A recent report found that 42% of U.S. adults are obese.
Obesity should be addressed through a multi-modal management approach involving a range of healthcare providers including primary care physicians, obesity specialists, nutritionists, and counselors, a liver disease specialist says.
Obesity rates have increased steadily over the past decade and now 42% of U.S. adults are severely overweight, according to a recent report from NORC at the University of Chicago.
Obesity is a serious problem in the United States, says Tejas Joshi, MD, director of liver diseases at Marshall Health. "It is a growing issue. Ten years ago, one-third of Americans were normal weight, one-third were over-weight, and one-third of them were obese. A recent study showed 42% of the U.S. adult population is suffering from obesity. As we look to 2030, we expect 50% of U.S. adults will be obese."
Obesity is related to several medical conditions, he says. "The severity of the obesity problem is directly linked to the health conditions associated with obesity. There are consequences, and some of the consequences are going to be in different formats—mechanical, metabolic, and neurological. One mechanical consequence is sleep apnea, which causes difficulty in sleeping. Another mechanical consequence is added weight on joints leading to arthritis. Metabolic consequences include conditions such as diabetes, high cholesterol, and fatty liver disease. A neurological consequence is depression."
Obesity has also been linked to a dozen kinds of cancer, including gastrointestinal, urinary, and pancreatic cancers, Joshi says.
Many healthcare providers should be involved in helping obese patients achieve weight loss, he says. "Optimally, we should approach obesity through multi-modal management via various providers—primary care, obesity specialists, nutritionists, counselors, as well as education from specialists that the patient may be seeing secondary to obesity-related consequences. So, if you are seeing a heart specialist because you have cardiovascular disease on top of obesity, the multi-modal management approach includes the heart specialist talking about a cardiac-health diet and weight loss. If you are seeing a hepatologist because you are suffering from fatty liver disease not related to alcohol, then the hepatologist should be involved in educating, counseling, and putting referrals in."
Through multi-modal management, we can achieve meaningful weight loss and address the obesity epidemic, Joshi says. "Your primary care provider could be the one to prescribe medicines, provide you with information, and put referrals in. A nutritionist could talk about various diets. When it comes to counselors, we must recognize that obesity plays a role in depression—depression can worsen obesity in some cases and obesity can drive depression."
Relatively new medications are a step forward in efforts to address obesity, he says. "GLP-1 agonists are one of the newest classes of medication that has achieved Food and Drug Administration approval for the treatment of obesity. There are more of these GLP-1 agonists as a class—even more are entering Phase 3 clinical trials. These drugs are a good addition to the treatments that healthcare providers have to battle the obesity epidemic."
Ozempic, which is FDA-approved for treatment of diabetes, is a GLP-1 agonist that should not be prescribed to treat obesity, Joshi says. "In the case of Ozempic, we have to prescribe medications based on their FDA-approved indications. If you have a patient who is diabetic who also has obesity, then if you started them on Ozempic one of the effects is weight loss. But providers should be prescribing medicines based on their FDA-approval."
Lifestyle changes are essential to address obesity, he says. "In lifestyle, we have to recognize appropriate times to eat and when not to eat. For example, you probably should not eat a couple of hours prior to sleeping. We need to recognize healthy foods—those that are not complex carbohydrates. We need to recognize that given the illness you are currently suffering from, there may be a specific diet scientifically shown to benefit that condition. Exercise is important. It is recommended that we get about 150 minutes per week of moderate-intensity exercise such as brisk walking 30 minutes a day."
In Joshi's practice, FibroScan, an ultrasound-based diagnostic tool that measures liver scarring, has helped influence patients' behaviors, he says. "I plan to publish a study that shows FibroScan motivated my patients to lose weight. We had patients who we diagnosed with FibroScan. We gave them educational material. We had them return in 90 days. And just learning that their liver was affected by their lifestyle choices and their weight was a motivating factor. On return, we had these patients re-examined, and they had lost weight. Their sugar numbers had gone down. FibroScan helped motivate them."
About 37 million Americans have kidney disease, according to the American Kidney Fund. About 800,000 Americans are living with kidney failure, and nearly 570,000 of those people are on dialysis, the American Kidney Fund says.
Dialysis centers nationwide are facing workforce shortages among the nurses who run the centers and the technicians who operate the dialysis machines, says Robert Provenzano, MD, a nephrologist at Ascension St. John Hospital in Detroit and a co-author of a recent journal article on using a calculated risk score to monitor blockages in vascular access for dialysis known as hemodialysis vascular access stenosis.
"The workforce in dialysis centers has always been challenging. … During COVID, the dialysis nurses faced a major challenge, not only from all the masking and personal protective equipment, but also from a very high acuity rate. In other words, their patients were very sick, and they started dying in very large numbers. As a matter of fact, for the first time in 30 years, the number of people on dialysis dropped. That's how significant the mortality was. So, the nurses who were both emotionally and physically overwhelmed just went elsewhere. They went to hospitals, which also had shortages. The hospitals can afford to pay more," he says.
Hemodialysis vascular access stenosis is a primary complication of dialysis, and it requires labor intensive efforts to monitor the condition, Provenzano says.
"The protection of vascular access is so important that the Centers for Medicare and Medicaid Services, which is the primary funder of dialysis services, has mandated that all patients receive surveillance. Surveillance is a very broad term, and they leave it up to the providers of dialysis care to determine what surveillance is. For the most part, dialysis centers do a physical examination on the access. A physical exam on the access is where you examine it, you touch it, you palpate it, and you listen with your stethoscope and try to make a determination whether there's a blockage," he says.
Physical examinations are a burden for the nursing staff at dialysis centers, Provenzano says. "Often, the caregivers doing the physical exam are the nurses who are understaffed, very busy, and they don't have the time to do it. So, it often isn't done. As a result, providers have adopted other methods of doing surveillance. One is an ultrasound that is usually conducted by a technician. They can see if there's a blockage. The problem with that technique is it's very expensive and it also slows down operations in the dialysis unit."
Using a calculated risk score, which estimates the probability of a vascular access blockage on a scale of 1 to 10, with higher scores indicating higher risk, helps dialysis center nurses to focus on fewer patients, he says.
"There are typically about 100 patients in each dialysis unit. If a nurse is running around trying to figure out which one of those 100 patients needs attention for their access, it's more efficient for the nurse to know which of those 100 actually has a problem. What this technology does is it shows the seven people who are going to have an event. So, the nurse can focus on seven instead of the other 93, and just make a simple referral to the vascular surgeon or the interventional radiologist to prevent the blockage. So, it takes just a few minutes instead of hours and hours."
Combining the calculated risk score with a physical examination is an effective way to conduct vascular access surveillance, Provenzano says. "When you have the people who are identified by the algorithm as a high risk for blockage, then those few people have a physical exam to verify whether there's evidence that a blockage exists. So, they build on each other to improve the positive predictive aspect of the process."
More than two-thirds of healthcare organizations do not have succession plans for physician retirements.
Healthcare organizations should be bracing for a wave of physician retirements, according to a new white paper from Jackson Physician Search.
A report published by the Association of American Medical Colleges in 2022 found that nearly half of physicians were more than 55 in 2021. As a result, more than two of five of physicians will be at least 65 within the next 10 years.
"Even more staggering than that is we are seeing physicians choosing to retire early, due in part to burnout, the influence of the pandemic, reprioritizing lifestyle, and having the financial stability to retire earlier than they planned for. The retirement of physicians is going to result in a significant loss of clinical expertise and experience, which is going to have an impact on healthcare," says Helen Falkner, a regional vice president of recruiting at Jackson Physician Search.
The new white paper is based largely on a physician retirement survey that Jackson Physician Search conducted with physicians and administrators in November and December 2022. The survey has several key findings:
While physicians believe six months notice of retirement is adequate, administrators prefer one to three years of notice.
The majority of physicians plan to work part-time or contract somewhere else rather than fully retire. Most administrators believe retiring physicians are leaving medicine entirely.
Burnout is the top reasons cited by physicians for retirement, but administrators believe age is the top reason for physician retirement.
About 25% of physician survey respondents reported that COVID-19 had pushed them to want to retire early, and 60% of those still plan to do so.
As early as age 50, some physicians are cutting back their working hours.
When physicians were asked what factors would encourage them to delay full retirement, 58% said they would delay retirement if they could work part-time and 52% said they would delay retirement if they could have flexible schedules.
More than two-thirds of healthcare organizations do not have succession plans for physician retirements.
The white paper has five key takeaways for healthcare organization administrators:
Start retirement conversations with physicians when they reach age 55
Conduct physician retention efforts and burnout mitigation
As physicians approach retirement age, give them several options to ease workload and improve work circumstances
Consider ways to keep aging physicians engaged such as teaching opportunities
Adapt to the needs of younger physicians by revising job descriptions and compensation packages
Physician retention plans
There are five primary elements of physician retention plans, Falkner says:
"It is important to note that retention starts at recruitment. The number one indicator of turnover is poor cultural fit. So, for organizations as they are interviewing, if the organization has a strong culture, low turnover, and good communication between physicians and management, those are elements that should be emphasized in the hiring and recruitment process. Organizations should be hiring for fit versus hiring to fill positions. Hiring for fit is going to be one of the best ways that organizations can have a good chance at retaining."
"Organizations should provide personal growth opportunities for physicians. Burnout is at an all-time high, and it is critical as an administrator to keep a pulse on the physician staff and offer opportunities to explore things outside of the physicians' day-to-day clinical responsibilities such as medical mission work and volunteer work."
"Just as important as personal growth opportunities are career advancement opportunities such as clinical or administrative leadership positions. Again, it comes back to knowing your physician staff—the better you know your staff, the better you will be able to find ways for those physicians to challenge themselves."
"Administrators need to provide their physicians with a good work-life balance. It is important to have open conversations with physicians and to take a collaborative approach so that you can develop mechanisms that will help physicians better achieve work-life balance. Tied into work-life balance is encouraging time off. It can help physicians deal with the pressures of their job and allows them to spend more time with family."
"The level of compensation is always going to play a role in your ability to retain physicians. For physicians, many of them are saddled with significant debt, and any effort to boost compensation will help you retain physicians. For those organizations offering career advancement opportunities, that is a great way to offer more compensation for a physician who steps into an administrative or blended administrative-clinical role."
Holding retirement conversations
When administrators initiate retirement conversations with physicians, the best advice is to approach the conversation early in an open and transparent way, then the conversation should be revisited often, says Tara Osseck, a regional vice president of recruiting at Jackson Physician Search.
"Administrators need to give physicians the space and opportunity to talk about their retirement plans in an environment that is not threatening. You do not want the physician to feel the organization is trying to push them out the door. Administrators should provide assurance that the physician is not going to be sidelined and offer the opportunity to work part-time," she says.
Understanding a physician's retirement motivations and plans post-retirement can help an administrator to offer options and, in certain circumstances, convince the physician to keep working in some capacity, Osseck says. "As physicians are eager to discuss and consider options to lighten their workload such as a reduced schedule, reduced patient load, and elimination of call, they also are eager to leave a legacy in some way. For many physicians, that may be in the form of teaching or mentorship, which can be an asset for an organization."
Succession planning
A crucial part of succession planning for retiring physicians is to share knowledge between the retiring physician and the new physician, Falkner says. "A successful physician succession plan includes the developmental processes and systems to facilitate the transfer of knowledge from the retiring physician and the new physician. That can involve creating documentation, sharing standard operating procedures, creating access to patient records, and encouraging communication and collaboration between the retiring physician and the new physician."
There are several other key factors in succession planning, she says:
Goal setting: You need to identify the goals of your succession plan and make a business case for why it is important to your organization.
Research and forecasting: Understanding the recruitment needs when a physician retires can include gathering data on your current physicians such as demographics and specialties. Data can help administrators create a timeline that estimates when physicians are likely to retire.
Due diligence: Administrators should meet with stakeholders and develop job descriptions. Key stakeholders should include not just the retiring physician but also physicians who are remaining.
Mentorship and leadership training: Administrators should provide opportunities for new physicians to ensure a smooth transition. This can involve pairing a new physician with an experienced physician, providing on-the-job training, and offering continuing education opportunities.
Contingency planning: Even the best succession plan can have gaps. Ideally, you want to have a pipeline of candidates who are ready to work, but it is also important to have an established relationship with a locum tenens agency that can help to quickly fill openings in the short-term.
The primary supply chain function is to ensure availability of supplies, equipment, and services at the best available rates, the top supply chain officer at RWJBarnabas Health says.
The key to success in healthcare supply chain management is balancing effectiveness and efficiency, says Bob Taylor, MBA, senior vice president of supply chain for RWJBarnabas Health.
Taylor has been senior vice president of supply chain at the West Orange, New Jersey-based health system since July 2017. His prior experience includes serving as assistant vice president of supply chain at Birmingham, Alabama-based UAB Health System for nearly a decade.
HealthLeaders recently talked with Taylor about a range of issues, including the challenges of serving as the top supply chain officer at RWJBarnabas Health, balancing competing needs that impact supply chain, conducting value analysis, and involving clinicians in supply chain decision-making. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the top supply chain officer at RWJBarnabas Health?
Bob Taylor: RWJBarnabas Health, the largest, most comprehensive academic health system in New Jersey, relies on the vitality of our supply chain to deliver safe and effective care every day. This entails monitoring and managing a multifaceted network of resources across our 12 facilities with a service area covering eight counties with five million people. My charge is to maintain the delicate balance of creating efficiency and effectiveness in our supply chain to meet the many, and sometimes competing, needs within our organization. As our health system transitions to value-based care—and amid ongoing difficulties in the global healthcare supply chain—we are challenged to sustain a function that is optimized for exceptional value while continuing to deliver smoothly on patient outcomes.
HL: How do you balance the competing needs within the health system that impact supply chain?
Taylor: Supply chain sits at the intersection of cost, quality, and outcomes. We have a primary function of ensuring availability of supplies, equipment, and services at the best available rates. This must be balanced with ensuring that those items are of high quality and deliver the outcomes that are expected to improve patient care. If we purchase products that are inexpensive but low quality, they may result in poor patient outcomes, which ultimately will translate to cost elsewhere in the healthcare continuum. We are also in a natural tension with our partners as we are looking to reduce cost of care while most supplier partners are looking to increase revenues. This sometimes necessitates looking at new vendor relationships or making broader commitments to fewer vendors to secure value.
Bob Taylor, MBA, senior vice president of supply chain at RWJBarnabas Health. Photo courtesy of RWJBarnabas Health.
HL: How is the supply chain managed at RWJBarnabas Health?
Taylor: Like most hospital systems, our supply chain is complex and interconnected. We take a highly strategic, data-driven approach to managing our procurement process to ensure best practices and to enhance quality and patient outcomes in the most fiscally responsible way possible.
Our core corporate function includes strategic sourcing and contracting, value analysis, capital equipment procurement, procure to pay, and "final mile" management of delivering goods and services to our clinicians and patients. Using data and analytics solutions not only give us the ability to see the bigger picture, but they also enable us to optimize and increase efficiency, while eliminating waste.
Our function is supported by a team of more than 400 people who are committed to delivering exceptional service and value as well as improving the quality of patient care.
HL: How do you conduct value analysis?
Taylor: We have a robust value analysis function across the system comprised of experienced clinicians. The value analysis team collaborates with the many councils, collaboratives, and physician groups to help select the most clinically appropriate products based on clinical evidence and efficacy. Once products are selected the strategic sourcing and contracting team negotiates the contract details for execution.
HL: Tell me about your group purchasing organization.
Taylor: Our system uses a GPO to purchase most of our commodity goods. In some cases, where it makes sense, we contract directly with suppliers.
HealthTrust Purchasing Group is the GPO. Like all GPOs, HPG contracts with suppliers on behalf of the aggregate GPO membership, and as a member we can access the agreements for our use. As our health system is large, we can also frequently further negotiate more favorable pricing with GPO suppliers.
Now that the crisis phase of the pandemic has passed, what are the primary supply chain challenges at RWJBarnabas Health?
While the pandemic's crisis phase is somewhat over, we are still experiencing enormous disruptions that are putting the supply chain function under risk. As the global shortage on healthcare supplies continues, vendors are working to build resiliency, which can lower risk but result in higher costs.
Our team takes a proactive approach to integrate strategies and best-in-class practices to optimize scarce resources, alleviate shortages, and expand capacity quickly. The ability to increase efficiency and manage costs while making sure our dedicated and skilled medical practitioners have the resources to do their jobs is key for us.
HL: How do you involve clinicians in supply chain decision-making?
Taylor: Our supply chain is highly integrated and involves RWJBarnabas Health clinicians throughout the process. We collaborate with our clinical leaders on an ongoing basis and have created formalized cross-functional and specialty-focused teams across our initiatives. For example, our doctors, nurses, and other clinical team members actively participate in product selection, compliance management, managing use of supplies, and more. Their ability to help us understand the exact resources they need to practice medicine adds tremendous value and efficiency.
HL: What are the primary keys to success in supply chain management?
Taylor: Right now, it is crucial for us to have flexibility and the ability to pivot as things change. This also makes it more important than ever to engage and collaborate with our internal partners across the system.
I think of the supply chain in terms of having two main branches: One is effectiveness, which means doing the right thing. The other is efficiency, which means doing things right. It is crucial to strike a balance between the two.
If we are only efficient, we could end up doing all the wrong things just very efficiently, which does not add value. If we are only effective, we may do all the right things but do them so poorly that we again do not add value. Both efficiency and effectiveness are required and in balance to do the right things the right way.
In quality improvement initiatives, empower frontline leaders to help inform the priorities, chief medical officer says.
The biggest quality improvement initiative at UNC Hospitals has been advancing the journey to high reliability, says Chief Medical Officer and Vice President of Medical Affairs Thomas Ivester, MD, MPH.
Ivester has been chief medical officer and vice president of medical affairs at UNC Hospitals since April 2017. Previously, he served as medical director and physician service leader for obstetrics at UNC Hospitals, based in Chapel Hill, North Carolina.
HealthLeaders recently talked with Ivester about a range of topics, including his top challenges at UNC Hospitals, quality improvement, and patient safety. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of UNC Hospitals?
Thomas Ivester: The general challenges of chief medical officers tend to be that we are often saddled with vast areas of responsibility such as quality and the medical staff. At the same time, we don't always have clear lines of authority, especially since employment relationships can be different and different areas of the organization have different reporting relationships. In addition, we don't often have purview over revenue-generating activities, which can hinder our influence.
At UNC Hospitals, I have a couple of challenges. One is we have grown significantly over the past couple of decades, and our organizational structure particularly on the medical staff side has not necessarily kept up in terms of modernizing. That is a priority for me—getting the medical staff better organized to execute.
At the same time, we have also grown substantially as a system, which means governance over our big priorities is informed and influenced by a lot of other entities that were not a part of us 20 years ago. There are several positives that go along with that, but it also introduces several challenges in terms of governance and decision-making.
HL: How have you risen to the challenge of organizing the medical staff?
Ivester: We have done several things. One of my first activities was to revamp and standardize the job descriptions of each level of medical directorship and physician service leader at the institution. I had to make those job descriptions and their associated responsibilities and lines of accountability clear.
I have also had to engage an effective cascade throughout the medical staff to make sure that organizational priorities are disseminated all the way to the front line and that we are also being informed by what frontline leaders are observing and having a pathway of getting it back up to the senior levels of the organization.
Another key strategy is learning to delegate more effectively, and that is a skill that I am still learning. We need to enable and empower a group of lieutenants to help to execute and lead strategy across the multiple domains that I have to oversee.
HL: How have you risen to the growth of the organization and the challenge of governance?
Ivester: I have been forging relationships with my CMO colleagues across the health system, so that we can connect one-on-one or in small groups. We also convene as a larger group at a monthly roundtable to discuss topics that cut across our organization, to present ideas and to work together to solve challenges.
Thomas Ivester, MD, MPH, chief medical officer and vice president of medical affairs at UNC Hospitals. Photo courtesy of UNC Hospitals.
HL: What are the keys to success in implementing quality improvement initiatives?
Ivester: One of the keys for us has been to focus on a finite number of priorities. That relies upon the principle that we truly believe we can do anything, but we certainly cannot do everything. So, we need to select the right priorities and de-select the priorities that are not right for the moment.
We also work diligently to empower our frontline leaders to help inform the priorities. We try to enable those local leaders to identify and select their local priorities from our broader strategy, so initiatives are much more relevant to the folks that they are overseeing at their local unit, clinic, or area of service.
Finally, the engagement piece is critical. We do that by supporting the work of frontline leaders including our medical directors with project resources. We set clear expectations. We provide the right data at the right time. We make commitments that last longer than the current fiscal year.
HL: Give an example of a quality improvement initiative you have been involved in at UNC Hospitals.
Ivester: Our biggest quality initiative has been the launch of what we call Carolina Quality, which is our multi-year strategy that forms the foundation of our journey to high reliability. This is based on a full commitment to the tenets of just culture, daily huddles, leadership rounds, and safety reporting. This is all supported by a robust data strategy and ongoing optimization of care team and patient experience.
This is the biggest quality initiative in our history, and it is based on things we already do. We just need to do them better and in a more integrated way.
HL: What are the keys to success in implementing patient safety initiatives?
Ivester: In a lot of ways, they are similar to implementing quality initiatives. Oftentimes, our safety initiatives are focused on faster, more agile decision-making and change management. That requires gathering a guiding coalition, with clear accountability and expectations as well setting timelines for execution.
It is also important to continually remind folks of the "why." There must be a compelling reason for doing what we are doing. The "how" becomes infinitely easier if you can get people to understand and buy into the "why."
HL: Give an example of a patient safety initiative you have been involved in at UNC Hospitals.
Ivester: Probably the most important thing for us was implementing our daily safety huddles. We did this a couple of years ago in the middle of the pandemic. This has been a fantastic platform, and we borrowed ideas from many colleagues across the country to develop our system. It starts in the morning with more than 300 Tier 1 safety huddles taking place across the entire medical center. They are escalating issues around operations, quality, and safety to a Tier 2 huddle that involves director-level leaders across the institution. Ultimately, it culminates in our Tier 3 safety huddle that occurs daily at 10 a.m. and involves every member of our executive team hearing every escalation from the preceding 24 hours.
We have demonstrated that we are able to solve between 85% and 90% of escalated issues within the same day, often within just a few hours. Every other issue is resolved within one to two weeks, or it is converted into an improvement project.
Along with the huddles, we have instituted a formal mechanism for managing the array of root cause analyses that are taking place across the institution, so that performance is being monitored and we are executing with far greater fidelity through enhanced accountability.
HL: You have a clinical background in obstetrics and gynecology. How has this clinical background helped you serve in physician leadership roles?
Ivester: Having a clinical background does lend substantial credibility to physician leadership roles. Whether you are a CMO, a quality leader, or serving in another role, to be able to demonstrate that you are still rolling up your sleeves and can work alongside colleagues in a clinical arena can be helpful. The variety of my practice in obstetrics gives me insights into several areas. I work in the inpatient setting. I work in the operating room. I do imaging. So, I have insights into the work of clinical folks across the spectrum of clinical venues.
HL: How would you characterize your leadership style?
Ivester: I tend to be relational. I connect directly with people in smaller, more intimate settings where we have an opportunity to get on the same page as well as understand one another's priorities and concerns. I work to find common ground.
I certainly do not mind at all being on stage and trying to rally the troops. I am a visionary person and work a lot on strategy. I try to coalesce people under a unifying vision, but I make sure that vision is not just mine. It reflects the input of folks across a unit or the institution. I want to strike a balance between inclusiveness and consensus. However, there are times when I need to step in and make an executive decision.
Another piece is I put a lot of thought in trying to connect seemingly disparate priorities or areas of work, then try to find a common ground. It has helped me to bring together folks from across the institution, and it gets back to operating under a unified vision or set of goals.
Ivester is a contributor to the HealthLeaders Exchange. The HealthLeaders Exchange community is a private idea-sharing network for senior executives in hospitals, health plans and physician organizations. To join, please visit theHealthLeaders Exchange LinkedIn page.
Pediatric experts from 15 different specialties and departments collaborate to make teen's fourth liver transplant a success.
A fourth liver transplant for a Montana teenager was an exercise in clinical leadership, care coordination, and team-based care, the surgeon who led the care team says.
Standard liver transplant teams involve several care team members, including care coordinators, nursing staff, surgeons, anesthesiologists, blood bank, and hepatologists. In this case, the care team consisted of pediatric experts from 15 different specialties and departments across Children's Hospital Colorado, including cardiac surgeons and a dialysis team.
Seth was 17 when he had his fourth liver transplant more than a year ago. When he was 2 years old, he was diagnosed with a genetic liver disease known as progressive familial intrahepatic cholestasis. At 8, Seth was diagnosed with a type of liver cancer known as hepatocellular carcinoma, which led to his first liver transplant.
Unfortunately, a complication with his liver and a critical illness compromised the first and second liver transplants. After the third liver transplant, Seth and his family were able to return to a normal life, and he lived for about 8 years without serious complications. But in November 2021, his artery clotted and he developed infected bilomas that were not responsive to medical management or interventional radiology treatment.
It is extremely uncommon to conduct four liver transplants in a patient, Michael Wachs, MD, chief of abdominal transplant surgery at Children's Hospital Colorado, told HealthLeaders. "The reason I thought it was reasonable to do was the first three transplants were conducted close together—they were all part of an initial complication and getting Seth through that. Then he had a period of years when he did well. In my mind, I grouped the first three transplants he had as a young child as his first transplant experience, so the fourth transplant was more like doing a second transplant."
The possibility of complications expanded the care team, he says. "In this case, because it was the fourth transplant, we were concerned about the outflow of the liver, which is only a couple of centimeters from the diaphragm and the heart. We had put a stent in during the previous transplant and that was going to have to come out. Then we were going to have to suture the new liver above where the stent used to be. So, we were going to be very close to the heart and we had to coordinate with the cardiac surgeons and the cardiac bypass team—the team that runs the bypass pump."
Dialysis was also a possibility, Wachs says. "It was pretty clear that if it was a tough operation, we were most likely going to have to do dialysis in the operating room, so we had to bring in a dialysis team, which is a group of nurses that runs the dialysis machine and the nephrologists determine how much dialysis the patient needs."
Logistics were also a challenge, he says. "It was not a live donor transplant—it was going to be a deceased donor transplant—we never knew when it was going to happen. … To have all of our people ready at any given time, we had to have more than one person from each team in on the plan. For example, if the main cardiac surgeon was not on call that day and we had the perfect immunologic organ, we wanted to have a backup cardiac surgeon. So, not only were there more groups involved, there was duplication of effort to make sure there was always going to be somebody available."
Collaboration was one of the keys to success in Seth's fourth liver transplant, Wachs says. "There is always collaboration among the groups that are involved in transplants, but we were communicating with the other teams that are not typically involved in a liver transplant. It is not just asking for their help—you need to ask for their opinions. So, I sat down several times with the cardiac surgeons and the radiologists to try to anticipate what we were going to do first, second, and third, and when we might need the heart surgeons. We talked with them about whether we could get the stent out, and what were the options if we had to go around it. We worked through those various steps and drew them out almost like you draw out a playbook in a football game. That was the primary collaboration—everybody talked about how the operation would go if we ran into particular situations."
Team-based care was pivotal, he says. "A good team functions by having leadership where you find good people to surround yourself with, and you let them brainstorm, you ask them questions, and you let them use their expertise to help you do the best that you can. I do not believe in a top-down approach. The old-fashioned surgery approach is the surgeon being the captain of the ship. That's great when the ship is going down—somebody must be in charge. But most of the time, when you want things to go well, the better approach is to have a level playing field of colleagues, where you put together a team of colleagues that work well together and complement each other. Then you plan out what you are going to do. Everybody gets the credit when it goes well. Everybody shares the blame when it does not go well."
Clinical leadership was also crucial, Wachs says. "My approach to clinical leadership is to lead from behind, which involves putting good people together, giving everyone a chance to speak, then once everyone has been heard, putting things together in a way that makes sense. Collaborative leadership is how we conduct transplant operations."
In survey data, 80% of primary care physicians and 64% of patients reported they would prefer to conduct future visits in-person rather than via telehealth.
Although most primary care physicians and patients were satisfied with telehealth visits during the coronavirus pandemic, majorities of both populations prefer in-person visits in the future, according to a new research article.
Many in-person medical visits were not possible during the early phase of the pandemic, and telehealth visits increased sharply. The future of telehealth visits after the pandemic is unclear.
The new research article, which was published today by Health Affairs, features survey data collected from 337 primary care physicians and 1,417 patients. The physician survey was conducted from Feb. 12 to May 24, 2021. The patient survey was conducted from April 30 to May 11, 2021.
The study includes several key findings:
80% of primary care physicians reported that they would prefer to conduct future patient visits in-person rather than via telehealth
64% of patients reported that they would prefer to conduct future visits in-person rather than via telehealth
60% of physicians reported that the quality of telehealth visits was inferior to in-person visits; 29% reported quality was equivalent
33% of patients reported that the quality of their video visits was inferior to in-person visits; 51% reported quality was equivalent
The most common reason given for lower quality of telehealth visits compared to in-person visits was the lack of a physical examination (92% of physicians and 90% of patients)
90% physicians and patients reported that telehealth visits went well during the pandemic
45% of physicians reported rapport was worse by video than by in-person visits
20% of patients reported rapport was worse by video than by in-person visits
52% of physicians reported very or somewhat frequent difficulties with video or audio quality, 39% of physicians reported they very or somewhat frequently had Internet connectivity difficulties, and 34% of physicians reported the video platform or software did not work well
Regarding their most recent video visit, 23% of patients reported that they had difficulties with video or audio quality, 17% of patients reported they had Internet connectivity difficulties, and 18% of patients reported that the video platform did not work well
Older patients, patients with lower educational attainment, and Asian patients were more likely than other patients to prefer in-person visits over telehealth visits in the future
"We found that telemedicine was widely accepted and appreciated by patients and physicians early in the COVID-19 pandemic; however, majorities of both groups expressed a preference for in-person visits in the future. … More physicians see the quality of care by video as inferior, with concerns about limitations on physical examinations that are mirrored by patients. Investing in tools that enhance the virtual physical may be beneficial both in their own right and in terms of facilitating virtual care when needed," the study's co-authors wrote.
Interpreting the data
The study suggests a diminished role for telehealth in primary care after the pandemic, the study's co-authors wrote. "Few physicians indicated a preference to continue telemedicine as their main modality of care, although many saw a role for a small share of care provided this way, particularly for mental health. In parallel, few patients would choose a video visit if in-person visits were available. … Results suggest that in the long term, telemedicine can play a role in providing access to care during health emergencies, but it will likely play a smaller role in primary care, at least in the immediate future, with a focus on patients who prefer or need this modality and on specific conditions such as behavioral health."
The quality of care in telehealth visits is a concern for primary care physicians, the co-authors wrote. "Most physicians felt that the quality of care provided by video was generally worse than what they could provide in person, even in a pandemic. That said, perception of quality varied across visit types, with behavioral health seen as largely equivalent. Further, the most common concern about quality was the lack of a physical exam. Together this evidence suggests that perception of quality may vary even within categories such as management of chronic conditions, such that visits for which a physician feels a physical exam is important are the least likely to be seen as high quality in the video setting."
Patients were less concerned about quality of care in telehealth visits, the co-authors wrote. "Results may reflect the fact that patients were evaluating only a single visit and thus made a more neutral judgment in the absence of more experience, or perhaps that they did not face cumulative burdens from video care in the way that physicians may have. Consistent with this idea, for patients, quality of care in the video setting was linked to the appeal of virtual care in the future. Because concerns about quality were connected to not having a physical exam, this reinforces the possibility that some kinds of care are better suited to video care even from the patient's perspective and that improvements to home tools such as blood pressure cuffs could improve perceived or actual quality from the patient side and facilitate willingness to seek virtual care when appropriate."
The study found that there could be concerns about a "digital divide," the co-authors wrote. "What we did find is that older respondents, those with less education, and those who were Asian were less likely to want to continue using video visits. This is consistent with concerns about a 'digital divide' in telemedicine use that favors those who are younger, wealthier, and White, both in the COVID-19 pandemic and more broadly."
Last year, 5,492 adults were treated at Intermountain Health's Behavioral Health Access Centers.
Intermountain Health has improved access to services for mental health patients by opening 24/7 outpatient centers.
With a nationwide shortage of psychiatrists, access is one of the biggest challenges in behavioral health. More than half of U.S. adults with mental illness do not receive treatment, according to Mental Health America.
Intermountain has opened Behavioral Health Access Centers at three hospitals in Utah. "Prior to the access centers, the only place someone in a mental health crisis would go to was the emergency department. The ED was the gateway for behavioral health screenings and determining whether someone needed to be admitted to a behavioral health unit or discharged," Clint Thurgood, crisis services director at Intermountain, told HealthLeaders.
The Behavioral Health Access Centers are an alternative to the ED for mental health patients who are not at risk of harming themselves or others, he says. "The access centers are built in close proximity to the EDs. When patients come to the ED, the triage nurse in the ED asks a couple of questions related to their immediate safety and whether they are at risk of harming themselves, which would constitute a medical emergency. If the patient does not have a medical emergency, they are physically escorted to the access center to be triaged and registered similar to the procedure in the ED."
The access centers are staffed with a psychiatrist during the day, along with several other psychiatric care providers, Thurgood says. "We have crisis workers who could be a mental health social worker or licensed family therapist. We also have psychiatric nurses and psychiatric technicians. The access centers are designed to ensure that the patients who are in need of psychiatric care are meeting with the right providers at the right time."
With the access centers in place, mental health patients in crisis do not have to go to the ED, he says. "Patients do not need to go to the ED to be screened. As we have seen at our three locations, more and more people are self-presenting to the access centers, which have community-facing doors. So, the public can access them. The police can access them if they have patients who are appropriate to be seen in the access center. We are open for walk-ins."
The access centers have reduced the number of mental health patients seeking care in the EDs at the three hospitals as well as decreased the number of these patients who are admitted to the hospitals, Thurgood says. "One of the successes we have seen with the access centers is that at our EDs about 55% of all adults who come to our hospitals needing a psychiatric crisis evaluation end up being admitted to the hospital. But for patients who are seen at the access centers, the rate of admission goes from 55% down to 39%. More patients can successfully discharge to home."
Last year, 5,492 adults were treated in the three access centers.
Patients receive a thorough evaluation in the access centers, he says. "There are psychiatric consults provided by the psychiatrists. Crisis evaluation consults are provided the crisis workers. There are standardized screening tools such as the Columbia Suicide Severity Rating Scale to determine a patient's suicidality."
The access centers are a lower cost setting for treating mental health patients than EDs, Thurgood says. "Over the past five years at the hospitals with access centers, about 80% of adults with mental health crises have been seen in the access centers rather than the ED. We know that the most expensive place to receive care is the ED. So, by shifting the volume of patients away from the ED to the access centers, costs are much lower for Intermountain as well as the cost impact on the patients. It is about a third to a quarter of the cost to receive care in an access center compared to an ED."
Patients seen in the access centers receive a care plan and are connected to outpatient services in the community, he says. "By coming to the access center, patients as needed can stay in the access center for as many as 23 hours of observation. This gives us time to assess their needs and to connect them with formal and informal resources to create a care plan, including a plan for discharge from the hospital and a follow-up plan in the community."
Patients who are prescribed medication by access center psychiatrists are targeted for follow-up care, Thurgood says. "There is a concern about starting a patient on medication if they do not have follow-up care. So, a key component of the access centers is having case management workers who can connect with the patient following their discharge from the access center to make sure they have ongoing care. So, if the psychiatrist starts a patient on a medication at the access center, a case manager needs to call them the next day and say, 'Let's set you up with an outpatient provider who can continue monitoring you, so you have somewhere to go for the next seven to 14 days.'"
The new chief medical officer of OU Health faces challenges including access to care, workforce shortages, and financial sustainability.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
The first chief medical officer of OU Health plans to focus on quality and safety, medical informatics, data analytics, patient experience, digital health, population health, and process improvement.
Carolyn Kloek, MD, was recently named as the inaugural CMO of the Oklahoma City, Oklahoma-based health system. She previously served as senior vice president of clinical strategy and integration at OU Health. Her other leadership positions include serving as vice chair of quality and innovation at Dean McGee Eye Institute.
HealthLeaders recently talked with Kloek about a range of topics, including defining the CMO role at OU Health, achieving high-quality care, and driving innovation at OU Health. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You are the inaugural CMO at OU Health. What are the primary ways you plan to define the role?
Carolyn Kloek: It is a tremendous opportunity, and I am thrilled to be able to work with teams across OU Health.
As the CMO, I see myself as a leader to drive change and improvements in our performance in many different areas. I also think that healthcare is a team sport, and I will be leaning into teamwork, supporting our teams in their efforts to drive improvement in our patient outcomes.
The scope of work under the office of the CMO has several areas that we are actively building out, which includes quality and safety, medical informatics, data analytics, patient experience, digital health, population health, and process improvement. There are tremendous synergies between all of these areas, and I will be working hard to set up teams within each area, then matrixing those teams so we can drive performance improvement.
HL: What do anticipate will be your biggest challenges in serving as CMO of OU Health?
Kloek: There are some overarching themes of challenges that we face at OU Health. One is our access to care, particularly in Oklahoma, which is a state that is largely rural. Access to care is an issue that we need to tackle. It is on OU Health and healthcare professionals in general to aid in the development of strategies to improve access for patients in the rural parts of the state and to ensure that we are delivering equitable care to all patients seeking care at OU Health.
Another challenge we are facing is in our workforce shortages. Our providers, nursing staff, and other key pieces of the healthcare workforce are stretched thin. We depend heavily on these valuable, highly skilled professionals to create access and to deliver high-quality care. We need to continue to do everything we can to support members of our healthcare workforce and get creative in the ways that we design and deliver care at OU Health.
Financial sustainability is another challenge that we and many other healthcare organizations are facing. At this point in time coming out of the coronavirus pandemic and as the state's only academic health system, it is critical that we remain strong financially while we concurrently provide top-notch clinical care to meet the most complex medical needs in the state and fulfill our academic mission as well.
HL: You were vice chair of quality and innovation at the Dean McGee Eye Institute. What are the primary keys to success in achieving high-quality care?
Kloek: One of the important principles is the commitment to strong leadership in delivering high-quality patient care. It is on leaders to work with their teams to establish a culture of quality and safety, to set clear goals, and to provide the necessary resources and support to care teams.
Tied with leadership is a culture of continuous quality improvement—creating a continuous cycle and driving to always improve in our healthcare settings.
We need a data-driven approach to improvement. Performance needs to be measured—you can only manage what you measure. Data becomes the tip of the spear to help us identify the areas in which we are underperforming. Then we need to ask ourselves, why, and what can we do to improve performance? On the flip side, we can also use data to tell us where we are doing well, then try to scale that across the organization.
Collaboration and teamwork are also important to performance improvement in a health system, which is a complicated ecosystem.
HL: How can OU Health drive innovation?
Kloek: As the only academic health system in Oklahoma, OU Health is very well positioned to drive innovation. We have the unique aspect of having the tripartite mission—the alignment of clinical care, education, and research. We can innovate in each of those areas. By innovating in those areas, each one feeds and builds on the other areas and makes those areas stronger. You get into a virtuous cycle that drives innovation in each of the three domains.
Carolyn Kloek, MD, chief medical officer of OU Health. Photo courtesy of OU Health.
HL: What are the key elements of patient safety?
Kloek: For health systems to drive safety, there needs to be a preoccupation with the delivery of safe care across the board. There needs to be a hardwiring of safety within all elements of the organization. You need to look at areas where you are underperforming and understand the safety areas you need to be tackling in order to improve. Similarly, you need to look at areas where you are doing well—find out the safe practices that you are proud of and want to scale across the organization.
An important element of patient safety is capturing the voice and input of our frontline caregivers. They are often the best positioned to identify practices that are enhancing patient safety as well as any areas where we could be improving.
HL: You have a clinical background in internal medicine and ophthalmology. How has this clinical background helped you serve in physician leadership roles?
Kloek: Having had diversity of training both in internal medicine during my internship and ophthalmology is incredibly helpful. It has given me perspective on many different sites of service in a health system—in the inpatient setting, ambulatory care, operating rooms, and ambulatory surgery centers. I have worked as a clinician delivering care in all of these settings, and that diversity of experience has been helpful in leadership positions.
HL: What advice can you offer to other female physicians who may be interested in administrative leadership roles?
Kloek: The first piece of advice is to believe in yourself. You need to have confidence in yourself and believe that you can achieve in whatever area you are striving to grow and lead.
It is helpful to develop leadership skills, and that comes from proactively developing leadership skills. There are formal paths to doing that through leadership courses specifically tailored to physicians, and you need to pair that with leadership experience in the clinical setting. Gaining leadership experience in the clinical setting often does not start big. It can be asking yourself, "What can I help fix? What can I help address to make this environment better for my patients and for my colleagues?" You need to roll up your sleeves. With on-the-ground leadership experience, opportunities will start to come as you have wins in different areas.
Another piece of advice is to build a network of support and mentorship. When I look at the mentors I have had along the way, they have been able to give me coaching, give me advice, open up opportunities, and help me to this day as I continue to grow as a leader.
The last piece of advice is to embrace diversity and inclusivity in all forms. We all are strengthened by seeking the input of a diversity of people—people with different thoughts and different backgrounds.
The immediate release of test results without counseling from a clinician is controversial.
The vast majority of patients want to receive test results online even if their healthcare provider has not reviewed the test results, according to a new research article.
In April 2021, a federal rule went into effect requiring immediate electronic availability of medical test results upon request by patients and care partners. Providing patients access to their medical records has been proposed as a way to strengthen patient-clinician relationships. However, the immediate release of test results without counseling from a clinician is controversial.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 8,000 adult patients and care partners who had gotten test results through an online patient portal from April 5, 2021, to April 4, 2022.
The survey was conducted at four academic medical centers: University of California, Davis Health; University of Colorado Anschutz Medical Center; University of Texas Southwestern Medical Center; and Vanderbilt University Medical Center.
The study features several key data points:
95.7% of all survey respondents wanted to receive test results immediately through the online patient portal, even if the results had not been reviewed by a healthcare provider
95.3% of survey respondents who received abnormal test results reported that they wanted to continue to receive test results immediately through the online patient portal
Most survey respondents (57.3%) reported their test results were normal
7.5% of survey respondents reported that receiving test results before they were contacted by a healthcare provider increased worry
Increased worry was more common among survey respondents who received an abnormal test result (16.5%) than among survey respondents who received a normal test result (5.0%)
"In this multisite survey study of patient attitudes and preferences toward receiving immediately released test results via a patient portal, most respondents preferred to receive test results via the patient portal despite viewing results prior to discussion with a health care professional. This preference persisted among patients with nonnormal results," the study's co-authors wrote.
Interpreting the data
Balancing patient worry with immediate access to test results is a key issue, study co-author Liz Salmi, communications and patient initiatives director of OpenNotes at Beth Israel Deaconess Medical Center, said in a prepared statement. "As healthcare systems continue to navigate this new era of health information transparency, balancing patients' expectation of immediate access to their information with the need to manage increased worry is important. Additional research is necessary to better understand the nuance of worry from receiving abnormal test results, especially as it relates to revealing information about a newly diagnosed condition such as Huntington's disease or cancer."
There are apparently positive factors to receiving test results immediately even when the results are abnormal, the study's co-authors wrote. "We found that 95.3% of participants who received abnormal test results would like to continue to receive immediately released results through the portal. This finding suggests that there may be benefits to receiving abnormal results online, such as allowing patients to choose where and with whom to view such results."
Most survey respondents (92.3%) reported receiving precounseling about their test results, but there was no association found between precounseling and lower levels of worry. The study's co-authors wrote that there can be several approaches to precounseling.
"Precounseling strategies might encompass both technical and social-technical approaches, including in-person anticipatory guidance, improved asynchronous communication, and portal-based educational materials. Other strategies include optimizing existing patient portal interfaces to give users control over their notification preferences related to sensitive or abnormal results or timing the release of test results during working hours. Additional research is necessary to further investigate the efficacy of strategies to mitigate emotional distress."
Bob Taylor, MBA, senior vice president of supply chain at RWJBarnabas Health. Photo courtesy of RWJBarnabas Health.
Thomas Ivester, MD, MPH, chief medical officer and vice president of medical affairs at UNC Hospitals. Photo courtesy of UNC Hospitals.
