At physician practices affiliated with Virginia Mason Medical Center, effective workflow optimization addresses burnout challenges with a team-based approach.
Through workflow optimization, physician practices can create a team-based approach to care that alleviates physician burnout, a Seattle-based internist says.
Inefficient workflows contribute to physician burnout in several ways, says Richard Furlong, MD, an internist affiliated with Virginia Mason Medical Center.
"The elements of physician burnout that are impacted by a flow that is not optimized are waiting unnecessarily, having a visit that you are conducting not set up for you, having a schedule that is mismatched relative to the demands upon you, and having a sequence of tasks that you are burdened with that are not matched with your skill level," Furlong says.
Effective workflow optimization addresses burnout challenges with a team-based approach, he says.
"Optimization initiatives that address flow are usually targeted at those categories—lack of set up, mismatch of supply and demand, and poor skill-task alignment."
Furlong and his care team colleagues have focused primarily on three workflow optimization tactics that foster team work: spreading the work burden among physicians, adoption of standardized work roles, and colocation of team members when feasible.
"We have team members who can help us, but we have to organize the work so that can happen," he says.
Data collected by The Advisory Board indicate that the workflow optimization efforts are having a positive impact on the employment satisfaction of physicians, advanced registered nurse practitioners, and physician assistants at Virginia Mason Kirkland Medical Center, where Furlong is based.
For the past two years, 100% of physicians, APRNs, and PAs surveyed have reported they were engaged or content with their workplace. Engagement is considered an indication of a staff member's dedication to the organization and willingness to go above and beyond on the job.
Spreading responsibilities
To prevent physicians from burning out, and to help them work at the top of their license, patients in Furlong's practice are often seen by caregivers other than the physicians, including clinical pharmacists, care managers, RNs, physician assistants, and nurse practitioners.
For example, diabetic patients can be seen by care managers and nurses who can help the patients manage their chronic condition.
"We have a process in place where the patient can be referred to a care manager, and the care manager becomes a co-owner of that patient. We'll make phone calls in between visits, and patients will have nurse-only visits for insulin teaching and lifestyle modification," Furlong says.
"The physician is not out of the loop but is not involved in every one of the care touches. When the patient comes back after three months to have their A1C checked and their meds reviewed, we have done some focused training with our APs to handle those follow-up visits," Furlong says.
Clinical pharmacists have been playing an increasingly important role in spreading the workload, he says.
"What a lot of clinics have not done is to take some of their staff—especially the clinical pharmacists—and plug them into the workstation of the provider who is out of the office on any given day. That has been successful for us because a lot times the clinical pharmacists have capacity in their day to help physicians," Furlong says.
The role of clinical pharmacists has been expanding steadily at Furlong's practice.
"They are involved in seeing patients in face-to-face, direct care. They started out seeing our coagulation patients—our patients on Warfarin. Then we had them see our hypertension patients. Now, we have them seeing patients on antidepressants and chronic opiates," he says.
Most primary care practices could benefit from utilizing clinical pharmacists, Furlong says. "They are in the mix in primary care in a big way. A lot of other healthcare institutions are getting onboard with using clinical pharmacists; and if you are not, you are behind."
Standardized roles
Establishing standardized roles can ease the workload burden on physicians, Furlong says.
For example, his practice has established new standardized roles to limit the number of patient portal and phone messages that are handled directly by physicians.
"The intent was to discern which messages could be handled by someone other than the physicians. So, we had a meeting with the pharmacists and asked them what kind of questions they would be willing to field and bypass the physician," Furlong says.
Medical assistants have also adopted a new standardized role to help manage patient messages, he says.
Colocation
Having care team members located at the same site can enable workflow optimization and ease physician workload, Furlong says.
Having pharmacists on-site can be particularly helpful in giving physicians timely support. For example, they can help review the medications of patients after discharge from a hospital.
"The patient could have 15 medications and there is often confusion about what they were discharged on. The pharmacists are good at digging in and sorting all that out. Sometimes, they can jump in and help on the spot," Furlong says.
And if it isn't possible to have all team members on-site? From a workflow optimization standpoint, it is possible to overcome the lack of care team colocation, he says. "Every health system has an electronic health record, so there are communication tools within the EHR."
For women aged 30 to 65, new national recommendations could mean end of Pap smear tests.
New recommendations for cervical cancer screening feature a significant change—giving women aged 30 to 65 the option to undergo one test every five years.
Screening every three years with cytology alone. Cytology is also known as Pap smear testing.
Screening every five years with testing for high-risk human papillomavirus (hrHPV) alone.
So-called cotesting for cervical cancer with both cytology and hrHPV techniques every five years.
This is the first time women have been given the option to be screened with hrHPV testing alone. The recommendations, which were published this week in JAMA, replace guidance issued in 2012.
A JAMAarticle accompanying the new guidance says the option of hrHPV testing alone reflects a trend toward less frequent testing. "These recommendations continue the trend of decreasing participant burden by lengthening screening intervals, making the 'annual Pap' a historical artifact," the article says.
The hrHPV test detects the DNA of human papillomavirus strains that have been linked with cervical cancer.
Weighing trade-offs
According to the new recommendations, cytology alone every three years or hrHPV testing alone every five years are the preferred cervical cancer screening methods for women aged 30 to 65 years.
Cotesting with cytology and hrHPV exams is considered an "alternative strategy" under the recommendations, but cotesting could result in more tests and procedures than either cytology or hrHPV testing alone.
Physicians and patients face sorting through trade-offs to determine the best screening strategy.
The recommendations estimate that hrHPV testing alone and cotesting would avoid about one additional cancer case per 1,000 women screened compared to cytology alone for a "very small" gain in life years. However, hrHPV testing and cotesting expose women to more tests and procedures than cytology alone.
The JAMA accompanying article says there is a similar trade-off between cotesting and hrHPV testing.
"Cotesting is slightly better than primary hrHPV testing at detecting precancerous lesions but is associated with increased tests and diagnostic procedures that may not benefit the patient and that have real costs to the health system," the article says.
Cytology is the lowest cost option and could be the best fit for public health systems, according to the article.
"Public health systems in general will more explicitly face trade-offs between less expensive techniques (cytology every three years) involving more clinician visits and more expensive approaches with substantially fewer patient touch points," the article says.
With more screening options available, physicians and healthcare organizations need to increase educational efforts for patients.
"What is clear is that new strategies will be needed to assist healthcare consumers in making informed choices from a broader range of options. New risk communication tools and messaging strategies will be needed to promote adherence and to increase acceptance of the lengthened intervals," the article says.
Cost and value
While cytology is the lowest cost screening method, the new recommendations do not address the comparative cost or value of cytology, hrHPV testing, and cotesting.
However, a JAMAeditorial accompanying the recommendations shows how healthcare organizations and researchers can assess the cost and value of the cervical cancer screening options.
One method to assess cost effectiveness and value is quality-adjusted life-years (QALY) analysis. The metric features both benefits and harms to estimate total costs per strategy and cost-effectiveness. Under QALY analysis, high-value screening strategies maximize benefits while minimizing harms and cost.
Physicians will have to help their patients assess value, the editorial says.
"If it is left to individuals to decide whether hrHPV testing or cotesting provides an appropriate balance of benefits and harms as compared with cytology, user-friendly educational tools will need to be developed to assure that women are making informed choices reflective of their preferences," the editorial says.
The Institute for Healthcare Improvement is launching a three-year effort to help decrease maternal mortality and morbidity.
The Institute for Healthcare Improvement (IHI) has launched a three-year initiative to address alarmingly high rates of maternal mortality and morbidity.
IHI, which launched the effort this month with support from the Merck for Mothers $500 million program, is focusing first on designing an approach to improving maternal health, says IHI Executive Director Jill Duncan, RN, MS, MPH.
"It is our commitment to build partnerships with those whose life work is to address women's health—specifically the racial disparities that exist around maternal mortality and morbidity. We are doing outreach and building partnerships," she says.
Among high-resource countries, the United States has the highest maternal mortality rate, according to the Washington, D.C.–based Alliance for Innovation in Maternal Health (AIM). Worldwide, only Afghanistan, Sudan, and the United States are experiencing rising rates of maternal mortality, AIM says.
Best practices
One of the top priorities of IHI's maternal health initiative is promoting the adoption of maternal safety bundles, Duncan says.
"There are safety bundles that organizations are adopting to address hemorrhage, hypertension, C-section rates, and blood clots. They are part of the AIM initiative and have been adopted by several states."
Prevention of retained vaginal sponges after birth
Reduction of peripartum racial and ethnic disparities
Safe reduction of primary Cesarean birth
Severe hypertension during pregnancy
Severe maternal morbidity review
Support after a severe maternal event
IHI is building on Merck's efforts to promote maternal safety bundles, Duncan says.
"Part of our interest is to work with partners who have found some success in spreading those bundles. We want to tie the bundles with our work in scaling best practices with improvement methodologies and accelerate the spreading of those bundles at the state level and at health systems."
Tackling disparity
Racial disparity is among the most vexing problems associated with maternal health, with black women experiencing mortality and morbidity at rates three to four times higher than other mothers, according to IHI.
There is a complex mix of medical and social reasons for the racial disparity, Duncan says.
"Black women are more likely to be uninsured. We are also recognizing the urgency of health systems and other organizations to grapple with unconscious biases—both institutional and structural racism—and the impact that has on black women in this country. It impacts the care that they get and the outcomes they experience."
She says there are several strategies that can be pursued to address the racial disparity in maternal health:
Improving treatment of health conditions and pregnancy complications
Adopting evidence-based methods to decrease complications
Advancing the understanding of the experience of black women
Reducing risk factors
Increasing protective factors such as the support women receive before, during, and after pregnancy
Addressing racial disparity in maternal health will take inspired leadership, Duncan says.
"It takes bold, courageous, and creative leaders in health systems and communities to act in new ways and radically redesign the way they think, the way they work, and the way they connect."
Tobacco use is associated with several negative surgical outcomes, including impaired wound healing, increased infection, and poor lower joint replacement results.
Tobacco smokers who have orthopedic surgery face higher risks of complications and should be enrolled in smoking cessation programs, research shows.
A recent review of 26 scientific articles on smoking and orthopedic surgery found significant risk of negative outcomes for patients.
"People who smoke heavily before orthopedic surgery may have more nonmedical complications than nonsmokers. Therefore, all orthopedic surgery patients should be screened for tobacco use," wrote the author of the review in Hospital Practice, E. Carlos Rodriguez-Merchan MD, PhD.
Smoking cessation
Rodriguez-Merchan says surgeons should help patients stop smoking before and after orthopedic surgery.
"The adoption of smoking cessation methods such as transdermal patches, chewing gum, lozenges, inhalers, sprays, bupropion, and varenicline in the perioperative period should be recommended. Perioperative smoking cessation appears to be an efficacious method to decrease postoperative complications even if it is implemented as late as four weeks before surgery."
Research published last year examined an online smoking cessation program used by smokers undergoing orthopedic trauma surgery. The study showed both strengths and weaknesses of the cessation program.
The study featured 31 orthopedic trauma patients. Engagement in the online cessation program was high, with 28 of the patients using the program during their hospital admissions. In addition, 20 patients completed follow-up smoking cessation phone calls after discharge.
The patients reported several weaknesses of the online cessation program:
Lack of time
Desire for additional support
Computer illiteracy or technology issues
Feeling unprepared or too stressed to quit
Reaching the point where nothing more could be learned from the online program
Smoking complications
Rodriguez-Merchan found multiple scientific articles that concluded smoking increases the risk of complications after orthopedic surgery.
"Orthopedic perioperative complications of smoking include impaired wound healing, augmented infection, delayed and/or impaired fracture union and arthrodesis, and worst total knee and hip arthroplasty results," he wrote.
One fracture study found that a cessation protocol started in the inpatient setting and performed for six weeks decreased the risk of developing at least one postoperative complication. For the control group, 38% experienced at least one complication, compared to 20% of patients in the cessation protocol.
Spine surgery research determined that smoking has a negative impact on surgical outcomes after lumbar and cervical spine procedures.
A spinal fusion study showed smoking increases the rate of perioperative complications. Smoking cessation was recommended for four weeks following surgery.
In anterior cruciate ligament surgery research, smoking was linked to increased rates of infection and venous thromboembolism after ACL reconstruction.
With a shortage of pharmacists and clinicians in rural areas, telepharmacy and telehealth clinical pharmacy services can fill the gap.
Telepharmacy and telehealthapproaches to clinical pharmacy services are helping to address pharmacist and clinician shortages in rural areas of the country.
Telepharmacy, which features the dispensing of medications and other pharmacy services, has allowed Scotland County Hospital in Memphis, Missouri, to establish a 24/7 pharmacy after years of being limited to a part-time service.
"We tried to hire a full-time pharmacist for about a year to have an on-site pharmacist. We knew it would create a larger cost center, but we also knew it would improve care. We had one or two people interview, and neither one took the position," says Randall Tobler, MD, CEO of Scotland County Hospital.
In September 2017, the hospital launched a hybrid pharmacy model, with a part-time pharmacy director and a telepharmacy service provided by San Francisco–based PipelineRx.
"Decisions related to formulary are done with our pharmacist of record. Pipeline certifies and validates oncology orders, checks for drug interactions, and makes dosing adjustments," Tobler says.
At the University of Iowa in Iowa City, the College of Pharmacy is operating a telehealth clinical pharmacist service called Centralized Healthcare Solutions. CHS is under the umbrella of the College of Pharmacy and any revenue generated flows to the university.
"We expand the types of clinical services to rural communities that they either don't have access to, can't afford, or can't staff," says Christopher Parker, PharmD, executive director of operations at CHS.
CHS, which started out focusing on patients with cardiovascular disease, was launched in November 2016.
"We would work with patients who had a past history of cardiovascular disease—a previous heart attack or a previous stroke—and we would help to lower their risk by getting their blood pressure under control and making sure they were on the right medications," Parker says.
Telepharmacy service
Contracting with a telepharmacy provider has helped Scotland County Hospital fill a critical need, Tobler says.
For several years, the hospital had relied on the local retail pharmacy to also serve as the hospital's pharmacy. "The pharmacist did the best he could to meet our 24/7 needs such as reviewing orders, but he wasn't a 365/24/7-guy-in-town all the time," he says.
The lack of continuing coverage created a compliance problem.
"Many times, we had to invoke the emergency rule to have orders reviewed after the fact. Under Medicare, all first-dose orders—whether it is the patient's own medication or something a doctor prescribes—have to be reviewed by a pharmacist unless there is an emergency," Tobler says.
"When I took over here about three years ago, I just felt that was not optimal, and we looked for ways to make it work financially. The way we made it work was by employing PipelineRx as a telepharmacy service," he says.
The telepharmacy service works on a daily basis with pharmacy technicians at the hospital.
"The techs have a daily call with Pipeline and they discuss whether ordered medications have been administered," Tobler says.
Although the critical access hospital is too small to generate statistically significant data about the telepharmacy service, he says gains have been realized.
"In general, we have stepped up the scrutiny of our prescribing. In essence, it gives me and our physicians a sense that there is someone looking over our shoulders to give a second opinion on prescribing," he says.
Pharmacy technicians are also functioning in a more optimal manner, Tobler says.
"The pharmacy techs have always been conscious of which drugs are going in the bins, but some of the burden of the pharmacist role has been taken off of them. They also have a new backstop that gives them peace of mind to focus on their core duties for patients," he says.
Patients have definitely benefited, Tobler says. "The turnaround times are much better. Now, the nurses can take routine orders, and they are not waiting. Patients are not getting delayed dosing because they are waiting for verification."
Telehealth service
CHS has expanded its clinical pharmacy services far beyond lowering the cardiovascular risk of patients.
"We have expanded to areas like focusing on tobacco cessation. We are working now to set up a contract to provide a tobacco cessation program for patients at high risk for hospitalization because of COPD," Parker says.
"We also focus on targeted disease interventions. In the rural settings, a lot of the clinics have trouble focusing in certain areas—uncontrolled blood pressure, diabetes, asthma. We will help them identify where they are struggling clinically, then figure out ways for our team to help," he says.
In addition to expanded services, CHS has expanded the number and variety of its clients.
"We have the gamut. We have privately owned rural primary care clinics. We have rural health systems that have hospitals and clinics. We have larger health systems that have rural clinics as part of their systems," he says.
Although CHS does not provide dispensing, it does ease staffing shortages at rural clinics, Parker says.
"The feedback we have gotten from the clinics in rural settings revolves around them not being able to hire enough primary care physicians. When we work with these clinics, the providers can refer patients to us for chronic diseases like diabetes. Then the patient may only need to see a primary care physician once or twice a year," he says.
Based on research conducted at rural clinics, Parker says CHS has generated several positive results:
Diabetes patients were able to achieve lower hemoglobin A1C values compared to patients in a control group.
Patients who were on guideline adherence for their disease state achieved double adherence compared to patients who did not work with CHS pharmacists.
Some clinics allowed CHS to manage patients independently. In those situations, CHS had a greater impact on lowering cardiovascular disease risk.
CHS is offering health systems, hospitals, and clinics an unconventional service, Parker says. "This model expands the role that a pharmacist plays."
Addressing the racial disparity in peripheral artery disease care can include data-driven performance improvement efforts and targeting high-risk patients for treatment at high-quality hospitals.
Significant racial disparities exist in the treatment of peripheral artery disease (PAD), and low-performing regions of the country should launch care improvement initiatives to help close the gaps, researchers say.
The disparity between black patients and white patients was particularly stark for short-term PAD outcomes such as amputation and major adverse limb events (MALEs), the researchers wrote in an article published this month in the Journal of Vascular Surgery.
"These differences in short-term outcomes likely reflect the effect of differences in local factors, such as access to care, insurance status, and treatment at high-volume centers, all of which varied significantly across regions."
The researchers studied data from 90,418 patients, 17% of whom were black. For the regional analysis, the country was segmented into 18 regions.
The disparity in amputation rates was glaring, the researchers wrote.
"As black patients were less likely to present in follow-up, they likely experience even higher rates of amputation and limb events relative to white patients. Our sensitivity analysis reveals that amputation rates could be as high as almost double the rates experienced by white patients."
Regional variation
In addition to facing higher risk in general for adverse short-term outcomes, black patients faced variable risks in several regions of the country:
Three regions had significantly higher adjusted mortality rates than the other regions
Two regions had significantly lower adjusted rates of MALE
One region had significantly lower adjusted amputation rates
Three regions had significantly higher adjusted amputation rates
The existence of regional variation in PAD care is consistent with earlier research in multiple surgical disciplines, the researchers wrote.
"A wealth of evidence demonstrates that geographic and regional variation influences healthcare costs, utilization, treatment strategies, and outcomes. In recent years, an increased focus on regional variation in surgical practice revealed that where a patient resides often has an impact on the patient's propensity to undergo surgery or amputation more than the actual surgical indication."
Success strategies
The researchers say health systems and hospitals can pursue several strategies to address disparities in PAD care:
Use data from the Society for Vascular Surgery Vascular Quality Initiative to compare outcomes results with other regions and surgical centers. The data can support quality improvement initiatives and encourage adoption of best practices.
Earlier research has shown that blacks are more likely than whites to live near high-quality hospitals, but they are more likely to receive care at low-quality hospitals. To address PAD care disparity, healthcare providers should target high-risk patients for treatment at high-quality hospitals with high service volume.
Underperforming regions should launch care improvement initiatives such as boosting access to care.
Daylong shifts in the emergency room pose a threat to physician health and patient safety, researchers say.
Recently published research shows the cognitive abilities of emergency room physicians were significantly impaired after working a 24-hour shift.
The researchers, who published their work in this month's edition of the Annals of Emergency Medicine, gauged the cognitive function of 40 ER physicians after a night of rest at home, after a 14-hour shift, and after a 24-hour shift.
While there was no difference in cognitive function after a night of rest at home compared to working a 14-hour shift, the researchers found ER physicians posted lower scores for three out of four cognitive functions after working a 24-hour shift.
"The cognitive abilities of emergency physicians were significantly altered after a 24-hour shift, whereas they were not significantly different from the rested condition after a 14-hour night shift," the researchers wrote.
While the research suggests that a 14-hour night shift could be a more optimal schedule for ER doctors, the primary conclusion of the Annals of Emergency Medicine article is that 24-hour shifts should be discontinued.
"Our results mainly suggest that emergency physicians should not continue to work 24 consecutive hours," the researchers wrote.
The risks associated with physician fatigue have been published in earlier research, they wrote. "Chronic tiredness related to long working hours is common among physicians. It has also been clearly established that chronic tiredness negatively affects patient safety."
In their study, the Annals of Emergency Medicine researchers found that ER physicians underestimated the level of their cognitive impairment.
"The lack of correlation that we found between the self-evaluation of tiredness and cognitive performance suggests that emergency physicians were not able to accurately evaluate their tiredness and attention capacity. This could lead to increased risks to their own health and patient safety," the researchers wrote.
Assessing cognition
The researchers assessed four measures of cognitive function: processing speed, working memory capacity, cognitive flexibility, and perceptual reasoning.
Processing speed is important for multitasking. Working memory capacity features short-term memory, which enables decision algorithms and helps determine the level of an emergency. Cognitive flexibility supports strategic capacity and executive functions. Perceptual reasoning, enables understanding of abstract concepts and rules.
ER physicians underwent a three-part assessment:
A questionnaire collected demographic and lifestyle data as well as highlights of the previous night shift
Participants conducted a self-assessment of tiredness, sleep deprivation, and degradation of attention and mood
An examiner evaluated participants' cognitive abilities
The researchers found that ER physicians who work 24-hour shifts experienced decreased functionality in processing speed, working memory capacity and perceptual reasoning. When compared to cognitive abilities after resting at home, decreased performance ranged from 10% to 21%.
The researchers say these decreases in cognitive function likely have negative impacts on emergency departments. "Because these cognitive abilities are involved in the practice of emergency medicine, their decrease is likely to affect abilities such as using a decision algorithm, making a diagnosis, prioritizing emergencies, or multitasking."
Mitigation
Earlier research and the Annals of Emergency Medicine article suggest several methods to avoid sleep deprivation among ER physicians:
Napping and strict sleep hygiene have been proposed
For residents, the Accreditation Council for Graduate Medical Education Task Force recommendsstrategic napping for residents
The Annals of Emergency Medicine say conscious effort is required to achieve strategic napping because of demanding workloads and busy periods in the ER setting
The journal of the Federation of State Medical Boards has published a special issue with a range of perspectives on burnout and wellness, including physician mental health and help-seeking behavior.
Physician burnout has reached crisis proportions and medical regulators need to step up efforts to address the problem, a special issue of the Journal of Medical Regulation says.
"The time has come to help the healers heal themselves—and return to productivity and career fulfillment. As medical regulators, we need to protect the public—the millions of patients whose physicians are impacted by burnout each year," JMR Editor in Chief Heidi Koenig, MD, wrote in the special issue.
The special issue, which was published by the Federation of State Medical Boards, features four articles about physician mental health, FSMB wellness and burnout initiatives, assessment and referral, and help-seeking behavior.
1. Physician mental health
Fear is a primary barrier to care for physicians with mental health conditions, the first article says.
"Most mental health problems can be effectively managed, but real and perceived barriers—such as confidentiality concerns and fear of negative ramifications on one’s reputation, licensure, or hospital privileging—keep many physicians from addressing their mental health needs."
The article includes three recommendations to address physician burnout and wellness:
Community response: Education programs should encourage peers and mentors to help distressed colleagues get care. Active involvement of peers and mentors also promotes normalizing the seeking of help.
Stigma reduction: Policies must make it safe for staff members to seek support or treatment, as early as possible after onset of distress.
Licensing: Mental health questions in state licensing documents have the unintended effect of driving distressed clinicians underground. These questions should focus on competence rather than illness. Mental health questions should be phrased the same as physical health questions.
2. FSMB initiatives
The FSMB plans to be in the vanguard of efforts to address physician burnout and wellness.
About two years ago, the regulatory association formed a workgroup of state medical board members and stakeholders to study burnout and wellness.
"This was a timely decision for the FSMB as it positioned the organization alongside several others at the forefront of working to identify and address what has become an epidemic," the second article says.
Burnout and wellnessrecommendations that the FSMB workgroup adopted in April are included in the JMR special issue.
In addition to the workgroup, FSMB is participating in a collaborative effort to find solutions to burnout led by the National Academy of Medicine.
Individual state medical boards also have been launching burnout and wellness initiatives. Licensing changes allow physicians to not report a potential impairment as long as they are receiving treatment, the article says.
UC San Diego launched HEAR in 2009. Over the previous decade, there had been one medical student or physician suicide every year.
Hundreds of medical professionals have received help through the program, the article says.
"Through June 2017, 1,537 UC San Diego healthcare personnel have been screened, 320 individuals have dialogued with a counselor either in person, by phone or electronically, and more than 300 have been referred confidentially for evaluation and treatment by a mental health professional."
The HEAR program has two essential elements:
Education and outreach: Lifting stigma and supporting help-seeking behavior
Proactive approach: Identifying at-risk clinicians for support and care referrals
HEAR appears to have impacted suicides at UC San Diego, the article says.
"There have been two suicides among UC San Diego medical and pharmacy students, residents, fellow and physician faculty since 2009, and none in nurses or other professional health care staff since they were added to the HEAR umbrella."
The figures are small but significant, the article says.
"Although the numbers are too small to perform statistical analysis, based on the rate of suicide in the UC San Diego academic and clinical community before 2009, we have observed six fewer suicides than in the same timespan previously."
To evaluate ISP, researchers gathered data from six medical schools from 2007 to 2013. The ISP online questionnaire was completed by 1,449 medical students, residents, and faculty physicians, with 97.5% reporting some degree of stress but only 5.3% receiving care.
ISP is designed to identify people at risk of suicide by offering anonymous online screening. A counselor reviews the screening information, then posts a confidential response to the ISP website. After the screening assessment, ISP participants can exchange confidential messages online or get a referral for care.
Researchers found participant engagement with the ISP service was robust—81.2% returned to the ISP website to see the counselor's screening response.
Out of the 1,449 ISP participants in the study, 131 either asked to speak with a counselor in person or requested a mental health referral.
ISP, which is a key component of HEAR, is a viable option for suicide prevention for healthcare professionals, the article says.
"The core components of ISP—participant anonymity, allowing participants to feel more comfortable addressing their concerns, and personalized interactive engagement with experienced counselors—offer an innovative method of overcoming barriers to help-seeking."
Researchers find synergies that help accountable care organizations with advanced primary care physicians succeed financially and deliver high-quality care.
Advanced primary care boosts the savings rate and quality performance of accountable care organizations, research released this week says.
Researchers found a symbiotic relationship between ACOs and advanced primary care models such as patient-centered medical homes, the report says.
"Systems that already provided advanced primary care had a strong foundation on which to build an ACO, while becoming an ACO helped advanced primary care systems succeed by encouraging structural changes that align well with the PCMH model."
ACOs and advanced primary care share several keys to success, the researchers wrote.
"Many successful ACOs rely on good care coordination using care managers; robust and timely electronic health record information; increased access to care through means such as patient web portals and expanded office hours; and a focus on safety and quality improvement."
Two primary findings of the report are that ACOs with advanced primary care physicians have an increased likelihood of financial and quality of care success.
1. Shared savings gains
In their quantitative analysis, the researchers focused on 333 ACOs that participated in the Medicare Shared Savings Program in 2014. MSSP success was measured by shared savings earned and quality measure performance.
In MSSP, an ACO is given a total-cost-of-care spending benchmark based on historical performance. The ACO can earn shared savings payments if care expenditures are below the spending benchmark.
To assess the impact of advanced primary care on ACOs in MSSP, the researchers segmented the ACOs into quartiles, with the lowest quartile having no PCMH physicians and the highest quartile having 42.6% of physicians in PCMHs.
The researchers found that ACOs with PCMH physicians had modest but significantly higher shared savings compared to ACOs with no PCMH physicians.
"The savings rates of ACOs in the second highest and the highest quartiles for PCMH PCP share were on average 1.3 and 1.2 percentage points, respectively, higher relative to those in the lowest quartile group. The magnitudes of the estimates were non-trivial given that the mean savings rate was 0.6% for the study sample," the researchers wrote.
2. Quality boost
In 2014, MSSP had 33 quality measures. PCMH primary care physicians improve ACO quality performance, the report says.
"ACOs with a higher PCMH PCP share demonstrated higher quality as well, specifically in health promotion scores, health status scores, preventive service scores and chronic disease management scores."
Specific areas of higher quality performance included diabetic and coronary artery disease composite measures, pneumococcal vaccination, depression assessments, and tobacco screening.
SSM Health's new chief quality officer values performance improvement and a high-reliability approach.
The first-ever chief quality officer at SSM Health has set a lofty goal for the health system.
"My vision is to have the highest quality healthcare of anywhere in the country within the next five years by any measure. All of the models are different; so, if you want to score well on those, you have to do well in virtually everything," says Alexander Garza, MD, MPH, who became chief quality officer in January.
The health system features 24 hospitals and 9,900 clinicians.
Laura Kaiser, who has served as president and CEO of the St. Louis, Missouri–based health system since May 2017, is committed to quality and patient safety. Kaiser's decision to hire a chief quality officer for the whole health system demonstrates that commitment, Garza says.
HealthLeaders spoke recently with Garza. Following is a lightly edited transcript of that conversation.
HL: What are the primary quality challenges at SSM?
Garza: There are five areas we are focusing on this year. Sepsis mortality is one. It's a very expensive condition to treat, so there is a financial reason for addressing it.
We are engaged in two infection prevention initiatives. One for central line-associated blood infections and the other for catheter-associated urinary tract infections. By and large, these are infections that are within our control.
The fourth focus is readmission reduction. This metric applies to the whole health system—it measures how well we are organized in moving patients from acute care, to postacute, to ambulatory, and how good we are at recognizing risk for readmission.
The fifth focus is opioid reduction and dealing with our opioid epidemic. We are addressing it through multiple phases of care—the emergency department, inpatient, ambulatory, and our behavioral health and additional services.
HL: At a national scale, what are some of the most significant quality challenges?
Garza: What I get concerned about is people being too metric-focused when we are talking about quality. The performance metrics are part of quality, but there's also the patient experience and how well you are doing performance improvement as an organization. We teach our clinicians to do good healthcare work, but we don't train them as well to do performance improvement.
From our health system's point of view, I would rather [that] people focus on how to look at quality and how to do performance improvement. That would do much more good for us than focusing on a percentage or comparing us to a benchmark.
Quality is an umbrella term that includes more than metrics—infection prevention, regulatory issues, and safety.
My vision is moving our clinicians and our staff away from meeting specific metrics to thinking more from a high-reliability organization point of view. The goal is to be perceptive of what is going on around you, then making sure you can prevent errors that come up while adhering to best practices.
HL: Give an example of the high-reliability approach.
Garza: One of our Oklahoma facilities came up with a tracking system to make sure they were eliminating all of the risks associated with catheter-associated urinary infection. They bought into performance improvement.
It wasn't me coming down and saying, "You have to prevent urinary tract infections." The staff recognized the infections were not good for our patients. They developed a performance improvement system to treat our patients best, lower the risk, and improve performance all at the same time.
HL: Two decades after publication of "To Err is Human," patient safety remains an area of concern such as the estimated 400,000 deaths annually linked to medical errors. Why does patient safety remain a vexing problem?
Garza: Healthcare has not reached a tipping point where patient safety is the No. 1 priority. We talk about it a lot, and we have made good strides, but we haven't reached [that] point yet. You see it in other industries, when they step back and say change is needed.
Part of it is generational—as new physicians, new nurses, and new physician assistants come onboard, they will be graduating from programs that have an increased emphasis on quality. A new attitude is being built into them as professionals.
Making safety a front-and-center issue is a multi-level process.
There are obvious things like making sure we are doing surgery on the right side. You also need to identify the right safety policies, implement those policies, and hold people accountable. You always ask for two forms of identification from patients; you mark the surgical side; you have timeouts in the OR—these are all parts of those policies.
Senior leadership needs to show that they have bought into this as well. They need to make safety one of their priorities. When the executives at the system, regional, or hospital level promote safety, it helps change the culture.
HL: How do you engage physicians to participate in quality initiatives?
Garza: Whether they deserve it or not, physicians can get the reputation of not being participatory, but I think they do want to participate. It's all in how we get them to the table and how we engage them. We need to show that it is worthwhile to participate.
There are simple things like setting up meeting times that are convenient and asking for their opinion on how things could work. For example, as part of our patient safety surgical checklist we were talking about spine surgery and surgery on the wrong level of the spine. Adding [spine level] to the surgical checklist seemed like an easy answer to me. I sent the proposal to our orthopedists, and I got three emails and three phone calls on why it wasn't a good idea.
It was great. When I spoke with them, they thought they had a better approach. So, I had three different orthopedic spine surgeons from three different regions of our system coming together to work on this.
It showed [physicians] do think about these things seriously, and we need to give them the opportunity to solve problems.
