With an increasing volume of mental health visits at emergency rooms, telemedicine has the potential to improve clinical care and ER operations.
Researchers are calling for the expansion of telepsychiatry services in the country's emergency departments (EDs).
In an article published this month in the American Journal of Emergency Medicine, the researchers found multiple benefits from ED telepsychiatry.
"The development of novel patient platforms such as telemedicine may offer an innovative approach to mental health care in the ED that may optimize and improve patient outcomes while also helping to reduce challenges such as ED overcrowding and limited specialist availability," the researchers wrote.
Earlier research has shown a pressing need to boost mental health services in emergency rooms. One study showed that 1 out of 8 ED visits involves mental health as the chief complaint.
There are two main clinical benefits from enhancing ED mental health services, the corresponding author of the American Journal of Emergency Medicine research, Bernard Chang, MD, PhD, told HealthLeaders this week:
The ED allows clinicians to intervene in the ultra-acute setting, when a psychiatric event has occurred or is at greatest risk of occurring
The ED can help offer seamless integration with behavioral health specialists that patients may otherwise have challenges coordinating on their own
Anxiety and depression appear to be particularly well-suited for ED telepsychiatry, Chang says. "Many of the assessments and treatments can be done remotely."
He says telepsychiatry can spare anxiety and depression patients the stress associated with busy EDs. "The acute care environment may sometime exacerbate psych complaints. So, the less time patients can be in that chaotic environment, the better, particularly those with anxiety or depression."
Several healthcare organizations have published positive results from using a telemedicine platform for psychiatry, Chang and his coauthor wrote. In addition to treating depression and anxiety, those programs reported success in cognitive behavior therapy as well as supportive therapy for PTSD patients.
Telemedicine programs such as telestroke care have been adopted at many EDs, but ED telepsychiatry is relatively rare. Financial factors are among the obstacles, the American Journal of Emergency Medicine researchers wrote.
"In a survey of several ED telepsychiatry programs, researchers found that key challenges included financial sustainability of such programs ranging from initial upfront startup costs to ongoing carrying costs associated with maintaining such a program."
Despite the challenges, the potential benefits of ED telepsychiatry are significant, the researchers wrote.
"ED overcrowding has been associated with multiple negative outcomes from patient satisfaction, medical errors, and patient perceptions of clinician communication. ED telepsychiatry may help offset patient burden in the ED and improve overall length of stay and patient satisfaction."
Researchers say reforming state and local rules for advanced practice providers can boost productivity, lower cost of care, and improve access to healthcare services.
Expanding the scope of practice for physician assistants and advanced practice registered nurses is a golden opportunity for U.S. healthcare, Brookings Institution researchers say.
Reducing restrictions on scope of practice (SOP) for physician assistants (PAs) and advanced practice registered nurses (APRNs) generates significant benefits without compromising quality of care, the researchers say.
"To the extent that APRNs and PAs provide healthcare that is equal in quality at a lower cost—as the existing research demonstrates—removing restrictions on their practice can help alleviate shortages and improve efficiency," they wrote in their report, "Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants."
The study was published this month.
SOPs, which are mainly generated in state legislatures, feature limitations on the tasks and autonomy of advanced practice providers such as APRNs and PAs. Physicians generally are not subject to SOP restrictions.
The researchers say SOPs have three primary negative impacts:
Depressed productivity: Finetuning the staffing mix of clinical care teams increases efficiency, but it is often blocked by anticompetitive policy barriers in SOPs
Cost of care: Compared to physicians, APRNs and PAs are lower-cost sources of labor who can provide equivalent quality of care
Access: SOP restrictions on advanced practice providers are a missed opportunity to ease the country's physician shortage
Physicians and their associations have lobbied against SOP reform based on quality of care concerns. "Opponents contend that quality of care may suffer under the direction of a non-physician practitioner, citing the shorter length of training and clinical experience required," the researchers wrote.
There is no evidence to support the quality of care claim, the researchers wrote. "The academic literature finds no evidence of harm to patients associated with less-restrictive SOP laws."
If there is no quality concern, then there is no justification for restrictive SOP laws, they wrote.
"When no harm is present, the restrictions serve only to generate artificial barriers to care that ultimately provide physicians with protection from competition, prevent the attainment of system-wide efficiencies, and constrain overall provider capacity."
There are three main SOP rules for PAs:
SOP determination: Entities responsible for setting SOP for PAs varies by state, with rules set at practices, state medical boards, and state legislatures
Supervision: Oversight requirements for PAs include work plans that specify allowed procedures as well as guidelines for physician consultation and monitoring
Prescription authority: Medication rules include the exclusion of some drugs from a PA's allowable prescriptions
SOP rules for APRNs are set in state legislatures, and there are two main rules:
Practice authority: The practice independence of APRNs ranges from no restrictions, to collaborative or consultative arrangements, to supervisory relationships
Prescription authority: State laws grant prescription authority, set the schedule or types of medications allowed, and determine the level of physician supervision
Policy proposals
The Brookings researchers make six primary recommendations to ease SOP restrictions:
States should allow APRNs and PAs to practice in accordance with their education, training, and experience
When a physician and an advanced practice provider are both qualified to perform a service, the clinician with the comparative advantage should provide the service to maximize efficiency
For APRNs, end supervisory or delegative practice arrangements, stop formal collaborative practice agreements, allow prescription of medications, and scrap APRN-to-physician ratio rules
Set the level of interaction between physicians and PAs at the practice level, which would end legislated caps on PA-to-physician supervision ratios and allow the clinicians to set optimal staffing at the local level
Until APRNs and PAs can buy their own malpractice insurance, policymakers should be sensitive to the malpractice liability of physicians who supervise advanced practice providers
The federal government should encourage best practices at the state level and fund SOP research
Researchers say these organizational and individual solutions can reduce overall physician burnout symptoms by 10%.
Physician burnout has reached crisis proportions, but there are several interventions that can ease the suffering, a recent review of the scientific literature on burnout shows.
"Rates of burnout symptoms that have been associated with adverse effects on patients, the healthcare workforce, costs, and physician health exceed 50% in studies of both physicians‐in‐training and practicing physicians," the researchers wrote.
"This problem represents a public health crisis."
Burnout is a work‐related malady with three characteristics: emotional exhaustion, depersonalization, and perception of reduced personal accomplishment.
The researchers say physician burnout has negative impacts on patient care, physician health, and healthcare system operations:
Patient care: medical errors, lower quality of care, longer recovery time, and lower patient satisfaction
Physician health: substance abuse, depression and suicidal ideation, poor self-care, and motor vehicle crashes
Healthcare system operations: physician productivity reductions, reduced patient access, and higher physician turnover
For healthcare organizations, there are significant financial losses associated with physician burnout. The cost to replace one physician can be more than $1 million depending on the specialty, the researchers wrote.
"Physician burnout may also increase healthcare expenditures indirectly via higher rates of medical errors and malpractice claims, absenteeism, and lower job productivity," they wrote.
Addressing physician burnout requires both organizational and individual interventions, the researchers wrote.
"Not only do both categories of approaches offer at least modest benefit, but both are necessary, and addressing physician burnout should be viewed as a shared responsibility across healthcare systems, organizations, institutions, and individual physicians."
However, organizational interventions have the highest potential to ease burnout, the researchers wrote.
"Individuals who choose to become physicians do not appear to be inherently more vulnerable to stress and burnout, emphasizing the importance of work‐related, organizational and healthcare system factors in the current physician burnout crisis."
The researchers identified five primary drivers for physician burnout: excessive workload, work inefficiency, work-home balance, loss of control, and loss of meaning from work. There are organizational and individual interventions for each driver.
Organizational interventions
Excessive workload: fair productivity goals, duty-hour limits, and appropriate job role assignments
Work inefficiency: optimize electronic medical records, shift clerical burdens to non-physician staff, and meet regulatory requirement appropriately
Work-home balance: respect home responsibilities in scheduling decisions, specify all required work tasks in assigned work hours, and support flexible work schedules
Loss of control: establish work requirements with physician engagement, and promote physician leadership and shared decision-making
Loss of meaning from work: promote core values, maximize patient time with physicians, foster physician communities, provide professional development opportunities, and offer leadership and awareness training about burnout
Individual interventions
Excessive workload: consider part-time status, and make informed practice choices to promote efficiency and physician satisfaction
Work inefficiency: prioritize and delegate tasks appropriately, and attend efficiency and workplace skills training
Work-home balance: reflect on life priorities and maintain self-care
Loss of control: attend stress management training, embrace positive coping strategies, and practice mindfulness
Loss of meaning from work: embrace positive psychology, recognize fulfilling work roles, practice mindfulness, and participate in small-group activities with other physicians to share work experiences
Healthcare organizations should consider burnout as a top metric, the researchers wrote. "At the organizational level, burnout assessment should be considered part of the 'dashboard' of tracked institutional performance measures, quality indicators, and leadership performance."
Once physician burnout is identified, interventions make a difference, they wrote.
With interventions, researchers have found decreases in the proportion of physicians with burnout symptoms: 14% for emotional exhaustion, 10% for overall burnout symptoms, and 4% for depersonalization.
Researchers find that patients at a hospital-based emergency department were 20% more likely to be admitted compared to patients at freestanding emergency departments.
Contrary to some critics, recent research shows that freestanding emergency departments may not admit patients for inpatient care at higher rates than hospital-based emergency departments.
The research, which was published this month in the American Journal of Emergency Medicine, was conducted at Cleveland Clinic's tertiary hospital-based emergency department (HBED) and two of the health system's freestanding emergency departments (FSEDs).
"These results show that a patient who presented to our HBED trended towards a 20% higher likelihood of admission than if a similar patient presented to our hospital-based FSED," the researchers wrote.
While the 20% variation was not considered statistically significant, it does represent a trend, according to the researchers.
There are two kinds of freestanding emergency departments:
Non-hospital, for-profit organizations operate independent freestanding emergency departments, which are not recognized as emergency departments by the Centers for Medicare & Medicaid Services.
Data for the 3,230-patient study was collected from 2015 health system statistics. The researchers focused on admission rates for four health conditions: chest pain, chronic obstructive pulmonary disease, asthma, and congestive heart failure.
The patients were closely split in their emergency department usage, with 53% using the HBED and 47% using the two FSEDs.
The researchers found that more of the HBED patients were admitted than the FSED patients:
Of the 1,708 patients who used the HBED, 49% (842) were admitted
Of the 1,522 patients who used the FSEDs, 42% (645) were admitted
In addition to the presenting condition, the researchers note several factors can influence an emergency medicine physician's decision to admit a patient. Those factors include convenience, transportation costs, availability of outpatient follow-up, social supports, and the need to 'turn' a bed to reduce waiting room time.
The researchers speculate there are at least two possible explanations for the observed higher rate of admissions from their HBED compared to the FSEDs.
1. Facility factor
An earlier study demonstrated that facility-related factors drive higher rates of admission from emergency departments.
"Having higher hospital occupancy rates, higher number of inpatient beds, being in an urban location, and having a level 1 or 2 trauma center were all associated with higher ED admission rates," the Cleveland Clinic researchers wrote.
For example, chest pain patients evaluated in an HBED could receive faster additional care as inpatients rather than waiting for a second set of lab work in the ED and an outpatient cardiac stress test.
2. 'Turn' temptation
HBED physicians may be under pressure to ease waiting room congestion and 'turn' beds.
"In a busy HBED the physician that does not 'turn' beds quickly can pose a risk to quality and patient satisfaction for the entire hospital system," the researchers wrote.
They say FSED physicians appear to have less bed-turning pressure.
"FSEDs tend to have lower volumes and shorter wait times. The pressure to 'turn' patients quickly is not as profound allowing the physician time to arrange follow-up and perform longer work ups."
"Based on our data, we are trying to document something that was previously unrecognized in the literature—a significant fraction of patients with clinical sepsis are not admitted to the hospital after presenting to the ED," says Ithan Peltan, MD, MSc, an attending physician at Intermountain and a leader of the research effort.
Peltan and his research team studied 8,239 adult ED sepsis patients at two tertiary hospitals and two community hospitals in Utah. The researchers found that 1,607 of the patients—19.5% of the total—were discharged rather than admitted to the hospital.
"The conventional wisdom assumes that all sepsis patients coming to the emergency department are being admitted, but our data shows some are being discharged. … We need a reconceptualization of who these patients are and how our care guidelines are being formulated," Peltan says.
Peltan's team presented the research last month at an American Thoracic Society conference in San Diego. Although the findings are preliminary, the researchers found that it is probably appropriate for some sepsis patients to be discharged from an ED into outpatient care.
"There was no significant difference in 30-day mortality for discharged versus admitted sepsis patients," the researchers wrote in the abstract they presented in San Diego.
Discharge safety uncertain
The researchers have shown that ED physicians are sending some patients home, and the next step is to characterize which sepsis patients are appropriate for ED discharge, Peltan says.
"We are not at the point where we can recommend routine discharge of any sepsis patients for outpatient management in the community."
He says there likely are several factors that determine whether a sepsis patient in the ED is a good candidate for discharge:
Patients who are not gravely ill and are not in need of intensive care intervention
Patients who are not at high risk of deterioration
Patients who can get the care they need as outpatients such as compliance with prescribed medications
Patients who can set and attend follow-up visits
A major element of safely discharging sepsis patients from EDs is developing a risk stratification methodology for sepsis similar to risk tools created for pneumonia, Peltan says. "We need that kind of risk-stratification tool for sepsis."
Risk stratification will help ED physicians sort out the best care path for sepsis patients, he says. "Who are the patients who need to be admitted? Who are the patients we might miss but need to be admitted? Which patients can be managed as outpatients?"
Physician decision-making varies
Peltan's team found significant variation in ED physician decision-making on whether to admit or discharge sepsis patients.
"We looked at physician-level behaviors and found some physicians did not discharge any of their sepsis patients and some physicians discharged nearly 40% of their sepsis patients," he says.
The decision-making variation is a valuable data point, Peltan says.
"Somewhere in the middle, there probably is a happy medium within that range of variation."
The final version of the Peltan team's research is slated for publication in 2019.
Nearly two-thirds of emergency medicine physicians work in urban communities, and the staffing mix in rural counties reflects an emergency physician shortage in those areas of the country.
Emergency department staffing patterns have a gaping urban-rural divide, new research shows.
In 2014 Medicare data, the distribution of emergency medicine physicians is strongly skewed toward urban areas. The researchers found urban counties had a much higher proportion of emergency physicians—63.9% compared to 44.8% in rural counties.
The shortage of emergency physicians in rural areas is severe, says M. Kennedy Hall, MD, MHS, lead author of the research and an emergency department physician at Harborview Medical Center in Seattle.
"Rural area patients are now considered a disparity population, and rural areas are faced with an ongoing problem of insufficient numbers of emergency medicine-specialty physicians to staff their emergency departments," Hall told HealthLeaders last week.
Hall says earlier research has shown that rural areas have fewer incentives and more barriers compared to urban areas for ER physicians seeking employment. That research found several factors influence job location choice:
Lifestyle
Access to amenities and recreation
ER volume and acuity
Family and spouse considerations
Access to specialists
Location of residency programs, which are mostly set in urban locations
In rural areas, research published in 2013 indicates there also are budgetary and strategic factors at play in the employment of ER physicians. Some hospital executives reported that low ER patient volume and acuity did not justify hiring emergency medicine specialists. The executives also reported satisfaction with the care provided by their non-emergency medicine physicians and advanced practice providers.
In rural areas, cost considerations discourage the hiring of emergency medicine physicians, Hall says.
"A provider mix with preferential hiring of non-emergency medicine physicians and advance practice providers at lower salaries can form a larger staff than a few highly paid emergency medicine-specialty physicians, which can in turn provide care to larger rural areas."
ER Staffing Mix Reflection of Urban-Rural Gap
Hall and his team found that rural areas have a much larger proportion of nonemergency physicians and advanced practice providers than urban areas.
In the study, which was published by Annals of Emergency Medicine, urban counties accounted for 50,157 emergency medicine clinicians, with ER physicians dominating the mix:
Emergency physicians, 63.9%
Non-emergency physicians such as family practice doctors, 12.0%
Advanced practice providers such as nurse practitioners and physician assistants, 24.1%
Rural counties accounted for 8,408 emergency medicine clinicians, with non-emergency physicians and advanced practice providers outnumbering emergency medicine physicians:
Emergency physicians, 44.8%
Non-emergency physicians, 28.3%
Advanced practice providers, 26.8%
In addition to lower staffing costs and easing the ER physician shortage, Hall says non-emergency physicians and advanced practice providers are a good fit at rural ERs with expanded care models.
He says non-ER physician providers can be essential caregivers in an integrated emergency medicine and primary care model.
"As emergency departments increasingly serve as health safety nets in rural areas—becoming both primary sources for hospital admission and hubs for unplanned acute care—a mixed ER staff of emergency physicians, non-emergency physicians, and advanced practice providers may be able to better collaborate on care coordination."
Under this model, non-emergency physicians and advanced practice providers give more comprehensive care than traditional ER models, says Hall, an assistant professor at the University of Washington School of Medicine in Seattle.
"The varied and usually primary care-centered training and skills of non-emergency medicine physicians and advanced practice providers serve as a valuable asset in addressing patients' health over a longer term than typically considered in traditional ER models."
Hall says hospital executives should consider four factors when deciding ER staffing targets:
Whether patient volume is large enough to generate a cost-neutral or cost-saving employment of emergency medicine physicians
Whether budget considerations dictate the hiring of non-emergency physician staff to serve a coverage area adequately
Whether the care model favors emergency physicians or a more balanced mix of healthcare providers
Whether there is the capability to provide training and experience for non-ER physicians who lack emergency medicine board certification
A North Carolina health system finds racial disparity in pneumonia patient readmission rates, identifies causes of problem, launches interventions, and eliminates gap.
In less than two years, Novant Health eliminated disproportionately higher hospital readmission rates for African-American pneumonia patients, who had readmission rates 4% higher than Caucasian patients.
The impetus for the initiative came in April 2016, when Novant President and CEO Carl Armato signed the American Hospital Association's #123for Equity Campaign pledge.
"That's really what jumpstarted this project," says Regina Fambrough, program manager for diversity and inclusion.
After signing the equity pledge, one of the first steps taken to address diversity gaps at Novant was an examination of readmissions data at the health system, which features 11 acute care hospitals.
In the analysis, readmissions were segmented by race, ethnicity, language, gender, age, and payer source.
"What we found was there was a disparity, and it could continue to get worse. The readmission rates for African-American pneumonia patients were 4% higher than for the Caucasian population," says Tanya Blackmon, executive vice president and chief diversity and inclusion officer.
Novant closed the gap last year:
In the third quarter of 2017, the readmission rate disparity was cut in half to 2%
In the fourth quarter of 2017, readmission rates for pneumonia showed no disparity
Finding Disparity Causes
In May 2016, the Winston-Salem-based health system formed the Pneumonia Readmissions Team to study the source of the disparity and to launch interventions aimed at closing the readmissions gap.
The Pneumonia Readmissions Team, which includes Blackmon and Fambrough, is an interdisciplinary panel that meets monthly.
The panel includes a hospitalist physician, the health system's transcultural health manager, the director of case management, a care coordination representative, nursing, pharmacy, a pulmonary navigator, and a data and analytics representative.
The team's data analysis, which included 100 comprehensive medical record reviews, revealed two primary causes of the African-American pneumonia readmissions gap:
For patients who were readmitted, there was often fewer case management assessments compared to other patients and few people to provide home care.
Care coordinator calls to African-American pneumonia patients were problematic. For example, when the transcultural health manager called these patients, Blackmon said she found they didn't realize the calls were from a care coordinator.
Novant has launched several initiatives to close the African-American pneumonia readmissions gap, such as:
Collaboration between case management and electronic health record report writers to redesign patient lists to encourage assessments at discharge, which has helped boost case management assessments 22%
Warm handoff: Discharge nurses tell the patient that the care coordination team will be following up by phone and to expect a call
Pulmonary navigators, who were hired to work closely with pneumonia and COPD patients, organize timely patient referrals to the care coordination team for follow-up postdischarge
In 2017, Novant launched new scheduling for patient follow-up visits, with follow-up visits set before hospital discharge. The new scheduling drove a 12% improvement in African-American pneumonia patients receiving a follow-up visit within seven days of discharge, and there was a 25% increase in patients keeping appointments.
Blackmon says Novant expects to have return on investment numbers for the initiative later this year, but says the effort is generating cost savings.
"We are all in agreement that there are avoidable costs here—when you are readmitting a patient, you may not get reimbursed for the readmission," she says.
In February, the Centers for Medicare & Medicaid Services recognized Novant's pneumonia disparity work with the inaugural Health Equity Award. Kaiser Permanente also received the award, which was presented in Baltimore.
A New Jersey health system launches several efforts to prevent and contain workplace violence against healthcare workers.
Workplace violence is a widespread problem within the healthcare setting that must be prevented for the safety of clinicians and patients.
That's why RWJBarnabas Health is taking a stand against workplace violence at its hospitals and clinics.
Over the past year, West Orange, New Jersey–based RWJBarnabas Health, an academic integrated healthcare system, has launched or enhanced efforts to curb workplace violence.
"Nurses, nursing assistants, and security guards are more likely to encounter violent behavior, but it is not limited to them. You can find violent incidents in all areas of a health system's facilities," says Nancy Holecek, RN, MHA, MAS, senior vice president and CNO of RWJBarnabas Health's Northern New Jersey Region.
Data showing the impact of the health system's violence prevention efforts is not available yet, but RWJBarnabas is currently collecting data to gauge the impact, monitor violence trends, and plan additional prevention measures, Holecek says.
“There are several indicators that we monitor related to our workplace violence efforts, including the number of reported incidences, employee health referrals, and medical claims data,” she says.
Here are five things that RWJBarnabas is doing to thwart workplace violence:
Created facility safety assessments
Facility safety assessments seek to ensure buildings are as safe as possible, Holecek says.
"We have been looking at our technology, looking at our visitor access system, and looking at our security workforce to ensure that we have the most updated technology and that we have our entrances covered and locked down at the appropriate time," she says.
A major facility challenge is aligning safety and service, she says. "We have to always make sure that we balance the security piece with open access for anyone who needs our services."
Instituted quick reporting technology for violent incidents
RWJBarnabas focused on ease of reporting largely because workplace violence incidents are underreported, Holecek says.
"If it's an event that results in a serious injury, then it gets reported. If it's something minor or a threat, unless staff members truly feel they are in danger, they generally treat the incident as part of the symptoms or disease that a patient is presenting," she says.
The health system has adopted reporting technology that allows staff members to click on a computer desktop icon and quickly file reports on workplace violence, she says.
Eased reporting has created a data opportunity, she says. “We have seen an increase in reported events, which was to be expected. The trending of this data related to number, severity, location, and person—patient, visitor or other—will allow us to better track, respond, and strategize our efforts.”
Raised awareness among staff
Raising awareness about workplace violence boosts safety and increases the likelihood of reporting, Holecek says.
"Oftentimes, [violent behavior] is something a patient can't control [because of] dementia or a behavioral health issue. Our staff understand this and make excuses for it. The problem with that is we can't collect data and we can't intervene; so, we are encouraging our staff to report," she says.
Enhanced training
RWJBarnabas is improving its Behavioral Emergency Safety Training (BEST) with the help of a consultant.
"The focus is to de-escalate the behavior—not to pin the person against a wall. This has been very successful. It works a large percentage of the time," Holecek says of BEST.
The consultant is adding a new layer to the BEST training—instructing staff about duty to warn, duty to act, and duty to respond.
"The consultant is training trainers who will go out to work with our security workforce, behavioral health workforce, and emergency workforce, and then expand to make sure all of our employees are trained," she says.
Added violent incidents to daily debriefings at each of RWJBarnabas' 11 hospitals
Addressing incidents of workplace violence has become part of a larger high-reliability initiative at RWJBarnabas.
The initiative includes 15-minute leadership huddles in the morning at every RWJBarnabas hospital to review facilitywide issues from the previous 24 hours. Workplace violence incidents are among the topics discussed.
The CEO usually leads the morning huddle, with about 45 participants ranging from the C-suite to the department director ranks.
"This informs the entire senior team and department heads so they know what has transpired. It helps us stay abreast of any incidents of workplace violence that may have occurred," Holecek says.
Another workplace prevention effort
In addition to those initiatives, the health system formed a steering committee to lead workplace violence prevention efforts.
The Workplace Disruption Prevention Steering Committee oversees the office of emergency management, security, and workplace violence.
The steering committee is an interdisciplinary group with representatives from compliance, emergency management, HR, legal, nursing, physicians, IT, and security.
"On the Workplace Violence Committee, we have the same steering committee members, but we also have an emergency department physician and a nurse from behavioral health. We wanted to make sure there were people who experience these kinds of issues day in and day out," she says.
Guidance to prevent workplace violence
Recent guidance issued by The Joint Commission features seven recommendations to prevent workplace violence that could help healthcare organizations prevent violent encounters.
Holecek says she and her colleagues are examining the workplace violence report released by The Joint Commission.
The report could prompt more workplace violence initiatives at RWJBarnabas, she says.
New research provides guidance for implementing clinician dress codes at health systems, hospitals, and physician practices.
Physician attire impacts patient satisfaction, with preferences for clinician couture varying by care setting and patient attributes such as age, researchers have found.
"Our work shows that patients care. So, for institutions that don't have a dress code or formal policy for attire, it might be time to consider one," article co-author Vineet Chopra, MD, MSc, of the University of Michigan Medical School and VA Ann Arbor Healthcare System told Healthleaders this week.
Out of 4062 patients surveyed, 53% said physician attire was important to them. The research was published in BMJ Open.
Overall, patients preferred formal attire with a white coat, ranking that ensemble an 8.1 on a scale of 1 to 10. "Our work shows white coats matter the most. I think this is an important takeaway for institutions," Chopra says.
The researchers found that preference for physician attire is influenced by patient attributes and care settings:
Female patients preferred scrubs with white coats in emergency room and hospital setting compared to men (41% vs. 31%)
In hospitals, patients 65 and older preferred formal attire with white coats more than younger patients (44% vs. 36%)
Younger patients preferred scrubs and white coats over formal attire (28% vs. 21%)
Patients with a college degree preferred formal attire and white coat for family physicians more than patients without a degree (48% vs. 42%)
Patients preferred formal attire with white coat for primary care (44%) and hospital physicians (39%), but scrubs were rated highest for ER physicians (40%) and surgeons (42%)
Patients also had regional differences in their preference for physician attire.
"While formal attire and white coats were preferred across all regions, 50% of respondents in the West and 51% in the South selected this as their preferred option compared with 38% and 40% in the Northeast and Midwest, respectively," the researchers wrote.
The findings on patient preference variation for physician attire indicate that healthcare organizations should take a nuanced approach to dress codes, Chopra says.
"Preferences may vary based on location and context. Institutions may want to consider examining specific areas to understand whether or not more defined dress codes might be indicated."
The research is consistent with common perceptions about professionals, the researchers wrote.
"These findings make intuitive sense: Patients often have notions of how a 'professional' should dress and are more likely to respond positively to those that meet these stereotypes. Strategies targeting physician dress may therefore enhance trust and satisfaction."
The research is based on a questionnaire that included photos of a male and a female physician in seven different sets of attire. Patients were asked to rate the physicians in several clinical settings. The rating system had five domains: knowledgeable, trustworthy, caring, approachable, and comfortable.
Formal attire with white coat scored highest for all five domains.
The research includes several other key data points:
In the overall rankings, scrubs with a white coat ranked second to formal attire with white coat. Formal attire without a white coat ranked third.
In ER and surgery settings, scrubs alone were preferred by 34% of patients followed by scrubs with white coats (23%)
36% of patients said physician attire impacted satisfaction with their care
55% of respondents said doctors should wear a white coat during office visits with patients
Matching physician attire with patient expectations can improve patient experience, the researchers wrote.
"Providers engaged in care of elderly patients … may consider donning formal attire more so than surgeons or emergency room physicians where scrubs may be more important. Similarly, hospitals in Southern regions of the USA may wish to endorse formal attire and white coats."
The research has policy implications, they wrote.
"Patients appear to care about attire and may expect to see their doctor in certain ways. Hospitals, clinics, emergency departments and ambulatory surgical centers should consider using these data to set dress codes for physicians providing care in these settings."
Several factors are making specialists hot commodities, including the aging population, lifestyle-related diseases such as obesity, and a shortage of psychiatrists, healthcare staffing agency says.
In an annual healthcare staffing survey, family physicians rank as the top requested recruiting assignment for the 12th year in a row, but demand for specialists is trending upward.
Recruitment activity is shifting toward medical specialists, according to the 2018 Review of Physician and Advanced Practitioner Recruiting Incentives. The survey, published by Dallas-based Merritt Hawkins, found 74% of search assignments were for specialists, up from 67% three years ago.
In physician compensation, the survey found invasive cardiologists had the highest average starting salaries at $590,000. Orthopedic surgeons were second at $533,000.
Three factors are driving increased demand for medical specialists, starting with the country's aging population, says Travis Singleton, Merritt Hawkins executive vice president.
"It is specialists such as cardiologists, orthopedic surgeons, pulmonologists and others who care for the ailing organs, bones, and brains of our fastest growing patient cohort—seniors, who are disproportionate users of care."
Lifestyle-related disease and behavioral health are also increasing demand for specialists, he says. "Rising rates of obesity, diabetes, drug abuse, and mental health problems are creating a sicker patient population, the kind commonly treated by specialists."
The third factor boosting demand for specialists is the cyclical nature of the physician employment market, Singleton says.
"Hospitals, medical groups, and other healthcare facilities have emphasized primary care recruitment in recent years, and now they need specialists to whom their primary care doctors can refer."
The survey was conducted from April 2017 to March 2018, and it is based on a sample of 3,045 clinician search assignments. In addition to the medical specialist and top compensation findings, the survey has six other key points:
Reflecting an ongoing shortage, psychiatrists were second on the list of Merritt Hawkins' most requested recruiting assignments for the third year in a row.
Demand for nurse practitioners (NPs) and physician assistants (PAs) is rising. Merritt Hawkins conducted more search assignments for NPs and PAs than in any other 12-month period tracked by the company.
While the tying of physician compensation to value is spreading, value was linked to only 8% of compensation in the survey.
In record highs for the survey, the average physician signing bonus was $33,707, the average starting salary for family physicians was $241,000, and the average starting salary for a nurse practitioner was $129,000.
Employment remains the dominant physician staffing model, with more than 90% of Merritt Hawkins' search assignments set at employed practice settings and less than 10% at independent practices.
In a record high for the survey, 62% of recruiting assignments were in communities of 100,000 or more. The survey authors linked the trend to the rising demand for medical specialists, who tend to practice in large communities.
The shortage of psychiatrists has been worsening for years, Singleton says.
"In 2005, psychiatry was No. 13 in our list of most requested types of searches. Five years ago, in 2013, psychiatry was No. 4 on the list. For the last three years, it has been No. 2, trailing only family medicine."
Psychiatrists are a dire pain point in the nation's clinician shortage, he says. "We judge the shortage in psychiatry to be more severe than any other specialty we recruit."
There is little relief in sight, Singleton says. "Though there has been increased interest in psychiatry among medical graduates selecting residency programs recently, our ability to train more psychiatrists remains limited because residency positions are limited."
