient safety is a top priority for CMOs and other clinical leaders. These leaders must foster a non-punitive workplace culture to encourage frontline staff members to report patient safety concerns and events.
"If there is a recognition that there is a potential patient safety event, whether it is a medication event, equipment event, or staffing issue, those concerns must be brought to leadership," says Jennifer Khelil, DO, MBA, executive vice president and chief clinical officer of Virtua Health. "Staff members must feel comfortable bringing these concerns to leadership. If the culture is punitive, people are not going to speak up."
Having a non-punitive workplace is part of a culture of patient safety, where staff feel comfortable speaking up without fear of backlash, according to Kevin Post, DO, CMO of Avera Health.
"They can speak up for the safety of the patients and the safety of their coworkers without fearing retaliation coming back against them," Post says. "That starts with leadership and putting systems in place where we encourage our staff members to speak their mind; and when they do, we reward them and recognize them."
With a non-punitive culture, staff members are more likely to report when they are involved in a medical error, according to Sylvain "Syl" Trepanier, DNP, RN, chief nursing officer at Providence.
"They won't shy away from raising their hand and saying they made an error," Trepanier says. "You learn together, and you do not blame the individual. You focus on the processes."
Jennifer Khelil, DO, MBA, is executive vice president and chief clinical officer of Virtua Health. Photo courtesy of Virtua Health.
How to promote a non-punitive workplace
To establish a non-punitive workplace, healthcare leaders need to be visible and to interact with care teams, Khelil explains.
"They need to be on the floors with the care teams," Khelil says. "They need to thank teams and staff members who bring concerns forward."
Healthcare leaders should also follow up when patient safety concerns are reported, according to Khelil.
"When a staff member brings a concern to you that could have turned into a patient safety event, you need to close the loop and circle back to that individual," Khelil says. "You need to let that individual know that because they spoke up, a change was put into place so that the issue does not arise again."
In a non-punitive workplace, staff members should be recognized and rewarded when they report patient safety concerns.
Avera Health has a Good Catch Award, which is given to staff members when incidents occur that could have caused injury or harm to a patient, but it was caught before it reached the patient. The health system has a process where frontline caregivers can report when a good catch occurs, and learnings can be disseminated throughout the entire health system.
"So, if an error nearly occurred in one area of our health system, we have a communication channel in place to share that learning in a confidential way," Post says. "We also lift up the employee who had the courage to speak up for the greater good of the patient and the organization."
Healthcare leaders in a non-punitive workplace are aware of the working conditions and care processes at the frontlines, according to Trepanier.
"You can't be a subject matter expert at everything, but you need to know what resources are available and what the work is about," Trepanier says. "You need to have a lot of curiosity and ask a lot of questions. You should not resort to blaming people in the first instance and focus on the processes instead."
This new executive has prior experience leading the accountable care organization at Memorial Hermann Health System.
BayCare Health System has named a new executive to lead value-based care efforts at the Clearwater, Florida-based health system.
Kriel Ramcharitar, MD, MPH, became vice president and CMO for value-based care at BayCare effective May 19. Prior to joining BayCare, he served as a faculty member with the Jefferson College of Public Health at Thomas Jefferson University in Philadelphia. Ramcharitar's leadership experience in value-based care includes serving as vice president and CMO of Memorial Hermann Health System's Accountable Care Organization and Population Health Service Organization.
A health system must have the right structure and infrastructure to support value-based care, according to Ramcharitar.
"Value-based care has a rich and multidisciplinary basis, including everything from finance to operations to health management to care coordination," Ramcharitar says. "It also must link in with the enterprise strategic goals and the highest leadership level in order for it to translate and transform into true operational action."
Ramcharitar says the structure and infrastructure needed to support value-based care includes having multidisciplinary teams in areas such as care coordination, pharmacy, quality teams that help with quality gap closure, and managed care contracting to ensure that value-based care agreements have metrics that matter. In addition, Ramcharitar says that a health system must have an electronic medical record (EMR) that supports value-based care implementation and monitoring to help the health system know how it is performing on metrics in terms of cost and quality.
"The structure requires the skills of team members with multidisciplinary expertise, including physicians, care coordinators, social workers, and pharmacists," Ramcharitar says. "That informs the structure to effectively deliver value-based care and to have favorable outcomes, both for quality and total cost of care across populations and communities."
Kriel Ramcharitar, MD, MPH, is vice president and CMO for value-based care at BayCare Health System. Photo courtesy of BayCare Health System.
Keys to success in running effective ACOs
There are several factors involved in operating a successful ACO, according to Ramcharitar.
"You need effective care coordination that is proportionate to the needs of your communities and populations," Ramcharitar says. "You need an evidence-based approach to pharmacy, including medication adherence and comprehensive medication management."
An ACO should have teams conducting outreach for quality gap closure, Ramcharitar explains. For example, an ACO should have outreach to patients who need breast cancer and colorectal cancer screening.
An ACO needs robust data analytics and a strong electronic medical record that enables care teams to make actionable decisions on factors related to quality, Ramcharitar says.
An engaged and high-performing physician network is crucial for an ACO, according to Ramcharitar, who adds that the ACO leadership needs to be collaborative with the network both in terms of performance and understanding the challenges physicians have in value-based care and population health. This is especially true when there are different EMRs across the network.
"At the physician practice level, they may spend several hours in their EMRs sifting through population health data," Ramcharitar says. "This can be a root cause of physician distress. So, you need to talk with your physician partners to understand the challenges they are having in terms of being able to get data and focus on population needs."
Another factor in ACO performance can be employer-based education, Ramcharitar explains.
"Often within an ACO, you have cohorts and sub-populations that are based on employer contracts," Ramcharitar says. "You need to enable employers to understand all of the services that come with being part of the ACO, so they can effectively access and manage high quality in-network services."
Succeeding in population health
At the most basic level, population health involves providing care to communities and looking at the distribution of outcomes within communities, according to Ramcharitar.
"Population health is about understanding a population," Ramcharitar says. "For example, you need to know the prevalence of type 2 diabetes, chronic obstructive pulmonary disease, and other chronic diseases within a population."
Succeeding in population health involves a strong collaborative approach with primary care, according to Ramcharitar.
"You need to have a strong primary care infrastructure to support population health," Ramcharitar says. "For example, with quality gap closure, you need to improve on annual wellness visits across the population."
Preventative care is an effective population health management strategy, Ramcharitar explains.
"For example, you need to look at cancer screening programs," Ramcharitar says. "We know at the population level that the single most effective thing that we can do to prevent premature morbidity and mortality from cancer is screening."
At a practical level, health systems must consider how population health delivery models are linked to effective reimbursement models, according to Ramcharitar.
"Population health is the delivery of effective healthcare services at the population level, but they have to be linked to the right value-based care agreements with payer partners," Ramcharitar says.
In the hospital setting, it is imperative for physicians and nurses to work together to boost patient experience.
"The reality is that if we work in nursing and physician siloes, we will not get a good patient experience outcome," says Omayra Mansfield, MD, MHA, who was recently named as CMO of AdventHealth Celebration hospital.. "At the end of the day, the patient wants to see nurses, physicians, and the rest of the care team working cohesively to advance their care. So, the RN-MD relationship is critical for patient experience."
Click on the video below to get Mansfield's perspective on physicians and nurses working together to improve patient experience. Click here to read the accompanying HealthLeaders story.
The American Diabetes Association has established standards of care for diabetes patients in the hospital setting.
Three dozen hospitals across the country have been recognized for providing care to diabetes patients based on guidelines established by the American Diabetes Association (ADA).
For diabetes patients in the hospital setting, hyperglycemia, hypoglycemia, and glucose variability have been linked to adverse outcomes, including morbidity and mortality, according to a study published by the Journal of Clinical Endocrinology and Metabolism. The ADA says hospitals that follow their guidelines can improve outcomes, shorten hospital stays, and reduce hospital readmissions and emergency department visits.
"We are following the American Diabetes Association standards of care for diabetes patients," says Harpreet Pall, MD, MBA, CMO of Hackensack Meridian Jersey Shore University Medical Center, which is part of Hackensack Meridian Health. "We are using these standards to address all aspects of diabetes care for our patients. This has been a tremendous benefit for our diabetes patients in the hospital setting."
It is meaningful and important for a hospital CMO to be involved in the standard of care for patients with diabetes, according to Pall. The goal is for admitted patients to have a safe and efficient time in the hospital.
"We also want to make sure that the care that is being delivered to patients is based on evidence," Pall says. "We want to make sure that there is evidence that therapy decreases complications."
The ADA standards are helpful because they give hospital clinical teams a roadmap to follow, Pall explains.
"The care teams know that there is a standard way to approach care that is evidence-based and improves outcomes for patients who are affected by diabetes," Pall says.
The ADA standards of care are essential in the management of hospitalized diabetes patients at Denver Health, according to Rocio Pereira, MD, chief of endocrinology at the health system.
"We regularly review the American Diabetes Association's standards of care to make sure we are following recommendations," Pereira says. "As those standards of care change, we make sure we are keeping up to date with the newest recommendations."
Harpreet Pall, MD, MBA, is CMO of Hackensack Meridian Jersey Shore University Medical Center. Photo courtesy of Hackensack Meridian Health.
Examples of following the ADA guidelines
The ADA standards guide hospitals in managing glucose variability in the hospital setting.
"We provide a lot of education to our providers who are putting in the orders for different medications that can affect patients' insulin sensitivity and glucose level," Pereira says. "For example, we make sure that providers are aware that when they start a patient on a steroid medication, it can increase the patient's glucose level."
Multidisciplinary teams are focused on managing glucose variability among diabetes patients at Hackensack Meridian Jersey Shore University Medical Center, according to Pall.
"Our clinical diabetes advocates, which include diabetes educators, are consistently looking at the reports of patients who are admitted to the hospital," Pall says. "They measure and monitor glucose levels as well as hemoglobin A1C with the endocrinologists as appropriate."
The ADA guidelines call for providing a personalized approach to managing glucose levels that are outside the normal range among diabetes patients, since no two patients are alike.
"Although we have protocols and order sets, we also know that these patients' blood sugar levels are not always going to do what we think they are going to do," Pereira says. "It depends on factors such as their insulin sensitivity and the medications that are being used. So, we make sure that the care teams are trained to know the factors that affect blood sugar."
It is important to involve patients and families in the care that is provided to diabetes patients in the hospital setting, according to Pall.
"The multidisciplinary teams that we have consisting of endocrinologists, diabetes educators, nurses, and dietitians must involve the patient and the family as they discuss options related to their care," Pall says. "That is how we can ensure that our care comes across as being personal and not just a standard cookbook of treatment options."
The ADA guidelines call on hospitals to have structured order sets in their electronic health records that provide guidance for the care of diabetes patients in the inpatient setting.
Denver Health has structured order sets in the health system's EHR, including an order set for managing blood sugar. That order set helps providers know the options for the types of insulin that can be used for a particular patient.
"Having order sets in the EHR makes it much easier for the providers to know what they should order for patients depending on different conditions," Pereira says. "The order sets are great to educate our providers, including residents and fellows."
Having structured order sets in the EHR is crucial for diabetes and its management, according to Pall, especially because the insulin dosages can change depending on a patient's medications.
"The order sets for diabetes care in the hospital are well designed and standardized," Pall says. "We have discharge order sets as well. We have guidelines associated with the order sets, so it is obvious for clinicians who are using these order sets to know the parameters for their use."
Having structured order sets in the EHR is important for care teams to have a standard way to approach diabetes care, Pall explains.
"In the absence of structured order sets, things could get missed or the parameters for certain therapies could be variable," Pall says. "It is important to keep care consistent, so we are giving the right treatment to the right patient."
The ADA guidelines call on hospitals to have specialized care teams for their patients who have diabetes.
"Clinical diabetes advocates are a cornerstone of our specialized diabetes care team," Pall says. "They partner effectively with our endocrinologists, nurses, patient experience liaisons, case managers, and dietitians."
Having a specialized care team for hospital patients with diabetes boosts the quality of care and improves outcomes, Pall explains.
"Diabetes is a complex condition," Pall says. "These patients have multiple medical, social, and dietary needs. Having a team to address all aspects of a patient's care—not just the medical aspect—is important. We want to provide care that is personalized and geared toward the needs of the patient."
Michael Fiorina, DO, is CMO of Independence Health System. Photo courtesy of Independence Health System.
George Yoo, MD, is CMO of Karmanos Cancer Institute. Photo courtesy of Karmanos Cancer Institute.
Claire Lauzon-Vallone, RN, MBA, is vice president of quality and safety at CHRISTUS Health. Photo courtesy of CHRISTUS Health.
Ghazala Sharieff, MD, MBA, is executive senior vice president and chief medical and operations officer of acute care at Scripps Health. Photo courtesy of Scripps Health.
Anup Singh, MD, is chief medical executive of California Pacific Medical Center. Photo courtesy of Sutter Health.
Harpreet Pall, MD, MBA, is CMO of Hackensack Meridian Jersey Shore University Medical Center. Photo courtesy of Hackensack Meridian Health.