Maryland health systems are not financially rewarded for providing high volumes of services in hospitals.
The capitated reimbursement model in Maryland is one of the biggest challenges in serving as a clinical leader in the state, the chief clinical officer of LifeBridge Health says.
Daniel Durand, MD, has been chief clinical officer of LifeBridge since July 2021. He has also been chair of radiology at the health system since February 2016. Prior to taking on the chief clinical officer role at LifeBridge, Durand was the health system's chief innovation officer.
HealthLeaders recently talked with Durand about a range of issues, including innovation, clinical care predictions for 2023, and physician engagement. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as chief clinical officer of LifeBridge?
Daniel Durand: The challenges that are specific to LifeBridge versus other health systems have a lot to do with where we are in our evolution as a health system—we are a mid-sized health system—and a lot to do with the state of Maryland. One of my responsibilities is the clinically integrated network. In the state of Maryland, we have capitated hospital systems, so the hospitals are not volume-oriented. If too much volume goes to the hospitals, you lose money. There is a lot of effort to rethink healthcare delivery and think about everything we need to do in the hospitals and things we can do outside the hospital at ambulatory surgery centers and the home. LifeBridge has one of the largest home healthcare networks in the state.
The challenge in being at LifeBridge is also an opportunity. It is challenging because the hospitals cannot be unending profit centers. When you construct a network, you need to think about what you are going to deploy in the network—what you are going to keep out of the hospital. That puts us in a different position than many other states. You have to think about how things are different here based on how the reimbursement is different.
Daniel Durand, MD, chief clinical officer of LifeBridge Health. Photo courtesy of LifeBridge Health.
HL: Give me examples of innovations that this reimbursement model helps.
Durand: There are companies that are selling software suites, risk stratification tools, or services that take low-acuity cases and put you in a position to manage them in the patient's home entirely or bring the patient into the emergency room and then admit them into the home. Keeping patients out of the hospital in a medically responsible way has an incredibly high return on investment.
In other states, health systems have 50% to 80% of their revenue coming from hospitals. In most geographies, that means that most of that 50% to 80% is fee-for-service volume oriented, so more hospital services are better for you financially. In this geography, it is the exact opposite. It means our revenue is at risk for the total cost of care—you are not going to get paid for the amount of times patients come into your hospitals.
Things like home care and hospital at home have a good ROI in the state of Maryland, as do ambulatory surgery centers. Things that are harder to build a case for because of the way the reimbursement system is structured are new capital projects on hospital campuses.
HL: Do you have any clinical care predictions for 2023?
Durand: Generally speaking, we are going to continue to see strategic virtualization. During the coronavirus pandemic, what we have learned is that there are many possibilities for using telehealth tools. You are going to start to see for both physicians and other types of roles that we are going to virtualize a lot more. It is the only way we are going to get at some of the financial issues health systems are having across the country because I do not think revenue is going to solve the problem. We must find ways to take out cost. You must figure out to do the same or better with fewer people. You will see a lot of virtual nursing. There will be a lot more use of artificial intelligence algorithms in radiology—AI will screen images and the ones that have likely findings will get read first.
More and more cloud-based and machine-learning algorithms are going to be pointed at different things, and it is going to allow us to better deploy our staff, whether it is an acute facility or more longitudinal care. Then there is going to be more distributed care—there will be more hospital at home this year than ever before. That is going to grow exponentially.
There are a lot of exciting developments that got tabled or ignored during the pandemic, when there was a lot of emphasis on COVID therapeutics and COVID vaccines. There is some overlap. For example, mRNA technology, which is largely a way of vaccinating people, is going to become important for a variety of viruses but also cancer. I think mRNA is going to be a big deal because it got a huge coming-out party during COVID.
There is a big queue of exciting things coming into the cellular therapy space for cancer. Whether it is this year or coming years, you are going to see that space grow.
There are also anti-obesity medicines, which are on my radar as a cost issue, but there is also the idea of obesity being treated as more of a medical condition. There will be more interventions than just saying, "Go lose some weight on your own." It is becoming a treatable condition.
HL: What are the primary elements of physician engagement?
Durand: It is relational. The primary elements are making yourself available and communicating that you have time for people. Physicians do not have a lot of time. So, figuring out how to communicate with them is crucial. Laying the foundation for that involves developing relationships with people, which is getting to know them and that is enough to get somewhere with about half of physicians. There is also a credibility aspect. It is hard to be a chief clinical officer or chief medical officer too early in your career because people do not want to hear the opinion of someone who has not been in the trenches for a while. So, practicing and having credibility on some level is important.
You must be one of them. You must be practicing or have practiced. You must be viewed as professional, and you must get to know them and let them know you have respect for what they are doing.
The worst thing to do with physician engagement is to make your first contact with a physician some kind of remedial issue, where you are correcting them. Doctors do not like that.
HL: What are the keys to success for physician leadership?
Durand: Preparation, discipline, and humbleness are important. If I am going to do well with anybody, I need to understand why they practice medicine. The answer is a little different for every physician—you must understand what they are in it for. You put yourself in a position to lead physicians if you know why they are there to begin with. You must get to the "why."
The things we ask people to do are often counter-intuitive. As chief clinical officer, most of my initiatives have to do with change management—we are changing something. Often things are the way they are because the doctors like it. When you come along and want to change something, the odds are pretty good that the doctors are not going to be happy about the change. So, getting to the "why" behind a change is important.
HL: You have been playing a key role in strategically growing and shaping LifeBridge's provider network. What have been the primary elements of this effort?
Durand: The biggest thing driving the success of our provider network has been our partners division, which is overseen by our CFO, and it is mainly a portfolio of for-profit companies that we own outside of the hospitals. There are nursing homes, home care companies, and imaging centers—pretty much everything we need has been solved with a hybrid approach. It is a health system approach because it sits within the health system, and it exists to serve the health system and its patients. The acquisitions that are made are informed by the needs of the health system, but we have preserved an entrepreneurial spirit of independently run businesses.
Many times, when we acquire a business, we keep the founder on. That is invaluable because one of the issues with health systems is they can become too bureaucratic. We have a scrappy, entrepreneurial thread that drives almost all of our non-hospital expansion. It is a unique feature of how we do business at LifeBridge.
Our approach has been successful in a couple of ways. It is consumer oriented. So, when you go out and acquire small businesses that have brought themselves up by their own bootstraps, you do not get a lot of stale ideas or complacent people. You get people who know how to appeal to patients. They do business in a way that is completely different than what I experienced at academic centers or even as a consultant to large community-based health systems. It rubs off on everything. We are ahead of the curve when it comes to things like the convenience of urgent care.
A top RWJBarnabas Health executive shares cost-saving strategies with HealthLeaders.
An executive from RWJBarnabas Health will share his Top 20 revenue and cost-savings strategies for medical groups at a Medical Group Management Association (MGMA) conference in March.
In the current market conditions, revenue and cost-savings initiatives can be pivotal for medical groups. There are several challenges facing medical groups, including historically high inflation, workforce shortages, and tight financial and capital constraints.
Michael O'Connell, MHA, interim chief operating officer at RWJBarnabas Health Medical Group, is set to present his Top 20 revenue and cost-saving strategies at the MGMA's Medical Practice Excellence: Financial and Operations Conference, which will be held March 19 to March 21 in Orlando, Florida. RWJBarnabas Health Medical Group features about 5,000 clinicians who are associated with RWJBarnabas Health through employment, joint ventures, management services agreements, or professional services agreements.
In a recent conversation with HealthLeaders, O'Connell shared his Top 10 cost-saving strategies.
1. Development of standard work
There is significant variation in the different work that is conducted at medical groups, and the development of standard work helps reduce cost.
There needs to be standardization of work, whether it is for billing, setting standards and benchmarks for contracting, credentialling, coding, or preauthorization. The consistency helps to create good data reports and data analytics. It also helps benchmark yourself against high-performing medical groups. Creating standardized work improves efficiency, productivity, outcomes, and, ultimately, saves costs.
2. Supply chain management
Standardization in the ordering of supplies reduces costs.
A key to successful supply chain management is to make sure that you have physician partnership and physician buy-in. O'Connell worked in an organization where they had 10 different hip implants that they used for hip replacements. The costs ranged from $2,000 to $20,000, but the outcomes were the same for all of the hip implants. By working with the physicians to use only two or three hip implants, they were able to reduce costs.
Supply chain savings can be as simple as the table paper in an exam room. If the quality of the table paper is such that you must pull the table paper twice because it is thin and it rips, you are wasting money.
3. Efficient physician credentialling
When physicians join organizations, you must make sure they are credentialled and privileged in both hospitals and various managed care plans. Physicians are often brought on quickly, but then they are not credentialled so they can't see patients, or if they do see patients, they cannot get paid.
It usually takes 90 to 120 days after a contract is signed to be sure that an organization has all of the information for the physician to not only be approved on the medical staff but also approved on all of the managed care plans such as Medicare and Medicaid. If a physician starts and they are not fully credentialled, you are not going to get paid. So, there can be a tremendous amount of inefficiency in bringing providers onboard.
4. Team-based care
Medical groups can establish team-based care by making sure that each team member has the requisite skills and abilities to be able to provide care.
For example, medical assistants can support the physicians with standardization of their tasks such as preparing the patient and the chart in advance or reviewing the physician's in box. There are many opportunities to create standard work. Especially as you hire staff and train them, if you are training them for 5,000 physicians who all have different standard work, it makes it highly inefficient.
The more you can agree on standardized work for team-based care, it reduces cost in terms of efficiency.
5. Real estate management
It is relatively common for medical groups to acquire more real estate than what is needed. What ends up happening is that you have exam rooms, and if you have developed these exam rooms in such a way where they have pieces of equipment and tools that do not get used effectively, you are spending for unused real estate space.
O'Connell has found that when medical groups want to expand, sometimes they will acquire a real estate space that is not used fully. They may not be using it Monday through Friday from 8 a.m. to 5 p.m. They may not be using it on the weekends or nights. There are other strategies. For example, you can do time shares, where you can sublease a space for a day or two days a week, which is much more cost effective than renting real estate when you have unused space. You may also find that you are not using space as effectively as possible. Especially with telemedicine, you do not necessarily need to do telemedicine in exam rooms—you can do it in offices or even at home.
6. Data analytics and reports
You need to make sure that the data reports and analytics that involve time, effort, and energy are really helping to impact your medical group.
Many organizations have developed score cards and dashboards, which are meant to serve as important tools in making sure that they can manage their organizations in timely and effective ways. Sometimes, you get stale in looking at data and you are not doing anything meaningful with it. So, you need to look on at least an annual basis at the data to see what you are going to do with it. For example, if you find there are patient no-shows, are you doing anything in terms of performance improvement efforts?
You can save significant costs if you pay attention to the data.
7. Effective staff recruitment
Especially with the Great Resignation and high staff turnover, particularly in nursing, you need to make sure that you have effective staff recruitment and retention efforts.
Often when organizations are hurting for staff, hiring a warm body is something they want to do. That is not the most effective way to make sure that the individual who is coming fits the mission, vision, and goals of the organization.
Having an effective staff recruitment program, which includes peer interviewing and having candidates shadow someone in their role so they can get an idea of the culture and the job expectations, helps an organization. Reducing turnover and making sure that you recruit people who are going to stay for long periods of time definitely has cost savings.
8. Staff productivity
Whether it is someone who works in medical records or medical reception or another role, there should be expectations for productivity. You need to understand whether people are consistently working 40 hours or are getting paid overtime. You can have mechanisms to be able to do some backup staffing, so staff does not have to go into overtime. Do you have individuals who can cover staff at the end of the day or at the end of the week?
You also need to develop standards. O'Connell cites the example of a biller who went on vacation. The person who provided coverage was able to get the work done in half the time. So, you need to make sure that you have standards for productivity that are expected for staff. You need to measure and monitor productivity. You need to give feedback on a timely basis so staff know the expectations for productivity.
About 80% of budgets can be staffing, so you must make sure that staff are as productive as possible.
9. Comprehensive onboarding
O'Connell has found that people come onboard and because of the stressors of the organization they do not necessarily get the appropriate onboarding that they need to be successful in their jobs. When you look at the percentages of staff that are turning over within the first 90 days or within the first year, while they may say they are leaving for compensation or for other factors, most likely it is because they have not had the comprehensive onboarding that is needed.
O'Connell has found that successful organizations make sure people feel they are in a culture of trust and respect—that they can ask questions and that they can learn—and everything is not thrown at them all at once. Comprehensive onboarding reduces turnover and generates cost savings for the organization.
10. Optimizing scope of practice
You need to make sure that you have staff that are working at the top of their license. You do not want nurses who are doing medical assistant work. You want to deploy staff to the best of their abilities.
For example, O'Connell worked with a medical group that had a cost center, and they had five nurses in the cost center. They found out that 25% of each one of the nurse's work was non-nursing work. So, when one of the nurses left, instead of hiring another nurse, they made sure that the nurses that were there only worked on nursing work and they recruited a medical receptionist to do the other work that the nurses were doing. That saved a significant amount of money.
It is similar with advanced practice practitioners. Do you have physician assistants or nurse practitioners who are performing work that could be performed by a nurse or by a medical receptionist? You need to make sure that advanced practice practitioners are working to the top of their license and there are others who can support their work.
There are differences between coaching and mentoring. In coaching, the person receiving the coaching is assumed to have the answers for attaining their career goals and the coach draws those answers out. In mentoring, there is more of an advice-driven relationship, where mentors are experts who share their experiences with mentees to help them grow and meet their career goals.
"In many ways, the coach does not have to be an expert. They must be an expert in listening, asking questions, and being a mirror for the client they are working with to help them get to the answer that is within themselves," says Courtney Holladay, PhD, associate vice president of the MD Anderson Leadership Institute.
MD Anderson has been collecting data about coaching since the launch of its leadership institute in 2018. With the data, MD Anderson staff that have received coaching can be compared to a control group that has not received coaching. "We have seen a significant difference. From fiscal year 2019 to fiscal year 2022, the turnover for the coaching group was 9%; for the those who have not participated in coaching, the turnover rate was 20%," Holladay says.
There are a couple of reasons why coaching has reduced turnover, she says. "The investment that we are making in the individual makes them feel they are receiving support from the institution. We have heard from candidates who have joined MD Anderson and received onboarding coaching that was a differentiator for them in terms of why they joined MD Anderson. The other piece is that there is a lot of literature that says having goals and career-focused direction leads to engagement within the organization and leads to employees being more likely to stay with an organization."
The data also indicates that coaching has increased new research publications and clinical trials activated.
All staff members are eligible to receive coaching, Holladay says. "We have been building up our programming to be able to coach everyone. We were not able to start there, but we are now in a place where we are able to offer coaching for anyone who is interested."
MD Anderson offers four kinds of coaching.
Onboarding coaching is offered automatically to new executives and new faculty leaders as soon as they start working at MD Anderson. There are 15 sessions that typically last about nine months. People receiving coaching have 12 sessions one-on-one with their coach and three sessions with their managers.
Traditional coaching involves a series of one-on-one sessions, where the coach works with a staff member on making specific behavioral adjustments to capitalize on strengths and address development needs. Traditional coaching includes 18 hours of coaching, with three of those hours dedicated to a triad check-in, which is the coach, the staff member, and the staff member's manager. Traditional coaching it is typically nine months to a year.
Leadership development cohort program coaching can target different competencies and different topics such as holding difficult conversations. This type of coaching also can focus on a particular goal that the coach works with the staff member to attain. The length of the coaching is dependent on the particular cohort program, ranging from five months to a year.
On-demand coaching allows staff members to go online and look for a coach. Managers are made aware of the coaching request so they can support the coaching engagement, and staff members are asked to do a quick self-assessment to make sure they are ready for what coaching entails. The length of on-demand coaching is the most variable. If the staff member and the coach are focusing on a specific issue, the duration of the coaching could be three to five sessions. If the coaching is focused on a long-term goal, the duration could be nine months.
Holladay offered advice to other healthcare organizations that are interested in launching coaching programs. "You should start small, build on success, and continue to grow. We have been successful by being very focused on how we could provide coaching early on, how we could do coaching well, and how we could generate outcomes. Then we focused on growing our coach population, which allowed us to ultimately achieve our goal of offering coaching to anyone who wants it."
Researchers show tie between burnout and discrimination, abuse, and sexual harassment.
Emergency medicine residents who experience workplace mistreatment are more likely to be burned out than residents who do not experience workplace mistreatment, according to a new research article.
Earlier research has shown that emergency departments are a hotbed for workplace mistreatment. A New York City study found that 97% of emergency medicine residents had experienced verbal harassment in an ED. A study published in 2016 found that 78% of ED healthcare workers had reported a violent assault in the prior year.
The new research article, which was published by Annals of Emergency Medicine, is based on survey data collected from 7,680 emergency medicine residents. The study examined three types of mistreatment: discrimination; physical, verbal, or emotional abuse; and sexual harassment. Burnout was measured with two factors from the Maslach Burnout Inventory: emotional exhaustion and depersonalization.
The research article features several key findings:
31.7% of survey respondents reported burnout
3.2% of survey respondents reported career choice regret
29.9% of survey respondents reported experiencing mistreatment a few times per year, and 18.3% of survey respondents reported experiencing mistreatment a few times per month or more
Compared to residents who did not experience mistreatment, residents who experienced mistreatment were more likely to report burnout—for mistreatment a few times per year, the odds ratio was 1.6; for mistreatment a few times per month or more, the odds ratio was 3.3
Compared to residents who did not report burnout, residents who reported burnout were more likely to have career choice regret (odds ratio 11.3)
After adjusting the data for burnout, there was not a significant association between the frequency of mistreatment and career choice regret
Overall, the incidence of burnout was similar among men (30.5%) and women (32.5%), but after adjusting the data for mistreatment, women were less likely to report burnout than men (odds ratio 0.77)
Senior residents were more likely to report burnout than first-year residents
Senior residents were more likely to report career choice regret than first-year or second-year residents
"Workplace mistreatment is associated with burnout, but not career choice regret, among emergency medicine residents. Efforts to address workplace mistreatment may improve emergency medicine residents' professional well-being," the study's co-authors wrote.
The residents' perspective
Limiting mistreatment of staff in the ED setting is a challenge, Jessica Adkins Murphy, MD, president of the Emergency Medicine Residents' Association and an emergency medicine resident practicing at University of Kentucky Hospital, told HealthLeaders.
"The reason this has been so challenging is because in the emergency room we are dealing with a lot of people who are having the worst days of their lives. Many people have addiction issues and psychiatric emergencies. They are unable to inhibit their reactions to providers. That is why we see a high level of workplace violence in the emergency room. That has led to challenges in implementing zero tolerance policies for mistreatment," she said.
The ED setting is unlike most other workplaces, Murphy said. "We can't treat people the way airports treat people. At an airport, if you have shown violence toward staff, you do not get to fly. Flying is seen as a privilege. On the other hand, healthcare is something we need to provide to people regardless of their psychiatric condition or behavior. We must provide emergency care to people. Some people want hospitals to function more like airports, but it doesn't work in practice. However, we can set the tone for what is acceptable in the emergency department. We can post notices that we have a no-tolerance policy for abuse and mistreatment."
To reduce mistreatment in the ED setting, developing the staff's de-escalation skills is crucial, she said. "We could do a lot more to educate staff on de-escalation. As important a skill as it is to suture and to be able to intubate patients, you need to be able to effectively de-escalate patients and their family members. When it seems like tensions are running high, we should be able to defuse the situation instead of letting it get to the point where there is risk of violence. It does not work 100% of the time, but it can be effective."
The study's finding that there is no association between mistreatment and residents feeling career choice regret is not surprising, Murphy said. "The rate of career choice regret was only about 3% in residents. They were not at the point of regretting going into this career path. This is compared to other studies that have found rates of career choice regret as high as 30% in practicing physicians who are out of residency. In this study, it appears that residents were not at a severe level of burnout where they regretted going into this profession."
It is also unsurprising that senior residents were more likely to report burnout than first-year residents, she said. "You would expect that someone who has been through mistreatment several times might have developed enough resilience to let moral injuries roll off them, but that is not the case. Depending on how supported you feel, how many hours you have worked, or how things are going at home, mistreatment can make you feel so fatigued that you do not have the resilience or emotional energy to deal with these things, which can result in burnout."
Parkview Physicians Group CMO offers clinical care predictions for 2023.
This year, healthcare providers will be focusing on reducing costs while maintaining quality of services, says Thomas Bond, MD, chief medical officer of Parkview Physicians Group in Indiana.
Parkview Physicians Group is owned by Fort Wayne, Indiana-based Parkview Health, which features nine hospitals and a network of primary care and specialty clinicians. There are about 800 physicians and 300 advanced practice providers in Parkview Physicians Group.
Bond joined Parkview Health as a primary care physician in 1998. His current responsibilities include quality and safety, clinical integration, service excellence, and provider relations.
HealthLeaders recently talked with Bond about a range of issues, including clinical care predictions for 2023, the challenges of serving as CMO of a large physician group, and physician shortages.
This transcript has been lightly edited for brevity and clarity.
HealthLeaders: What are your clinical care predictions for 2023?
Thomas Bond: The biggest thing I see is that there is going to be an increased emphasis on cost, particularly in the ambulatory world. There is going to be continuing pressure on us to deliver high-quality services at a lower cost. I can't see government and payers continuing to shell out more money, so we are going to feel pressure on cost.
In our market, we will see more and more people going to the government health plans and less commercial coverage. That's going to put challenges on us. We will need to figure out how to deliver the same clinical quality and outcomes while being more efficient and cost-conscious in that delivery. We will need to think outside the box on how we can reduce cost.
HL: What are the primary challenges of serving as the CMO of Parkview Physicians Group?
Bond: The primary challenge is the sheer size of the group. It has gotten harder as one CMO to deal with all of our providers. We are looking at hiring more CMOs and dividing up the physician leadership hierarchy.
HL: How have you risen to the challenge of leading a large physician group?
Bond: I am trying to find physicians in the group who have leadership potential, then getting them the skills to advance their leadership. We try to find section chiefs and medical directors, which helps in physician leadership and hierarchy. It also helps facilitate our communication pathways to engage individual group members.
HL: What are the keys to success for physician leadership?
Bond: Change management and communication skills are key attributes. Change management is important because of the quickly changing conditions in healthcare.
Being a physician leader, you need to have credibility with your group and your operations team. We have administrators such as senior vice presidents and vice presidents, but physicians have greater trust in their physician leaders.
HL: What are the primary elements of physician engagement?
Bond: Trust, integrity, and follow-through are what physicians want. Physicians don't mind being told "no" as long as you follow through and let them know why. If you are not responsive or following up on things, that hurts your relationship with physicians.
HL: How has your clinical background as a primary care physician helped you serve as CMO of Parkview Physicians Group?
Bond: Being a family physician, you always have to work with different specialties. You have relationships and communication with specialists, so that has helped me establish camaraderie and understanding with many kinds of physicians.
HL: How do you establish and build relationships with physicians?
Bond: It is important to meet the providers, so I purposely round with every one of our physicians and advanced practice providers throughout the year. I make time to connect with clinicians, so I am not always coming to them with an issue. I don't wait for an issue to come up—I check in with the clinicians and see how things are going from their perspective and see whether there are things we need to do. I am purposely trying to keep communication open.
Thomas Bond, MD, chief medical officer of Parkview Physicians Group. Photo courtesy of Parkview Health.
HL: Are you experiencing any physician shortages?
Bond: We are seeing most of our physician shortages in primary care and neurology.
HL: How are you addressing those shortages?
Bond: We have been using a lot of locum tenens physicians. So, we are using contracted labor.
Recruitment and retention are also huge pushes for us. We are trying to be more creative in how we recruit—we are doing more searches than we have done in the past. We are getting more creative on work shifts.
In retention, we have established a mentoring and onboarding program for all of our providers. For the first year of employment, clinicians are assigned a mentor, which has helped reduce our turnover rate. We established this program four years ago, and our turnover rate has gone down. We are also working with the spouses of our clinicians to help them adapt to living in Indiana.
HL: You are involved in quality and safety work. What are the keys to success in quality-improvement initiatives?
Bond: A big key to success is getting physicians to buy into initiatives. A lot of times, our quality measures are determined by our payers. Sometimes, those payer metrics are not what we deem as quality, so we have to try to get physicians to understand the "why" behind initiatives and incentive dollars.
We also try to keep track of what is going on locally. For example, we are having a problem with obesity in our area, so we need to engage physicians in what they think is the solution for that and quality metrics we can put in place.
HL: What are the keys to success in patient safety initiatives?
Bond: You can talk about a patient safety issue, but if you do not have the numbers for your community, it is difficult to get buy-in for patient safety initiatives. For example, if you can show a high rate of wrong-side surgeries, that can give you the burning platform to prompt change. Sharing safety data is essential, and we have tried to have transparency on patient safety data.
HL: Give me an example of a patient safety initiative that you have been involved in.
Bond: We have tried to establish a just culture—if you see an adverse event, you are encouraged to speak up. If there is an error with a patient, there is not retaliation for reporting it. This has been a journey for us—we have been at it for about five years. It started off with just trying to increase reporting. We set reporting goals for departments because we knew that reporting was low. The next effort was trying to get leader feedback on adverse events within 24 hours. Then, in seven days, there had to be resolution, with a fix in place.
HL: How would you characterize your leadership style?
Bond: I am more of a servant leader. I do not see myself above my co-workers. I feel that we are all equals. My role is to help clinicians with barriers that are getting in their way and to help them be successful. I do constant rounding to let clinicians know that I am here to serve them.
Financial challenges are second most pressing issue in annual survey conducted by the American College of Healthcare Executives.
Workforce challenges ranked Number One on the list of hospital CEO top concerns in 2022, according to an annual survey conducted by the American College of Healthcare Executives.
Workforce shortages have become a pressing issue for the clinical operations at health systems, hospitals, and physician practices across the country. Healthcare organizations are facing workforce shortages across the board, with nursing shortages, physician shortages, and shortages in many other areas such as technicians.
The American College of Healthcare Executives is an international professional society of more than 48,000 healthcare executives who lead hospitals, health systems, and other healthcare organizations. The annual survey asked community hospital CEOs to rank their top 11 concerns and to identify specific areas of concern within each of those issues. The survey was sent to more than 1,300 community hospital CEOs and nearly 300 executives participated in the survey.
This marks the second year in a row that workforce or personnel challenges has been the top-ranked issue. Before that, financial challenges ranked first in the survey for 16 consecutive years.
Hospitals need to pursue both long- and short-term initiatives to tackle workforce issues to continue to provide care for their patients now and in the future, Deborah Bowen, FACHE, president and CEO of the American College of Healthcare Executives, said in a prepared statement. "Longer-term solutions include strengthening the workforce pipeline through creative partnerships, such as those with colleges to grow the number of nurses and technicians. More immediate solutions include supporting and developing all staff, building staff resilience, organizing services to reflect the realities of the labor market, and exploring alternative models of care."
The Top 5 concerns identified by hospital CEOs were as follows:
Workforce challenges such as personnel shortages
Behavioral health and addiction issues
Patient safety and quality
The Top 5 workforce concerns identified by hospital CEOs were as follows:
Shortages of registered nurses
Shortages of technicians
Burnout among non-physician staff
Shortages of therapists
Shortages of physician specialists
The Top 5 financial concerns identified by hospital CEOs were as follows:
Increasing costs for staff and supplies
Reducing operating costs
Managed care and other commercial insurance payments
Government funding cuts in addition to reductions in Medicaid and Medicare reimbursement
The Top 5 behavioral heath and addiction issues identified by hospital CEOs were as follows:
Lack of appropriate facilities and programs in the community
Lack of funding to address behavioral health and addiction issues
Insufficient reimbursement for behavioral health and addiction services
High volume of opioid addiction and related conditions
Legal and regulatory frameworks limiting treatment options
Researchers examined data from 166 facilities from 2012 to 2017.
To reduce antibiotic resistance, hospitals should use care setting-specific antibiotic stewardship programs that are based on the type of facility and patient age, a recently published research article found.
Antimicrobial resistance occurs when germs such as bacteria and fungi develop the ability to be resistant to the drugs that are designed to kill them, according to the Centers for Disease Control and Prevention (CDC). In the United States, there are more than 2.8 million antimicrobial-resistant infections annually that are associated with more than 35,000 deaths, the CDC says.
The recent research article, which was published by JAC-Antimicrobial Resistance, is based on data collected from 166 facilities from 2012 to 2017. The data was separated into four patient groups: children, adults, children treated at standalone pediatric facilities, and children treated at facilities that serve both children and adults.
The results of the research article include a key finding: resistance rates for antibiotics were associated with age and care setting. For example, ertapenem-resistant Enterobacter cloacae in children increased significantly compared with adults, and ertapenem-resistant Enterobacter cloacae among children in pediatric facilities increased significantly compared to facilities that serve both children and adults.
Interpreting the data
The research article is based on a powerful set of data, a co-author of the study told HealthLeaders. "It's important to look at this project as using a national dataset. All too often, research involving antibiotic resistance is either a single institution looking within their organization or research that looks at national datasets that do not have this level of detail. So, one of our goals was to evaluate the influence of patient age and care setting on the profile of antibiotic resistance," said Mark Hoffman, PhD, chief research information officer at Kansas City, Missouri-based Children's Mercy Hospital.
The researchers found that the results varied depending on the combination of the bacteria and the antibiotic, he said. "In some cases, we found that older patients were more likely to have an antibiotic-resistant bacteria than younger patients. In other cases, we would find that younger patients were more likely to have an antibiotic-resistant version of that bacteria."
In many cases, there were decreases in antibiotic resistance, which is encouraging because the national efforts in antibiotics stewardship appear to be making a difference, Hoffman said. "We did see in Shigella and Streptococcus, as two examples, evidence that there are increasing patterns of resistance to bacteria-drug combinations. But we also saw several instances where the prevalence of resistant bacteria is apparently dropping."
The difference in antibiotic resistance between children and adults varies based on the combination of the bacteria and the drug, he said. "We did find some evidence that for some combinations children were more likely to have a resistant version of the bacteria than adults and vice versa for other combinations. Reflecting on the patient context or the patient demographics including their age is underutilized, but we have shown that it is an important factor."
The impact of the facility category on antibiotic resistance in children varied, Hoffman said. "We know that children treated in standalone pediatric facilities are often more complex; so, to some extent, that can be a reflection on a variety of risk factors that children treated at standalone facilities are challenged with. That can be one factor. Standalone pediatric facilities are also often leaders in antibiotic stewardship; so, in the instances where we saw lower prevalence of resistant bacteria in the pediatric setting, our hope is that reflects our efforts in antibiotics stewardship."
The study is particularly helpful for emergency department clinicians, he said. "Inemergency departments, decisions are made about which antibiotic you start the patient on. Do you start them with Cipro or do you start them with another antibiotic? Having our data in the hands of emergency physicians can help inform that first treatment before they have the culture results. The more information those providers have about patterns, the better decisions they can make in terms of that first treatment decision that is made in the absence of a culture result."
The study is an example of harnessing data, Hoffman said. "A key factor of our strategy was using national data resources to better understand what is happening locally and what is happening for different categories of patients. At Children's Mercy Hospital, we are always focused on how we can use data to better treat children, and our study is a step forward in providing more tools for providers as they make important decisions."
Healthcare organizations need to step up their efforts to recruit and retain physicians.
With demand outstripping supply for physicians in many specialties, Jackson Physician Search has released a new white paper to help healthcare organizations to recruit and retain clinicians.
"Demand for healthcare services is increasing due to an aging population, expanded access to health insurance, and a general public well-versed in the importance of preventative care. However, there are not enough physicians to meet the increasing demand for these services," the white paper says.
The white paper highlights several key developments in the physician job market:
As retirements increase, healthcare organizations are struggling to replace specialists such as neurologists and urologists who see a wide variety of cases. Subspecialists coming out of training want jobs where they can focus on their area of expertise.
Demand for mental health providers increased 85% from 2020 to 2022 as mental health problems spiked nationwide.
Physician expectations are changing—they want signing bonuses, flexible schedules, and a better work-life balance.
Specialists who can work in telehealth such as psychiatrists and radiologists are becoming increasingly hard to recruit for positions that require them to work in an office full time.
Healthcare organizations in rural areas are being particularly hard hit by retirements, and they face multiple challenges such as rising costs, lower reimbursement for services, and staffing problems.
At Jackson Physician Search, many of the 2022 physician placements had starting salary guarantees above the MGMA median.
A pair of Jackson Physician Search executives talked with HealthLeaders about the nature of the physician job market and how healthcare organizations can rise to the challenge of recruiting and retaining clinicians.
"The physician recruitment market is tighter than ever," says Tara Osseck, regional vice president of recruiting at Jackson Physician Search.
To recruit physicians under the current market conditions, healthcare organizations must accentuate the positive aspects of their job opportunities, she says. "When you are looking at strategies to recruit physicians under increasingly competitive market conditions, first and foremost it starts with a very clear understanding of the need then developing a strategic approach to marketing a job's positive differentiators. That can be above average compensation, long-term earning potential, attractive recruitment incentives, a great location, and a fast-track to partnership or career growth. Whatever your positive differentiators or hooks are, you need to be able to leverage those to your advantage."
To be successful in physician recruitment, healthcare organizations need to know about the market for the specialties they are recruiting, Osseck says. "You need to have a keen understanding of physician supply and demand in the particular specialties you are recruiting. You need to understand the annual attrition rate and the people who are coming out of training each year to be able to focus on a realistic candidate pool. That helps establish candidate parameters."
It is also important to be open to candidate feedback and to adapt to market trends, she says. "If you want to be successful and competitive in today's marketplace, you need to be willing to adapt to how younger physicians want to practice, even if you have to deviate from how your older physicians have historically practiced."
Rural healthcare organizations have to be thorough in their physician recruitment efforts, says Brent Barnacle, regional vice president of business development at Jackson Physician Search. "When looking at these rural areas, you have a small candidate pool. So, for healthcare organizations seeking physicians, it is important to be clear about who you are looking for, the scope of work, the compensation, and what your community has to offer. … You can get laser-focused on the type of individual you are looking for culturally and put together an attractive package for job candidates."
In any physician search, it is important to have an efficient hiring process, but this is crucial in rural recruiting, Osseck says. "Before you are working with your first candidate, you need to know the key stakeholders and decision-makers. You need a hiring process that is functioning like a well-oiled machine, which keeps everyone moving with a sense of urgency."
When rural healthcare organizations put together a recruiting package, they need to know what candidates are looking for in a rural community, Barnacle says. "Pushing a five-day workweek can be a difficult thing to overcome because a lot of physicians who are working in rural communities are looking for a good work-life balance. A four-day workweek can be key."
Offering competitive compensation is essential, he says. "Compensation is important and you need to be competitive in your market. The closer healthcare organizations can get to median compensation, the more competitive they can be. If you are lower in compensation, it is going to take more time to find a physician."
Under the current market conditions, retention of physicians is critical, Barnacle says. "Retention is the conversation of the times, in every industry but more so in healthcare because we have Baby Boomer physicians who are retiring and there are not enough younger physicians coming in to fill those opportunities. You do not want to lose a physician to another organization then have to go through a recruitment process."
Retention starts in the hiring process, he says. "It starts with finding the right cultural fit. It starts with finding the right physician who wants to be a part of your community. It starts with learning about the spouse and the kids such as having schools in the community that are going to be a good fit for the kids. All of those pieces play a role in retention."
Once physicians have been hired, giving them a voice in the organization is pivotal in retention, Barnacle says. "A lot of times, physicians feel there is a disconnect between the C-suite and the physicians. I know the CEO of a large physician group who routinely rounds on all of his physicians and asks, 'What else do you need from me to perform your job at a high level?' Even if he cannot get what a physician is looking for, the physician feels valued, appreciated, and like they have a voice."
Healthcare organizations must be receptive to improving work-life balance, particularly if they want to retain physicians for the long-term, Osseck says. "Flexible schedules and the four-day workweek are becoming increasingly standard. Things that support a flexible schedule include telemedicine partially or exclusively in the scope of practice, block-shift schedules such as seven days on and seven days off, and ways to reduce or eliminate being on call such as having advanced practice providers on call."
Healthcare organizations must design an environment that makes it difficult for physicians to want to leave, she says. "It could be pairing physicians with physician mentors. It could be having physicians participate in focus groups to build two-way communication. It could be working with a spouse and kids to get them networked within the community. It is making personal connections, which some healthcare organizations fail to focus on."
Peter Charvat shares his perspectives as chief clinical officer of the Bon Secours Richmond market.
Emergency medicine provides a solid foundation for serving in physician leadership roles, says Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market.
Bon Secours is part of Bon Secours Mercy Health. The Bon Secours Richmond market features seven hospitals.
Charvat's previous position was chief medical officer and vice president at St. Joseph's Main Hospital and St. Joseph's Children's Hospital in Tampa, Florida. Prior to working at St. Joseph's, he was chief medical officer and vice president at Johnston Health in Smithfield, North Carolina. He also served as a physician and Department of Emergency Medicine chair at St. Cloud Hospital in Minnesota.
HealthLeaders recently talked with Charvat about a range of issues, including clinical care predictions for 2023, the primary elements of physician engagement, and the keys to success in physician leadership. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You have a clinical background in emergency medicine. How has this clinical background helped you serve as a physician leader?
Peter Charvat: First is the experience of working with a diverse group of clinicians and secondly working as a team. Emergency medicine is one of the specialties where you connect with physicians across the spectrum such as hospitalists, pediatricians, obstetricians, and surgeons. That has helped me because in my current role I work with physicians across all medical specialties.
The team-based care model has been just as important in serving as a physician leader. Emergency departments are definitely a place where you have a tightknit team—physicians, nurses, technicians, registration staff, and social workers. There is a full spectrum of frontline team members. We depend on each other and constantly work together. That gave me an appreciation for the skill sets that everybody on the team brings. In emergency medicine, the team makes the physician stronger, and the physician adds to the skill set of others.
HL: How do you rise to the challenge of clinical leadership in a broad and diverse market?
Charvat: First, a lot of my job is engaging, leading, and supporting teams. We have teams at the hospitals, at our service lines, and at our medical group. I try to find out the barriers they are having and how to support their work.
Second, in my role, there is a lot coming at me, and it would be easy to get reactive. I could spend my whole day just responding to what is coming at me. Instead, I do all I can to set aside about 25% of my time to be more proactive and forward-thinking. That's how I help keep the organization moving forward. A lot of that is creating vision—where are we now and how do we build on the success that we have had at Bon Secours Richmond?
HL: You are serving as a regional chief clinical officer. How do you balance overseeing clinical care at multiple facilities?
Charvat: Part of it is connecting with the staff. I make it a point to do rounding every week at our practices and hospitals, which helps me get to know people. That helps me identify the challenges at each of our sites of care and how I can help work through barriers. At lot of this role cannot be done in an office—you must get out and connect with people. I must appreciate the differences at the different sites of care and the market, and I must find ways to support those teams.
Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market. Photo courtesy of Bon Secours Mercy Health.
HL: Do you have any clinical care predictions for 2023?
Charvat: We will probably hear a lot more about long COVID and the chronic after-effects of acute COVID infections. We are learning that COVID has two phases: the acute phase, where we have gotten better at diagnosis and treatment, and the after-effect phase after infection, which affects multiple organs and can have multiple effects. We are challenged with how we diagnose long COVID, and we have few treatment options. This year, we are going to be increasingly focused on the long COVID syndrome, trying to come to a common understanding of what long COVID means, and supporting patients through their journey with long COVID.
In addition, toward the end of 2022 we saw a rise in non-COVID respiratory infections. We probably took our eye off the ball a little bit for influenza and RSV, and we saw them come on strongly at the end of last year. In 2023, we need to remain diligent—in addition to COVID, there are many other respiratory illnesses that we need to be aware of. We need to push for immunizations and preventive care.
HL: What are the primary elements of physician engagement?
Charvat: To sum it up in three words, it's credentials, objectivity, and similarity.
If you are going to engage and work closely with physicians, as a leader you must have credentials. We need to bring something to the table, whether it is administrative expertise or an understanding of what physicians need in their practice. We must bring value to the conversation with physicians.
In terms of objectivity, when we engage physicians, we must be open-minded and objective. We may not always be on the same page or see things exactly the same, but as leaders we need to be objective, to put ourselves in physicians' frame of reference, and to understand the challenges they are facing in clinical practice.
For similarity, we may have some differences, but we need to focus on what we agree upon such as high-quality patient care, safety absolutes, and putting the patient first. From there, how can we engage and have conversations about how we support physician practice and how physicians can support patients and the organization?
HL: What are the keys to success for physician leadership?
Charvat: One thing is to diversify your skill set. When I transitioned from clinical practice to an administrative role, I realized that I had a lot of gaps in nonclinical skills such as finance and human resources. We are constant students in medicine—there is research to follow, new techniques, new therapies, and diagnostic options available. In the clinical world, physicians are constantly learning, and when you take on administrative roles learning must continue.
Physician leaders also need to see the perspectives of those they work with and be part of a team. In medicine, you are working closely with clinical teams such as other physicians and nurses. When you get into leadership roles, you are spending time with non-clinician leaders. You need to be aware of everybody's perspectives and the unique skills they bring to the table. You need to complement each other and emerge stronger as a team.
HL: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges at Bon Secours Mercy Health?
Charvat: Two things that come top of mind are clinical workforce and more complex patients.
Early in the pandemic, we saw a lot of frontline healthcare workers leaving the workforce or moving to different positions, s there were shortages, which we saw a lot in nursing. Fortunately, we have been able to develop some programs to respond to this challenge, and we have done a good job at attracting and retaining talent.
The other thing is that, overall, patients are becoming more medically complex. There is a lot more chronic illness, and we need to continue to prepare to provide higher levels of service to patients in our hospitals. There is a shift of care from the inpatient to the outpatient setting, but at the same time, the patients who are in the hospitals are very complex, with comorbidities and chronic conditions. Fortunately, we have a lot of diagnostic and treatment options. We need to position ourselves with education, training, technology, and resources to manage this increasingly complex patient population.
HL: What are the primary efforts you have in place to address workforce shortages?
Charvat: We are looking at educational opportunities for our associates—giving them opportunities for new degrees and training. We are giving associates opportunities for mobility within the organization. Fortunately, we are very broad and diverse, so we have a variety of opportunities within our markets. We are also providing appropriate work-life balance for the well-being needs of our associates.
For the physician workforce, we are focusing on physician well-being. We are trying to support the health of our practitioners. We also have many opportunities for physicians in our organization—different hospitals, different practices, inpatient settings, and outpatient settings. We can offer a range of work experiences that can draw physicians to our markets.
HL: Why is patient medical complexity increasing?
Charvat: One factor is we have become better at managing disease, so we are able to care for patients longer and longer through their diseases. We can manage chronic illnesses. If you look at the new technologies and therapies that we have compared to where we were 20 years ago, we have a lot more treatment options available.
There are also demographics. The population is getting older, and naturally they are going to have more illnesses and chronic disease. We are going to see more and more patients with a multitude of chronic illnesses that need management.
Primary care visits when mental health conditions were the main diagnosis increased nearly 50% from 2006 to 2018, a new study found.
The number of primary care visits for a mental health concern increased from 2006 to 2018, according to a new research article.
According to the National Institute of Mental Health, nearly one in five American adults had a mental, emotional, or behavioral condition in 2020. Mental health conditions have been associated with increased healthcare utilization.
The new research article, which was published in Health Affairs, is based on data collected from more than 100,000 primary care visits from 2006 to 2018. Data was drawn from the National Ambulatory Medical Care Survey.
The new research article has several key data points:
Primary care visits that had a mental health condition as a primary diagnosis increased from 3.4% of visits in 2006-2007 to 6.3% of visits by 2016 and 2018
Primary care visits that addressed a mental health concern including visits when a mental health concern was not a primary diagnosis increased from 10.7% of visits in 2006-2007 to 15.9% of visits by 2016 and 2018
Four factors were associated with a greater likelihood that a mental health concern would be addressed during a primary care visit: younger age, payment through Medicare or Medicaid, female sex, and the visit physician being the patient's usual primary care physician
Patients identified as Black or other race were less likely to have a mental health concern addressed in a primary care visit than White patients
Anxiety and stress-related diagnoses were the most common mental health concerns addressed in primary care visits, peaking at 38.0% of visits for a mental health condition in 2014-2015
The percentage of primary care visits to address depressive symptoms decreased from 32.4% in 2006-2007 to 20.8% in 2016 and 2018
The percentage of primary care visits to address serious mental illness decreased from 5.4% of visits in 2006-2007 to 3.0% of visits in 2016 and 2018
Nearly three-quarters of primary care visits to address a mental health concern resulted in treatment with psychotropic medication, counseling and psychotherapy, or referral to another physician
The most common treatment offered in primary care visits for a mental health concern was a prescription for a psychotropic medication
Interpreting the data
The increase in primary care visits to address a mental health concern during the study period raises questions about the sustainability of U.S. primary care, the research article's co-authors wrote. "Although the number of graduating medical students entering primary care specialties continues to be insufficient to meet the growing needs of an aging population, primary care physicians have been asked to provide more and more services, both within the context of the visit and during the intervals between visits."
To avoid strain on U.S. primary care, primary care physicians should have adequate preparation and resources to address mental health concerns, the research article's co-authors wrote. "In the context of policy and care delivery changes, equipping primary care providers to address mental health needs is crucial. Resources and systems that support primary care and behavioral health integration, including co-located therapy or psychiatry providers, e-consultation services, longer visit lengths, and billing and documentation systems that simplify addressing both mental and physical health needs may help ease the increasing pressure on primary care providers seeking to address their patients' needs globally."
Patients who had visits with their usual primary care physician were more likely to receive care for mental health conditions, the co-authors wrote. "Not surprisingly, mental health concerns were significantly more likely to be addressed in a visit with a patient's usual primary care physician than in a visit with another primary care physician. In addition, a patient's own primary care physician was more likely to prescribe a medication to a patient with a mental health concern."
The data indicate there is a healthcare disparity based on race for primary care visits to address a mental health concern, the co-authors wrote. "Black and Hispanic patients in our sample were disproportionately less likely to have a mental health concern addressed in the context of a primary care visit. The differences in our study in the likelihood of Black or Hispanic patients having a mental health concern addressed outweigh the differences in prevalence of any mental illness among Black versus White and Hispanic versus non-Hispanic people reported in recent national estimates from the National Survey on Drug Use and Health."
The study's findings can help guide changes in primary care in the United States, the co-authors wrote. "Given the significant prevalence of mental health diagnoses, the impact of comorbid mental health conditions on utilization, and shortages of mental health professionals, these findings have important implications for the future organization and financing of U.S. primary care."