In-house leadership coaches make determined and sustained efforts to help physicians change behaviors that can derail their careers.
Physician leaders can benefit from in-house staff development programs.
"Internal physician coaching has been a real success for us," Keith Olson, MS, director of physician consulting services at Ann & Robert H. Lurie Children's Hospital of Chicago, said during a presentation this week at the MGMA annual conference in Boston.
Olson said in-house physician leader training has several advantages over consultants or sending physicians to leadership programs, including a higher degree of effectiveness in changing people's behavior.
"Other organizations send physicians to an executive program—two weeks at Harvard, Stanford, or Kellogg in Chicago. What I hear from physicians who come back from these programs is, 'It was a great experience, and I met some great people.' Then three weeks later not one behavior has been changed. Those programs also are very expensive," he said.
In-house leadership coaches can make a determined and sustained effort to help physicians change behaviors—such as constantly interrupting their peers—that can derail their careers, Olson said.
"The difference is that instead of going to a program and getting information, we're talking for weeks on end about the behaviors they pull out of structured materials and want to get better at. I keep these behaviors in front of them."
Measuring success
Lurie Children's Hospital currently has 45 doctors enrolled in the organization's physician leadership program. Participants are meeting with Olson every two weeks, monthly, or quarterly.
After his presentation at the MGMA conference, Olson told HealthLeaders that there are four primary measures of success for an in-house physician leadership program:
Since participation in executive coaching should be elective—and physicians have a low tolerance for anything that wastes time—high demand and continued participation in ongoing coaching is an indicator that participants view a program as worthy.
In a successful program, peer referrals should be a major source of participants.
Annual feedback should be gathered from participants asking about the effectiveness of the program and getting input about what will make the program more effective.
The ultimate indicator of success is that growth and development are seen in the participants by their leaders and peers.
Growth has been a key measure of success for the leadership program at Lurie Children's Hospital, he told HealthLeaders. "It's exploded in growth, and that is one indicator of success because it's elective."
Competencies and learnings
During his presentation at the MGMA conference, Olson shared core competencies for leadership coaches and the lessons that have been learned from the leadership program at Lurie Children's Hospital.
There are a pair of essential leadership coaching competencies, he said.
"One is the coaching skills, the trust-building skills, and the listening skills—these are skills that help change people's behavior. As one of my clients said to me, 'Keith, you are politely blunt.' To get people to change their behavior, you have to be able to be politely blunt."
The other core competency is physician-centric. "The other bucket is understanding a physician's world," Olson said.
"Surgeries run long, clinics run long, and grant proposals are due. A physician's world is a chaotic place. We keep trying to cram a traditional approach to leadership development on the physician's world, and it fails."
He said Lurie Children's Hospital has learned several lessons from operating an in-house physician leadership program:
Leadership programs should be perceived as an investment in key talent, not a place where people who are behaving badly are sent.
Leadership coaches must adapt to the physician's world such as being flexible to odd work hours. Coaches should not get upset when meetings are cancelled or rescheduled.
Leadership coaches should encourage physician leaders to develop tools and techniques to have a sustainable path in their lives. The drive that got physicians through residency, fellowship, and the early phase of their careers is not only unsustainable but also a potentially toxic influence on leadership abilities.
Having an internal leadership coach creates the ability to have ad hoc sessions in a timely manner. Internal coaches tend to be readily available when a leadership program participant needs to talk with someone about pressing issues such as a stressful conversation involving negative feedback.
The health system has implemented a behavioral health integration program that features mental health screening at primary care clinics.
As part of a $15 million behavioral health initiative launched last year, Columbus-based OhioHealth is striving to screen nearly all of its primary care patients for depression, anxiety, and suicide risk.
As a study released in June by the Centers for Disease Control and Prevention reports, suicide rates have been rising in nearly every state. In 2016, there were 45,000 Americans over the age of 10 who died by suicide, the CDC says.
To help prevent suicide in the communities it serves, OhioHealth is implementing a behavioral health integration program that features screening at primary care clinics, where patients identified with mental health conditions are enrolled in a course of multidisciplinary treatment.
"This can identify patients in distress when they are seeing their primary care physician, giving us an opportunity to intervene before there is a disastrous outcome," says Dallas Erdmann, MD, system chief of behavioral services at OhioHealth.
Every patient over the age of 16 is screened. Patients who score high on the PHQ-9 questionnaire are referred to a behavioral health provider—either a social worker or a counselor—who helps manage anxiety or depression for six to nine months. A psychiatrist helps supervise the caseload in weekly meetings.
Primary care practices are a logical setting to serve as the backbone of OhioHealth's behavioral health integration program, says Amanda Maynard, DO, an OhioHealth primary care doctor and a physician champion for the program.
"We are the first line of defense for all disease processes. Depression and anxiety are prevalent in society today," she says.
The behavioral health integration program is simultaneously increasing access to mental health services and helping OhioHealth cope with a shortage of psychiatrists, Erdmann says.
"This model supports primary care doctors in caring for mild-to-moderate depression and anxiety. Those are bread-and-butter conditions, and this program frees up psychiatrists to attend to the more complicated cases of refractory depression, bipolar disorder, and psychosis that primary care doctors are uncomfortable attending to because they have not had the training," he says.
OhioHealth launched the behavioral health integration program in late 2017. So far, 15 of the OhioHealth Physician Group's 25 practices have joined the program, with a total of 63 physicians participating.
Key metrics of the program include patient enrollment in integrated services and achievement of a 50% reduction in PHQ-9 scores. As of September, 1,000 patients had enrolled in the program, and about 35% of patients enrolled in the program for at least six months had achieved a 50% reduction in PHQ-9 scores.
OhioHealth has taken a systematic approach to implementing the behavioral health integration program at the organizational and primary care practice levels, with expectations that the effort will be sustainable and effective.
Organizational rollout
Erdmann says there have been four primary steps to implementing the behavioral health integration program at the health system level:
OhioHealth's senior leadership has been actively involved and invested in the effort from its onset.
Physician champions and other crucial individuals were identified at primary care practices to help the senior leadership team problem solve and operationalize the program.
Psychiatric providers have been enlisted to participate in the program and support primary care physicians.
A training program was crafted to prepare clinics to join in the program.
The training process for primary care practices takes about a day and a half, with a select handful of staff members present for instruction, including one physician or nurse practitioner, one practice manager, one medical assistant, and one office specialist, Erdmann says.
"We get fairly in-depth defining the process, setting the workflow, looking for nuances to roll the program out in the particular clinic, identifying some of the roles and responsibilities of the various team members, and cross-training staff members to be able to work as a team," Erdmann says.
Social workers receive supplemental training, he says. "For the behavioral health providers—the social workers—we provide them with additional training in documentation and the care model."
The training is conducted with in-house resources and has been led by Heather Esber, system program manager of service lines for OhioHealth.
Practice implementation
Maynard's practice was one of the first OhioHealth sites to implement the behavioral health integration program.
"We thought our site would be one of the better sites because not only are we downtown but we also have close proximity to a Level 1 trauma center, and we are very close to women's domestic shelters and suboxone clinics. We thought downtown was a good site because of the prevalence of mental illness," she says.
Implementing the behavioral health integration program has not been a heavy burden on the practice, Maynard says. "There were some growing pains such as working the program into the workflow to be effective. It took a week to figure out the best way to do it."
She considers the PHQ-9 questionnaire as collecting a vital sign.
"It was time management. The patients get the questionnaire when they check in at the front desk. They are either filling it out or have filled it out by the time the medical assistant rooms them. Then that information is either handed to the physician or it is placed in the computer system. The physician looks at the questionnaire and decides where to go from there," she says.
The providers in Maynard's practice are comfortable with their treatment role in the behavioral health integration program, she says.
"We are very capable of getting patients on medication for mood disorders; however, 99% of bipolar and schizophrenic patients are also going to need a psychiatrist onboard with us. That is a benefit of this program: these patients can see me in the primary care office, and I can reach out to our psychiatrists who can direct me on medication adjustments," she says.
Patients who score high on the PHQ-9 question related to suicide are immediately referred to an emergency room for evaluation, Maynard says. If the patient has a family member with them, the family member escorts the patient to the ER, which is a block away. If the patient is alone, the patient is transported via ambulance to the ER. After arriving at the ER, patients are held for evaluation for 72 hours.
Sustainable and effective
Erdmann says the behavioral health integration program is expected to be sustainable and cost effective.
The Centers for Medicaid & Medicare Services recently approved billing codes for collaborative care that will help fund the behavioral health integration program. "It's a way to encourage this form of treatment. We are preparing to start using them," he says.
Boosting behavioral health services is also expected to reduce total cost of care, Erdmann says.
"This can help reduce the cost of care and improve overall health and healthcare outcomes as we identify and catch illnesses early in a preventative way and identify comorbid factors that impact the outcomes of other disease states," he says.
He cited diabetes as an example.
"If you look at actuarial data for healthcare and healthcare costs, you could take a group of patients who have diabetes and understand the cost per member per month. If you take those same patients and add in a comorbid depression, the cost of care doubles. It doubles because of the impact of depression on the patients' ability to care for themselves," Erdmann says.
The behavioral health integration program is improving OhioHealth organizationally on several fronts, he says.
"It is helping to prepare OhioHealth in a variety of ways to address some of the ongoing issues in healthcare. It helps us view the whole patient, and adopt team-based care. It is helping us identify health issues before they reach a crisis level. And by addressing comorbidities, it is helping us reduce total cost of care," he says.
Maynard says the behavioral health integration program has improved access to vital services.
"Typically, if you put a patient into psychiatry the waiting list can be four to six months. What I have seen as a primary care doctor is some of these patients need to be seen sooner rather than later. This program has created access to resources including psychiatrists who can help us manage patients. It makes us like a one-stop shop for patients," she says.
Patients are benefiting, Maynard says. "We have made a big difference in a lot of these patients' lives. Some were not coming out of their homes. Some were not active with their children. Some had no jobs or aspiration to do anything. In some of my patients, I have seen drastic changes."
New research shows a significant increase in emergency department violence, but there are strategies to address the problem.
Violence against ER physicians is pervasive and increasing, research released this week shows.
In a survey conducted for the American College of Emergency Physicians (ACEP), a majority of the 3,539 doctors polled said they had been the victims of workplace violence recently. About 62% of ER physicians reported being assaulted in the past year, with 24% saying they had been assaulted two to five times.
"The main point is this is a problem that is real, it is increasing, and unfortunately the results of this poll will not surprise any practicing physician," Vidor Friedman, MD, ACEP president-elect and an ER physician in Florida, said during a press conference Tuesday.
The press conference focused on research findings, solutions for violence in ERs, and the impact on patients who witness acts of violence.
In addition to the survey, "ACEP Emergency Department Violence Poll Research Results," unpublished research unveiled on Tuesday showed a significant increase in ER violence in Michigan.
The Michigan research compares survey data from 2005 and 2018. In 2005, about 28% of ER physicians surveyed said some form of violence had been perpetrated against them in the past year. In 2018, the figure had risen to 38% of ER physicians.
Physicians are not the only emergency department personnel enduring violent encounters, the lead author of the Michigan research said during Tuesday's press conference.
"Every job title had violence perpetrated against them. What we found is that the time you spend with the patient increases the chance that violence will be perpetrated against you," said Terry Kowalenko, MD, chair of emergency medicine at Beaumont Hospitals in Dearborn, Michigan.
The ACEP survey features several key findings:
71% of ER physicians reported witnessing an assault at work
97% of assailants were patients
The most common administrative and security responses to physical assaults were to place a behavioral flag in the patient's medical chart (28%) or to have the patient arrested (21%)
27% of ER physicians reported sustaining an injury from a workplace assault
The top five kinds of physical assaults were hit or slap (44%), spit (30%), punch (28%), kick (27%), and scratch (17%)
About 80% of ER physicians reported that workplace violence reduces staff productivity, increases emotional trauma, and extends wait times
The Number One suggestion (49%) to address ER violence was increasing security
69% of ER physicians reported that workplace violence has increased over the past five years
Solving the problem
Kowalenko said there are four approaches to addressing violence in emergency departments: hospital policies, environment changes, staff education, and legal.
Policies related to violence in the ER should be clear and consistently enforced. This approach applies to policies that may seem indirectly related to violence such as rules governing how many visitors can see a patient at one time.
Environmental factors include security, cameras, and "badging" in and out of an ER's treatment area.
Education of staff should not be limited to reacting to violent situations. Training should include identifying potentially violent patients and strategies to defuse potentially violent situations.
More than two dozen states have adopted laws that make assaulting a healthcare worker a felony. These laws make assaulting a healthcare worker equivalent to assaulting a police officer.
Friedman said ER physicians and other staff members should consider pressing charges after a patient assaults them.
"Healthcare workers underreport violence because we want to take care of people. We don't want to create more of a problem when one already exists, but we are enabling the problem to a certain extent," he said.
Impact on patients
In the ACEP survey, 77% of ER physicians reported that emergency department violence undermines patient care.
Patient care suffers when there is violence in an emergency department, Friedman said.
"Emergency room patients can be traumatized to the point where they leave without being seen or treated because they were exposed to acts of violence. It also increases wait times and distracts physicians and nurses from the other patients in the emergency department who need their care," he said.
The management association presents survey data that highlights the best practices of the best medical groups.
Among physician practices, better performers excel in three primary areas: strategy, operations, and culture, according to a new report from the Medical Group Management Association (MGMA).
MGMA released its "Winning Strategies from Top Medical Groups" report this week during the organization's annual conference in Boston. The report is based on data collected from more than 2,900 medical groups.
In addition to the common themes of exceptional strategy, operations, and culture, top performing medical groups have an enlightened approach to investment, the report says.
"While better performers have lower costs in some areas, their total expenses are often higher. They invest in good people, good technology and good systems—and then they maximize the return on those investments, achieving lower operating costs as a percent of revenue," the report says.
This week, MGMA President and CEO Halee Fisher-Wright, MD, told HealthLeaders that top performing medical groups are methodical when investing in their organizations.
"We have found that better performers are systematic about improvement and continually invest time and effort in new resources while maximizing the tools and information already available to them. The decision on what to invest in is directly tied to what the practice identifies as organizational goals. They only invest in those items that allow them to make significant progress toward those goals," she said.
Strategy
Top performing medical groups can overcome "an overwhelmed, in-the-weeds mentality" by focusing continuously on strategic progress, the report says.
Fisher-Wright said planning and monitoring are essential for successful strategies.
"Identify what is important to the practice—more time, more revenue, better culture—then set goals. Those goals are your strategic outcomes. It is crucial to regularly monitor performance against your strategic plan or budget, and plan on making changes as necessary. We recommend checking in at least monthly. Better performing organizations understand that lasting progress first starts with clear, focused efforts and investing in tools to accompany the vision," she said.
The report identifies 11 successful approaches to strategy:
1. Establish metrics and goals to maintain performance and accountability
3. Review vendor contracts for cost, value and strategic alignment
4. Invest in appropriate technology
5. Assess costs and reduce them when possible
6. Revise systems and processes that support the organization, particularly revenue cycle, billing, and collections
7. Increase patient access and engagement with cross-departmental strategies
8. Develop and implement standard work
9. Tie incentives to goals
10. Adjust schedules, operating hours and staffing to achieve goals
11. Focus on efficiently reporting key metrics, then benchmark metrics to identify new strategic opportunities
Operations
Similarly to successful investment strategies, top performing medical groups take a methodical approach to operational improvements.
"Better performers are systematic about improvement—they invest time in the effort, they invest resources, and they maximize the tools and information available to them," the report says
Better performers reported three top areas for improvement efforts:
Better performers reported three top technology investments:
New or upgraded EHR systems to support better patient communication, better provider experience, and efficiency
Electronic communication systems such as secure text messaging platforms for use between providers and secure file transfer systems to reduce faxing
Upgraded billing and coding software as well as revenue cycle management systems
Culture
Top performing medical groups focus on patient and staff engagement as well as a patient-focused culture, the report says.
"One example is how they approach provider and staff satisfaction surveys. It probably won’t come as a surprise to learn that better performers are more likely to conduct them," the report says.
Better performers had a higher likelihood of conducting surveys to measure satisfaction metrics:
90.4% of top performing medical groups conducted employee satisfaction surveys compared to 79.8% of all medical groups
87.3% of top performing medical groups conducted provider satisfaction surveys compared to 74.9% of all medical groups
It is important for practice leaders model behavior and values to foster a patient-centered culture, Fisher-Wright said.
"Inclusiveness and transparency are keys to success in any organization. Including the main stakeholders on creating and sharing goals and results with everyone within the organization—even with the board of directors—allows the entire staff to collaborate and create positive progress and improvement," she said.
Medicare-eligible people living in housing with supportive services use less hospital services, new research shows.
Evidence is mounting that housing is a highly significant factor in population health.
A study released this week found that Medicare-eligible residents of housing with supportive services had lower hospital utilization than a comparable group of seniors living in housing without supportive services.
Michael Gusmano, PhD, the lead author of the research and an associate professor of health policy at Rutgers University in New Brunswick, New Jersey, says the utilization finding is the key takeaway of the study.
"Our research supports the hypothesis that stable housing with supportive services can reduce the use of expensive medical care. In particular, it can have a significant effect on hospitalizations for ambulatory care sensitive conditions because social work staff are able to identify people who require community-based services and facilitate their use," he told HealthLeaders last week.
The researchers studied 1,248 Medicare beneficiaries in a housing program operated by Selfhelp Community Services in New York City. In the same zip codes, 15,947 other Medicare beneficiaries who did not live in housing with supportive services functioned as the study's control group.
Supportive services included psychological assessments, counseling and advocacy, health education, wellness programs, socialization, referral to public benefits and entitlements, and educational programs to control chronic disease. The housing also had technology features such as telehealth systems for checking vital signs and a virtual senior center.
Three primary findings demonstrated healthcare utilization benefits of living in housing with supportive services:
Hospital utilization was measured by discharge rate. The researchers found the hospital discharge rate for the intervention group was 32% lower than the control group.
Hospital length-of-stay was one day shorter for the intervention group.
The rate of hospital discharges for ambulatory care sensitive conditions was 30% lower for the intervention group.
Earlier research has shown that tying affordable housing to supportive services allows the elderly to remain in their homes as they age with an improved ability to access healthcare and social services.
How healthcare providers can invest in housing
Government programs and community partnerships are being established to help health systems and hospitals invest in housing, Gusmano says.
"There are now 13 states with Delivery System Reform Incentive Payment waivers, which are designed to encourage hospitals to address social and economic determinants of health and healthcare services and reduce avoidable hospitalizations. Several other states have or are pursuing waivers to use Medicaid money to facilitate housing services for people who are homeless or at risk of homelessness," he says.
Partnerships between housing organizations and healthcare providers can address social determinants of health such as housing, Gusmano says. "Encouraging hospitals to work with community partners for the purpose of addressing the housing needs of their patients is consistent with that goal."
For health systems and hospitals, investing in housing is a component of the shift to value-based care, he says.
"Although hospital bottom lines may still be helped when patients use more hospital services, efforts to develop and implement 'value-based' payments are trying to change these incentives. If these efforts are successful, hospitals will need to understand and address the social factors that lead to avoiding the use of hospital services."
While conceding more research is needed, physician wellness advocates say there are compelling justifications to move ahead with burnout interventions.
Physician burnout contrarians are drawing a skeptical response from physician wellness advocates.
On Sept. 18, 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.
Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai, says the editorial has prompted reflection among physician wellness advocates.
"This editorial has had some reverberations in the community of individuals who are trying to take on and address the issue of well-being. … There are a number of things the editorial rightfully draws attention to. There is a lot of uncertainty about the best instrument to use to measure the well-being of physicians," Ripp says.
However, there is justified urgency to act, he says.
"There is a lot of suffering in our profession; and in some ways, to harp on the term that is used to describe the suffering or to focus on what measure you use lets the suffering continue without possible interventions that could help physicians."
Contrarian view
This week, a co-author of the editorial told HealthLeaders that terminology matters.
"We know that the general level of physician dissatisfaction and work misery seems to have increased, and physicians are certainly more vocal about their misery, with many suggestions for the source of that dissatisfaction. But labeling this as burnout implies a level of specificity and understanding of a defined clinical entity that I think is not justified," said Thomas Schwenk, MD, professor of family medicine and dean of the school of medicine at the University of Nevada in Reno.
Focusing on physician burnout, which is a relatively new diagnosis, could be dangerously misguided, Schwenk said.
"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.
Schwenk singled out one intervention as problematic.
"I have particular concern about much of the attention on building resilience in students and physicians, as if we are simply not tough enough in a difficult world. Practicing medicine has always been exhausting, exhilarating, and demanding, but physicians never talked about burnout because they felt a greater reciprocity between the demands and the rewards of practice, and a stronger covenant with their patients and communities that energized them," he said.
Pressing ahead
Ripp says healthcare organizations have a duty to help suffering physicians even though there is incomplete information about burnout.
"We should not use the imperfection in how we measure well-being to say that we can't act. If you found an infection that affected 50% of the population, and you didn't have the best tools to diagnosis it, and you weren't exactly sure what to call it, but it was having real consequences, you would not wait to act until you had the perfect diagnostic tool," he says.
Ripp concedes more burnout research is needed but contends there is enough research to guide interventional approaches.
"We need more research, but we also have enough to act. The alternative would be to say, 'We don't have enough information, so we are not ready to look at interventions.' We have enough information to show that there is burnout and there are concerning consequences both to individual physicians and quality of care," he says.
Studies published in 2016 and 2017 demonstrate the causes of physician burnout and effective interventions, says Mickey Todd Trockel, MD, PhD, a clinical associate professor at the Stanford University School of Medicine in Stanford, California.
"Effective responses have already been crafted. Two good systematic reviews and meta-analyses demonstrate effectiveness of interventions. Nevertheless, we have much room to improve. Physicians and those they serve will benefit from continued research on the causes of burnout and associated development of more effective individual and organizational level interventions," Trockel says.
There is little doubt that physician burnout exists as a serious problem, he says.
"A growing body of research demonstrates compelling relationships between burnout and adverse consequences to affected physicians and the quality of care they provide for their patients. In this light, the risk of understating seems greater than the risk of overstating the problem of physician burnout," Trockel says.
Scribes have the potential to address several causes of physician burnout at primary care practices.
High-quality scribes generate high-level gains in primary care practices.
That's the conclusion of recent research published in JAMA Internal Medicine, which found scribes decreased physician EHR documentation burden, boosted work efficiency, and improved patient visit interactions.
Scribes can have a significant impact on a prominent factor for physician burnout, the researchers wrote.
"Emerging evidence indicates that EHRs, as currently implemented, increase clerical workload and physician stress and interfere with direct physician-patient interaction, thereby diminishing professional satisfaction and contributing to professional burnout," the researchers wrote.
The research featured 18 primary care physicians (PCPs) in a study conducted from July 2016 to June 2017. For the study, the researchers enlisted scribes from a private agency that was relatively more expensive compared to internally employed scribes.
There were several key results:
Scribes were associated with fewer after-hours EHR documentation by PCPs
Scribes increased the likelihood that PCPs would spend more than 75% of a visit interacting with the patient rather than interacting with a computer
Scribes were associated with PCPs completing encounter documentation by the end of the next business day
Among patients, 61.2% reported that scribes made a positive impact on visits, and only 2.4% reported scribes had a negative impact
The vast majority of PCPs (88%) reported satisfaction with the quality of scribe EHR documentation
"We found that scribe assistance resulted in significant reduction in PCP-reported EHR documentation burden outside visits and significant increase in time spent on face-to-face patient interaction during visits. These self-reported results were corroborated by objective improvement in measured time to completion of encounter documentation," the researchers wrote.
The scribes also demonstrated a likelihood of improving work-life balance, which has been linked to physician burnout.
"During periods of scribe assistance, the PCPs reported significant reductions in their EHR documentation burden during off hours, suggesting that scribes may also improve a physician's work-life balance," the researchers wrote.
Potential drawbacks
There are at least half dozen potential pitfalls associated with employing scribes in the primary care setting, according to Richard Grant, MD, MPH, a coauthor of the JAMA Internal Medicine article and member of the Division of Research at Kaiser Permanente Northern California in Oakland:
Cost of scribe services
Scribe quality, which was high with the private service used in the study but varies with internal scribes
Scribe turnover can be high such as scribes using the position as stepping stone for medical school or nursing school
Patients could be reluctant to share sensitive information with a scribe present during office visits
Many health systems view scribes as a way to add more patients to a physician's panel, which offsets burnout-condition gains
Scribes do not address EHRs that are poorly designed for patient care
Identification of syncope causes and predictors can help clinicians formulate care plans to avoid hospital readmissions.
There are four primary causes for syncope readmissions, new research shows.
Syncope accounts for about 3% of total emergency department visits. In 2000, the total cost of care for the treatment of syncope was estimated at $2.4 billion annually.
The new research, which was published this month in the Journal of the American Heart Association, found syncope readmissions were more costly than initial hospital admissions for syncope. The median cost of a syncope/collapse hospital admission was $19,439. The median cost of an all-cause 30-day readmission was $26,127.
The identification of syncope causes and predictors can help clinicians formulate care plans to avoid hospital readmissions.
The JAHA research, which examined more than 282,000 syncope admissions, identifies the causes and predictors. Four primary causes for readmissions were identified:
Syncope/collapse was the most common single diagnosis for 30-day readmissions at 7.9% of patients
Combined cardiac causes tallied 17.2% of readmitted patients, with arrhythmia accounting for the largest percentage of patients at 7.2%, followed by congestive heart failure at 3.7%
Combined infectious causes tallied 13.7% of readmitted patients, with septicemia accounting for the largest percentage of patients at 3.7%, followed by urinary tract infection at 2.9%
Combined neurological causes tallied 10.9% of readmitted patients, with acute cerebrovascular disease accounting for the largest percentage of patients at 3.2% followed by seizures at 2.2%
The research found that 9.3% of syncope patients were readmitted to a hospital within 30 days of a hospital admission. Eight factors were associated with a high risk for readmission:
There are several benefits to identifying syncope patients who are at high risk of readmission, says Amer Kadri, MD, lead author of the JAHA research and a clinical assistant professor of medicine at Cleveland Clinic's Medicine Institute.
"The primary benefit is better patient care. That reflects higher survival, lower early readmission, and a better quality of life. From an administrative point of view, that would also decrease the burden on our resources and healthcare system," he told HealthLeaders via email.
Taking a thorough patient history and conducting a detailed physical examination are cornerstones of syncope diagnosis and treatment, Kadri says. "Once you know what the pathology is, it becomes easier to manage it appropriately."
Syncope patients at high risk for readmission require further measurement and monitoring before and after discharge, he says. For example, Kadri says patients discharged to an extended care facility (ECF) should trigger a "high-risk syncope pathway" of care:
The hospital-based care team should ensure that the ECF care team has information about what happened to the patient during hospitalization
There should be an effective management plan hand-off, including a printed discharge summary attached to the patient's chart
There should be a physician-to-physician phone call between the hospital-based clinician and the accepting physician at the ECF
Social workers or case managers should arrange specialty clinic follow-up appointments
A pharmacist should review pre-admission and discharge medication lists
Thorough assessment
All clinical variables should be considered when assessing a syncope patient's readmission risk, Kadri says.
Syncope can be a symptom rather than an underlying disease, which necessitates a thorough assessment, he says.
"Syncope is defined by transient loss of consciousness due to generalized cerebral hypoperfusion. That means syncope can be caused by any pathology that produces decreased brain blood perfusion followed by loss of consciousness with complete resolution shortly after," Kadri says.
For example, changes in medication can result in syncope, he says.
"If a patient reports recurrent syncope and presyncope—near fainting—in the morning there may have been a recent adjustment of their antihypertension medication, and they can suffer from low blood pressure, slow heart rate, or even more serious conditions like heart block. In this case, syncope would be a side effect of the medicine rather than a disease."
The JAHA research shows that considering all variables helps to identify true risk factors for readmission, he says.
"In our model, we found that older age—as an isolated variable—was a risk factor for readmission; however, when we implemented all other variables together, advancing age was not associated with higher risk of readmission."
In pediatric settings, care bundles for needle procedures such as lidocaine administration and comfort positioning can significantly reduce pain.
Needles don't have to hurt a child.
In 2014, Minneapolis-based Children's Hospitals and Clinics of Minnesota launched an initiative to close a painful care gap. Patients and families had reported in surveys that needle procedures were their single largest source of pain and anxiety. Staff members surveyed had said needle pain was a low priority.
Over a three-year implementation period, Children's Minnesota attained 95% compliance with best practice strategies for needle procedures and achieved several other measures of success, researchers wrote this month in the journal Pain Reports.
"Comparison of baseline audits with continuous post-implementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed," the researchers wrote.
In surveys, the percentage of families who said hospital staff "always did everything they could to help with pain” increased from 78.3% to 85.3%. For the metric "child's pain was always well controlled," family satisfaction increased from 59.6% to 72.1%.
At Children's Minnesota, which features two hospitals as well as 26 primary and specialty clinics, more than 200,000 patients undergo needle procedures such as vaccinations and blood draws annually.
Needle procedures are more than a pain.
Vaccinations are a common needle procedure in children and needles have been associated with vaccine hesitancy. An estimated 25% of adults fear needles, with most fears developing in childhood.
Children's Minnesota followed a four-step process to implement its needle-pain initiative, which is called Children's Comfort Promise.
1. Strategy selection
After conducting the surveys of patients, families, and staff members in 2013, Children's Minnesota performed a review of evidence-based pain management strategies.
The organization chose four bundles of care for needle procedures that would be offered to all patients and families:
For children 36 weeks or older, numbing of the skin with 4% lidocaine cream or needless-less lidocaine application with a disposable gas-propelled injector
For infants as old as 12 months, sucrose or breastfeeding
Comfort positioning such as swaddling and skin-to-skin contact for infants, and sitting on a parent's lap for children over 6 months
Age appropriate distraction, including toys, books, pinwheels, and videos
A key TPS concept that Children's Minnesota embraced was "value stream," which analyzes a current state and designs a future state, as well as examines a service from its beginning to end.
At Children's Minnesota, the TPS process featured identifying multidisciplinary core team members, leadership sponsors, scope, objectives, and metrics. A nurse served as the value stream manager, with support from a lean coach and physician sponsor. Executive sponsorship featured the chief medical officer and chief nursing officer.
3. Rolling implementation
In early 2014, Children's Minnesota launched Children's Comfort Promise at the organization's two outpatient laboratories. The labs were chosen as pilot sites because they had relatively small staffs and high needle-procedure volumes, with more than 30,000 needle procedures annually.
The initiative was rolled out methodically through 2016:
After the lab pilots, five inpatient medical-surgical units began the initiative later in 2014
In 2015, several sites got involved, including both emergency departments, four neonatal units, three critical care units, two short-stay units, radiology, and the outpatient surgery program
In 2016, all 26 ambulatory clinics implemented Children's Comfort Promise
After the pilot phase at the laboratory settings, expansion of the initiative was supported with baseline audit reviews, observations, and findings from the pilot to guide the TPS process.
The audits featured three metrics: the type of needle procedure, whether the four pain avoidance strategies were offered, and whether the staff found the strategies helpful when used.
4. Cultural shift
Measuring and communicating the positive performance of the needle care bundles was crucial to overcoming initial resistance to Children's Comfort Promise from staff members, the researchers wrote.
Three positive results were particularly convincing:
Wait times went down instead of up, contrary to many staff members' expectation
Lidocaine administration did not result in a single case of venous constriction impeding insertion of a needle into a vein
The four care bundle strategies provided immediate benefit to patients
To cement Children's Comfort Promise organization-wide, leadership performance bonuses were tied to attaining target goals. "The new care standard was integrated into all organizational policies, the electronic medical record, and new staff orientation, making nonadherence a performance issue," the researchers wrote.
Best practices for giving bad news over the phone include communicating directly from physician to patient, being supportive, and arranging a follow-up visit.
Conveying breast cancer diagnoses over the phone has been on the rise over the past decade, new research shows.
"Reports of communication problems by cancer patients have been associated with poor compliance with medical treatment and increased distress. Consequently, disparities between physician practices and patient expectations about the mode of bad news delivery may negatively impact breast cancer patient outcomes," the Supportive Care in Cancer researchers wrote.
The researchers examined data from nearly 2,900 patients who had received a breast cancer diagnosis from 1967 to 2017. There were several key findings:
From 1967 to 2006, breast cancer diagnoses were conveyed more often in person than via telephone calls
From 2006 to 2017, more than half of breast cancer diagnoses were conveyed through telephone calls
From 2015 to 2017, 60% of breast cancer diagnoses were conveyed via telephone calls
The researchers say there are two primary reasons why breast cancer patients are receiving more diagnoses via telephone calls.
First, modes of communication have changed over the past decade.
"The digital age has increased the use of telemedicine for cancer care, especially for patients living far from cancer centers. … Consequently, our study suggests that some physicians have decided to talk to their patients about test results sooner over the telephone and before the posting of the test results versus later at a clinic visit," the researchers wrote.
Second, more patients are requesting test results over the phone.
"Some patients are actively involved in their care and request delivery of bad news over the telephone. This mutual decision between the healthcare provider and patient about when, where, and how to communicate medical results is a natural sequel to the cultural shift toward patient autonomy and shared decision-making," the researchers wrote.
Best practices
There are several best practices for delivering bad news such as a breast cancer diagnosis, according to Natalie Long, MD, a family physician at University of Missouri Health Care in Columbia, Missouri. Four out of seven of the co-authors for the Supportive Care in Cancer research are affiliated with the University of Missouri. Long was not a co-author.
First, try to anticipate how the patient would like to be informed—a telephone call, in-person visit, or portal message. Try to determine whether the patient's preference will change based on the results.
Bad news should be conveyed in a caring and informative manner.
Any time bad news is delivered it should be given directly by the physician to the patient. Bad news should not be conveyed by staff, via voice mail, or through a family member.
In-person discussions should be held in a private and quiet location.
For telephone conversations, the physician should ask whether now is a good time to talk before delivering the news. If the time is not good, an alternative time should be arranged.
Set the context and prepare the patient by leading with an introductory statement to allow the patient to prepare for the possibility of bad news such as, "Unfortunately, the biopsy results are not what we were hoping for."
Bad news should be delivered clearly and unequivocally, followed by a pause to allow the patient to process the news.
The physician should be supportive because the patient is likely to have an emotional response. Empathy can include supportive phrases and physical contact, if appropriate.
Securing close follow up is crucial, especially if bad news is given over the phone. This allows the patient to prepare questions and bring supportive friends or family members.
Medical education
Medical schools should develop curriculum for delivering bad news over the phone, Long says.
"University of Missouri School of Medicine's curriculum now includes additional training for first-year medical students to talk about situations and techniques for breaking bad news over the phone. We teach students to use the same principals we use for in-person notification and apply those techniques over the phone," Long says.
Timing and empathy are crucial factors.
"The first goal is to make sure the patient is in a good place to talk, not in a car, at the store, or in the middle of a work setting. The students are taught skills related to listening, empathy, offering a good follow-up plan, and ensuring the patient has a support system to process the news," Long says.
Arranging follow-up visits in-person are also essential.
"We also talk to our students about the importance of offering a follow-up visit to go over the results in more detail. It gives the patient time to process the news before we talk about next steps in the treatment. Often, the patient is only able to process a small amount of information when delivering bad news, so an in-person follow up will allow time to provide a more detailed explanation," she says.
Medical students should be prepared to hold these conversations, Long says. "By teaching our medical students a patient-centered approach to notification, we are leading the next generation of physicians to inject humanity into healthcare."
