This simple framework helps guide clinicians through condition diagnosis, prescribing, patient monitoring, and deciding therapy duration.
A four-phase approach to prescribing and managing antibiotics focuses on critical time points to achieve effective antibiotics stewardship, a recent article in JAMA says.
Appropriate prescribing of antibiotics by healthcare providers 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. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.
The lead author of the JAMA article, Pranita Tamma, MD, MHS, of Johns Hopkins University School of Medicine, is a co-creator of the 4 Moments of Antibiotic Decision-Making concept.
"The 4 Moments concept is a simple construct that clinicians can incorporate into their daily decision making to decide whether antibiotics are needed in the first place; and if they are needed, making sure the right antibiotic for that particular patient is being administered and for only as long as necessary," Tamma told Healthleaders recently.
In the acute care setting, the 4 Moments approach creates a simple framework for comprehensive administration of antibiotics, she said.
"Our hope would be that the Four Moments are discussed on a daily basis— depending on the moment relevant to the particular patient—during clinical rounds with team care involving nursing, pharmacy, and clinicians to ensure the best possible outcomes for patients."
Moment 1
At the first step of care, Moment 1 is when prescribers should decide deliberately on whether a noninfectious process is at play. In dyspnea patients, several noninfectious conditions could be an underlying cause such as aspiration pneumonitis, atelectasis, congestive heart failure, and pulmonary embolism.
At Moment 1, clinicians should assess relevant patient information to gauge the likelihood of an infection and advisability of prescribing antibiotics.
Moment 2
There are a pair of considerations at Moment 2.
First, cultures should be obtained when advisable before antibiotics are administered. Second, after antibiotics have been ordered the care team should administer the medication promptly.
To facilitate Moment 2 decision making, there should be hospital treatment guidelines for common inpatient infections.
Moment 3
A day or two after antibiotics have been administered, clinicians should consider whether to continue the medication, narrow the therapy, or change from intravenous to oral antibiotics. Review of a patient's antibiotics treatment should be conducted daily and documented in progress notes, including indications to continue antibiotics, plans to narrow therapy, and anticipated therapy duration.
Moment 4
Therapy duration is the focus of Moment 4.
Studies indicate that therapy duration should be shorter than previously practiced for many of the infections treated in the acute care setting such as community-acquired pneumonia, ventilator-associated pneumonia, intra-abdominal infections, and urinary tract infections.
Adopting best practices
Part of good antibiotics stewardship is breaking bad habits, Tamma said.
"Very often as clinicians, it becomes practice to start antibiotics as a reflex. For example, if a hospitalized patient has a fever, antibiotics are administered. If the same patient was at home, we would probably suggest he or she monitor symptoms for some time before considering antibiotics," she said.
Monitoring the administration of antibiotics in the inpatient setting is crucial, Tamma said.
"After antibiotics are started for a hospitalized patient, clinicians often get consumed with other aspects of the patient's medical care and sometimes forget that antibiotics are still onboard or forget to review whether the antibiotics can be changed to less toxic agents or switched from intravenous to oral antibiotics."
CPOs impact health systems on several crucial fronts, including patient safety, cost containment, and standardization.
Chief pharmacy officers play a leadership role in key areas for health systems such as standardization, says the new CPO at West Virginia University Health System.
Pharmacy is a critical component of an integrated health system, with significant financial and clinical considerations. Financially, medication costs are rising, and precision medicine is likely to extend that burden. Clinically, medications are often pivotal to achieving good outcomes, but they pose patient safety risks.
Todd Karpinski, PHARMD, is set to join WVU Medicine in Morgantown on Feb. 18. CPO is a newly created position at the health system.
He is currently national director of ambulatory pharmacy at The Resource Group—a business consulting division of St. Louis-based Ascension Healthcare.
HealthLeaders recently spoke with Karpinski about the CPO role. Following is a lightly edited transcript of that conversation.
HL: What are the key responsibilities of a CPO?
Karpinski: The role of the chief pharmacy officer has evolved over the past five to 10 years as health systems have come together, merged, and acquired new facilities. There has been a strong push around standardization of medication processing across all of a health system's sites.
It’s the primary responsibility of the chief pharmacy officer to help lead the strategy and effort to bring the facilities together and standardize how medications are being used, what types of medications are being purchased, and how we are ensuring safe medication practices across all facilities.
A growing concern we see in healthcare is rising costs of drugs. It's imperative for chief pharmacy officers to work with physicians and clinicians to ensure that we are using the most cost-effective medications while targeting good clinical outcomes.
HL: How can CPOs manage standardization processes?
Karpinski: From a safety standpoint, there are key recommendations from the Institute for Safe Medication Practices to prevent patient harm. You need to implement all of those recommendations.
In pharmacy operations, we try to reduce waste utilizing lean methodologies to reduce variation and decrease waste. In using lean, you also improve quality and safety. You look methodically at how every piece of pharmacy operates and apply lean principles to get the most efficient operation possible. Standardizing our processes helps keep our patients safe.
HL: How does having a CPO benefit a health system?
Karpinski: Each hospital tends to have a director of pharmacy who traditionally has reported to a vice president or the chief operating officer. The goal for each individual pharmacy may or may not be aligned with the overarching goals of the health system and achievement of quality outcomes, clinical outcomes, and finance outcomes.
It's imperative to have one individual in an executive pharmacist role to bring the directors together to make sure that everyone is pulling in the same direction.
The chief pharmacy officer is now considered an executive leadership position, so you are at the table with the CEO, COO, CFO, chief nursing officer, and chief medical officer to help set strategy for the health system, particularly for how medications are going to be utilized to promote good outcomes for patients.
HL: How does a CPO add value to the C-Suite?
Karpinski: Number One, you get to be part of setting the overall strategy for the organization. You get to hear the key concerns that other executives are facing, and you can work with them to develop strategies as pharmacists to meet their goals or to alleviate some of their anxieties. You can work with the CFO on how much money is being spent on medication and revenue opportunities with the growth of specialty pharmacies, creating your own pharmacy benefit manager capability, and development of retail pharmacies.
Secondly, reporting directly to the CEO puts the chief pharmacy officer in a top-level position within the organization, which hopefully removes barriers to getting things done, when you work through several executives.
Patient safety deficiencies are spotlighted in a new documentary.
One of the most influential reports on patient safety has inspired the production of a documentary film.
In 1999, the Institute of Medicine published "To Err Is Human: Building a Safer Health System," which included the alarming statistic that as many as 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.
This week, the son of patient safety pioneer John Eisenberg, MD, is making the general public release of To Err Is Human, a documentary film inspired by the Institute of Medicine report.
"One of the reasons we felt the film was important right now is it's been 20 years since 'To Err Is Human' was published and patient safety has taken a back seat to other issues in healthcare, but it's paramount to the success of the healthcare system," filmmaker Mike Eisenberg told HealthLeaders.
Eisenberg said his father, who served as director of the Agency for Healthcare Research and Quality and died in 2002, was a guiding force for the documentary.
"It always came back to what my father would have wanted people to know about this issue and how he would have told this story. That guided us down the path of trying to stay positive and solutions-oriented. We wanted to show healthcare at its best rather than presenting medical error as a monster that is unbeatable," said Eisenberg, who is the director, editor, and co-producer of the documentary.
Eisenberg said three of the major themes of the film are zero-harm healthcare, maximizing the gains of patient engagement, and generating benefits from simulation.
The film, which is available on Amazon and iTunes, features interviews with three dozen healthcare leaders on patient safety issues and the heart-wrenching story of the Sheridans.
Medical catastrophe struck the Sheridans twice. First, a medical error after birth resulted in son Cal developing cerebral palsy. Second, father Pat lost his battle with cancer after a pathology report that showed a deadly malignancy languished and delayed care.
The delayed pathology report was hard for Pat Sheridan to bear, his wife said in the film. "I remember Pat crying. To think that another error had taken place—this time with him—that was difficult for us to witness."
The Sheridans' story, told by mom Sue, is interspersed between the healthcare expert interviews, which include prominent figures such as Don Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services.
Extending the documentary's reach
In addition to this week's general public release, To Err Is Human has been viewed at dozens of screenings at healthcare organizations, with 75 screenings held last year and 30 booked for this year so far.
"A really effective way to make change is to have a screening with a panel discussion afterward in which local or national experts talk about the film and what we can do to keep the momentum going forward. It's not enough to make a film, do a good job, and be patient," Eisenberg said.
He hopes the documentary will accelerate the drive to transform patient safety.
"This film needs to serve as a motivational tool for healthcare to keep going and keep doing better, and for patients to understand the problems so they can engage with that process."
Editor's note: This story was updated Monday, January 28, 2019, for added clarity.
The academic health system in New Jersey has taken several specific steps toward workplace violence prevention and designated leaders to continue problem-solving.
Workplace violence is a widespread problem within the healthcare setting that must be prevented for the safety of clinicians and patients.
That's why RWJBarnabas Health in New Jersey is taking a stand against workplace violence at its hospitals and clinics. The academic integrated healthcare system has launched or enhanced efforts to curb workplace violence in several key ways.
"Nurses, nursing assistants, and security guards are more likely to encounter violent behavior, but it is not limited to them. You can find violent incidents in all areas of a health system's facilities," says Nancy Holecek, RN, MHA, MAS, senior vice president and chief nursing officer of RWJBarnabas Health's Northern New Jersey Region.
Here are five things that RWJBarnabas is doing to thwart workplace violence:
1. Created facility safety assessments
Facility safety assessments seek to ensure buildings are as safe as possible, Holecek says.
"We have been looking at our technology, looking at our visitor access system, and looking at our security workforce to ensure that we have the most updated technology and that we have our entrances covered and locked down at the appropriate time," she says.
A major facility challenge is aligning safety and service, she says. "We have to always make sure that we balance the security piece with open access for anyone who needs our services."
2. Instituted quick reporting technology for violent incidents
RWJBarnabas focused on ease of reporting largely because workplace violence incidents are underreported, Holecek says.
"If it's an event that results in a serious injury, then it gets reported. If it's something minor or a threat, unless staff members truly feel they are in danger, they generally treat the incident as part of the symptoms or disease that a patient is presenting," she says.
The health system has adopted reporting technology that allows staff members to click on a computer desktop icon and quickly file reports on workplace violence, she says.
Eased reporting has created a data opportunity, she says. “We have seen an increase in reported events, which was to be expected. The trending of this data related to number, severity, location, and person—patient, visitor or other—will allow us to better track, respond, and strategize our efforts.”
3. Raised awareness among staff
Raising awareness about workplace violence boosts safety and increases the likelihood of reporting, Holecek says.
"Oftentimes, [violent behavior] is something a patient can't control [because of] dementia or a behavioral health issue. Our staff understand this and make excuses for it. The problem with that is we can't collect data and we can't intervene; so, we are encouraging our staff to report," she says.
4. Enhanced training
RWJBarnabas is improving its Behavioral Emergency Safety Training (BEST) with the help of a consultant.
"The focus is to de-escalate the behavior—not to pin the person against a wall. This has been very successful. It works a large percentage of the time," Holecek says of BEST.
The consultant is adding a new layer to the BEST training—instructing staff about duty to warn, duty to act, and duty to respond.
"The consultant is training trainers who will go out to work with our security workforce, behavioral health workforce, and emergency workforce, and then expand to make sure all of our employees are trained," she says.
5. Added violent incidents to daily debriefings
Addressing incidents of workplace violence has become part of a larger high-reliability initiative at RWJBarnabas.
The initiative includes 15-minute leadership huddles in the morning at each of RWJBarnabas's 11 hospitals to review facilitywide issues from the previous 24 hours. Workplace violence incidents are among the topics discussed.
The CEO usually leads the morning huddle, with about 45 participants ranging from the C-suite to the department director ranks.
"This informs the entire senior team and department heads so they know what has transpired. It helps us stay abreast of any incidents of workplace violence that may have occurred," Holecek says.
In addition to those initiatives, the health system formed a steering committee—an interdisciplinary group with representatives from compliance, emergency management, HR, legal, nursing, physicians, IT, and security—to lead workplace violence prevention efforts.
This article is based on an earlier HealthLeaders article.
Multicultural patients face multiple barriers to receiving care for depression such as scant referral options.
A Virginia-based health center's quality improvement project was able to significantly improve depression care for a vulnerable multicultural population, research shows.
Annual societal costs associated with depression are estimated at $210 billion, and depression is the top cause of disability globally. For minority, immigrant, or refugee patients,cultural factors often impede on depression treatment such as confusion about the concept "warm handoff."
Depression screening is a building block for behavioral health interventions, the lead author of the research, Ann Schaeffer, DNP, a certified nurse midwife at Harrisonburg Community Health Center (HCHC) in Virginia, told HealthLeaders.
"Improving depression screening should lead to measurable outcomes for those who screen positive, including referral to mental health specialists, prescription of appropriate medications, and perhaps most importantly, scheduling of follow-up appointments to monitor signs and symptoms of depression," she said.
At HCHC, an effort was launched to boost access to depression services in vulnerable multicultural communities, Schaeffer said.
"There are multiple barriers. These include clinics not prepared with screening tools in multiple languages; providers not culturally aware of the stigma attached to depression; lack of provider confidence in client engagement; and few referral options for multicultural populations," she said.
The HCHC initiative made significant progress. Evidence-based care practice increased to 71.4%, adherence to follow-up care increased from 33.3% to 60.0%., and the rate of screening in patients' preferred language increased to 85.2%.
To topple barriers to care, HCHC implemented a four-part intervention.
1. Utilizing multilingual screening
With the Patient Health Questionnaire in six languages as the screening instrument, any score other than zero was considered positive and led to a brief intervention and follow-up planning.
The PHQ, which features nine questions, was made available to patients in English, Spanish, Arabic, Russian, Kurdish, Swahili, and Tigrinya.
2. Sharing decision-making
After a patient screened positive, the care team used the Option Grid shared decision-making tool to guide the conversation about follow-up care. The Option Grid was translated into the top three languages in the patient population: Arabic, English, and Spanish.
Option Grid features standardized tools to help patients share what matters most to them, are easy to read, are simple to use, and meet shared decision-making standards.
3. Engaging with patients
HCHC used a tracking log that monitored weekly follow-up calls, behavioral health appointments, and handoffs to social workers in primary care practices.
The tracking log had several other elements.
A checklist of seven depression risk factors such as chronic illness and abuse
A nine-point checklist for plan of care, including education, watchful waiting, and medication
Choice of follow up—appointment, phone call, or none
Outcome of follow-up care and plan for future care
Tracking of PHQ scores, which were collected at all patient follow-up visits
4. Building strong team
HCHC held team meetings every two weeks to focus on education, training, capacity building, and communicating about the initiative.
Sudden cardiac arrest is a leading cause of death and some hospitals are equipped to play leading role in care.
Cardiac arrest patients would benefit from a regionalized system of care similar to tiered trauma centers, recent research indicates.
In high-income countries, sudden cardiac arrest is the most common cause of death. For patients who achieve return of spontaneous circulation and are taken to a hospital, most do not survive to discharge.
With a patient population drawn from southwestern Pennsylvania, Ohio, West Virginia, and Maryland, the researchers targeted hospitals that received cardiac arrest patients transferred from other hospitals. These "cardiac arrest receiving centers" were viewed as the best facilities locally.
"Both early interfacility transfer to a cardiac arrest receiving center and direct transport to a cardiac arrest receiving center from the scene are independently associated with reduced mortality," the researchers wrote.
The study, based on 5,000 cases of cardiac arrest, found that treatment at a cardiac arrest receiving center generated a 27% decrease in hazard of death compared to treatment at other hospitals.
Regionalizing cardiac arrest care is a golden opportunity, the researchers wrote. "Given the prevalence of out-of-hospital sudden cardiac arrest, the potential for improved outcomes through optimization of regionalized care is considerable."
Excelling in cardiac arrest care
The lead author of the research, Jonathan Elmer, MD, MS, at the University of Pittsburgh School of Medicine in Pittsburgh, told Healthleaders recently that transfer was a key metric for cardiac arrest receiving centers.
"We focused on centers that received large numbers of patients via interfacility transfer. These centers are viewed locally as centers of excellence, and the centers shipping out patients were the feeder hospitals," he said.
Cardiac arrest receiving centers need to be strong in at least four areas, Elmer said.
Cardiac arrest and post-arrest care is complex and time-sensitive, so patients need a diverse team of clinicians beyond a cardiologist
Hospitals should have a robust system of local expertise in heart, brain, and general critical care
There needs to be continuum of care coverage from the early stage of resuscitation through prognostication and prediction of outcome
Bridges should link acute hospitalization to post-acute rehabilitation settings
Patients with average acuity could be best suited for treatment at a cardiac arrest receiving center because few patients survive severe cardiac arrest and mild cases can be treated at most hospitals, Elmer said. "Patients who are too well or too sick to benefit from tertiary care are patients who are probably best cared for near their family."
In new survey, 68% of clinicians reported frequent incidents of catheter dislodgement.
Dislodgement of venous access devices such as catheters is widespread and underreported, a survey of 1,500 clinicians shows.
There are several negative impacts from dislodgement of peripheral and central catheters including interrupted treatment, supply waste with catheter replacement, phlebitis, and infection.
Dislodgement is a significant source of wasteful spending at health systems and hospitals, the author of the survey, Nancy Moureau, RN, PhD, of Hartwell Georgia-based PICC Excellence Inc., told HealthLeaders last week.
"Accidental dislodgement may be a much bigger problem than central line associated blood stream infections. It contributes to the increasing cost of healthcare. When we look at the estimates of dislodged catheters, there are more than five million incidents. If you put dollars and cents to that, it's more than a billion dollars that is lost every year," she said.
The survey found high rates of catheter dislodgement.
68% of clinicians surveyed said accidental dislodgement occurred often, daily, or multiple times daily
The top three reasons for dislodgement were confused patient (80%), patients removing catheters (74%), and loose IV catheter tape or securement (65%)
Audits essential step
Auditing incidences of catheter dislodgement and other vascular access device failures is crucial to managing care, Moureau said.
"With value-based purchasing and pay-for-performance, everyone is on alert to reduce complications with these devices whether they are peripheral or central. By auditing complications—specifically dislodgement—we can identify causes and incidents. Then you can look to the solutions."
The electronic medical record should account for discontinuation of vascular access devices for a patient including dislodgement, Moureau said.
"The EMR should have appropriate choices that include dislodgement and whether it was associated with securement, the dressing, or a patient dislodgement or a staff dislodgement. Looking at the reasons helps us to reach what the solutions may be."
Health systems and hospitals also should encourage reporting of catheter dislodgements, she said.
"Hospitals can stress compliance with documentation and work on electronic medical record documentation in order to provide clear choices that are consistent with the reasons for catheter failure with dislodgement. Making a more accurate notation is one of the best ways hospitals can move forward with managing dislodgement."
Auditing is foundational to improving vascular access device care, Moureau said. "Audit can help you achieve two key results: increasing education and helping to recognize where there are safety issues."
Shared decision-making about health conditions is linked to lower likelihood of patient legal action.
Shared decision-making can significantly lower the probability that patients will file lawsuits and complaints, recent research indicates.
Multiple benefits have been associated with shared decision-making such as facilitating patient-centered care and managing overutilization of lab tests as informed patients forego invasive exams.
Shared decision-making provides clinicians with a measure of legal relief, the research team wrote in the Annals of Emergency Medicine. "Although intent as reported on a survey does not always predict behavior, our results suggest that the use of shared decision-making confers medicolegal protection in the event of an adverse outcome."
The researchers used a Web-based research recruitment platform to enlist 800 study participants. The participants were surveyed after completing decision-making vignettes for an appendicitis scenario.
Study participants who engaged in brief or thorough shared decision-making were 80% less likely to want a lawyer than participants who did not engage in shared decision-making.
"Participants exposed to either level of shared decision-making reported higher trust, rated their physicians more highly, and were less likely to fault their physicians for the adverse outcome compared with those exposed to the no shared decision-making vignette," the researchers wrote.
There are three primary barriers to shared decision-making, the lead author of the research, Elizabeth Schoenfeld, MD, MS, assistant professor, Department of Emergency Medicine at UMass Medical School-Baystate, and adjunct faculty at Tufts University School of Medicine, told HealthLeaders recently.
1. Finding the time
"Clinicians feel that shared decision-making takes up too much time," Schoenfeld said.
It takes organizational commitment to include patient preferences in decision-making, she said.
"We can't just create work-arounds, like sending patients decision aids in the mail, or having a non-clinician start the shared decision-making process. We have to actually commit to giving clinicians time to have these conversations. Clinicians, for their part, can get better at having these conversations efficiently, but a conversation will always take longer than a directive," Schoenfeld said.
2. Weighing options
Clinicians often feel shared decision-making is inappropriate because the options are not equally advisable, she said.
"The clinician thinks that option A is probably better for the patient than option B, and therefore doesn't want to discuss the options. The problem with this is that many of our 'medically reasonable' decisions have consequences to patients that we have either not considered or have not given sufficient weight."
Clinicians need to commit to shared decision-making even when they think one option makes more sense, Schoenfeld said. "We need to remember that decisions that seem straightforward to us may be less so when the patient's preferences are considered."
3. Encouraging patient participation
Many clinicians assume that some of their patients do not want to be involved in shared decision-making, but patients want to be involved in decisions when they understand the consequences, she said.
"This means that clinicians should err on the side of thoroughly explaining options and consequences before they seek patient feedback. It also probably reflects that we could all be better at communicating medical decision-making."
The crisis declaration includes a call for three interventions to help physicians and their employers address burnout.
The Massachusetts Medical Society and three other Bay State healthcare organizations have declared physician burnout a public health crisis.
Recent research indicates that nearly half of physicians 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.
"We need our healthcare institutions to recognize burnout at the highest level, and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us," Alain Chaoui, MD, president of the Massachusetts Medical Society and a practicing family physician, said in a prepared statement.
In a report released today, the medical society calls for urgent action in tandem with the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, and the Massachusetts Health and Hospital Association.
In addition to alarmingly high physician burnout rates, the report lists several dire consequences associated with the phenomenon.
Burnout reduces the work effort of physicians about 1%, which is equivalent to losing the graduates of seven medical schools each year
Burnout-related departures from the medical profession are worsening the country's physician shortage, which is estimated to reach 120,000 by 2030
The Massachusetts report's call to action includes three interventions to reduce physician burnout.
1. Addressing mental health
Efforts should be initiated immediately to stop stigmatizing physicians with burnout, the report says.
"Physicians face stigma and professional obstacles to seeking appropriate care and treatment for burnout and related mental health concerns. Physician institutions — including physician associations, hospitals, and licensing bodies — should take deliberate steps to facilitate appropriate treatment and support without stigma or unnecessary constraints on physicians' ability to practice."
In addition, statewide physician health programs are needed to help encourage physicians to seek help for symptoms of burnout, the report says.
2. Improving electronic health records
in a recent survey, EHRs were the top "pain point" at physician practices.
The report makes four recommendations to ease the EHR burden on physicians.
Involve physicians in efforts to develop user-friendly EHR technology
Allow software developers to craft apps for certified EHR systems to boost functionality and usability
Establish application programming interfaces that enable third parties to develop apps for EHRs
Develop artificial intelligence capabilities such as analyzing physician narratives and clinical documentation
3. Appointing chief wellness officers
Research shows effective leadership can have a significant impact on physician burnout. The report calls on health systems and hospitals to have chief wellness officers with five primary responsibilities.
Assess the organization's levels and extent of burnout
Establish quality improvement goals and processes as well as report findings about key areas such as wellness and physician satisfaction
Report findings, trends, and strategies to C-suite leadership and boards of directors as a dashboard metric
Develop technological and staffing approaches to easing physician work and administrative burden such as scribes and EHR improvements
Propagate successful approaches to curbing physician burnout
Skeptical perspective
While there is widespread concern in the medical community over physician burnout, alarm over the condition is not unanimous.
In September, a JAMAeditorial claimed there is insufficient data about physician burnout to guide an effective response to the phenomenon.
"The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome. The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic," the editorial says.
Focusing on physician burnout, which is a relatively new diagnosis, could be dangerously misguided, a co-author of the editorial, Thomas Schwenk, MD, professor of family medicine and dean of the school of medicine at the University of Nevada in Reno, told HealthLeaders in September.
"What is more important to note is the high level of depression as a criterion-based diagnosis, with a more clear understanding of pathophysiology and consequences including student, resident, and physician suicide. This would be a more worthy area of focus. It is possible that the use of the term 'burnout' has increased as a sort of more acceptable substitute for a diagnosis that still carries considerable stigma, namely depression," he said.
The University of Pennsylvania Health System reduced hospital readmissions in one year by joining forces with a payer and using value-based approaches.
A relationship between the University of Pennsylvania Health System (UPHS) and Independence Blue Cross has generated a remarkable reduction in hospital readmissions.
For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital’s readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.
After the first year of a five-year contract with Philadelphia-based Independence, UPHS achieved a 25% reduction in hospital readmissions. Hospitals that intervene to reduce readmissions typically achieve 1% reductions.
The new contract took effect July 1, 2017.
Patrick Brennan, MD, chief medical officer and senior vice president of UPHS, says the health system expects further readmission reductions this year and into the future.
"We have already achieved a dramatic reduction through our relationship with Independence, and we can expand on that. In the current fiscal year, we are improving on what we did last year. There are aspects of our work that will be refined and become second nature over time," he says.
Three value-based and innovative approaches are largely responsible for the readmission reductions at UPHS.
1. Embracing value-based partnership
Data sharing between UPHS and Independence has been essential to reduce readmissions and redesign care, Brennan said.
"We have a data exchange with them. It was born out of earlier iterations of their pay-for-value program. We weren't getting information in anywhere near real-time—we really couldn’t manage. For example, we would be held accountable for readmissions and go through an entire year and into the next fiscal year without a sense of our performance," he says.
The five-year contract with Independence has a trio of value-based programs.
The readmissions program, which puts UPHS at financial risk for 30-day readmissions
Reducing the total cost of care for the health system's attributed population, such as establishing preferred provider relationships with skilled nursing facilities
Expanding episodes of care to about a dozen bundles, which include sepsis, hysterectomy, hip and knee replacement, heart failure, and back surgery
UPHS and Independence have invested considerable time and effort to build a mutually beneficial relationship, Brennan says. "This partnership did not happen overnight—it's been developing over years. A mutual trust has developed between the organizations. The fact that we are able to share information has been the foundation."
The Independence contract has prompted UPHS to improve clinical care broadly, he says. For example, patients at high risk for readmission now receive a call from a scheduler who assists in arranging follow-up outpatient appointments.
"This contract galvanized our interest in redesigning care. The trigger was the readmission program; but as we got deeper into the contract, we realized we were going to have to redesign our whole process of care. We could not have done that without the information systems we have enterprise-wide. All of our practices and all of our hospitals are on the same information system," Brennan says.
2. Upgrading information systems
UPHS has installed readmission scoring systems in the electronic health record that clinicians can access. "Every discharge gets scored, and we can see who is at risk," Brennan says.
Risk stratification allows UPHS clinicians to focus resources on patients who are at highest risk of readmission. Patients classified at high risk of readmission return to the hospital 16% of the time. Patients classified at low risk of readmission return to the hospital less than 1% of the time.
Redesigning care has necessitated different behaviors among physicians, nurses, and social workers, which has prompted the health system to leverage technology to monitor new metrics, he says.
"We are working hand-in-glove with our informatics folks to enable us to measure our performance. The beauty of the changes we have made to our information system is we can tell how often people are using order sets and we can tell whether the after-visit summary and the discharge plan are fully complete at the time of discharge," Brennan says.
UPHS is planning to roll out more information system upgrades that will help drive down readmissions.
"We're also moving toward the adoption of other systems that will give us predictive information about the best services that would be best-suited for patients at discharge. Other systems will give us insight into the patient records when they are at other facilities. We really want to know how patients who have left us are performing," Brennan said.
3. Avoiding seven-day readmissions
UPHS has focused on reducing readmission seven days after discharge.
"We think 30% to 40% of our readmissions occur within seven days—that has been a consistent number over the past 10 years," Brennan says.
Avoiding readmissions within seven days of discharge has become an organizational imperative at UPHS.
"Seven days—we really own that. If we can't keep someone at the next level of care for seven days, something happened in our processes. That gets back to what we call system of care design and how we are getting patients ready for discharge and providing information to the next level of care," he says.
A pair of work groups is focused on readmissions within seven days.
One work group accurately identifies patient diagnosis at time of admission and adjusts the diagnosis through the course of the hospitalization to ensure that care teams have accurate information on patient status. For example, a patient might be admitted with a diagnosis of stroke but leave with a diagnosis of seizure disorder.
The other work group is focused on discharge—establishing a discharge work plan that includes a readiness assessment for discharge, the risk score for readmission, and tools that provide the patient with an after-visit summary.
UPHS has taken a proactive approach to addressing shortcomings that lead to readmissions within seven days, Brennan says.
"For patients who have seven-day readmissions, they are patients with acute issues that aren't being addressed in a timely fashion, or patients who show up somewhere for follow-up care and there is inadequate information available to the clinician," he says.
