Oswego Health has a comprehensive approach to patient safety, the health system's new CMO says.
Patient safety involves multiple facets, and it should be among the top priorities at health systems and hospitals, according to the new CMO of Oswego Health in New York.
Wajeeh Sana, MD, was announced as CMO of Oswego Health in early July. He has worked at the nonprofit health system since 2013. At Oswego Health, he has served as medical director and chairman of Oswego Hospital's emergency department and president of the Oswego Hospital medical staff.
Oswego Health takes a comprehensive approach to patient safety, Sana says.
For example, the health system uses two factors to identify patients. First, the organization performs medication safety. Second, Oswego Health conducts infection prevention, fall prevention, and suicide prevention, as well as calling a timeout before surgical procedures to make sure surgeons are performing the correct surgery on the correct patient.
The most recent patient safety initiative launched at Oswego Health is for fall prevention.
"We have developed comprehensive policies around fall prevention," Sana says. "Right now, we are in the process of providing education about fall prevention and implementation of the policies to our staff."
An essential element of the fall prevention initiative is identifying patients who are at high risk.
"We are educating staff on what to look for," Sana says. "High-risk patients include people who come into the hospital with an altered mental status, people who have mobility issues, and people who are on medications that can put them at high risk."
Wajeeh Sana, MD, is CMO of Oswego Health. Photo courtesy of Oswego Health.
Sana developed a keen understanding of physician engagement during his time as president of the Oswego Hospital medical staff, and he says there are four essential elements of physician engagement.
"First, you need clear communication with your physician leaders. Second, you need to value their input and their time because we all know how busy physicians are," Sana says. "Third, you should assign physician champions for different projects in your organization. Fourth, organizational support is important as well as rewarding the efforts of physicians."
CMOs should use a targeted approach when selecting physician champions, according to Sana.
"We look for leaders in their fields," Sana says. "These include medical directors and experts in their fields."
Having a clinical background in emergency medicine and serving as medical director and chairman of Oswego Hospital's emergency department helped prepare Sana to serve in the CMO role.
"In serving in an emergency room, you are a gateway to the hospital," Sana says. "You have patients coming in from primary care offices and consultants' offices."
"I was the emergency medicine medical director for 12 years," Sana says. "I managed multiple physicians and advanced practice providers. I was in contact with hospital leadership. In the emergency room, your role is to work with all consultants. So, I developed a good relationship with our medical staff, which makes my job as CMO easier."
Market challenge
Mirroring a national trend, recruiting physicians and other healthcare workers is the biggest challenge at Oswego Health, according to Sana.
"We have staffing challenges in primary care as well as specialty care such as in gastroenterology, neurology, and nephrology," Sana says. "We have done significant outreach and tried to hire more primary care doctors and the primary care practices have expanded over the past few years."
A couple of strategies adopted by Oswego Health have been successful in the recruitment of primary care physicians, according to Sana.
"We want primary care physicians to choose us as a place to work," Sana says. "We have concentrated on the quality of our primary care, so physicians want to work for us. We have also recruited physicians who have ties to our area."
For healthcare workers in general, Oswego Health has concentrated on building a strong human resources pipeline, starting as young as ninth grade, according to Sana.
"We have an early college health sciences program and have just graduated our first cohort," Sana says. "Through partnerships with our local community college, students come to our hospital and shadow multiple departments, including laboratory services, radiology, and finance."
The health system also has a robust tuition assistance program, according to Sana.
"If any employee wants to go back to school for roles such as medical imaging technician or degrees such as BSN or MSN, we will help pay for that," Sana says. "Tuition assistance is both a recruitment and retention tool for us. The investment in our staff has set us apart."
While CMOs concentrate on clinical areas such as patient safety and care quality, they also impact the bottom line at healthcare organizations. For example, managing cost of care is a key financial component of care delivery, and CMOs must understand financial connections like this to help ensure the success of their organizations.
"In leadership, it is imperative to have an acute understanding and keen awareness of the environment," says Scheinbart, the author of The Chief Medical Officer’s Financial Primer: The Vital Handbook for Physician Executives, which was published by the American Association for Physician Leadership. "Unfortunately, while physicians are expertly trained and highly specialized in clinical care, they do not always come with the knowledge of the finance environment that wraps around everything that a healthcare organization does."
"If there is a lack of awareness of the finance environment, it is an impediment to the success of all the stakeholders," he says.
Cost of care
Health system and hospital CMOs need to understand the cost of care at their organization, Scheinbart says.
"Early on, hospitals charged for the cost of care based on the cost of gauze, Band-Aids, and X-ray plates, for example, and it was passed on as a straight charge and payment was expected," he says. "We are nowhere in that universe anymore."
Cost of care has become more complex, Scheinbart says.
"To pay for hospital costs, there is a highly complex system of players who are involved in the dollars when the patient is in the hospital," he says. "So, the CMO needs to understand the cost of everything that occurs for the patient to bring value back to the hospital."
A CMO needs to know what costs are being incurred, who manages those costs, and the impact of those costs, Scheinbart says.
"If you carry these costs forward to the net margin of the institution and how that margin plays a significant role in the future prospects of the organization, not every CMO understands the criticality that they bear when it comes to the success of the organization," he says.
Revenue structure
CMOs also need to know the revenue structure of the organization.
Healthcare isn't like a kid's lemonade stand, Scheinbart says. CMOs need to be aware of not-so-straightforward transactions.
"Third parties pay for the care and adjudicate the payment in the process of the billing, claims, and collections," he says. "Those elements ought to be understood by CMOs because not everything is a straight payment. There are pathways and processes that bring the dollars into the organization. Then embedded in that are both incentives and penalties, particularly from the Centers for Medicare & Medicaid Services (CMS)."
A CMO, he says, may be tasked with improving a domain that is measured through Press Ganey, such as communication with doctors. That, too, has financial implications.
"There are questions that patients are asked when they are filling out their Press Ganey surveys," Scheinbart says. "When those surveys are collated, the results are given and there is a score. There can be money associated with the score. CMOs need to work with their revenue team and compensate physicians appropriately in their contract linked to that domain."
Press Ganey scores impact a hospital's CMS star ratings, which are indirectly tied to reimbursement from Medicare.
"The higher the star rating for the hospital, the greater payment to the hospital through value-based care," Scheinbart says.
Financing of health systems and hospitals
Above all else, Scheinbart says, CMOs should have a good understanding of how their health system or hospital is financed.
"A CMO might spend a lot of time dealing with quality and credentialling, but what they really ought to be doing is driving the financial health of the health system or hospital, so that the organization has working dollars to put back into patient care," he says.
CMOs should collaborate with CFOs to get a clear understanding of a health system's or hospital's financial structure and give CFOs a better idea of how clinical care affects those finances. The more CMOs and CFOs work together, the better their decision-making will be.
"CMOs may be responsible for a significant portion of quality and safety of patient care, but their efforts may lower the financial stability of the organization," he Scheinbart says. "This can hurt the bond rating for nonprofits or the underwriting ability for for-profit organizations."
For example, if a CMO does not manage cost of care, it can hurt the bottom line.
"In a nonprofit setting," he adds, "some CMOs who are new to the role may not understand that a $2 billion health system has a 3% margin, which is $60 million. That $60 million must be returned back into the health system by law. That $60 million gets carved up by every interested stakeholder, such as department heads who want an endoscopy suite or a patient transportation system."
In that case, a CMO must know how to advocate for care delivery improvements and be able to explain how those improvements boost the bottom line.
"For example, the CMO may understand that the work they do on length of stay elevates the health system by $1 million or $2 million in terms of revenue on the balance sheet," he says. "Then it is reasonable for the CMO to seek $350,000 for new software, so they can improve quality."
In addition to adding beds, hospitals with tight capacity must focus on operations reforms and new workflows.
Patient capacity is the biggest challenge at University of California Davis Medical Center, according to the hospital's new CMO.
Joseph Galante, MD, was named CMO of UC Davis Medical Center in July. He previously served as interim CMO of the medical center for a year and trauma medical director of the hospital for many years.
"Like many health systems, our biggest challenge has been capacity," Galante says. "We are full. Unlike other health systems that have beds that are not staffed, we have staffed all of our beds."
A unique element of the medical center's patient capacity crunch has been California's seismic compliance requirements, according to Galante.
"We have had to close 70 beds over the past year," Galante says. "By closing those beds, we had to find 70 new beds to open in different locations throughout the hospital."
UC Davis Medical Center has had to do more than open beds to address the facility's capacity challenge, according to Galante.
"You must apply the operations and work flows to be able to move patients more seamlessly and get them discharged," Galante says.
On the operations front, UC Davis Medical Center has instituted a program on the outpatient side to identify patients who are at high risk for hospital readmission, according to Galante.
"We have a patient navigator and nursing team that can help those patients navigate as an outpatient without returning to the emergency department and becoming readmitted," Galante says. "We call this our Multi-Visit Patients program."
New workflows have been added in the medical center's emergency department to boost patient throughput as well.
In most traditional emergency departments, patients would expect to check in, wait in the waiting room, get a bed, then care begins. However, the medical center has a process to start care as soon as a patient checks in, according to Galante.
"We have physicians at the front of the emergency department and patients can get care while they are waiting in the waiting room—you may leave the waiting room to get imaging studies or labs," Galante says. "Then you come back to the waiting room, but you are getting care without touching a bed, which helps with throughput and eliminates the need to wait for care."
Promoting patient safety and quality
Galante says patient safety and quality have been his top concerns as CMO, interim CMO, and trauma medical director at UC Davis Medical Center.
"We have a variety of different paths that we take for patient safety and quality," Galante says.
The medical center compares itself to Vizient rankings for other academic medical centers as well as metrics through The Joint Commission, according to Galante.
"We continue to monitor the metrics for patient safety and quality," Galante says. "Just as importantly, we do both bedside engagement of the physicians and nursing staff that deliver care as well as systems monitoring of the quality of care that we deliver."
The hospital's Patient Safety Events Committee reviews patient safety events daily. The medical center also engages patients to promote safety and quality, according to Galante.
"We have incorporated patients into our quality spectrum through the Speak Up program, where patients can alert us to issues that arise during their care," Galante says. "We have the Code Help Hotline, which patients can call to let us know that there are issues arising in their care."
With the Code Help Hotline, patients are given a phone number they can contact, and the calls go to the medical center's patient relations team.
"It not only alerts us to potential quality issues that come up, but also helps us remain patient centric," Galante says. "This service is for inpatients with urgent hospital needs."
Joseph Galante, MD, is CMO of UC Davis Medical Center. Photo courtesy of UC Davis Medical Center.
Clinical staff engagement
Engaging the clinical staff of the medical center was one of the key elements of serving as interim CMO, according to Galante.
"Coming out of the coronavirus pandemic, our staff and physicians have been under stress and have been experiencing burnout," Galante says.
To engage staff, a CMO must be present and available for healthcare workers, according to Galante.
"I have been able to do some clinical care each week, so people see me in my scrubs working in the hospital," Galante says. "Additionally, I try to go out each week and meet with different teams to engage them in their workplace, so they see the CMO. I ask questions, engage them, and find out how we can help them overcome barriers they are experiencing while delivering care."
Coping with high costs
The medical center has been experiencing high costs in the labor arena and from inflation's impact on supply costs, according to Galante.
"The pandemic certainly did not help us on either of these fronts," Galante says. "Workforce shortages are driving up labor costs across the entire spectrum of our staff."
To contain labor costs, the medical center has been focusing on recruiting full-time staff rather than employing contract labor such as locum tenens physicians, according to Galante.
"Temporary labor can cost about two times what hiring permanent staff costs," Galante says. "If you can hire someone into your organization and build them into your culture, the amount of time that they stay makes it worth the recruitment costs that are invested up front."
In addition to hiring full-time staff, the medical center needs to ensure that full-time staff are productive, according to Galante.
"That involves eliminating low-value work," Galante says. "It helps to bring in technology to eliminate continuous monitoring of patients and note taking functions. You want to get people to work at the top of their licenses."
To address high supply costs, the medical center is taking advantage of the purchasing power associated with being part of a large health system, according to Galante.
"We can leverage as a joint system to be able to contain costs and negotiate lower prices from supply vendors," Galante says. "We can come up with reasonable contracts through our purchasing power. We also have done some work with inventory management to make sure that we are not overstocking."
CMOs and other healthcare leaders need to employ several strategies to restore trust, such as pushing back on misinformation about who profits from vaccines.
Trust in physicians and hospitals fell from 71.5% in April 2020 to 40.1% in January 2024, according to a new research article.
The trust patients place in physicians and hospitals is an important concern for CMOs and public health officials. If patients do not trust physicians and hospitals, they are less likely to follow their recommendations.
The coronavirus pandemic marks a turning point for trust in physicians and hospitals, says the lead author of the research article, Roy Perlis, MD, MSc, associate chief of research in the Department of Psychiatry and director of the Center for Quantitative Health at Massachusetts General Hospital.
"Prior to the pandemic, many physicians took it for granted that people would trust them," Perlis says. "Unfortunately, because there was so much misinformation and politicalization of healthcare during the pandemic, a lot of the initial trust in physicians and hospitals was squandered. What we have realized is that we need to rebuild trust if we are going to support public health in the future."
The loss of trust during the pandemic was not a surprise for the researchers, according to Perlis.
"Unfortunately, during the course of the pandemic, especially with the spread of misinformation about COVID and the vaccine, trust declined substantially," Perlis says. "We were not surprised that trust declined, but we were surprised by the magnitude of the drop."
The research article is based on survey data collected from more than 440,000 U.S. adults. In addition to the finding that trust in physicians and hospitals dropped 31%, the study, which was published in JAMA Network Open, includes three key results:
Higher levels of trust were associated with a higher chance of vaccination for COVID-19 (adjusted odds ratio 4.94) or influenza (adjusted odds ratio 5.09), as well as getting a COVID-19 booster (adjusted odds ratio 3.62).
Characteristics linked to decreased trust included being 25 to 64 years of age, female, lower educational level, lower income, Black, and living in a rural area.
When survey respondents were asked why they had lower levels of trust, the reasons cited included financial motives over patient care, poor quality of care and negligence, influence of external entities and agendas, and discrimination and bias.
Roy Perlis, MD, MSc, is associate chief of research in the Department of Psychiatry and director of the Center for Quantitative Health at Massachusetts General Hospital. Photo courtesy of Mass General Brigham.
Trust is essential to convince patients to follow recommendations such as vaccination, according to Perlis.
"If your doctor is telling you to do something either directly or through the hospital where you get your care, there is no reason to follow the recommendations if you do not trust what you are being told about something like vaccination," Perlis says. "That is one of the reasons why it is imperative that we restore trust."
Loss of trust is different for different groups, according to Perlis.
"Some of them may be more likely to have had bad experiences with healthcare. Historically, we know that we have not necessarily treated all groups equally well," Perlis says. "Unfortunately, public health became politicized during the pandemic, and some of the groups that were associated with less trust had more exposure to the politicization of healthcare."
For survey respondents, the reasons for loss of trust broke down into several categories, according to Perlis:
One reason was bad experiences in terms of their own care or the care of a family member.
There were concerns about conflicts of interest.
People were worried that doctors or hospitals may have financial motives rather than simply being focused on providing the best care.
There was concern that doctors or hospitals might be influenced by outside entities or outside agendas.
There was a subset of survey respondents who had experienced discrimination or bias in their interaction with the healthcare system.
Restoring trust in doctors and hospitals
There are several steps that CMOs and other healthcare leaders can take to restore trust, according to Perlis.
"It is one thing to say trust is down," Perlis says. "It is another thing to think about how we can repair trust, which we will need for all kinds of public health initiatives, including the next pandemic and anything that involves intervening to improve public health. We absolutely must prioritize restoring trust."
Strategies to restore trust will have to be crafted with the reasons why trust has eroded.
"The strategies to restore trust probably aren't a one-size-fits-all response," Perlis says. "They need to address some of the underlying concerns."
There are several ways that CMOs and other healthcare leaders can show people that conflict of interest does not drive decision-making.
"For example, we have transparency laws that make it easy for people to see whether their doctor is being paid by someone other than the hospital," Perlis says.
CMOs and other healthcare leaders need to push back on misinformation about who profits from things such as vaccines or medications.
"Simply clarifying who pays for these things and who benefits from them financially is important," Perlis says.
For people who have had bad experiences with healthcare or feel they were not treated well, that is more difficult to address.
"We need to find ways to re-engage with these people," Perlis says. "One way to do that is to listen. We can get people in to see their doctor and find out why they had bad experiences."
CMOs and other healthcare leaders need to make it easier for people to interact with the healthcare system.
"There are many reasons people get frustrated such as long wait times to see doctors," Perlis says. "We need more outreach and more accessibility."
CMOs need their physicians to be addressing prescription overload.
For patients on multiple medications, deprescribing is a key strategy to promote patient safety and care quality.
The primary risk with multiple medications is medication interactions. This risk can lead to an increase or decrease in the effects of medications as well as undesired effects and side effects.
Cost and waste are other considerations, according to Karna Patel, MD, MPH, vice president at Tampa General Hospital and president of Tampa General Medical Group.
"As you add more medications, there is more cost to pay for those medicines," Patel says. "Globally, prescribing multiple medications can lead to waste of pharmaceuticals."
When assessing patients on multiple medications, clinic visits and visits in other healthcare settings are an opportunity to go over a patient's medication list, according to Patel.
"At that time, we want to make sure all the medications the patient is taking are appropriate for their conditions," Patel says. "We also check for interactions. That is a great time to try to deprescribe or consolidate medications."
For example, there may be three medications for three conditions, but there are medications that can be used for treating more than one condition, according to Patel.
"We want to look for an opportunity to use one medication rather than three medications," Patel says. "Deprescribing is one way to move forward when a medication is not needed and you can consolidate medications, so you are prescribing only the medications that are absolutely needed for patients."
Cymbalta is an example of a medication that clinicians can use to deprescribe and consolidate medications, according to Patel.
"Cymbalta is a medicine that is approved for anxiety, depression, neuropathy, and chronic pain," Patel says. "In many cases, patients take multiple medications to address those problems, and there is an opportunity to discontinue those medications and switch to Cymbalta, which can help with all of those conditions."
At Tampa General Hospital, referrals to pharmacists are also an opportunity to assess patients on multiple medications, according to Maja Gift, MHA, BS Pharm, senior director of pharmacy services at the academic medical center.
"We may have a physician who is concerned that a patient is on a lot of medications, and they will issue a referral to a pharmacist to conduct a review," Gift says. "Pharmacists have a lot of training, and they know a lot of details about medications, so it makes sense to pull them into a situation where a medication review is required."
Deprescribing best practices
The first step in deprescribing is looking at the current clinical status of the patient and their list of conditions, according to Patel. Then, clinicians should look at the medications and the evidence-based guidelines to see which medications are necessary and aligned with the evidence-based guidelines, and which medications are well tolerated by the patient, he says.
"Keeping all those things in mind, you go down the list of medications and make the decision of which ones to keep and which ones to discontinue," Patel says. "In addition, you want to look at which medications can be consolidated to address multiple problems."
Medication therapy management is the process for deprescribing, according to Gift.
"That process includes having a pharmacist review every medication a patient is on, evaluate for drug interactions, and evaluate for duplication of therapy because one medication can be enough instead of multiple medications," Gift says.
Medication therapy management is reimbursed by the Centers for Medicare & Medicaid Services as well as most commercial payers, according to Gift.
Best practices for deprescribing include allotting time to do the job, according to Patel.
"If there is a long list of medications, it can take 30 minutes to go through everything and make sure that you can consolidate and deprescribe," Patel says.
Another best practice for deprescribing is knowing when a medication should not be discontinued abruptly, according to Patel.
"Some medications require tapering, especially medications that have the risk of withdrawal," Patel says. "Other medications that do not require tapering can be stopped without being concerned about withdrawal symptoms."
Why multiple medications should concern CMOs
Multiple medications for patients should be on a CMO's radar because medication management is a component of value-based care, according to Patel.
"We are focused more on patient experience, quality, outcomes, and cost of care," Patel says. "Medication management is an important area for CMOs and health systems because if we are aiming for all of those things, we want to make sure patients are getting the medications that are needed—not multiple medications that are duplicated or are interacting."
There are other reasons CMOs should be concerned about patients with multiple medications, according to Patel.
"The side effects that can result from multiple medications can lead to increases in healthcare utilization, risk of going to the emergency department, hospital admissions, or ICU stays," Patel says. "There are other risks such as impacting the quality of life from falls or other injuries."
The core elements of promoting quality care include three things, says this CMO.
Quality care is going to be a primary focus of the new CMO of Lifepoint Health.
Last month, Chris Frost, MD, was named senior vice president, chief medical officer, and chief quality officer of Lifepoint. He has served in two other leadership roles at the Brentwood, Tennessee-based health system: chief medical officer of Lifepoint Communities and national medical director of hospital-based services.
Frost says the core elements of promoting quality care include three things: a leadership component, a process improvement component, and a culture of safety.
"Those are the framework components of our Lifepoint National Quality Program," Frost says.
The leadership component includes the recognition of the importance of leadership in every aspect of the organization, according to Frost. It also includes engagement of all the quality stakeholders and an accountability process.
For process improvement, he says Lifepoint has a checklist of ten critical components for performance improvement such as huddles that clinical care teams use to focus on clinical workflows, learning whiteboards at every clinical care unit to identify opportunities for improvement, and tracking data that demonstrates progress or regress.
The culture of safety at Lifepoint includes the engagement of patients and their families as well as fostering an environment where all team members experience psychological safety and have a voice in the safety process, according to Frost.
Frost says the Lifepoint National Quality Program, which started in 2010 and is a combination of both quantitative and qualitative criteria, will be one of his main areas of attention.
"We have a deliberate focus on reduction of patient harms such as catheter-associated urinary tract infections and central line-associated bloodstream infections," Frost says. "We have demonstrated significant progress since starting the national quality program, including a 65% reduction in our overall patient harms."
Lifepoint has also recognized that there are external barometers of patient safety and quality of care such as The Leapfrog Group and Centers for Medicare & Medicaid Services Star Ratings, according to Frost.
"We have deliberately focused on integrating components of Leapfrog and CMS Stars into our national quality program," Frost says. "The point is that quality and the definition of quality have tried and true components that you see year-over-year, but it is not a static process. It is a dynamic process that requires evolution."
Chris Frost, MD, is senior vice president, chief medical officer, and chief quality officer at Lifepoint Health. Photo courtesy of Lifepoint Health.
Engaging a clinical staff
There are four facets of clinical staff engagement, according to Frost.
First, a CMO must make a deliberate effort to deconstruct historically hierarchical models of care, says Frost, who adds physicians have had an outsized influence in healthcare in the past.
"One of the success measures for engaging clinical staff is making sure that the definition of clinical staff is not limited to physicians," Frost says. "It includes physicians, advanced practice providers, nurses, physical therapists, pharmacists, and other clinical professionals."
Second, a CMO must leverage data and analytics, according to Frost.
"Data and analytics are related to the mantra of 'that which can be measured can be managed,'" Frost says. "Analytics allow us to convert raw data into a clinically meaningful narrative—how data demonstrates how our clinical workflows impact our patients."
Third, a CMO must manage quality-focused process improvement, according to Frost.
"You want to use a plan, do, study, act (PDSA) cycle," Frost says.
Fourth, a CMO must engage in change management, according to Frost.
"For process improvement to take root and to be sustained, you must have clinicians and staff willing to do things differently," Frost says. "Change management is the people side of change."
Prepared to lead
Frost says his clinical background in internal medicine and pediatrics provides a solid foundation for working in the CMO role.
Combined internal medicine and pediatrics training is usually a four-year program. Physicians do two years of internal medicine training and two years of pediatrics training, then they are eligible to become board certified in both specialties.
"The training allowed me to understand the social and clinical needs of the patient population from cradle to grave," Frost says.
Frost served as a hospitalist for nearly two decades, and he says his hospital medicine background is also beneficial in his new role.
"That experience has been incredibly helpful for the CMO role because I have an intimate understanding of the continuum of care of the patients," Frost says, "from the ambulatory setting to the acute care setting, to the post-acute care setting."
Challenge in Lifepoint markets
A key challenge at Lifepoint is serving nonurban communities, according to Frost.
"One aspect of Lifepoint's mission to make our communities healthier is allowing community members in nonurban settings to access care close to home," Frost says. "The challenge here includes physician recruitment and nurse recruitment."
To address these challenges, Lifepoint has been leveraging telehealth as a way to have critical clinical services offered to nonurban community members, according to Frost, who adds the health system has established nurse residency programs as a way to help train and introduce nursing team members to nonurban communities.
Another important aspect of serving patients in nonurban communities is addressing social determinants of health, according to Frost.
"We have seized on partnership opportunities with community organizations to address social determinants of health," Frost says. "This includes food insecurity, housing insecurity, and interpersonal safety. The health system is not necessarily positioned to address all social determinants of health, but partnerships with our community organizations have been meaningful work for our team members."
Allegheny Health Network has generated positive results from its physician well-being efforts, with physician burnout rates running at about 10% below the national rate.
The best physician well-being programs begin by measuring burnout and well-being, then selecting an appropriate strategy, the chief wellness officer of Allegheny Health Network (AHN) says.
Burnout takes a personal and professional toll on physicians, says Thomas Campbell, MD, MPH, chief wellness officer at AHN.
"On the personal side, there is increased substance abuse," he says. "Studies have shown that alcohol use and other substance use increases with higher levels of burnout. There is trouble with relationships at home with loved ones. There is also an increase in suicidal ideation and depression."
"On the professional side, increases in physician burnout cause decreases in quality of care, which we see with increased malpractice claims and increased near misses in patient safety events," he says. "There is a decrease in productivity—the efficiency of physicians and their ability to see more patients is decreased. Finally, burnout causes physicians to cut back hours or to leave the profession."
AHN launched a wellness program for physicians, advanced practice providers, nurses, and residents six years ago. The first step was to measure burnout and well-being, Campbell says.
"One of the reasons we use a measurement tool regularly is we didn't want to just try interventions and see how they worked," he says. "We want to have information from our survey that we can act on to pick interventions."
AHN selected a survey tool developed by a company at Penn State Health.
"We looked for a measurement tool that had validity for physicians, advanced practice providers, nurses, and residents," Campbell says. "They had experience measuring well-being and burnout for all those categories of workers, not just physicians. The company was led by a psychologist named Dan Shapiro, and we have continued to work with him over the past six years."
"They used Maslow's Hierarchy of Needs adapted to a healthcare industry well-being model, which includes basics such as good hydration and nutrition, moving up the pyramid to camaraderie, safety, appreciation, and feeling that you are contributing at full capacity," Campbell says.
The survey data indicates that AHN's well-being and burnout program is having a positive effect. Physician burnout levels have been running at about 10% lower than the national rate.
Thomas Campbell, MD, MPH, is chief wellness officer at AHN. Photo courtesy of AHN.
Setting a strategy
After selecting a measurement tool, AHN picked an established strategy for its wellness program. The health system picked the Stanford Model of Professional Fulfillment, which features three pillars: culture of wellness, efficiency of practice, and personal resilience.
1. Culture of wellness
The first step involves making sure that providers have multiple ways to reach out for help, Campbell says.
Survey data showed that physicians are reluctant to reach out to AHN's employee assistance program (EAP) because they are concerned about confidentiality.
"We created a help line so physicians could reach out to internal behavioral health providers 24/7," Campbell says. "We now have an EAP program that does not use internal reporting tools if people are uncomfortable with our internal behavioral health resources. We also established external resources, where people could get help through our county medical society."
AHN also conducted leadership education to create a culture that included psychological safety, so that physicians could feel comfortable sitting down one-on-one with their leaders, according to Campbell.
"The primary focus of the leadership training was how to lead your physicians with wellness in mind," he says.
The health system also removed questions about mental health history on physician credentialling forms.
"Those questions are a hinderance because they stigmatize doctors and prompt them to not reach out for help," Campbell says.
2. Efficiency of practice
Efficiency of practice is an essential element of promoting physician well-being, Campbell says.
"When you have a workday where everything is working well, you are less likely to get burned out," he says. "You are likely to get out of work on time, to be more fulfilled in your day, and to make yourself a better person physically and mentally outside of work."
AHN's effort to improve efficiency has focused on their Epic electronic health record.
"We have been trying to limit the amount of time physicians are on a computer to make their work more patient-centered," Campbell says. "We want physicians to spend less time at night—we call it pajama time—charting because they could not get to it during the workday."
To address this, AHN has formed teams of proficient Epic users to help physicians use the EHR more effectively.
"We call members of these teams IT officers, and these officers show physicians how to be more efficient in the EHR," Campbell says.
The health system has also adopted AI-driven ambient listening technology, which automates documentation during physician encounters with patients.
"We are trying to find ways to make the EHR work for the physician to promote a more efficient workday, create better documentation, and create tools that support better care," Campbell says.
AHN has also been working to build better teams around physicians
"We have been looking at what advanced practice providers, experienced nurses, and medical assistants can do together with physicians to create an optimum team working at the top of their capacity," Campbell says. "We are trying to establish more synergy and efficiency in the practice of medicine."
This team building effort has been particularly successful, he says, in the outpatient setting.
"In outpatient clinics, there is a great opportunity to allow advanced practice providers to do more within the scope of their licensure," Campbell says. "In the outpatient setting, we are also getting more out of nurses and nurse navigators."
3. Personal resilience
For physicians, teamwork is also tied to personal resilience and a commitment to wellness, Campbell says.
"We have found that resiliency is tied to the team around physicians, but physicians do need to keep an eye on their health and well-being," he says.
It is important to understand that personal resilience is individualized, Campbell says.
"What one person might need in terms of diet, sleep, hydration, and mental healthcare is often different than what another person might need to keep healthy," he says.
Campbell has found that his human resources colleagues and AHN's benefits offerings are crucial to supporting personal resilience.
"I have been looking at what programs that we have and what benefits that we have for those who may need help with issues such as weight management and addiction, including smoking cessation," he says. "We want to provide multiple ways for people to get the things that they need."
One such benefit is paternity leave and maternity leave, the latter of which was recently expanded.
An important element of personal resilience is finding ways to balance work and life outside of work, Campbell says.
"It is hard to achieve a perfect balance and a better term is probably integration," he says. "We have encouraged physicians to look at the integration of their work life and their personal life."
A national concern
The most recent survey data from the American Medical Association shows physician burnout below 50% for the first time since 2020. In 2023, 48% of physicians reported experiencing at least one symptom of burnout, which was down from 53% in 2022, according to the AMA. Physician burnout reached a record high in 2021, with 62% of physicians reporting at least one symptom of burnout, AMA survey data found.
Despite the improvement, physician burnout remains a troubling problem, according to the AMA.
"The shift marks a milestone in the ongoing battle against physician burnout, but the fight is far from over," a prepared statement from the AMA says. "Continued efforts are essential to address the root causes of physician burnout and ensure that doctors receive the support they need to thrive."
Campbell recently led a HealthLeaders strategy call on physician well-being.
Ashish Patel plans to translate his success in growing Phoenix Children's gastroenterology program into the physician-in-chief role.
The new physician-in-chief of Phoenix Children's earned the role based on his performance as division chief of gastroenterology at the pediatric health system.
Ashish Patel, MD, became division chief of gastroenterology at Phoenix Children's in April 2020. His prior leadership experience includes serving as associate clinical director of the pediatric gastroenterology program at University of Texas Southwestern Medical Center and director of the Southwestern Pediatric Inflammatory Bowel Disease Center at Children's Medical Center Dallas.
As division chief of gastroenterology, Patel says he pursued a program of excellence based on three pillars: clinical excellence, opportunities for research, and education and community outreach.
Clinical excellence
Patel promoted clinical excellence in the gastroenterology division by recruiting several new physicians. They were needed because of massive growth in the Phoenix area and growth of the health system.
"With a commitment to growth, the first thing we needed to do was to build on Phoenix Children's clinical excellence, and the way you do that is through recruiting excellent physicians," he says.
Patel recruited 10 new pediatric gastroenterologists, increasing the number of faculty positions in that area to 25. He also recruited two transplant-trained hepatologists and a pediatrics-trained liver and kidney surgeon.
In addition to addressing growth in the patient population, Patel's recruitment of new physicians was designed to fill gaps in the kind of care that Phoenix Children's provided. For example, there was no gastrointestinal motility program at the health system and there were no facilities in the state providing that service.
"We had to send patients to Texas to get motility studies done," Patel says. "I recruited a doctor from UT Southwestern to set up the motility program. He was among my first set of recruits. That allowed us to establish that we were in a growth phase, and people across the country saw that, which helped to boost recruitment."
There is a physician shortage in many specialties in the United States, but Patel was able to recruit physicians by leveraging his relationships and the growth opportunities at Phoenix Children's.
"One of the doctors we recruited was my first pediatric resident at UT Southwestern," he says. "Another doctor we recruited was one of my fellows at UT Southwestern. I talked with doctors about the vision and the opportunity at Phoenix Children's."
Ashish Patel, MD, is physician-in-chief of Phoenix Children's. Photo courtesy of Phoenix Children's.
Opportunities for Research
Patel says he learned the value of research at healthcare organizations from his time at UT Southwestern, an institution steeped in research.
"When I came to Phoenix Children's, I knew that the way we could build a national reputation was by being involved in research and being involved in efforts such as consortiums and collaborations," he says.
In 2020, research at Phoenix Children's was limited to a handful of industry-based studies that brought novel therapeutics to the pediatric population.
"What we wanted to do is add investigator-initiated studies that would advance science, medicine, and therapeutics," Patel says. "We have launched these kinds of studies in areas such as inflammatory bowel disease and feeding disorders."
An innovative area of research at Phoenix Children's is transnasal endoscopy, which does not require general anesthesia. Phoenix Children's and Children's Hospital of Philadelphia are national leaders in pediatric transnasal endoscopy.
"Transnasal endoscopy has benefits for children because they can avoid general anesthesia," Patel says. "It has benefits for the healthcare system in off-loading surgical caseload."
Education and community outreach
In 2020, Phoenix Children's had the largest pediatric gastroenterology program in the country that did not train future gastroenterologists. Creating a fellowship program was among Patel's top priorities, and a program was launched in 2021.
The goal was to create one of the best pediatric gastroenterology fellowship programs in the country, Patel says.
"When the core group sat down to plan for the fellowship program, we talked about what we loved about our fellowship experiences and what we thought could be done better," he says. "We wanted to achieve the perfect intersection of those things."
In the first year of interviewing fellows, candidates were told that the program offered an excellent clinical foundation, with opportunities for research, Patel says.
"Fellows would leave the program feeling comfortable in taking care of pediatric gastroenterology patients in multiple subspecialties," he says. "We also wanted to give fellows experiences in research—curriculum development, basic science research, clinical research, and quality improvement."
The gastroenterology fellowship program has been a success, Patel says.
"We have matched with fellows in each of the three years that the program has been open," he says. "In the past year, we recruited two fellows from our own residency program."
Since 2020, Phoenix Children's has launched several gastroenterology community outreach programs.
"Phoenix Children's foundation does amazing outreach throughout the Phoenix area," Patel says. "We have piggybacked on their resources to go out into the community to engage with families. We have created a Gastrointestinal Advisory Board, where we have asked families to advocate for what they feel is important in the GI field."
For example, this month an inflammatory bowel disease support group will meet at Phoenix Children's, Patel says.
"We will have an evening event where families can get some education, exposure to the research we are doing, and exposure to the support services that we have for our patients," he says.
Applying division chief success in the physician-in-chief role
Patel is eager to translate his division chief success to his new role.
"Now, my job is to take what I learned in growing the gastroenterology division over the past four years and take the approach of developing a vision, emphasizing mentorship and education, and promoting research at the 20 medical divisions at Phoenix Children's," he says. "I am going to be interacting with colleagues at the division-chief level."
Patel also plans to interact with the clinical staff.
"I want to attend their monthly faculty meetings, and I want to find out about their struggles," he says.
Two areas on which he focused as chief of gastroenterology are going to be particularly helpful in the physician-in-chief role, Patel says.
"I want to talk with the division chiefs about faculty outreach and recruiting," he says. "I want to help engage physicians and optimize recruiting."
Locum tenens clinicians can be a short-term solution for doctor shortages, but CMOs must plan carefully how to use them.
Locum tenens physicians can plug short-term gaps in the physician workforce, but CMOs must be aware of both the cost and the effect on workplace culture.
There are about 50,000 locum tenens physicians working in the United States, says Joseph Sturdivant, MD, CMO of IMN Enterprises, a healthcare staffing company. With a clinician shortage nationwide, he notes, they're a popular solution to fill workforce gaps.
About 88% of the nation’s health systems used locum tenens clinicians in 2023, Sturdivant says, and half of them expect to use more in 2024.
Here are 5 facts about employing locum tenens clinicians that you need to know:
Locum tenens clinicians can be a short-term solution for doctor shortages, but CMOs must plan carefully how to use them.
Locum tenens physicians can plug short-term gaps in the physician workforce, but CMOs must be aware of both the cost and the effect on workplace culture.
There are about 50,000 locum tenens physicians working in the United States, says Joseph Sturdivant, MD, CMO of IMN Enterprises, a healthcare staffing company. With a clinician shortage nationwide, he notes, they're a popular solution to fill workforce gaps.
About 88% of the nation’s health systems used locum tenens clinicians in 2023, Sturdivant says, and half of them expect to use more in 2024.
"What we have seen in the rise of locum tenens is the ability to fill the void of clinicians as we have an aging population and increased utilization of inpatient care," says Sturdivant, who is a practicing locum tenens physician. "There is a lack of physician coverage throughout the nation."
Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer at RWJBarnabas Health, says the health system uses locum tenens physicians in several departments.
"We have certain physician areas where we have a shortage, and having access to locum tenens physicians enables us to fill those gaps at least in the short term," he says.
Locum tenens clinicians are hired for various lengths of time, Sturdivant says. They can fill in for a week during the holidays, for a couple of months to cover maternity or paternity leave, or for several months while a healthcare organization recruits a permanent clinician.
In the longer term, Anderson says, it's more beneficial to have physicians who remain with a health system, hospital, or physician practice for long periods of time.
"Locum tenens physicians tend to come and go, and there is less opportunity for them to get to know the staff, get to know a facility, and get to know the community," he says.
Anderson says permanent clinicians are superior in the long term because they become familiar with their clinical colleagues, their institution, and the community they serve.
Financial perspective
There is a financial challenge associated with employing locum tenens clinicians, Anderson says.
"They tend to be more expensive than employed clinicians," he says. "So, in the long run financially, locum tenens is not the best model for us. It is important to fill gaps and make sure we can operate our business fully staffed. However, the incremental salary a locum tenens clinician typically demands is a cost burden."
Typically, locum tenens clinicians earn 25% to 40% more in monetary compensation than permanent clinicians, Sturdivant says. However, they are not given a benefits package as part of their compensation, which can account for one-third of the compensation that permanent clinicians have as part of their employment, he says.
Sturdivant says it's important not to view the impact in isolation.
"You must look at why organizations look at hiring locum tenens physicians," he says. "There might be a surge in patients and an organization's current staffing model cannot handle that level of patient care efficiently. Those inefficiencies can suck away the margin that serving a larger patient population can produce."
In addition, Sturdivant says, locum tenens clinicians can help to reduce doctor turnover as well as boost retention and provider satisfaction because permanent clinicians are overworked when there are openings in the permanent staff.
"If you are not meeting your staffing goals, your physicians are going to burn out and leave, which has a financial cost," he says. "When you talk about the financial bonus that locum tenens physicians receive, that cost is offset by improvements in patient care, permanent physician satisfaction, and margin that is generated from being fully staffed."
Having a pipeline to recruit permanent clinicians is an alternative to using locum tenens clinicians, Anderson says.
"In today's market, you will have a need to fill gaps here and there, but having a physician pipeline is the best solution," he says. "At RWJBarnabas, we have established a physician pipeline in partnership with Rutgers University. We are hiring physicians from Rutgers and retaining them in our communities."
Ensuring locum tenens assignments are successful
A successful locum tenens assignment, Studivant says, begins with teamwork.
"In my experience working in a locum tenens capacity, the facilities where I have struggled in my assignments are those that treated me not as a member of the team but as an expendable commodity," he says. "When I have worked as a medical director, I have had the most success with locum tenens clinicians when they are brought on as full members of the team."
Also crucial, he says, are onboarding processes.
"You want a locum tenens physician to get to know a facility and get to know the team they are working with," he says. "It is important to establish connectivity and relationships early on, so the locum tenens doctor can work as a team member with the other staff in the facility."
The onboarding process should include creating familiarity with an organization's culture, mission, vision, and values.
"They need to understand the strategic priorities of the organization," Anderson says.
That includes the quality and patient safety requirements of an organization.
"There needs to be transparency around the areas where you are focused in terms of quality and patient safety," he says. "You need to make sure that a locum tenens clinician sees the metrics that are being tracked. They need to understand the areas that are being prioritized. They also need to know how they can contribute to the outcomes that a facility is seeking."
Sturdivant says several studies have shown that locum tenens physicians compared to permanent providers are statistically indistinguishable in terms of quality care.
"[They] are not bouncing around from job to job because they are not doing a good job," he says. "They are highly educated and highly motivated professionals who have chosen to work locum tenens assignments with a skillset comparable to permanent physicians."
Sturdivant says physicians are attracted to locum tenens jobs because they can have a freedom of movement and the ability to set a working schedule.
"I personally have viewed my locum tenens work as an opportunity to put my toe in the water and test-drive different organizations and different practice patterns," he says. "Then you get the benefit of being in control. As a locum tenens clinician, you get to declare your availability in terms of scheduling."
Joseph Galante, MD, is CMO of UC Davis Medical Center. Photo courtesy of UC Davis Medical Center.
Chris Frost, MD, is senior vice president, chief medical officer, and chief quality officer at Lifepoint Health. Photo courtesy of Lifepoint Health.
