Researchers have adapted psychologist Abraham Maslow's Hierarchy to help healthcare organization leaders curb physician burnout.
A five-tier hierarchy has been proposed to help healthcare organizations prioritize interventions to address physician burnout.
Research published in September indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
In an article published recently by The American Journal of Medicine, researchers adapted psychologist Abraham Maslow's Hierarchy into a five-tier physician burnout and wellness hierarchy.
"Unlike long lists of variables, this hierarchical model is practical. Using an assessment strategy tailored to the hierarchy will identify the greatest need at whatever organizational scale measured: individual life, work unit, department, institution, or networked system. Put simply, this tells leaders where to start," the researchers wrote.
In priority order, the five-tiers of the physician burnout and wellness hierarchy are physical and mental health, safety and security, respect, appreciation and interpersonal connections, and healing patients and contributing to the fullest of a clinician's ability.
Tier 1: Physical and mental health
The potentially severe impact of nutrition on cognition is well documented, and many clinicians have poor nutrition such as skipping meals and eating too fast. Clinicians also are at high risk for dehydration—a United Kingdom study found that 45% of physicians and nurses ended their shifts clinically dehydrated. Sleep deprivation is also common among clinicians.
Beginning with research conducted in the 1800s, physicians have been found to suffer from depression at higher rates than other professionals. When present with other behavioral health disorders such as anxiety and hopelessness, depression is a suicide risk. A 2003 study found that about 350 U.S. physicians commit suicide annually.
The American Journal of Medicine researchers propose two interventions to address physical and mental health problems among physicians:
Assess the mental health of clinicians and their willingness to seek help such as employee assistance programs. If access to psychological care is deficient, healthcare organizations should bring behavioral health services on-site.
For clinicians and nurses, ease access to good nutrition, promote adequate sleep such as ensuring on-site sleeping quarters are comfortable and clean, make water and other beverages accessible, provide private bathrooms, and install breastfeeding stations.
Tier 2: Safety and security
The federal Occupational Safety and Health Administration has found that severe workplace violence that requires time off for recuperation occurs four times more frequently in the healthcare sector compared to private industry. Healthcare professionals are more likely to be injured in workplace settings with inadequate staffing, poor communication, subpar leadership, and insufficient attention to safety.
The American Journal of Medicine researchers propose three interventions to address safety and security concerns:
Violence de-escalation training for healthcare staff and deploying security to high-risk settings such as emergency rooms
Increasing total security staff
Maintaining adequate healthcare professional staffing
Tier 3: Respect
To limit burnout, clinicians need respect from supervisors and administrators, colleagues, patients, and technology such as electronic health records (EHRs), the researchers say.
A study of more than 20,000 workers found that employees who feel respected by immediate supervisors reported 89% greater enjoyment and satisfaction with their jobs. A recent study on incivility in operating rooms found that exposure of anesthesiology residents to even "run of the mill" rudeness was associated with diminished performance in four metrics: vigilance, diagnosis, communication, and patient management.
"There is growing attention on the impact of patient disrespect on health professionals and healthcare trainees. We don't yet have evidence that working repeatedly with rude, discriminatory, or abusive patients causes burnout. This model, however, predicts that patient disrespect is relevant and, where possible, policy and procedures should protect health professionals as much as is ethically reasonable," the researchers wrote.
Earlier research published in The American Journal of Medicine found that EHRs contribute to three primary elements of physician burnout—lack of enthusiasm, lack of accomplishment, and cynicism.
Actions to address lack of respect for clinicians include three interventions:
Supervisors and administrators should respond to physician requests, even when the answer is "no"
Adopt patient rights and responsibilities charters that include provisions to ban patient abuse of healthcare staff
Initiate improvements to EHRs such as easing information management and communication between healthcare professionals
Tier 4: Appreciation and interpersonal connections
The researchers say their model predicts that healthcare professionals desire and deserve appreciation much like other professionals. Studies indicate that healthcare worker satisfaction is improved when leaders express appreciation. A trial at Mayo Clinic curbed burnout by connecting physicians socially through sponsored after-hours dinners.
The American Journal of Medicine researchers propose four interventions to boost appreciation and interpersonal connections:
Provide fair compensation for physicians
Promote individualized, specific, and frequent communication of appreciation
Publicize successes such as effective clinician responses to complex medical cases
Foster interpersonal connections through establishment of shared spaces such as physician lounges
Tier 5: Healing patients and contributing to fullest of abilities
"For those drawn to medicine and healthcare, improving lives by ameliorating suffering and healing the ill is a need," the researchers wrote. Meeting this need includes conducting research and mentoring other clinicians, they say.
Actions to address self-actualization among clinicians include three interventions:
Reducing conflicts between business imperatives and the daily practice of medicine
Fostering opportunities to conduct clinical research
A new analysis of private healthcare claim records finds behavioral health disorders spiking among young people. Find out what one health system is doing to intervene.
Children and young adults are bearing the brunt of increased utilization of behavioral health services, a recent white paper published by New York–based FAIR Health says.
Over the past two decades, there has been a nationwide increase in behavioral health disorders. Suicide rates increased steadily from 1999 to 2014, according to the Centers for Disease Control and Prevention. A large-scale study found that the prevalence of major depression rose from 2005 to 2015. And the number of hospital stays for mental health and substance use disorders rose 12.2% from 2005 to 2014.
"To meet this growing demand for mental health services, we are seeing patients being treated in less traditional venues, such as in a telehealth setting. In some states, we also see behavioral health conditions represented among the top conditions presenting in hospital emergency rooms. By releasing the type of data we include in our recent study, stakeholders can better understand the prevalence of different types of mental health diagnoses and the demographic character of those statistics," she says.
Behavioral health by the numbers
The white paper features an analysis of data from 2007 to 2017 drawn from FAIR Health's database of 28 billion private healthcare claim records.
At the macro level, the FAIR Health data shows a 108% increase in behavioral health diagnoses, increasing from 1.3% to 2.7% of all medical claims. Generalized anxiety disorder claims spiked from 2007 to 2017, increasing from 12% to 22% of mental health claims.
The white paper includes behavioral health statistics for children and young adults that are particularly striking:
The pediatric share of claims for major depressive disorder rose from 15% to 23%.
Claims for generalized anxiety disorder (GAD) among high school- and college-aged people increased by greater percentages than any adult group. Claims for GAD rose 441% among college-aged people and 389% for high school-aged people.
In 2017, people 18 and under accounted for 32% of cannabis abuse claims, which was higher than any other age group.
Causes of increased behavioral health disorders in young people
Gelburd says there are likely three primary causes of the increase in behavioral health disorders among young people:
2. ACA: In 2010, the Patient Protection and Affordable Care Act made behavioral health an essential health benefit and enabled young people to remain as dependents on their parents' private insurance until age 26.
3. Social factors: The increased prevalence of depression and anxiety in young people may be associated with several social factors such as growing academic pressures, greater use of smartphones and social media, and school shootings.
Texas children's medical center rising to the challenge
Last year, Dell Children's Medical Center of Central Texas opened a new mental health unit at the Austin-based facility. The Grace Grego Maxwell Mental Health Unit has treated nearly 1,000 children over the past year, says Roshni Koli, MD, medical director of Pediatric Mental Health Services at Dell Children's.
"Being part of a children's hospital allows us to more holistically care for both the physical and mental health needs of our children and adolescents. Every child admitted to our MHU has an evaluation from our pediatric hospitalist team, which remains involved to help with any physical needs or questions that may arise," Koli says.
The new mental health unit features a multidisciplinary approach to care, including a dedicated art and music therapist as well as expanded nursing and social work teams. The new building also has an enclosed courtyard with a healing garden, so patients can get fresh air and play games such as basketball on a daily basis.
There are unique challenges when treating mental health disorders in children and young adults, Koli says.
"Children and adolescents with mental health disorders are among the most vulnerable individuals in our community. Understanding a child's mental health disorder means understanding their unique story and working closely with their family to understand all the aspects of their environment that are impacting their mental health," she says.
In supporting the construction and staffing of the Grace Grego Maxwell Mental Health Unit, the Austin metropolitan area is rising to the challenge of treating the growing number of young people who need mental health services, Koli says.
"The need for mental health treatment for our children and adolescents is large, and we often run into difficulties with shortages of providers and resources. However, our community recognizes the importance of mental health in our children and adolescents. With the continued collaboration with pediatricians, hospitals, and community partners, we can continue to reduce the stigma of mental health," she says.
The Dell Children's leadership team has played an important role in the new mental health unit's success, Koli says.
"We have been fortunate at Dell Children's to have the support of our leaders to expand our mental health program to meet these growing needs. Our vision is to provide excellent clinical care to every child who comes to our hospital and clinic, and to do so in a timely manner, reducing the barriers to accessing mental health care," she says.
There are a several areas where hospitals can manage ED malpractice risk, including medical condition diagnosis and opioid prescribing.
There are dozens of actions that health systems and hospitals can take to manage malpractice risk in their emergency departments, a new report published today says.
Emergency departments (EDs) are a crucial frontline healthcare setting, with more than 138 million visits to emergency rooms annually. EDs are the fourth most common healthcare setting for malpractice claims, according to Coverys, a medical liability firm that insures 42,000 medical professionals and 800 healthcare organizations.
A Coverys report published today on malpractice claims in EDs is based on an analysis of more than 1,300 medical liability claims from 2014 to 2018. The report features several key data points:
EDs accounted for about 13% of all medical liability claims. Surgery was the top target for medical liability claims, accounting for about 26% of claims.
Failure or delay in making a diagnosis accounted for 56% of ED claims.
Cardiac and vascular illnesses were the most common conditions identified on ED claims, accounting for 23% of the total, followed by infections (18%) and neurological conditions (8%).
More than one-third of ED claims involved the death of a patient.
The top risk management issues in EDs were clinical judgment (44%), clinical systems (10%), and documentation including electronic health records (10%).
The Coverys report provides risk management recommendations for 11 areas of ED operations and concerns:
Given that most ED malpractice claims involved failure or delay in making diagnoses, Coverys' Top 5 risk management recommendations are designed to improve diagnostic accuracy, Ann Burke, RN, director of risk management at the Boston-based company, told HealthLeaders.
1. Care transitions: EDs should commit to enhancing communication handoffs at all transitions of care based on a policy and structure for communication of patient information.
"Committing to improve communication is a first step to improving patient safety. Using standardized handoff processes to ensure crucial information is clearly communicated and transferred during care transitions is essential to safely moving the patient through the ED episode of care," Burke said.
2. Patient evaluation: EDs should ensure that patient evaluation occurs on an ongoing basis during the ED episode of care by requiring documentation of patient status at prescribed intervals, she said. "Concise and timely documentation cannot be understated as a critical communication component in patient safety."
3. Decision support: EDs should implement clinical decision support tools to assist clinicians in the diagnostic process, such as practice guidelines for high-risk presentation, clinical decision applications, and providing access to a dedicated radiologist and pharmacist to assist with diagnosis and treatment, Burke said.
"Because of the nature of the environment—fast paced, limited ability to elicit medical history, and high acuity—in which they work, ED providers should consider using additional resources that can help them arrive at an accurate and timely diagnosis."
4. Team effort: ED clinicians should communicate clearly and efficiently with laboratory and radiology professionals, as well as other relevant healthcare providers, she said. "Communication between diagnostic departments, other providers, and ED providers is an area where patient safety can be improved with the implementation and standardization of communication protocols."
5. Test results: EDs should develop a protocol to manage communication of outstanding test results for the patient, primary care provider, and consultants. The protocol should be hardwired into everyday routines such as customizing an electronic system that supports the protocol and its objectives, Burke said.
"Without a strong system in place, test results that are outstanding when a patient is discharged or transferred from the ED may place the patient at risk. It is important that a follow-up system is in place to ensure patients and providers receive timely notification."
Senior healthcare leaders from health systems and hospital across the country are set to share their technology adoption experiences and success stories.
Automation adoption and tapping the potential of technology to seize patient and clinician engagement opportunities are the dominant themes of next month's HealthLeaders Innovation Exchange in Ojai, California.
The event features four dozen top healthcare executives from health systems and hospitals across the country, including Intermountain Healthcare, OhioHealth, and Sutter Health. Here's a preview of the topics participants will address in roundtable discussions.
Automation
From clinical care, to workflow, to back-office operations, several automated technologies have taken hold in the healthcare sector, including artificial intelligence, predictive analytics, the Internet of Medical Things (IoMT), natural language processing, and robotic process automation.
Innovation Exchange participants are set to discuss a half-dozen automation adoption challenges and success stories:
Innovative approaches to automation as well as business and operational impacts
Processes for health systems in selecting innovation pilots, the role of information technology departments, and achieving scale
Automation partnerships and collaborations with third parties such as other health systems and nontraditional healthcare organizations
Executives who attend the Exchange plan to explore AI and predictive modeling that can help anticipate patient needs associated with social determinants of health, and understand how social determinants of health interact with chronic conditions and impact risk.
In addition, healthcare leaders will discuss how to scale innovation initiatives from pilots and prototypes.
Technological approaches to engagement
Patient engagement is a priority for health systems, not only in guiding patients to choose providers, but also in devising ways to involve patients in their own care. Examples of technology revolutionizing patient engagement include wearable sensor devices, online review platforms such as Google and Facebook, and chronic disease management apps.
Innovation Exchange participants are slated to explore technology solutions that can impact a wide range of engagement activity, including telemedicine, artificial intelligence, predictive modeling, and remote sensing:
Remote monitoring to serve vulnerable populations and address social determinants of health
Technology to manage population health initiatives
Generating and impacting online ratings on review websites such as Leapfrog
Technology that shapes the involvement of patients in their care such as navigating hospital services
AI and predictive analytics to allocate clinical resources and manage negative outcomes such as readmissions
Technology to boost clinician engagement such as monitoring adherence to evidence-based care
Technology that engages patients outside the hospital walls, including telehealth initiatives
Predictive tools to target high utilizers of healthcare services and help manage their care
Exchange participants also plan to discuss methods to elevate patient involvement in care with technology, navigators, educators, and motivational interviewing.
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Over a three-year period, NYU Langone Health was able to cut costs while maintaining clinical quality.
A value transformation initiative at NYU Langone Health (NYULH) in New York generated net cost savings estimated at $53.9 million over three years, according to a new medical journal article.
The new journal article, which was published in BMJ Quality & Safety, provides insights and direction for other health systems seeking to boost the value of care, the article authors wrote.
"Overall, we were able to achieve and sustain substantive cost savings at a major academic medical center while maintaining quality of care, thereby increasing the value of care provided. In an era of increasing value consciousness, our program provides a template for effective conduct of similar work at other institutions," they wrote.
The value-based initiative featured 74 projects in four primary areas:
Supply chain management such as surgical trays
Operational efficiency including improvement of discharge processes
Care of outlier patients such as individuals at the end of life
Resource utilization including blood management
The initiative has several key differences compared to value-based efforts at other health systems, the journal article authors wrote. "It integrates the cost-accounting strengths of some initiatives with the clinician-led and front-line-driven agenda of others. It does not consist of a few high-profile, major projects, but rather dozens of smaller ones. Moreover, unlike most other published programs, this initiative was institution-wide, not limited to a particular department."
Value-based initiative results
The value initiative was launched in April 2014, and examination of the effort's impact collected data from more than 160,000 hospitalizations through December 2017. Several positive impacts were generated:
Adjusted variable costs fell 7.7%
Admissions with medical diagnosis related groups (DRGs) were reduced an average of 0.2% per month compared to pre-initiative levels
In comparison to other teaching hospitals, expense per hospitalization improved from 13% above median to 2% above median
Total cost savings were estimated at $59.3 million, with about $10.3 million in savings for medical patients and $49.0 million for surgery patients
Annual intervention costs were about $1.5 million, so net savings were estimated at $53.9 million
Initiative leadership and shared savings incentive
In 2014, NYULH formed a value-based management task force to lead the initiative.
The health system's chief medical officer served as chairman of the task force. Two deputies reported directly to the task force chairman—a project leader with an MBA degree and a clinical leader who was a practicing hospitalist. The deputies' responsibilities included project prioritization and oversight as well as meeting with stakeholders for new projects. The task force leadership also including all hospital-based vice deans and senior vice presidents.
Health system departments that posted costs below projection received shared savings averaging 25%. The level of shared savings was determined based on performance metrics such as length of stay. Shared savings funding was expected to be used for department-specific value improvement programs such as supporting physician salary time that was dedicated to value-based efforts.
Keys to success
According to the journal article, there were eight contributing factors to the value initiative's success:
The effort was launched by the dean and CEO, and it was sponsored by the chief operating officer, which demonstrated institutional commitment
The program was data-driven, including urgency to address unsustainable Medicare losses, robust cost-accounting, and a centralized performance dashboard
To motivate clinicians, performance improvement was compared to other high-quality but lower cost academic medical centers
The focus of the initiative was value rather than cost reduction—every effort accounted for both quality and cost
Most projects had significant information technology elements, and there was vigorous support from the health system's chief information officer and information technology staff
The deputies to the task force chairman were a clinician and an MBA-degree holder, which helped ensure that clinical and business considerations were at play in every project
The initiative's shared savings program boosted alignment between individual departments and the health system
High-quality project managers were "the lifeblood" of the initiative
Emergency medicine pharmacists increase guideline-concordant prescribing at hospitals with both new and established antibiotic stewardship programs.
Employing emergency medicine pharmacists improves empiric antibiotic prescribing for pneumonia and intra-abdominal infections, recent research shows.
Appropriate prescribing of antibiotics is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. Antibiotics also have been linked to negative patient impacts such as Clostridium difficile infections.
The recent research published in the American Journal of Emergency Medicine found that employing emergency medicine pharmacists (EMPs) not only boosted guideline-concordant empiric antibiotic prescribing but also increased the likelihood that appropriate therapy would be ordered after patients were admitted for hospitalization.
The research, which featured 185 patients treated when EMPs were present and 135 patients treated when EMPs were not present, generated several key results:
The overall likelihood of empiric antibiotic prescribing was higher when an EMP was present than when an EMP was not present: 78% vs. 61%.
For community-acquired pneumonia, the rate of guideline-concordant prescribing was 95% when an EMP was present compared to 79% when an EMP was absent.
For community-acquired intra-abdominal infections, the rate of guideline-concordant prescribing was 62% when an EMP was present compared to 44% when an EMP was absent.
More than 80% of patients who received guideline-concordant antibiotics in the emergency room continued to receive appropriate therapy after hospital admission, compared to only 18.8% of admitted patients who received inappropriate therapy in the ER.
The presence of an EMP improved empiric antibiotic prescribing for hospitals with both new and established antimicrobial stewardship programs (ASPs).
"This study shows the importance of coupling ED clinical pharmacist activities with ASP initiatives. Total guideline-concordant prescribing significantly increased over time, with improved prescribing adherence demonstrated in both the early-ASP and established-ASP groups when an EMP was present," the researchers wrote.
EMPs can play a unique role in boosting guideline-concordant prescribing, the researchers found. "EMPs are in an ideal position to encourage appropriate empiric prescribing as they can make real-time recommendations for antibiotic selection or intervene and suggest alternatives when inappropriate antibiotics are ordered."
A healthcare system is pioneering provision of palliative care and supportive services to oncology patients receiving curative treatment.
A new initiative called Supportive Care of Oncology Patients (SCOOP) pathway has helped a health system generate gains in clinical outcomes and cost reductions by improving nurse navigation as well as providing palliative care and supportive services for oncology patients in curative treatment.
Studies have shown positive results from high-quality nurse navigation and the early introduction of supportive care services for advanced cancer patients.
Wilmington, Delaware–based Christiana Care Health System hypothesized that similar gains could be generated at its healthcare organization and it launched SCOOP in November 2016.
The program generated several positive impacts in its first two years, according to a research article published recently in Journal of Clinical Pathways:
Nurse navigator compliance with assigned tasks increased from 94% to 98%
Emergency room visits for targeted patients dropped from 54% to 35%
Hospital admissions for targeted patients dropped from 34% to 22%
Direct cost saving per patient was more than $1,500
"The biggest message is that you can provide a better experience, probably lower costs, and decrease hospital admissions if you take this kind of intensive navigation and supportive care approach to patients who are being treated for cure if their acuity is high enough," says Christopher Koprowski, MD, MBA, associate cancer service line leader at Christiana Care.
Initially, participants in SCOOP were limited to patients with esophagus and lung cancers, colorectal and anal malignancies, and head and neck cancers. The pathway was expanded to include patients with hepatobiliary and pancreatic malignancies as well as brain tumors.
The SCOOP pathway initiative features four interventions: a nurse navigation electronic checklist; mandatory screening of curative patients for suitability to receive supportive and palliative care services; flags in the inpatient EHR when participating patients visit an emergency room, are admitted to a hospital, and are discharged; and an improved educational brochure for patients.
1. Nurse navigation electronic checklist
According to the Journal of Clinical Pathways article, the nurse navigation electronic checklist includes several key features:
The checklist is integrated into Christiana Care's EHR
The checklist is displayed automatically and updated daily as nurse navigators complete checklist tasks
After a nurse navigator fills out required fields, a patient-specific and time-driven set of tasks is generated for the navigators to complete
Tasks stay on the checklist until they have been completed
"Before, the nurse navigators had no daily electronic task list. They were writing things in steno pads; and there was no systematic, constant reminder to them to get these tasks done. So, a lot of the tasks were falling below the radar," Koprowski says.
For example, the electronic checklists include tasks such as trying to ensure that patients attend medical appointments and receive nutrition support.
2. Mandatory screening of patients
A pivotal component of SCOOP was adding palliative care and supportive services staff to Christiana Care's multidisciplinary oncology clinics, which was made possible with newly allocated financial resources, Koprowski says. Before SCOOP was launched, referrals from the clinics for palliative care and supportive services were made on an ad hoc basis.
"Now, supportive care staff review the records; and if the patient appears to have imminent problems, supportive care will see them immediately at a multidisciplinary clinic. Otherwise, supportive care provides patients with contact information to make a non-urgent referral to see them in the supportive and palliative care office," he says.
Palliative care and supportive services provided to patients include dentistry, nutrition, hydration, and psychosocial oncology.
3. Electronic alerts
EHR alerts for emergency room visits and inpatient stays have been helpful to the nurse navigators and their patients, Koprowski says.
"When a patient has visited an emergency room, a nurse navigator can immediately contact the medical or radiation oncology nurses to let them know that the patient may not be in for treatment. They may also let the medical or radiation oncology nurses know that it may be appropriate for the attending physicians to contact the inpatient physicians. Finally, the alerts enable the nurse navigators to communicate with the discharge planning staff in the hospital, so there is a seamless transfer from inpatient to outpatient care," he says.
4. Revised patient brochure
Elements of Christiana Care's new educational brochure for oncology patients include:
A map and directions for how to navigate the healthcare campus
Insights about how multidisciplinary clinic visits are conducted
Care information about radiation, chemotherapy and medications, surgery, palliative care and supportive services, and primary care
Emotional and coping options
Nutrition and well-being
Symptoms and side effects patients should expect
How to make and follow through on appointments
Post-treatment considerations
With SCOOP's success in the treatment of high-acuity oncology patients who are in curative care, the pathway may be extended to Christiana Care's high-acuity cardiology patients, Koprowski says.
"Cardiology already has similar clinical pathways for outpatients. It's quite possible that by enhancing navigation and providing more supportive care resources that they can get the same results we have generated. It could make it less likely that people will slip through the cracks," he says.
Online reviews reveal opportunities to improve patient experience at emergency departments and urgent care centers.
Studying online review platforms such as Yelp can help healthcare organizations understand and improve the patient experience at emergency departments and urgent care centers, new research shows.
In most areas of the country, urgent care centers have become an alternative to emergency rooms for acute medical needs. Both nonprofit healthcare organizations and private companies have opened freestanding urgent care centers in pharmacies, grocery stores, and other retail locations.
Yelp and other online review platforms are a golden opportunity for healthcare organizations to assess patient experience at emergency departments and urgent care centers, according to the new research published in Annals of Emergency Medicine.
"Studying differences in the patient experience between the ED and urgent care centers can provide insight into patients' needs and perceptions of these services. Furthermore, understanding differences in the patient experience may help health systems improve the allocation of, and investment in, alternative acute care settings," the researchers wrote.
Yelp data for emergency departments and urgent care centers
The Annals of Emergency Medicine research examined more than 100,000 Yelp reviews: 16,447 ED reviews and 84,502 urgent care center reviews. Yelp users pick ratings ranging from 1 star for the lowest rating to 5 stars for the highest rating.
The researchers' analysis of Yelp reviews of emergency departments and urgent care centers generated several key data points:
Ratings of urgent care centers were generally higher than ED ratings. More than 60% of ED reviews were 3 stars or fewer, and 60% of urgent care reviews were 4 stars or more.
There were five primary similar themes in 5-star reviews for EDs and urgent care centers—comfort and overall experience, professionalism, clean facilities, pediatric care, and friendly staff interactions.
There were six primary similar themes in 1-star reviews for EDs and urgent care centers—poor communication, telephone or reception experience, excessive wait times, billing or insurance problems, pain management, and diagnostic testing.
Unique themes in 5-star ED reviews included bedside manner, care for family members, and nighttime and weekend care access.
Unique themes in 5-star urgent care center reviews included pharmacy refills and prescriptions.
Unique themes in 1-star ED reviews included overall service and speed of care.
Unique themes in 1-star urgent care center reviews included lack of confidence in care and reception experience.
"Although in general strengths in ED and urgent care center reviews suggest patients perceive better clinical care in EDs and service in urgent care centers, the deficiencies in these reviews suggest [patients] expect both elements from both settings. Lessons learned from patient reviews in these clinical settings may help improve care delivery and the patient experience as the acute care markets emerge, grow, and change," the researchers wrote.
'Improving negative experiences and reinforcing positive ones'
The lead author of the research told HealthLeaders that patients posting Yelp reviews have differing drivers that set apart low and high ratings for EDs and urgent care centers.
"This suggests that people may seek different types of care from the two settings and that the expectations may be different. Additionally, there are components of urgent care centers that approach the patient experience in a much different way as compared to ERs," said Anish Agarwal, MD, MPH, a national clinician scholars fellow in the Department of Emergency Medicine at Penn Medicine in Philadelphia.
Although the researchers did not examine why patients are more likely to post reviews for urgent care centers than for EDs, Agarwal said he believes there are two reasons. "One, there are many more urgent care centers, and, two, a 'better' experience likely leads to a higher likelihood for an individual to post a review," he said.
A crucial lesson learned from the research is that healthcare organizations should pay attention to online reviews, Agarwal said.
"Patients and their families are using online platforms to rate, review, and research healthcare. These reviews are organic and free-form, so they can offer a lot of insights as compared to structured surveys that are randomly sent out. Obviously, these reviews come with selection bias and multiple other forms of bias, but the themes that emerge from them can provide important areas to focus on for both improving negative experiences and reinforcing positive ones."
At North Shore Medical Center in Massachusetts, antibiotics stewardship was the most effective intervention in reducing C. diff infections.
Resource-challenged community hospitals with high levels of Clostridium difficile (C. diff) infections among patients should focus on four contributing factors of the potentially deadly illness, recent research shows.
C. diff is the most common hospital-acquired infection at U.S. hospitals, the Centers for Disease Control and Prevention reported in 2015. Patients infected with C. diff shed millions of clostridial spores with every bowel movement, and the spores have been shown to survive for as long as five months on hospital surfaces.
In the hospital setting, there are multiple contributing factors that can drive C. diff infections. The lead author of the recent research, which was published in The Joint Commission Journal on Quality and Patient Safety, told HealthLeaders the main drivers of C. diff infections are likely to vary from hospital to hospital.
"There are many contributing factors, and they may carry different weights at different hospitals," said Barbara Lambl, MD, MPH, an infectious disease specialist and the hospital epidemiologist at North Shore Medical Center in Salem, Massachusetts. The medical center, which is an affiliate of Boston-based Partners HealthCare, features two community hospitals.
Systematic interventions
Starting in November 2013, North Shore Medical Center launched a systematic, four-pronged effort to reduce C. diff infections, according to the journal article:
1. Environmental services: Housekeeping efforts included cleaning of high-touch surfaces as well as terminal cleaning with bleach and ultraviolet disinfection.
2. Infection prevention: Several measures were introduced to increase staff hand washing with soap and water after caring for C. diff patients, including colorful signs posted on hand sanitizers outside patient rooms and anonymous observers to monitor hygiene compliance. When staff members raised concern that there were not enough sinks for hand washing, nine sinks were installed on five nursing units in two hospitals.
3. Antibiotic stewardship: In 2014, the medical center launched an effort to reduce use of clindamycin and fluoroquinolones. Studies have shown that clindamycin increases C. diff infection rates 20-fold, and fluoroquinolones increase risk 6-fold. A key component of the antibiotic stewardship initiative was an electronic decision support tool that encouraged clinicians to use alternative agents as substitutes for clindamycin and fluoroquinolones.
4. Emergency department processes: The ED staff developed an algorithm to identify and isolate patients with diarrhea or a recent C. diff infection. Inpatient nursing units were notified of patients who had been placed in isolation. Infection prevention practices in the ED were increased such as "SWAT teams" that properly cleaned and disinfected emergency room bays.
Interventions by the numbers
North Shore Medical Center's C. diff reduction efforts generated significant results over a four-year period:
Hospital-acquired C. diff infections fell 55.5%, from 12.2 cases per 10,000 patient-days to 5.4 cases
Antibiotics stewardship had the biggest impact, accounting for a 20.6% reduction in hospital-acquired C. diff infections
Use of high-risk antibiotics fell 88.1%
Infection prevention measures were the second-most effective intervention, accounting for a 13.0% reduction in hospital-acquired C. diff
Appropriate use of antibiotics
To craft the electronic decision support tool for antibiotics stewardship, North Shore Medical Center drew upon three of David Bates' "ten commandments," Lambl told HealthLeaders. "The decision support was speedy. It was timely. And it offered alternative antibiotics."
Staff pharmacists played a crucial role in securing physician compliance with antibiotics stewardship, she said.
"Getting the support of our pharmacist leaders and pharmacists was probably the most important factor in allaying clinician discomfort or unease about switching antibiotics. They would speak with the doctors and reassure anxious clinicians. Without the pharmacists, the whole thing might have failed. Electronic decision support can only get you so far. Having face-to-face interactions is critical."
Improving C. diff diagnostics to target only actively infected patients was also essential, Lambl said. "There's a difference between being colonized with a germ and being sick with the germ. People can be colonized with viruses and bacteria but not get sick. Whereas, other people who have the same germ will get very sick. That's the way it is with C. diff."
Testing needs to be able to distinguish between colonization and active infection, she said. "We believe that people who are just colonized are not transmitting infection to other patients. They certainly do not transmit at the same rate as people who are shedding millions and millions of spores with each diarrheal bowel movement."
Intermountain Healthcare has adopted a four-part strategy to establishing time and distance between people in crisis and firearms.
Intermountain Healthcare is tackling a daunting suicide prevention challenge—limiting access to guns for people in crisis.
In 2017, suicide was the 10th leading cause of death in the United States, with more than 47,000 lives claimed, according to the Centers for Disease Control and Prevention (CDC). In that year, there were more than twice as many suicides than homicides, the CDC found.
Visits to healthcare providers are a significant suicide prevention opportunity. One study found that 38% of people who attempted suicide made some type of healthcare visit in the week before the attempt.
To rise to the challenge and seize opportunity, Intermountain adopted the Zero Suicide initiative in June 2018.
"The Zero Suicide program is both a commitment to suicide prevention—acknowledging that these deaths are preventable—and a recognition that all of us in healthcare have a role to play, whether we are clinicians, administrators, or facility staff," says Morissa Henn, DPH, MPH, community health program director at the Salt Lake City, Utah-based health system.
Intermountain has made gun safety the centerpiece of the health system's approach to the Zero Suicide initiative, she says. "At Intermountain, we are proud to be developing our own version of Zero Suicide. Here in Utah, the strategy we developed recognizes some of the unique risks and protective factors in our communities. One of the key elements is understanding how important access to firearms is as a driver of Utah's high suicide rate."
Utah is an outlier for suicides involving firearms, Henn says, noting that 85% of all gun-related deaths are suicides. In the United States as a whole, about two-thirds of gun deaths are suicides.
"Firearms are widely accessible in Utah. Half of homes here have at least one firearm. Gun ownership ranges from 35% of homes in Salt Lake City to about 70% of homes in more rural areas," Henn says.
There are four primary components of Intermountain's approach to promoting gun safety: partnering with gun owners, holding structured conversations with patients, waging a social norms campaign, and offering gun-locking devices to patients.
1. Working with gun owners
"We focus explicitly on issues related to firearms access, and we are doing so in deep collaboration with Utah gun owners and gun advocates. We know that if we are going to move the dial on this problem here in Utah, the issues of access to firearms and suicide are inseparable," Henn says.
For example, Intermountain has developed public service announcements targeted at gun owners, she says. "These announcements make it clear that we are not trying to ban guns, which are part of our cultural heritage and recreational identity in Utah."
2. Structured patient conversations
In coordination with the Harvard School of Public Health, Intermountain has developed a course for healthcare professionals called Counseling on Access to Lethal Means (CALM). The one-hour course trains medical staff to have effective, sensitive, evidence-based conversations with patients about reducing access to lethal means for high-risk people.
The key elements of CALM include training about how to raise the topic of suicide prevention with patients, holding conversations about gun safety, and follow-up efforts, Henn says.
"CALM helps healthcare professionals to understand the rationale for having these conversations, provides some specific language to practice using, and makes these conversations part of a regular dialogue between healthcare providers and patients in a way that is prevention-oriented. We don't want to wait until people are in crisis. CALM develops plans to help patients and healthcare professionals navigate the dark times safely," she says.
3. Social norms campaign
Intermountain is developing a social norms campaign focused on social media and traditional media such as radio and billboards. The campaign will include encouraging help-seeking behaviors for people in crisis and promoting positive messages of hope and recovery.
"In consultation with many community stakeholders, we are in the process of developing what we hope will be a first-of-its-kind major, comprehensive, and evidence-based social norms campaign modeled on a successful underage drinking prevention campaign in Utah called Parents Empowered. … We also want to encourage a means-reduction approach—ensuring that there is always time and distance between someone in crisis and a lethal method such as firearms," Henn says.
4. Providing gun locks
To improve gun safety in people's homes, Intermountain plans to offer gun locks to patients who may be a high-risk for suicide imminently or in the future.
"As the largest provider of health services in Utah, we are looking at how Intermountain can distribute gun locks in our clinics and our hospitals. Oftentimes, gun locks are an important way to open the conversation and to encourage safe-storage behavior," she says.
Measuring progress
Intermountain has set four goals to help gauge the impact of the health system's gun safety efforts and other suicide prevention initiatives:
In conjunction with state-based efforts, Intermountain wants to achieve a 10% reduction in suicide rates among patients and in the health system's overall geographic region by the end of 2021.
Intermountain wants to get 5% of key caregivers—healthcare providers who interact with high-risk patients—to get CALM training by the end of this year.
After at-risk patients receive care at an Intermountain facility, the health system wants at least 40% of them to schedule and attend a behavioral health appointment within seven days.
The last goal is process-oriented such as identifying patient resources and triggers for suicidal thoughts, Henn says. "We want to develop brief, evidence-based interventions for safety planning—a collaboratively developed plan for someone who is identified as high-risk."
