Cultural competence has been embedded in One Medical, a primary care provider based in San Francisco.
One Medical has made culturally competent care a priority for the primary care provider.
Cultural competence is critical in decreasing healthcare disparities through culturally sensitive care, according to the Agency for Healthcare Research and Quality. "Culturally competent care is defined as care that respects diversity in the patient population and cultural factors that can affect health and healthcare, such as language, communication styles, beliefs, attitudes, and behaviors," AHRQ says.
One Medical has a similar definition of culturally competent care, says Hemalee Patel, DO, senior medical director for chronic care management. "Culturally competent care is the ability to deliver effective healthcare that meets the social, cultural, and language needs of a patient. You need to understand that for any given patient coming in the door, they may have a different experience from a provider, and they come with their own norms that may be different from a provider's. You need to understand and meet folks where they are at and be able to deliver effective care with empathy."
Culturally competent care is essential to provide high quality care, she says. "As the nation is becoming more diverse, it is important to be culturally competent. You need to build trust and a relationship in order to help patients from a preventative standpoint but also from an acute standpoint. You want folks to understand that they can come into a healthcare setting and feel that they are being heard, and they have a trusted source of care."
One Medical has embraced cultural competence as an organization, Patel says. "One Medical is a very diverse place. I came from a traditional health system. I feel that even in the interview process it was extremely important that they took my values into account and that everyone's values were heard. That is part of the culture here."
One Medical clinicians receive training and feedback about culturally competent care, she says. "In terms of providers, we have a lot of training opportunities and resources. We have training courses that we have providers go through. We are constantly giving feedback to providers. We are sharing information about their patients that they might not necessarily have seen. Our clinical learning team develops modules and workshops for providers to get the training when they need it."
At One Medical, culturally competent care is helping to achieve positive health outcomes, Patel says. "In my program, we are proud to say that outcomes of improvement in areas such as cholesterol and weight are equal across all races and ethnicities. That is data that we continue to look at, continue to gather, and continue to learn from."
She gave an example of a patient who required culturally competent care. "I had a patient who came in who had diabetes, and she was of Filipino background. In her entire family, everyone has diabetes, including her mom and her sister, who were on insulin. She was scared. When I asked her about her understanding of someone having diabetes, it was insulin and a short lifespan. For her, it was very important that family meals are traditional. She didn't understand how she could turn her diabetes around."
Understanding that traditional meals were important to the patient was an important element of providing culturally competent care, Patel says. "We could still do a lot in terms of mitigating her disease state. In the course of about six months, she was able to see her glucose levels coming down. She was still able to enjoy family meals. By improving her own metrics and her family observing this achievement, her mom and her sister also become One Medical patients, and they have also been able to shift the way they think about food without compromising their values."
Sareli was named CMO of the Hollywood, Florida-based health system last month. He first joined Memorial Healthcare System as an intensivist in 2009. He was appointed as chief of critical care for the health system in 2012. Sareli was promoted to chief physician executive of the Memorial Physician Group in 2019.
HealthLeaders recently talked with Sareli about a range of issues, including the challenges of serving as CMO, physician engagement, and his learnings from playing a key clinical leadership role during the coronavirus pandemic. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What do you anticipate will be your biggest challenges serving as CMO of Memorial Healthcare System?
Sareli: In general, there has been a no more difficult time in healthcare than in recent years, with supply chain challenges, labor challenges, external pressures from payers, and expectations from patients as they relate to access and service. With all those pressures in play, the goal of medicine remains the same—to treat the patient and give them the care that they deserve. We must keep our healthcare teams focused on providing that care despite the multitude of external pressures.
I believe the impact that COVID has had on people's mindset is truly coming to bear, and my challenge as CMO is to keep the staff focused on what really matters, which is that we are here to provide patient care. The fact that it has become more difficult than ever is a reality, but our challenge is to focus on the task at hand and not to be distracted by external pressures.
Despite the challenges that are impacting every health system in the United States, we have a health system with a situation that is much better than most health systems nationwide. From a financial position, our health system is strong. We see other health systems posting losses over $1 billion. We see hospitals laying off workers. We see units shutting down because they lack staff. We are fortunate not to be in those positions. Despite that, the challenges on the ground are real. It is important for us to keep perspective and important for us to keep focused on what really matters, which is patient care at the center of all things.
The challenge for me is to keep that message going, to facilitate efficiencies, and to make life easier for the people who are delivering care.
HL: How do you plan to keep the staff focused on patient care despite several challenges?
Sareli: I believe in a servant leadership mentality. For me, one of the key things is strengthening relationships and building new relationships. Ultimately, it is about trust, and it is close to impossible to earn trust without action. At the end of the day, you can say whatever you want, but people care about what you do and not what you say.
I have been in this health system for nearly 15 years. I have a lot of relationships throughout the health system—not only with physicians but also with many others. I believe I am facilitating efficiencies and allowing people to maximize their potential and develop trust in me. A lot of people know who I am, know what I am about, and know that I will inspire through action and not inspire through words.
Aharon Sareli, MD, chief medical officer of Memorial Healthcare System. Photo courtesy of Memorial Healthcare System.
HL: You say you have embraced servant leadership. What is your view of servant leadership, and why do you think it will be effective in the CMO role?
Sareli: Servant leadership is about a team mentality and recognizing that your role on the team is to facilitate everyone else's success. If you can embrace the concept of facilitating the team's success and not focusing entirely on your individual goals, that is a recipe for servant leadership. It's more about listening. It's more about common purpose. It's about establishing trust and allowing the leaders around you to realize their maximal potential and make meaningful changes.
A single person, no matter how many balls they have flying in the air, can only achieve so much. My true impact comes from the servant leadership model, where I am enabling others to rise to their true potential. Especially in the CMO role, where the scope of work that needs to be done is huge, the best path to success is the servant leadership model. I believe other approaches are susceptible to failure because I can only succeed in my role by all the people around me reaching their full potential and maximizing the impact they make.
HL: You served as chief physician executive of the Memorial Physician Group. What are the primary elements of physician engagement?
Sareli: This boils down to relationships and a matter of trust. You must build common purpose. You must have people around you—your clinical leaders. You must have those relationships and foundational trust, and you must build on that trust not by what you say but by what you do.
You also must listen more and talk less. You must allow people to be successful and listen to what they need to be successful. Ultimately, people are inspired by leaders who take action and not leaders who talk a good game.
HL: You have a clinical background in critical care. How will this clinical background help you serve in the CMO role?
Sareli: In critical care, there are multidisciplinary teams coming together and rounding on patients at the bedside. Each member of the team can contribute in their own way, but it is really the team that makes the impact on the patient. The intensivist leads a multidisciplinary team to enable care in the ICU, the idea being that by definition patients in the ICU are the most complex patients, and what you really need is someone who is able to keep an open line of vision as to everything that is going on with the patient but recognize that there are experts in each one of the fields.
You must bring the whole team together and understand the value of the team. It is similar to servant leadership, with the link being that the key to success is understanding the value of the team and your role as a leader in facilitating the success of the team.
A background in critical care is helpful in the CMO role. Success comes from team success—not through your singular success. At the same time, when the chips are down, the intensivist must stand up. There are certain situations where you must make tough calls, you must make decisions, and you must make the best decisions you can with input from your team. The CMO role carries that kind of responsibility.
HL: During the pandemic, you played a key role in clinical leadership for critical care. What were the main learnings you gained from this experience?
Sareli: In COVID, a main takeaway is that there was so much that we just could not do. We could not save some patients despite heroic efforts. But there were a lot of things that we could do. It is important to focus on what you can impact as opposed to getting lost in the negativity of what you cannot impact. Rather than to focus on the death and the dying, we had to remember the patients who have lives today because of everything that the care team put into place.
We must remember all the work we did to educate the community about social distancing and the importance of vaccination as well as dispelling a lot of the disinformation. It is easy to focus on the people who believe COVID was a conspiracy and the politics that got involved, but it is important for us to not focus on the negativity and focus on the positive things we achieved. If we saved one life, that was one life that we saved through our interventions.
Perspective is important. You need to focus on what you can do—not focus on what you cannot do. From a practical perspective, COVID was a crucible, and we learned to see what people are really made of during the pandemic under maximal strain. So many people stepped up to the plate and did everything they could. That is a positive to take away from COVID. We saw crisis management at its best, and I am very proud of what the critical care teams achieved during the pandemic.
HL: Now that the crisis phase of the pandemic has passed, what are the primary clinical care challenges facing Memorial Healthcare System?
Sareli: In every industry in the United States, everyone is facing major labor challenges. The labor market has changed. In healthcare, what we saw because of the pandemic was a lot of people retiring early, and we saw people leaving the bedside and switching to other careers.
We are very fortunate at Memorial that we are faring better than other health systems. But I think the most significant challenge for us is, No. 1, recovering from labor shortages. We need to shift systems to make bedside care more attractive and more flexible.
The other thing that is a major struggle is supply chain. We used to take supply chain for granted before the pandemic. Now, there are supply chain challenges in every industry, and healthcare is not immune to that.
The educational session, which focuses on pain points for outpatient surgery patient clinical experience and ways to address them, features Helene Finegold, patient experience officer at Allegheny Health Network's Anesthesia Institute, JP Garcia, director of patient experience at Providence, and Jessie Monnier, senior director of operations—ambulatory surgery centers at Providence.
A primary pain point for outpatient surgery patient clinical experience is managing communication between the physician's office and the surgery center.
One of the unique aspects of the ambulatory surgery center space is the relationship between the surgery center and the physician's office, Monnier says. "Working together on a communication plan for managing patients through their surgical experience oftentimes involves coordination of information between the physician's office and the surgery center such as pre-op labs, the workup that needs to be done so the surgery center can assess patient safety, and communicating to the patients about when they can expect to be contacted by the surgery center. The surgery center makes that initial contact, typically providing preparation details such as home care instructions and even financial responsibility. Then the surgery center provides an avenue for patients to reach out if they have questions about that initial contact and prior to arriving at the facility."
One of the challenges of getting patients from the physician's office to the surgery center is the dynamic nature of a surgery center, Finegold says. "For example, the patient is seen in the office but by the time it is close to surgery they may need a consult, or we may have to change the day of surgery. One of the things that helps us is every day we do a scheduling meeting, which includes anesthesiology, nursing, and communication with the schedulers. We sit together and we look at the schedule. We ask, 'How does it look today?' and 'What is going on this week?' Then we have the schedulers get back to the physician offices to communicate with the patients. We try to make sure when a change occurs, one voice gets back to the patient. When patients hear multiple things, it can be very problematic for them."
Physician offices and surgery centers must stay on the same page when communicating with patients, Garcia says. "If a ball is dropped, or one office says one thing and the schedulers say another, that does not inspire confidence for the patients. Those are human beings in front of you who likely have a lot of anxiety going into a procedure. We don't know what is going on in their minds. We must alleviate that anxiety, and we can do this through a seamless communication process in between all parties who are scheduling these surgical procedures."
Anesthesia and patient clinical experience
Communicating with patients about anesthesia can be a pain point at surgery centers.
The issue is patients often know their surgeon well, but the anesthesia piece remains mysterious for most patients, Finegold says. "For some patients, it is seamless; for others, they do not know what to expect. This can cause a lot of anxiety coming up to the day of surgery. An education program is important to inform patients. What is anesthesia? Who is an anesthesiologist? Who is a nurse anesthetist? What type of anesthetic is going to be used? The terms are confusing for patients."
Patient education and engagement is crucial, she says. "We want to give patients educational materials and give them a way to reach the anesthesia team if they have something bothering them or had a bad experience in the past. At our institute, to promote patient experience, we have created an email link and a phone number if patients have something that is bothering them coming up to surgery, so we can try to address it and optimize their experience. We do not want them waiting six weeks worrying about it."
When it comes to anesthesia, it is pivotal to communicate with patients and set expectations on the front-end, Monnier says. "When we manage expectations around anesthesia, that is one of the things that draws a lot of comments in the experience reports that I have seen. The initial encounter at the bedside with the physician involves talking with the patient about what to expect—things like pain management and nausea post-procedure."
Handling delays in procedures
Another patient clinical experience pain point is when procedures must be delayed at surgery centers.
This is an area where surgery centers can avoid patient suffering, Garcia says. "These wait times that patients are enduring involve suffering, and it is suffering they do not need to experience, especially when they are going into a procedure that they might be terrified of. It is truly important to ensure that patients are aware of any and all sorts of delays. We need to explain the 'why' behind delays. We need to instill confidence in patients. We want to assure them that nothing is wrong—to comfort them and meet them where they are. You need to be transparent about delays and offer reasons why delays occur."
Surgery centers need to pay attention to the schedule throughout the day, Monnier says. "Sometimes, we have cases that run long, and it is a domino effect for the rest of the day. So, you need to ensure that patients are kept apprised of delays before they even arrive at the surgery center. If they can delay their arrival by 30 minutes or an hour, it allows them to be in the comfort of their own home."
When delays occur, surgery center staff need to be honest, respectful, and transparent, Finegold says. "Patients have a right to be upset, and their feelings need to be acknowledged. You do the best you can. If you come up and say, 'I'm sorry,' people will understand."
In the racial maternal healthcare disparity, racism is "the elephant in the room," Bennett says. "The only way that we are truly going to impact significantly the maternal mortality crisis in the United States and the alarming disparities that affect Black pregnant women regardless of their education level and socioeconomic status is to first and foremost address racism. We need to address racism in all forms, including institutionally, systemic racism, and implicit bias."
This healthcare disparity needs to be approached from a multi-faceted level, including policy changes that address the historical racism within our healthcare system, she says. "Some of that has already started. Race has been removed from the Vaginal Birth After Cesarian Delivery calculator. That calculator helps to guide how patients are counseled about their success rate of being able to successfully have a vaginal delivery after they have had a Cesarian delivery. Historically, these kinds of tools have not had an equity lens, and unfortunately there has been underlying racism."
Racism has played a role in maternal care, Bennett says. "Racism affects how, when, and with whom Black pregnant people initiate and maintain prenatal care, the quality of that care, access to medications, medical and ancillary services, understanding and adherence to medical recommendations, and the necessary care required before, during, and after pregnancy. This affects the outcome of that person's pregnancy and the quality of the remainder of their and their baby's life."
Physicians have a role to play in addressing the healthcare disparity that is impacting Black mothers, she says. "Historical and modern renditions of racism have eroded the trust of physicians and healthcare systems at large, and it is up to us, currently practicing physicians, to correct this wrong and rebuild trust by re-imagining the physician-patient partnership."
Physicians need to address racism in their ranks, Bennett says. "There are physicians … that have racist practices and thoughts. Though implicit bias is defined as unconscious and unintentional, it is yet and still simply another form of racism. Taking an implicit bias course is merely a first step, an introduction; it is neither comprehensive nor a game changer. Racism can only be addressed by being antiracist. Much like love, antiracism is an action word. It takes intention, thoughtfulness, and deliberate and persistent action every day, with each patient encounter, every clinical impression, and every management decision."
Factors beyond racism in Black maternal mortality and morbidity
Beyond racism, maternal mortality and morbidity among Black mothers can be addressed in the pre-conception period, she says. "We can partner with people in the community so that we can ensure that we are addressing comorbidities such as hypertension, diabetes, and obesity—these are things we know are more prominent in the Black population. Once we can connect with the community, and we can make sure we are providing care that encourages people to enter into pregnancy in a more healthy way, that will allow for better pregnancy outcomes."
During pregnancy, establishing best practices and evidence-based protocols to ensure that equitable care is being provided across the maternal healthcare spectrum is extremely important, Bennett says. "Where you deliver your baby and who delivers your baby—down to the hospital and Zip Code—can impact your outcome. What that means to us as a health system is we need to be better—we need to make sure that every patient is being taken care of to our best ability. We need to minimize implicit biases that are definitely playing a role in how mothers are getting differential care. We also need to make sure as a community that we are elevating our standards and providing higher quality care, especially in our hospital systems that serve minority patients."
Memorial Healthcare System is committed to addressing the racial healthcare disparity in maternal care, she says. "What we can do specifically as a health system is create policies to make sure we are up-to-date on the most evidence-based medicine. We can also make sure through peer reviews and reviewing cases that not only ended in a poor outcome but also with near misses that we can go back and change our policies to ensure that we are addressing every single element that could have impacted care."
The video educational session, How to Improve HCAHPS Scores, features Ghazala Sharieff MD, MBA, corporate senior vice president of hospital operations and chief medical officer at Scripps Health as well as Brooke Horne, MPH, executive director of patient experience at Providence.
Sharieff and Horne discuss a range of issues related to improving HCAHPS scores. Two of the top topics are improving physician and nurse communication scores.
Improving physician communication scores
A primary element of encouraging physicians to improve their communication scores is sharing their HCAHPS data with them, Sharieff says. "Anybody who was less than 50th percentile was in red, so it was clear who was underperforming. Doctors do not want to be in that low percentile range, so they started asking for help."
At Scripps, underperforming physicians receive tips to improve their communication with patients, she says. "There are three questions on the inpatient score—are physicians listening carefully, are physicians explaining in a way that the patient can understand, and are physicians communicating with courtesy and respect? My tips mirror those questions. 'Are you explaining the care plan? Are you explaining any new medications?' I always end with the same question, 'Are you asking the patient whether there is anything you can explain further?' Sometimes, we use a lot of medical jargon that the patients do not understand. I will ask doctors whether they are asking their patients, 'Are there any questions that I can answer?' Or, 'What is your greatest concern today?' We want to show that we are listening to the patients' concerns."
Providence urges physicians to focus on listening carefully, courtesy and respect, and making sure patients understand their care, Horne says. "We ask patients to write down their top two or three priorities, so we can make sure our physicians are answering those questions and the patients feel heard. A provider can really make or break a patient experience. The relationship between a patient and a provider is critical."
Providence also uses physician champions to improve physician communication, she says. "Physician champions can help do peer-to-peer coaching. They can conduct peer-to-peer conversations around provider experience with our patients."
Key qualities of physician champions are for them to be engaged and well-known, Horne says. "It matters that physician champions are respected and known within the organization."
Improving nurse communication scores
The coronavirus pandemic put strain on nurse communication, and Providence has been working to make up ground, Horne says. "Over the past couple of years, we have been focusing on engaging our nurses. We want to have staff engagement because we cannot improve the patient experience if we are not engaging our nurses. We create an environment so our bedside nurses can help design improvement in patient experience. We are seeing things from their perspective. We are ensuring that they have the tools and the resources as well as the education to be successful."
At Providence, understanding what nurses lack to be successful is crucial, she says. "Oftentimes, it is the feeling of being understaffed. Other times, they do not have the equipment they need or the time. So, we are trying to make sure they have the time to round on the patients, and we are streamlining their work to make it more efficient. We want nurses to have the opportunity to be in the room with the patient, so they can ensure that the patient is heard and understood. We want them to be able to build relationships with patients, so they can treat our patients with courtesy and respect."
At Scripps, one of the ways the health system is promoting nurse communication is ensuring that they can work to the top of their license, Sharieff says. "We have hired what we call patient care assistants, and that relieves the burden of things somebody else can do. For example, the assistants can help a patient get up and go to the bathroom. We want our nurses to spend more time at the bedside doing things only they can do—communication about medications, going over discharge instructions, and connecting with the patients."
Scripps is also encouraging nurses to engage with patients at the bedside, she says. "Sitting at the bedside sounds really simple, but it is amazing to me what a difference that makes. We are enforcing a 'two-minute sit time.' The nurses like it because they are eye-to-eye with their patients. We are tackling nurse communication from multiple directions."
Fiel was named CMO of Morristown Medical Center in March. He had served as interim CMO since May 2022. Fiel previously served as chairman of the Department of Medicine at the medical center for two decades. He is also a professor of medicine at Thomas Jefferson University's Sidney Kimmel Medical College. Before working at Morristown Medical Center, his physician leadership roles included serving as chief of the Division of Pulmonary and Critical Care Medicine at Drexel University College of Medicine.
HealthLeaders recently talked with Fiel about a range of issues, including the challenges of being a CMO, balancing clinical work and leadership roles with research efforts, and addressing pediatric respiratory disease surges in recent months. The following transcript of that conversation has been edited lightly for clarity and brevity.
HealthLeaders: You have a clinical background in pulmonology. How has this clinical background helped you serve in physician leadership roles?
Stanley Fiel: I am an internist by training. Before I left Philadelphia, I was running the fellowship program at Drexel University and the ICUs. Working in an ICU with multi-organ failure and a multi-disciplinary approach, pulmonary doctors are very good generalists. I am not denigrating any other subspecialty by any stretch, but pulmonary and critical care allowed me to see the whole body. I dealt with patients with neurological impairments, kidney failure, cardiac failure, and post-surgical problems, so I had a very broad-based background in many areas of medicine.
The more one understands about the trials and tribulations of each of the specialties and what individual patients are going through, it is helpful in physician leadership. The broader based you are, the better. And I still see patients—I am still clinically active. That is an important part of having the respect of your fellow clinicians.
HL: What are the primary challenges of serving as CMO of Morristown Medical Center?
Fiel: For me, this is the first time I have been a CMO. I have been in medicine a long time—I finished my training at the University of Pennsylvania in 1980. So, I have been a pulmonary critical care doctor for decades, and I have been in leadership at academic medical centers. I have a good sense of how to deal with difficult decisions.
Moving into this role, it is a big role when you are responsible for all of the medical staff and all of the clinical activities to be sure that all of the physicians are operating appropriately for their license and for their credentials. The goal for Atlantic Health System and Morristown Medical Center is to create a healthier community, and we want to be at the forefront of quality.
It is important for me to be the standard-bearer for quality, involved with strategy, and how to make ends meet in the business of the future. I was the chair of medicine for the past 19 years, but now I am responsible for all of the medical activity. The challenges for me are in the areas where I lack experience—I have not been in an operating room for a long time. I have not been in the obstetrics suite. So, I am going down to different areas with my scrubs on once a week and seeing what gives down there. I am getting a new appreciation for the different disciplines that are now reporting up to me.
One of the challenges is dealing with some physicians who are difficult—not acting within the bounds of what we expect and not following guidelines or rules. The CMO has a vice principal role.
We don't have problems every day, but in a large organization with lots of physicians interacting under the pressures of work, there are issues that relate to their credentials and problems that go awry in the hospital. When individuals fall out of bounds, there are collaborative conversations, and they can be escalated up to improvement processes. If there is a problem with not meeting a standard we have established, there is a discussion around that, and we talk about ways to improve. A plan is created with the individual and the chair of their department, so we come to an agreement on whether they need some remediation or disciplinary action. The worst outcome is a physician can lose their privileges at our hospital, which is few and far between.
HL: How do you plan to rise to your challenges?
Fiel: Basically, I am not new to these challenges, I just need to learn more about some areas. I also have great colleagues to work with. There is a strong team approach to care at Morristown Medical Center. The nursing service and the infrastructure are wonderful, so it has given me the opportunity to learn a lot from the multi-disciplinary teams that are already in place. Given the situation, it has been easier for me to meet the challenges for some areas that I am not as familiar with.
HL: How have you addressed high patient volumes at Morristown Medical Center?
Fiel: This has been an issue that we have been dealing with for many years—there are more than 100,000 patients who come through our emergency department. Patients pass up emergency rooms in the surrounding area because of the high quality of care here, and the ED has been a challenge for us. There is a lot of teamwork. We learned a lot through COVID, so we have processes in place to handle patient volume.
We have dashboards for moving patients through the hospital. There is patient throughput and an approach to early discharges. We have leveraged a team approach and geographic rounding approach to patients so we can move patients through the hospital. Wherever the pressure points are, which includes the ED because we are so busy down there, we must get patients who are on the floors out. So, there is a process that is ongoing.
There is a challenge with nurses—we have lost nurses through the pandemic, and we are working on our staffing ratios to keep our quality care at the maximum. I must stress that we are taking a team approach to address the patient volumes that we have.
Stanley Fiel, MD, chief medical officer of Morristown Medical Center. Photo courtesy of Atlantic Health System.
HL: How have you addressed pediatric respiratory disease surges in recent months?
Fiel: These surges began before the winter, when we had RSV, flu, and COVID. The pediatricians were dealing primarily with the surge of RSV patients that occurred in October and November. We have the only pediatric intensive care unit for Atlantic Health System, and we had to deal with many patients.
With Morristown being our flagship and only pediatric hospital in the region, we were bulging at the seams. We had to take over some adult beds, which is the opposite of what we did during COVID, where we took over pediatric beds. As a result, we had to move some of our adult patients to other hospitals, so we could make room for the pediatric surge that we had. Our pediatric intensivists did an incredible job—they had to work back-to-back shifts and we had to worry about their resiliency. Their pediatric colleagues, who were the outpatient respiratory and pulmonary pediatricians, assisted the intensivists in the care of patients on the floors. It was a real team effort.
The other thing that happened that was incredible was that our adult nurses had to train up on the pediatric side because our intensive care nurses had to take care of kids. They had a crash course over 30 days.
HL: You have published more than 200 articles, abstracts, chapters, and monographs in the medical literature. How have you balanced your clinical work and leadership roles with your research efforts?
Fiel: When I finished training at the University of Pennsylvania, I got involved in a niche area in pulmonary medicine, which was adults with cystic fibrosis. That enabled me to have a special place through translational research on the burgeoning adult population. I was able to work nationally and internationally with individuals so that I could help bring forth new treatments and work with pharma as new drugs became available for this population.
I was able to work in the perfect time for a new area in adult care. I also worked collaboratively with some of the basic scientists and microbiologists to bring forth some of the new treatments. I had teams that I could work with to get grants, which enabled me to publish a lot and be known across the country and internationally.
It was a challenge, but I was able to balance things and compartmentalize. I was fortunate in the academic medical centers that I started in to have fellows and faculty who could work with me. With grant support, I developed a center where I had colleagues who could help me take care of patients. I brought that center to Morristown, and we became the largest CF center in New Jersey.
HL: You are a professor of medicine. What are the primary elements of being a good medical educator?
Fiel: Part of it is wanting to teach as well as enjoying students and residents. Part of the elements of being a good educator has to do with empathy, humility, listening, and being able to take those skills and pass them on to the future generation of physicians. That's a real privilege and a challenge. These are things that have been very important to me in my roles in academic medical centers.
At Morristown, we are in a unique situation in that we are not a pure academic medical center, and we are not a pure clinical hospital with no residencies. We have hundreds of residents in many areas of medicine. We have graduate education with fellowships. So, we are a training center, but we are not as steeped as a pure academic center such as Mount Sinai or University of Pennsylvania. It is a nice place to be, and the balance helps us deliver the quality of care that we do here.
Healthcare and social service workers were victims of 76% of all nonfatal injuries from workplace violence in 2020, according to the U.S. Bureau of Labor Statistics. Half of nurses surveyed by National Nurses United in 2022 reported an increase in workplace violence, more than double the previous year.
The Workplace Violence Prevention for Health Care and Social Service Worker Act was introduced by U.S. Sen. Tammy Baldwin (D-WI) and U.S. Rep. Joe Courtney (D-CT). The bill has bipartisan backing in the House of Representatives, with support from Don Bacon (R-NE), Jefferson Van Drew (R-NJ), and Brian Fitzpatrick (R-PA).
The main provision of the bill would require the federal Occupational Safety and Health Administration (OSHA) to issue a standard requiring healthcare and social service employers to write and implement a workplace violence prevention plan to prevent and protect employees from violent incidents.
"Violence in our hospitals and clinics has reached epidemic levels," National Nurses United President Deborah Burger, RN, said in a prepared statement. "Nurses have been punched, kicked, bitten, and choked or threatened with extreme violence. Tragically, some nurses have even lost their lives after being attacked on the job. This is why we urgently need legislative action to hold our employers accountable, through federal OSHA, for having a prevention plan in place to stop workplace violence before it occurs."
If the bill becomes law, it will apply to many healthcare settings, including hospitals, residential treatment facilities, nonresidential treatment settings, medical treatment or social service settings in correctional or detention facilities, psychiatric treatment facilities, substance use disorder treatment centers, community care settings such as group homes and mental health clinics, and federal healthcare facilities such as those operated by the Veterans Administration and the Indian Health Service.
The bill is modeled after a California healthcare workplace violence standard that was adopted through state legislation sponsored by the California Nurses Association, a National Nurses United affiliate.
The bill has several provisions, according to National Nurses United.
"[The bill] sets minimum requirements for the standard and for employers' workplace violence prevention plans, based on the groundbreaking California legislation. These requirements include unit-specific assessments and implementations of prevention measures, including physical changes to the environment, staffing for patient care and security, employee involvement in all steps of the plan, hands-on training, robust record-keeping requirements (including a violent incident log), and protections for employees to report workplace violence to their employer and law enforcement," National Nurses United said in a prepared statement.
Healthcare and social service workers deserve to work in a safe environment free from violence, Sen. Baldwin said in a prepared statement. "It is unacceptable that our healthcare workers are subjected to senseless acts of violence in their workplace, and we must do more to protect them. I am proud to introduce this legislation to give our nurses, doctors, healthcare support staff, and social service professionals with long-overdue basic protections, helping address our healthcare workforce shortage and keep our frontline heroes safe."
Research shows that female physicians spend more time with patients compared to their male counterparts.
Payment models that emphasize productivity and volume of patients seen are a primary cause of the physician gender pay gap, a healthcare finance professor says.
A recent Doximity report found a significant gender pay gap among physicians, with male doctors earning $110,000 more than their female counterparts. This represents a 26% gender pay gap in 2022, compared to a gender pay gap of 28% in 2021.
"There is increasing attention and research in this area. In the most recent research published in the New England Journal of Medicine, the study found that female primary care physicians earn less for the care that they provide but spend more time with their patients than their male colleagues," says Richard Priore, ScD, MHA, a clinical associate professor in the Department of Health Policy and Management at Tulane University.
The New England Journal of Medicine study found that female primary care physicians spent 15.7% more time with patients compared to their male counterparts. "The challenge for female physicians is they are spending more time with their patients and getting paid less," Priore says.
Female physicians appear less inclined to bow to the financial pressure of productivity-based business models at physician practices, he says. "Physicians have increasingly been put into a business mode, where there is pressure to see more patients in less time. My suspicion is that female physicians have not responded to this pressure in the same way male physicians have."
The physician gender pay gap is not the result of female clinicians putting in less effort than male clinicians, Priore says. "The New England Journal of Medicine study found that female physicians are not working less than their male counterparts—they are working just as hard as men are."
Payment reform is part of the solution to fixing the physician gender pay gap, he says. "We need to fundamentally change the way that physicians and hospitals are paid, and we need to increasingly pay for outcomes such as clinical outcomes and managing chronic conditions to keep patients out of the hospital. We need to address this issue to focus on wellness, prevention, and primary care."
More work needs to be done to understand the physician gender pay gap problem and to find solutions, Priore says. "There needs to be more research in the area in order to understand the problem. There needs to be more media attention and national research, whether it is from the National Institutes of Health or private foundations looking into this. We need to find out more about other underlying reasons for the physician gender pay gap. There also needs to be more senior leaders in health systems asking the question and being prepared to address the answers, especially if the answers are unpopular or do not paint the health system in a good light."
Previous research had found an increase in healthcare-acquired infections at hospitals during the coronavirus pandemic.
Hospital inpatients with COVID-19 have had much higher rates of healthcare-acquired infections (HAIs) than hospital inpatients without COVID-19, a new research article shows.
Previous research that compared data from 2019 to 2020 found that there was an increase in HAIs at hospitals. That research found higher infection rates for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.
The new research article, which was published by JAMA Network Open, features data collected from more than 5 million hospitalizations between 2020 and 2022 at 182 inpatient facilities operated by the HCA Healthcare health system. The researchers documented cases of CLABSI, CAUTI, MRSA, and Clostridioides difficile (Cdiff) among COVID-19 inpatients and inpatients without COVID-19.
The study includes several key findings:
The incidence of CLABSI was nearly 4-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
The incidence of CAUTI was 2.7-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
The incidence of MRSA was 3.0-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
For Cdiff, there was no significant difference in infection rates for COVID-19 inpatients and non-COVID-19 inpatients
COVID-19 inpatients had a mean 8.2-day length of stay compared to a mean 4.7-day length of stay for non-COVID-19 inpatients
"In this cross-sectional study of hospitals during the pandemic, HAI occurrence among inpatients without COVID-19 was similar to that during 2019 despite additional pressures for infection control and healthcare professionals. The findings suggest that patients with COVID-19 may be more susceptible to HAIs and may require additional prevention measures," the study's co-authors wrote.
Interpreting the data
A key finding of the study is that HAI rates for non-COVID inpatients did not increase at HCA Healthcare during the pandemic, the lead author of the research article told HealthLeaders.
"There have been some prior publications that say, 'Hospital infection rates have gone up since COVID.' The inference is that hospitals took their eye off the ball, or they were not as safe as they used to be. Until this study, no one had looked to see whether it was true that everybody was getting more infections or whether it was the introduction of a new population of patients that caused the infection rate to go up. In fact, our paper shows that for the non-COVID population, infection rates have been stable. It turns out that COVID patients are at high risk for hospital-acquired infections," says Kenneth Sands, chief epidemiologist at HCA Healthcare.
It would not be fair to say that COVID patients got worse care, he says. "They are just a new patient population, and the risks of infection had never been documented before. Now that they are documented, it provides the opportunity to start being aware of the higher risk and taking the appropriate extra steps."
The next step for researchers is to determine why COVID patients are at higher risk for hospital-acquired infections, Sands says.
COVID-19 inpatients drove the increase of HAIs during the pandemic, the study's coauthors wrote. "Our findings are consistent with previous reports that the occurrence of HAIs increased during the COVID-19 pandemic, reversing a multiyear national trend of improving performance regarding hospital infection. However, our subanalysis revealed that this increase in the overall infection rate appeared to be entirely due to the occurrence of HAIs in the COVID-19 population. Patients without COVID-19 had rates of HAIs that would be expected based on the incidence observed before the pandemic."
Three factors could have accounted for higher rates of HAIs among COVID-19 inpatients compared to non-COVID-19 inpatients, the study's co-authors wrote:
The COVID-19 inpatients had a longer length of stay, which is associated with higher risk of developing a HAI
Healthcare workers assigned to COVID-19 units may have had reduced resources and altered workflows
A decrease in infection prevention performance among COVID-19 inpatients could have been due to risks associated with this high-risk population
HAI rates among COVID-19 inpatients improved over time, the study's co-authors wrote. "While HAI rates were higher in the COVID-19 population, the occurrence of CLABSI, MRSA, and CAUTI in this population decreased over the course of the pandemic from 2020 to 2022. This is likely reflective of both improving practice in the management of COVID-19 as well as the decreasing acuity and length of stay in this population over time."
The new chief medical officer of Meritus Medical Center faces multiple challenges, including making the hospital the best care provider at the lowest cost possible.
While rural health has its challenges such as access, it is fulfilling because of the close connections between caregivers and patients, the chief medical officer of Meritus Medical Center says.
Atchuthanand Budi, MD, was named CMO of the Hagerstown, Maryland-based hospital in January. He previously served as associate chief medical officer of the medical center and was a physician-owner of a pediatrics practice for 20 years.
HealthLeaders recently talked about a range of issues with Budi, including the challenges of serving as CMO, learning about team-based care in neonatal intensive care units, and how running a pediatrics practice prepared him for physician leadership roles. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What do you anticipate will be your primary challenges in serving as CMO of Meritus Medical Center?
Budi: I have multiple challenges. We are changing the way healthcare is seen in many ways. One is that we as an organization want to make healthcare more cost-effective, so we want to be the best care provider at the lowest cost possible.
Two, we are working on the equity of healthcare access for every person in our county and surrounding areas, which is a challenge because a lot of people are not able to access healthcare for reasons such as lack of transportation. We are addressing those issues by providing clinics in remote areas so people can come to us.
Three, we have changed our hospitalist program. Previously, we were working with a contracted group; now, all of the hospitalists are employed by Meritus. Hospitalists see about 80% of the patients in the hospital. We hired some providers from the contracted group, and we hired a lot of people across the region and some from across the country.
Another challenge is we have a medical school launching, which is part of our organization, and we want to make sure that we have enough specialties and enough bandwidth so the medical students can be trained.
HL: How do you plan to rise to these challenges?
Budi: I have been in medicine for about 41 years, and I ran a private practice for about 20 years. Plus, I have been involved in several leadership roles. All of this experience gives me confidence that I can handle all of my challenges simultaneously. Running a private practice involved fiscal responsibility, and I want to make sure the cost of caring for patients is not prohibitive. Running a private practice also gives me the ability to be agile and move according to the needs of the community. The fact that I have served in leadership roles gives me an edge to face my challenges.
The most important thing is I have a great team of administrators and physician leaders who are helping me deal with challenges.
Atchuthanand Budi, MD, chief medical officer of Meritus Medical Center. Photo courtesy of Atchuthanand Budi.
HL: You serve a largely rural population. What are the primary challenges of serving a rural population?
Budi: Serving a rural population has more heart-warming situations than challenges. There are challenges such as healthcare access. But the feedback you get is positive and heart-warming because you are much closer to the population, and everyone knows you.
Washington County, unlike other rural areas, is fairly contained, and that is one of the reasons why we want to make our regional medical center the best place for people to get services, so , we are expanding our specialty services to make sure that we can take care of every need of the patients in our area.
Because people in the community know our providers, serving in a rural area is much more rewarding from a medicine standpoint because you make connections at a personal level.
HL: How do you rise to the access challenge with a rural population?
Budi: Instead of having offices around the hospital, we have opened multiple satellite offices for primary care in remote areas, so people can access them. We have used mobile clinics to reach people, especially for vaccinations.
HL: You have worked in neonatal intensive care units. What did you learn about team-based care working in that setting?
Budi: In my view, the neonatal intensive care unit is the best place to learn about team-based care. For example, if you have a pre-term baby weighing less than 2 pounds, you need respiratory therapists, you need nursing, you need a social worker, you need the parents, and you need the entire hospital network to help that baby grow in the best environment with the least possible complications. You also need the pharmacy because the drug dosing and the medications are unique for newborns. The social worker plays a key role by keeping everybody together and working with the parents. The case managers make sure all of the insurance companies are onboard.
I have seen that working together brings much better results for the baby, the family, and the hospital.
HL: You were a physician and owner at a pediatrics practice. How did this experience help prepare you to serve in physician leadership roles?
Budi: There were six providers in the group—four physicians and two nurse practitioners. I was the junior provider—the three other physicians were much older than me. I took over running the practice and also took over getting involved in building our own office. I worked with the nurses, the secretarial staff, the office manager, and my physician and nurse practitioner colleagues. I also dealt with different insurance companies to negotiate contract terms. I worked with different vaccine manufacturing companies to get the best rates on the best vaccines for our pediatric patients. I learned about public speaking.
I ran a practice successfully for more than 20 years, which gives me an edge in dealing with different groups of people. As CMO, I am working with different sets of people but in much larger numbers. All of the things I learned from running a practice helped give me the tools to be a good chief medical officer.
HL: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical care challenges facing Meritus Medical Center?
Budi: We have delved deeper into the inequities in healthcare in our region. We have a person who has been running the data and finding out where the main inequities have been. For example, in diabetes care, we have been looking at care for white and non-white patient populations as well as English-speaking and non-English-speaking patient populations. We have seen that diabetic care is poorer for non-English speaking and non-White populations. So, we are working on that.
We also found that the rate of breastfeeding is much lower in non-white and non-English-speaking populations, and we are trying to educate them. We are making sure that all information is available in English and Spanish in our hospital, which was not the case before.
There is also the challenge of the shortage of physicians and nurses, which we are seeing across the nation, and we are facing the same challenge. We have been able to maintain nursing staffing—we have a nursing school in our community, which helps us recruit nurses on a regular basis. We have a physician shortage in some specialties and in primary care, which is part of the reason we decided to start a medical school. We will have medical students who will train with us for several years, and a significant number of them will stay in our community. The medical school is set to open in 2025, and it will be called the Meritus School of Osteopathic Medicine.
HL: What advice would you offer to other physicians who may be interested in administrative leadership roles such as CMO?
Budi: The administrative role of the CMO should not be viewed that you are just a part of the administration. The chief medical officer should be the conduit between the medical staff of the hospital and the administrative staff. It is also ideal to hire a CMO from the community rather than outside the community. In my case, I know most of the hundreds of physicians in this community either at a personal level or because I have been involved in credentialling them. Having these relationships makes it easier for me to build bridges and make the communication much smoother.