Since Memorial Healthcare System launched a strategic sourcing department, the health system has exceeded the organization's record for savings.
Memorial Healthcare System has added a strategic sourcing department to its supply chain to shift away from transactional contracting, says Saul Kredi, MBA, vice president of supply chain management.
Kredi has been vice president of supply chain management at the Fort Lauderdale, Florida-based health system since May 2016. He was director of purchasing at Memorial from August 2010 to April 2016. His previous experience includes serving as materials manager at Miami Children's Hospital.
HealthLeaders recently talked with Kredi about a range of topics, including Memorial's supply chain philosophy, balancing the benefits and drawbacks of limiting the number of vendors in a supply chain, and the role of physicians in Memorial's supply chain. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as vice president of supply chain management at Memorial?
Saul Kredi: We have a few primary challenges. Coming off COVID, the supply chain team is fatigued. There is instability in the supply chain. We are reconstructing processes after having to operate in a certain way because of COVID. At Memorial, we are also transitioning to a new enterprise resource planning system called Workday.
HL: How are you reconstructing processes?
Kredi: We are taking it to the next level on how we work with our group purchasing organization on better predictive analytics for future backorders. We are working on becoming more proactive instead of reactive. We are realigning with the health system so we can be less reactive and can start planning and doing things organically.
HL: Give an example of a supply chain initiative you have been involved with at Memorial?
Kredi: I have constructed a strategic sourcing department. We had a transactional contracting department, but we needed the skillset of a strategic sourcing department as a best practice. Even though the group is very new—we are about 18 months into this new operation—we exceeded the record for savings at this health system over the past year. This group has generated results early on.
HL: How does the strategic sourcing department work?
Kredi: We have people assigned by service line that are the first point of contact. So, if we want to look at a service, a supply, or some equipment, we are going to start that conversation early on so we can shepherd it through the process. We can make sure that we do our competitive bids, make sure we understand what is needed, have conversations with physicians, and be fully integrated into the planning and execution of the process.
Instead of being a transactional supply chain, we are more strategic now.
HL: You previously served as director of purchasing at Memorial. How did this experience help prepare you to serve as vice president of supply chain management?
Kredi: When I was the director of purchasing, a lot of the processes and the things I put in place helped us to be better prepared. Before the pandemic, we had a supply of personal protective equipment that we managed for many years. I was able to construct the purchasing group and train the purchasing group as a team—we needed to retrain people and hire the right talent to be able to perform the purchasing function at a higher level. In taking over the role of vice president of supply chain, this experience prepared me to continue to develop our supply chain model. I was able to ask questions such as do we have the right talent? Do we need to train? What is our philosophy going to be? The supply chain needs to be aligned and not work in siloes.
When I took over, we had some siloes, and I worked to get the group together. As director of purchasing, I was able to look to the future and see what we needed. So, when I stepped into the vice president role, I already had the assessment done in terms of where we needed to focus.
Saul Kredi, MBA, vice president of supply chain management at Memorial Healthcare System. Photo courtesy of Memorial Healthcare System.
HL: What is your supply chain philosophy at Memorial?
Kredi: We want to make sure that we have the right product, at the right price, at the right time. The right product means we have the right quality product—we are collaborative in how we choose products in this health system using our value analysis team and other venues to make sure we have the right products to care for our patients.
HL: How is it helpful to reduce the number of vendors that you draw upon for your supply chain?
Kredi: No. 1, you get to standardize. You leverage your economies of scale going to one vendor. That is the positive side of reducing the number of vendors.
However, looking at this issue after the experience with COVID, there is value to having redundancy. We need to have options and avoid putting all of our eggs in one basket after all of the supply chain vulnerabilities that we experienced.
We want to standardize where we can and gain the economies of scale where we can. But we need to challenge vendors to have more redundancy, so production is not isolated in one area. If one plant shuts down, we need to be able to secure supply from somewhere else. In addition, vendors need to be more creative and not operate in a just-in-time environment for production.
HL: How has Memorial adopted automation in the health system's supply chain?
Kredi: We are evaluating that now. We are looking at a lot of automation as we transition to Workday as our enterprise resource planning system. We are also looking at more automation in our inventory locations. We are revamping our inventory processes with Workday.
Workday will allow us to manage all of our purchases and contracts. It will allow us to have a supply catalogue, with supplies that are approved for purchase. It will manage ordering and receiving products in the supply chain system. It will manage our inventory. It also manages human resources activities along with finance activities.
HL: How do you engage physicians in the supply chain?
Kredi: Engaging physicians in the supply chain is vital—this is a philosophical pillar for me. We have great relationships with our physicians, but we want to enhance the relationships. We want to be more proactive with physicians when looking at new technologies and products.
Physicians are crucial in negotiating what products we are going to use. Having physicians sitting at the table during negotiations is powerful with the vendors. It is vital to supply chain success to have physicians involved.
Physicians are involved in our value analysis team. We have clinical teams with physicians for new products. We also have ad hoc committees with physicians for certain categories. They give their feedback on how we should proceed, and we are aligned on how we are going to execute initiatives.
In the future, we are going to be more proactive in having physicians look at data and the market. We want to have physicians involved in helping us achieve cost savings and providing better care for our patients.
Researchers compared the performance of doctor of medicine (MD) and doctor of osteopathic medicine (DO) hospitalists in the care of Medicare beneficiaries.
Physicians who are doctors of medicine (MDs) and doctors of osteopathic medicine (DOs) generate similar results on key indicators of quality and cost of care, a new research article says.
Among practicing physicians, about 90% hold MD degrees and about 10% hold DO degrees. Medical education for MDs and DOs is similar, although DOs have a more holistic focus and inclusion of manipulation training in osteopathic schools. MDs and DOs are licensed to practice medicine in all 50 states.
The research article, which was published by Annals of Internal Medicine, features data collected from more than 329,000 Medicare admissions at acute care hospitals from January 2016 to December 2019. Among the Medicare admissions of patients over age 65, 77.0% received care from an MD hospitalist and 23% received care from a DO hospitalist. The inpatients in the study had been admitted to hospitals with urgent or emergency conditions.
The research article features four key findings:
30-day patient mortality was similar for MD and DO hospitalists, with a 9.4% rate for MDs and a 9.5% rate for DOs
30-day readmissions were similar for MD and DO hospitalists, with a 15.7% rate for MDs and a 15.6% rate for DOs
Hospital length of stay (LOS) for MDs and DOs was identical at 4.5 days
Medicare Part B spending for MDs and DOs was nearly identical at $1,004 and $1,003, respectively
"We found that allopathic and osteopathic physicians performed similarly in terms of patient mortality after hospital admission, readmissions, LOS, or health care spending when they cared for elderly patients and worked as the principal physician in a team of health care professionals that often included other allopathic and osteopathic physicians. These findings should be reassuring for policymakers, medical educators, and patients because they suggest that any differences between allopathic and osteopathic medical schools, either in terms of educational approach or students who enroll, are not associated with differences in quality or costs of care, at least in the inpatient setting," the research article's co-authors wrote.
Interpreting the data
There are four potential explanations for why quality and cost of care were found to be similar for MD and DO hospitalists, according to the research article.
MD and DO medical schools are both required to provide standardized medical education based on accreditation systems. MD and DO medical schools have similar accreditation standards such as a four-year curriculum that features science courses and clinical rotations. Standardized tests required for all physicians "may function as a safeguard toward excluding nonqualified medical students from either type of school."
Residency and fellowship training that physicians receive after medical school may help standardize how MDs and DOs practice medicine.
Lack of time, institutional support, and reimbursement are structural barriers that result in most DOs not using osteopathic manipulative treatment. So, there may be only minor differences in how MDs and DOs practice medicine.
This study compared MDs and DOs practicing within the same hospitals. So, hospital efforts to ensure care quality may limit the variation between the ways individual MDs and DOs practice medicine.
To promote population health, healthcare organizations need to serve their population as a whole, a top Sentara Health executive says.
At Sentara Health, population health involves being the trusted partner for individuals and communities on their journey to health and wellness, says Jordan Asher, MD, MS, executive vice president and chief physician executive.
Asher has held his current role since February 2021, when he was promoted from senior vice president to executive vice president. Prior to joining Sentara, he was chief clinical officer of Ascension Care Management, a subsidiary of the Ascension health system.
HealthLeaders spoke recently with Asher about a range of issues, including population health, health equity, and clinical quality. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as executive vice president and chief physician executive of Sentara?
Jordan Asher: When I think about the primary opportunities, it really is how do we continue on our journey as a company to think about how we deliver care and services to more patients and a broader population. Basically, how do we do our job even better and bigger for more people, especially those who need us the most from a health equity perspective. We want to focus on being a community asset.
The challenges are in a couple of different categories. No. 1, are the everyday challenges of dealing with issues as they come up—COVID has been a big example of that challenge. There is also the challenge of dealing with people where they are. We need to think about care from their perspective.
Then there is a strategic challenge of how we can continue to function in the face of situations such as labor shortages. We also need to be prepared for events such as hurricanes and other challenges that are hard to anticipate.
HL: How do you rise to those challenges?
Asher: No. 1, you must be right with yourself. As a leader, you must have a good understanding of who you are, your style, and your true North. No. 2 is how you help others rise to occasions—how do you think about servant leadership in support of those who you are asking to serve other people? Lastly, how do you keep an open mind and think about things differently all the time? For example, when we were going through COVID, I had to say, "How do we think about things 180 degrees differently than we have in the past?"
HL: How is Sentara promoting population health?
Asher: As we think about Sentara and how we are focused on population health, it is within the context of being the trusted partner for our individuals and communities on their journey to health and wellness. We need to think about population health from that perspective. Historically, health systems have focused on how they take care of patients when they are sick, and patients need services. For us, thinking about population health is saying, "How do I think about your health and wellness within the context of your journey both as an individual and as a community?" Then you need to set up structures and processes to promote population health and to be a community asset. We need to focus on the population as a whole.
HL: Give me some examples of those structures and processes that are supporting population health.
Asher: Sentara has multiple populations that it serves. Obviously, for our insurance side with Optima Health and Virginia Premier, there are members we serve from a health insurance perspective. Additionally, we are very active in population health structurally through our clinically integrated network, which is a whole department that is focused on population health as it relates to members that it serves under a clinically integrated network. Then, most importantly, is how we are thinking about the most vulnerable people who need us the most, including from a health equity perspective. We have created structures to focus on that population such as our Community Care structure. As a large organization, we need to bring all of these structures together and bring them to bear on all of the communities that we serve.
Jordan Asher, MD, MS, executive vice president and chief physician executive at Sentara Health. Photo courtesy of Sentara Health.
HL: Give examples of clinical quality initiatives you have been involved with at Sentara.
Asher: For Sentara, delivering high-quality care is the price of entry. We view that as a North Star for us. We have a structure for looking at quality and safety on an ongoing basis both within our individual locations and as an overall system.
For example, we have been focused on hospital-acquired infections—meaning that when patients are in our hospitals how do they not get an infection that is part of being in a hospital? We have design teams. We have teams that focus on hospital-acquired infections. Over the past four or five years, our hospital-acquired infection numbers have dropped precipitously. Those include catheter-associated urinary tract infections, infections after surgeries, and gastrointestinal infections.
Another area that we are focused on is mortality. We are well below the national average on expected mortality when patients come into our hospitals.
More recently, we have been looking at grievances and complaints as a quality indicator. When a patient has a concern or an issue, we take in that information, and we look at that as a quality indicator.
HL: What are the primary elements of promoting patient safety at Sentara?
Asher: We have a just culture of safety and quality, meaning that it is in our core—it is part of who we are to say that we are going to deliver safe care. For example, we open most meetings that we have as an organization with a safety story. These stories show that we follow a highly reliable process to deliver safe care. When you come to us for care, quality and safety and making sure that you are treated with the utmost safety and respect is paramount to us.
We also think about safety for the members of our care teams because your safety as an employee is top of mind for us as well.
HL: How are you approaching high reliability at Sentara?
Asher: We have been on this journey since way before I got here. It is about structure, talent, and process. We have a high-performance design team that is focused on delivering quality and safety. We tie that to setting our goals for key performance indicators. We tie that to everything, from the board down to the front line. We celebrate our successes. We are a learning institution, which is a strong concept for high reliability because we must be continuous learners. We want people to share with us when they think something has not gone correctly. We want to learn from that—we want to do root cause analyses to focus on how to improve.
HL: How is Sentara promoting health equity?
Asher: Health equity is core to our mission of how we improve health every day. We must improve health every day for everybody. Therefore, we must think about communities that have been historically marginalized.
For example, we have a health equity department that is focused on measuring disparities. We also have had incredible support from our community partners—engaging faith-based leadership in marginalized communities. Faith-based leadership is at the grassroots. Healthcare organizations must remember that we are here to serve as a community asset, and the best way to not only learn what is needed but also to create partnerships to deliver care in different ways is by partnering with communities.
HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you for leadership roles such as chief physician executive?
Asher: In internal medicine, we pretty much have to think about everything. Internal medicine has helped me because I must think very broadly as chief physician executive. I must encompass lots of different data points and kinds of information.
Internal medicine has also helped me because internists take care of people over a period of time. So, as an internist, I think more longitudinal than transactional.
The president and CEO of the Healthcare Distribution Alliance says the supply chain is adapting to the "new normal."
"Transformational change" in the healthcare sector is having a significant impact on the healthcare supply chain, says Chester "Chip" Davis, JD, president and CEO of the Healthcare Distribution Alliance (HDA).
As the U.S. healthcare system emerges from the coronavirus pandemic, the healthcare supply chain is recovering from serious disruptions such as shortages of personal protective equipment early in the pandemic. The healthcare supply chain is still coping with challenges, including drug shortages and a changing regulatory environment.
While the healthcare supply chain has been challenged in recent years, it has largely weathered the storm, Davis says. "While not perfect, the healthcare supply chain has been resilient during the pandemic and since the wind down of the pandemic. There are still areas we need to work on collectively with our partners both upstream and downstream. For example, there are growing concerns about the sustainability and viability of the generic drug market—that is a critical area for all stakeholders who rely on generic drugs, which is essentially the entire healthcare ecosystem."
The biggest lesson from the pandemic is the need for active communication and collaboration between all partners in the supply chain, he says. "I started at HDA in the first week of March 2020—right when the pandemic arrived here in the United States. In my first couple of months at HDA, seeing the evolution of the communication cycle, particularly with the federal government, improved when the communication was no longer one-way. When it was the federal government telling us what to do, it was difficult as opposed to a constant feedback loop. We think it is important to maintain two-way communication."
The expiration of the COVID-19 public health emergency is going to have a significant impact on the healthcare supply chain, Davis says. "Obviously, with the expiration of the PHE on May 11, the most important thing is to ensure the sustainable availability and distribution of the treatments for COVID-19 that were developed, including vaccines and therapeutics. During the pandemic, the government played a key centralized role, and by definition with the cessation of the PHE a lot of the medicines are transitioning into the traditional commercial market. The fortunate thing for everyone who relies on the healthcare system is that our members at HDA, who are distributors between the frontline manufacturers and the frontline providers, are in a unique position to ensure that the transition process will be as smooth as possible."
The healthcare supply chain is adjusting to the "new normal," he says. "Things have not gone back completely to what they were pre-pandemic. Healthcare is experiencing an incredible amount of transformational change and it is impacting our members."
Impact of regulatory environment
The second half of 2023 is going to be "very busy" for the healthcare supply chain, Davis says. "We have the final implementation date of DSCSA—the Drug Supply Chain Security Act—which was passed in November 2013. Everyone from manufacturers, to distributors, and to pharmacies must be ready to go as of Nov. 27, and everyone is in various stages of operational preparedness to be in compliance. There is a lot of focus both within the Biden administration and Capitol Hill on the supply chain—what worked during COVID and areas that need improvement. A lot of that will manifest itself through a piece of legislation called PAHPA—the Pandemic and All Hazards Preparedness Act. This must be reauthorized by Congress by Sept. 30."
Implementation of the federal Inflation Reduction Act will have an impact on the healthcare supply chain for years, he says. "That has a profound impact on our partners in the manufacturing community—both brand and generic manufacturers as well as biologics and biosimilars companies. Anything like the Inflation Reduction Act that has a major impact on our partners upstream is ultimately something that the supply chain is going to have to deal with as they realize what the changes to their business models are going to be. We will have to react to that accordingly."
Drug shortages
A challenge related to the healthcare supply chain that has re-emerged after the crisis phase of the pandemic is drug shortages, Davis says. "It is not an easy issue. In terms of the causation, it is not a sole-source problem. There are multiple reasons why there are drug shortages in certain areas of the treatment regimen. It can be related to anything from shortages of raw ingredients and raw materials, to generic or biosimilar companies not having access to the market when they get Food and Drug Administration approval because of formulary designs, to economic challenges in the generics market, where the generics companies are claiming the margins are too low for them to continue manufacturing products."
There are market anomalies that need to be addressed, he says. "At a time when there is sensitivity to high prescription drug costs, there are also instances where prices have gotten so low that manufacturers are having to make hard decisions about what products will remain in their portfolio and what products they are going to stop manufacturing."
The pharmaceutical supply chain has a role to play in easing drug shortages, Davis says. "In the unique position that our members are in, we have a 360-degree lens on the supply chain. We can look upstream to our manufacturing partners. We can try to find out whether they anticipate any manufacturing disruptions. Then we can use the logistics and data expertise that we have to plan accordingly, whether it is accessing secondary manufacturers or alternative manufacturers if we anticipate the primary manufacturer is going to run into challenges."
Common areas of medical misinformation are related to childhood vaccinations, natural remedies, and dietary supplements.
Medical misinformation, which was rampant during the coronavirus pandemic, continues to be a significant issue in healthcare, says Frank McGillin, MBA, CEO of The Clinic by Cleveland Clinic,a leading provider of expert second opinions.
Medical misinformation is one of the hallmarks of the pandemic. Medical misinformation was spread about coronavirus vaccines and treatments.
Now that the crisis phase of the pandemic has passed, medical misinformation has returned to areas subject to misinformation before the pandemic, McGillin says.
"What we are seeing is that the misinformation is in areas that were present before the pandemic. Vaccines in general continue to be the subject of misinformation, particularly around childhood vaccines, which is leaving many populations unprotected. There is also misinformation about natural remedies and dietary supplements. People are looking for alternatives. Sometimes, there is a belief that pharmaceuticals are not the best route forward. Unfortunately, there are a lot of people in the natural remedy space who are making unsubstantiated claims. They are tapping into people's fears and desires," he says.
When you look at the typical healthcare consumer who is trying to understand the health journey that they are facing, they are confronted with misinformation, McGillin says. "They are confronted with a lack of quality information. If you look at online health trackers, there is research that has shown that only a third of the responses that consumers have encountered for online symptom trackers have pointed them in the right direction. It gets back to healthcare is complex, and the quality of the questions that are asked help define the quality of the answer."
Online sources of information can lead patients astray, he says. "While Google is a wonderful resource, and our data shows Google is a go-to source for patients, often they do not have the expertise to ask the right questions when confronted with an overwhelming amount of data. It helps to have experts to parse that data."
Misinformation plays a role in misdiagnosis, but part of this problem is just access to quality information, particularly for rare or complex conditions, McGillin says. "In these cases, when you are talking with a physician, you want to access someone who has a lot of experience with your specific condition. That is part of the value of tapping into academic centers such as Cleveland Clinic. We see those kinds of patients regularly."
In addition to clinical consequences, the economic impact of medical misinformation is significant, he says.
"There are more than 10,000 conditions that can be potentially diagnosed and only about 250 symptoms. Some small variability can lead to one conclusion versus another. Our data shows that on average there could be savings for misdiagnosis of about $12,000 per occurrence. Some of that is over-utilization of unnecessary procedures. For example, there are people with back pain who may not be a good candidate for back surgery, but they have been led to believe either through their own research or from a physician that back surgery is appropriate. In reality, physical therapy is the frontline treatment for back pain, and it not only saves money but also spares patients the pain and suffering from recovering from an invasive procedure."
How clinicians can work with misinformed patients
When working with misinformed patients, trust is crucial for clinicians, McGillin says. "You need to establish a level of trust with the patient. Clinicians need to listen to their concerns. If you think about the typical interaction between a physician and a patient, there is not a lot of face time. So, the quality of that face time is important. Is the healthcare provider listening to you? This involves soft skills."
The clinician-patient interaction is pivotal, he says. "It begins with the interplay with the patient and listening to the patient. If a patient comes in and says, 'I printed out this information from the Internet about a condition.' Instead of dismissing the patient out of hand, the clinician needs to understand the patient's concerns. Facts alone are insufficient. People want to be listened to. People want to make sure you are addressing their concerns and their needs. If you do that, then patients will open their eyes to the facts and the scientific research. The worst thing a clinician can do is shut a patient down. They will think their views are not important, and they will not trust the physician."
More than half of medical groups report that workforce shortages are the biggest barrier to productivity growth.
Physician compensation has not kept pace with inflation, according to a Medical Group Management Association reportbased on 2022 data.
The 2023 MGMA Provider Compensation and Production report features data collected from nearly 190,000 clinicians at more than 6,800 healthcare organizations. The report provides insights on the evolving financial circumstances for clinicians.
"Despite physician and advanced practice provider (APP) productivity continuing its post-pandemic recovery, compensation gains are being outstripped by the most severe inflationary growth in decades," the report says.
For example, increases in median total compensation for primary care physicians in 2021 (2.13%) and 2022 (4.41%) were far lower than rates of inflation for 2021 (7%) and 2022 (6.5%), according to the report. "Primary care, surgical specialist, and nonsurgical specialist physician compensation all saw modest gains from 2021 to 2022; however, none of these benchmarks rise to the elevated levels of inflation," the report says.
The report has several key findings:
APPs experience the biggest change in median total compensation from pre-pandemic levels, but growth dipped slightly from 3.98% in 2021 to 3.70% in 2022
More than half (56%) of medical groups reported that staffing is the biggest barrier to productivity growth
A November 2022 MGMA poll found varying performance on productivity at medical groups, with 29% reporting that they had exceeded their productivity goals for the year, 36% reporting that they were on target, and 36% reporting that productivity was below expectations
Physicians with supervisory responsibility over APPs reported earning 7% to 15% more in total compensation than physicians without supervisory responsibilities
Primary care physicians working night shift hours reported earning $70,000 more than colleagues working the day shift and nearly $23,000 more than colleagues working afternoon-to-evening shifts
From 2020 to 2022, there was a "steady shift" to salary-based compensation models for clinicians away from production-based compensation models
MGMA Stat polls found a significant increase in medical groups incorporating quality metrics into their clinician compensation models, with 47% of medical groups linking quality performance metrics to physician compensation in May 2023 and 42% of medical groups linking quality performance metrics to physician compensation in May 2022
According to an October 2022 MGMA Stat poll, only 28% of medical groups reported adding an ancillary service in the previous year, with many organizations citing labor recruitment difficulties as the barrier
An April 2023 MGMA Stat poll reflected a trend toward hiring APPs to offset shortages of physicians and nurses, with 65% of medical groups planning to add new APP roles in 2023
The April 2023 MGMA Stat poll found nearly half (47%) of medical groups had added or created part-time or flexible-schedule physician roles in the past year in response to physician shortages
MGMA recommendations
Jessica Minesinger, an MGMA consultant and founder and CEO of Surgical Compensation & Consulting, made three recommendations for medical groups in the report.
Medical groups need to respond to "rampant" physician burnout, which is decreasing productivity, she said. "Taking a customized, positive, and proactive approach to identifying the causes and finding effective ways to reduce the impact of burnout on your physicians is critical. This includes recognizing the challenges unique to female and male providers. A one-size-fits-all approach won't suffice."
Minesinger identified several components to addressing turnover, disruption to staff, lost revenue and productivity, and recruitment costs, including retention, promotion, staff engagement, and well-being initiatives.
Caring for physicians and other staff members responsible for patient care is critical to financial sustainability, she said. "Establish and invest in leadership roles and departments tasked explicitly with increasing provider recruitment, retention, and well-being. Address the well-documented gender wage gap in medicine and the ongoing challenges female physicians face with openness and transparency. The ultimate goal is to provide the best possible patient care, experience, and outcomes."
The report calls on medical groups to establish retention committees to help ease workforce shortages.
The first step to establishing a retention committee is to create an electronic survey to poll physicians on their feelings about practicing in the medical group, the report says. "The survey should ask physicians: What one or two issues create the highest level of dissatisfaction in practicing with us? What one or two things are responsible for your highest level of satisfaction? What one or two issues would cause you to leave for another opportunity?"
A findings report should be developed from the electronic survey and presented to senior leadership, including CEO, chief operating officer, chief medical officer, chief financial officer, and chief human resources officer. "Discuss all issues, evaluate recommendations, and determine what can be agreed to in this initial meeting. Leave the final report with recommendations for attendees to review on their own, and schedule a second meeting for the following week with expectations that each category will be discussed and addressed," the report says.
Scripps Health has physician operating executives at the health system's five hospitals and about 80 medical directors.
Physician operating executives and medical directors are crucial players in healthcare administration at Scripps Health, says Ghazala Sharieff, MD, MBA, corporate senior vice president of hospital operations and chief medical officer at the San Diego-based health system.
Sharieff has held her current role since January 2020. Her previous experience includes serving as Scripps' chief experience officer and emergency department division director at Rady Children's Hospital.
HealthLeaders recently talked with Sharieff about a range of issues, including addressing healthcare worker burnout at Scripps, her learnings from being a command center leader during the coronavirus pandemic, and the primary elements of a positive patient experience. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: At Scripps, you serve as CMO for inpatient care and Anil Keswani serves as CMO for outpatient care. What are the benefits of splitting the CMO role?
Ghazala Sharieff: Our president and CEO, Chris Van Gorder, is incredible. He always thinks ahead of the curve. He split the role in January 2020, right before COVID hit. So, I was the coincident commander of our COVID response in addition to working on quality, patient experience, and all the regular CMO duties. Splitting the CMO role into two pieces has been crucial. Given what we went through over the past few years, particularly with patient experience and quality, it would have been difficult for me if I was manning everything. We have about 30 clinics and five hospitals—it would have been too much. With 17,000 employees, 3,000 physicians, and 2,000 volunteers, having one person man all of that would have been extremely difficult given the challenges over the past three years.
Dr. Keswani and I work very well together. When we started, we were unsure how we were going to work together—we each had a column and some areas that overlapped like a Venn diagram. Now, it is not like a mine-and-yours situation. The Venn diagram is getting bigger and bigger because we realize there is a spectrum of responsibilities. Most of the things that you do in inpatient care affect ambulatory care because you must have a handoff for patients who have been admitted and discharged, then need care on the ambulatory side.
So, it is working very well, and I highly recommend this structure for other organizations as large as we are.
Ghazala Sharieff, , MD, MBA, corporate senior vice president of hospital operations and chief medical officer at Scripps Health. Photo courtesy of Scripps Health.
HL: What are the main ways you are addressing healthcare worker burnout at Scripps?
Sharieff: During COVID, we launched the RISE program—Resilience in Stressful Events. This is a peer-to-peer responder program, and it has a physician component. Physicians do not like to speak with others about their concerns or crises. When they have another physician to talk to, that is a safe place, and it does not have any stigma attached to it.
We have employee assistance with psychologists. So, if a healthcare worker feels they need more than a peer responder, we have a psychology team that can meet with them.
We also have some simple things such as one-on-one coaching. And we have reminders about mental health such as a webpage for physicians with resources that are available to them.
It is important to have open communication about the burnout that many of us are feeling.
HL: What role do physicians play in healthcare organization administration at Scripps?
Sharieff: We have an amazing infrastructure. One of the first things our CEO asked me to do on the inpatient side when I became chief medical officer was to align my physicians. We have five physician operating executives—one at each of our hospitals. They are dyad partners with chief operating executives because you need physician leadership as well as administrator leadership to run daily operations.
We also have about 80 medical directors across the health system. The medical directors report to the physician operating executives, who report to me. So, we have clear accountability for the metrics that we are trying to improve with this infrastructure. Physicians have a huge role not just in patient experience but also in daily operations. That is our secret sauce.
HL: In general, when you look at the healthcare system, do you think physicians are becoming more involved in healthcare organization administration?
Sharieff: In general, there are a lot more physicians going into administration because they want to make a difference in their organizations. It is also because of the financial climate we are facing, with hospitals struggling with finances. We need physician leadership to help us prioritize. Everybody wants new equipment—there is so much new technology coming out that physicians want to have, but we need them to help us prioritize. What do we need today? Is new technology truly more effective or is it just something you want to try?
You are going to see much more physician involvement in hospital operations as well as on the ambulatory side.
HL: You co-led command center operations for Scripps during the coronavirus pandemic. What were your primary learnings from this experience?
Sharieff: I learned about situational leadership. There was a sense of panic. Among physicians, there was sincere concern not only about their patients but also about themselves and their families. Some of them were not going home because they were afraid they were going to bring the virus home to their families. They were living in hotels. We had to be more directive with our leadership. We would say, "This is the path we are going to take." Eventually, we were able to be more collaborative—bringing in more physicians and staff to help us design our policies. But at first, we had to take control of the situation, which was important. Somebody had to be that voice.
What I have learned is there is a cycle to leadership in a crisis.
We have also learned that we can pivot quickly when we need to. We learned that we could be organized, pivot quickly, and try things that are different. One example is our Sprint Teams—we identify a problem then put a team around it so we can move quickly. With the Sprint Teams, you may not have a solution totally mapped out. Nothing is going to be perfect when you roll it out, but you must start an initiative and pilot it, then you make adjustments as you go.
HL: You previously served as chief experience officer at Scripps. What are the primary elements of a positive patient experience in the inpatient setting?
Sharieff: The key drivers are nursing communication, physician communication, and the environment of the hospital. Patients want to be heard.
We have a unique patient experience effort that we call The One Thing Different campaign. What that means is that I do not want to script anybody. It is horrible when everybody says the same thing because the patients know that somebody has told them to ask questions. Scripting your staff does not work. The One Thing Different campaign started with me thinking about what I can do differently. We ask patients about their greatest concern. It has changed my practice and it has changed the practice of many of our staff as well.
HL: You have a clinical background in emergency medicine. How has your clinical background helped you to serve in leadership roles such as CMO?
Sharieff: For emergency physicians, situational leadership is important. When you have a critical patient come into the emergency department, you must be in charge. One person must be the captain. So, when we have rocky times or there is uncertainty, it is easy for me to slip into that role as CMO.
There is also a lot of camaraderie in the emergency department. After a night shift with the nurses, we would all go out for breakfast. There is that side of leadership as well. You cannot always be directive—you have got to be seen as collaborative.
You must roll up your sleeves as an emergency physician and work with your colleagues. There are leaders who I have seen who do not get in the field with their people, and that does not resonate with me. If my staff is doing something, I like to be there with them. That is the ER doctor in me, and it has affected how I am as a leader.
Emergency physicians need to be transparent with their colleagues and share the "why" behind what they are doing. I tell my staff, "Here is what we are doing for this patient. Here is why I am ordering tests." That naturally translated over to my CMO role. I explain to people what we are doing. It cannot be bossing people around. You must explain the process and why we are going a certain route.
The Mountain View, California-based health system's initiative features a partial hospitalization program and an intensive outpatient program.
The Maternal Outreach Mood Services (MOMS) program at El Camino Health has a significantly positive impact on new mothers experiencing psychiatric conditions, according to data presented last weekend at the American Psychiatric Association Annual Meeting.
The perinatal period is associated with the risk of psychiatric disorders, including depression, anxiety, and post-traumatic stress disorder (PTSD). During the perinatal period, the prevalence of depression is 19%, the prevalence of anxiety is 13%, and the prevalence of PTSD is 8%, the research presented at the American Psychiatric Association Annual Meeting says.
The MOMS program features a partial hospitalization program and an intensive outpatient program, says Nicole Tarui, MD, an El Camino Health psychiatrist and medical director of the MOMS program.
"At the partial hospitalization level of care, it is generally five days a week and six hours per day. Folks are usually in that level of care for two to three weeks, depending on how they are doing and how they are progressing through treatment. Once a patient is doing better and symptoms are reducing, they step down to the intensive outpatient program. That program is similar to the partial hospitalization program, but it is fewer hours. It starts at five days per week for three hours per day, then gradually goes down to four days per week and three days per week as folks get close to graduation," she says.
The MOMS program features a multidisciplinary team, with social workers, psychologists, perinatal psychiatrists, and nurses who deliver the care. The program offers group and individual therapy as well as medication management. New mothers are treated with their babies present. The types of therapy provided include cognitive behavioral therapy, dialectical behavioral therapy, and infant-parent psychotherapy.
The main sources of referrals into the MOMS program are other mental health providers, obstetricians/gynecologists, pediatricians, and the inpatient women's specialty unit at El Camino Hospital.
The research presented at the American Psychiatric Association Annual Meeting focuses on Edinburgh Postnatal Depression Scale (EPDS) scores for 88 mothers who participated in the MOMS program from July 2020 to June 2022. The patients ranged from 22 weeks of gestation to two years postpartum. The EPDS is a screening tool with 10 questions generating a score from 0 to 30. A score of 10 or higher indicates possible depression, according to the University of California-San Francisco.
The study includes two key findings:
For all diagnoses among the 88 patients, the mean EPDS score was 15 at admission to the MOMS program and 6 at discharge
For the 57 patients who were diagnosed with major depressive disorder, the mean EPDS score was 17 at admission to the MOMS program and 7 at discharge
Unique aspect of care
One of the unique aspects of the MOMS program is that mother and baby are together while the mother is in treatment, Tarui says. "On a daily basis, we are getting to see them interact in a group setting as well as in individual sessions. This is where I help parents understand that there may be some challenges that they are facing and how to overcome those challenges to develop a secure attachment with the baby."
Infant-parent psychotherapy is one of Tarui's areas of expertise.
"I work individually with the parent and their baby to be able to talk about their history, relationship dynamics, and the impacts on bonding with baby. … We use the information about someone's history to be able to understand whether there are challenges in the bonding. We also get a lot of information in real time—being able to see the interaction between mom and baby. We can see whether the mom is responding to the baby's cues and how the baby is responding to mom," she says.
In infant-parent psychotherapy sessions, the goal is not to be directive, Tarui says. "It is more about encouraging the parent to be able to understand how their past or their symptoms might be impacting the bonding. I just gently point out interactions that I am seeing. For example, if the baby is crying and mom is feeling particularly distressed at that moment, I am curious about what is happening for her and how she can tolerate that level of distress. I want to help her become attuned to the baby and his or her cues. That is what helps build reflective capacity in mom and develop a secure attachment to the baby."
Advice for health systems and hospitals
Tarui offered three pieces of advice for other health systems and hospitals interested in launching initiatives similar to the MOMS program.
First, collaboration is essential the MOMS program, she says. "There are many different aspects to the care and treatment, on the group level, the individual level, and in medication management. Being able to talk with colleagues who have done this work and have this expertise is crucial to understanding the barriers to treatment and other challenges."
Second, ongoing education is important, Tarui says. "Even for myself and the staff that we have in the MOMS program, the field of perinatal psychiatry is vast and there is so much to learn on an ongoing basis. I educate myself on developing treatments and new therapeutic modalities. That is key to delivering the highest quality of care."
Third, seek out education on infant-parent psychotherapy, she says. "Recently, we have been doing a lot of work with infant-parent psychotherapy, and we had an expert in the field from University of California-San Francisco come to train us. We have been able to integrate that education into the care that we are providing both on the group and individual level."
A New Jersey-based hospital has repurposed emergency department staff to improve efficiency.
An initiative launched in January has significantly improved efficiency at Cooperman Barnabas Medical Center's emergency department.
For patients, lengthy wait times are common at emergency rooms across the country. The result is a poor patient experience, with some patients choosing to leave emergency rooms to seek care at other facilities.
Since the efficiency initiative was launched, the emergency department at Cooperman Barnabas Medical Center has posted impressive wait time statistics:
The average wait time from patient arrival to being placed in a room is under 10 minutes.
The average time to talk to a healthcare provider is about 10 minutes.
The median turnaround time for patients to be seen, treated, and discharged was 160 minutes during the most recent month for which data is available.
The front-end process at the Livingston, New Jersey hospital's emergency department moves patients quickly, says Maria Aponte, MPA, BSN, RN, administrative director of emergency services.
"As soon as someone comes in, they are greeted by a security guard, who finds out whether they are a patient or a visitor. If you are a patient, you are seen by the first nurse, who does not conduct triage. The nurse does a quick assessment by asking a couple of questions. Then the patient is quickly registered with five registration questions. A full registration is not done on the front-end, which cuts down on a lot of the time. Five questions get asked and the patient gets directly bedded to the back," she says.
Clinicians see patients as quickly as possible, says Eric Handler, DO, chairman of emergency medicine. "On the provider side, not too much has changed other than we are really happy to have the patient in the room and being able to see them there instead of having to bring that process up front."
Rooms are available in part because the hospital is working hard to make sure patients are not boarded in the emergency department after they are admitted, Aponte says. "One of the biggest factors in efficiency is patient boarding. In the past, we had patients waiting for a bed upstairs for three or four hours. We have made sure that we have good throughput throughout the hospital. That means, when a physician puts in an order to admit a patient, the patient is bedded in the hospital as quickly as possible. We want to move patients out of the emergency department so we can see other patients. Becoming more efficient in the emergency department is a hospital-wide initiative."
Similarly, the emergency department is getting timely service when tests are ordered for a patient, Handler says.
"We have been having a bi-weekly throughput committee meeting, where we get together with all of the stakeholders and hold everybody accountable in a collegial way. We have stakeholders such as laboratory, transport, logistics, and radiology, and we make sure everybody is on the same page and being as efficient as we can. … With the throughput committee meeting, we are making sure that radiology does X-rays right away, and CAT scans, ultrasounds, and lab tests are done right away. We are making sure that these other stakeholders are onboard with the new process. We look at the metrics, and we look at the times, and we see how we can improve. We make sure all of the stakeholders are making us more efficient."
An innovative aspect of the efficiency initiative is that the emergency department was able to improve without hiring more staff, Aponte says. "What we did was repurpose staff. Before, we were sending resources to the front such as a provider in triage and getting lab work on the front-end. We were able to become more efficient and bring patients directly into a room by repurposing staff. A provider who was seeing patients in the front was freed up to see patients at the bedside. The nurse who was doing the triage in the front became a floating triage nurse who can provide triage at the bedside and assist the primary nurse who is providing care."
The emergency department also has an efficient discharge process, Handler says. "Once we get the results of tests back, we can make the determination whether it is safe to discharge the patient home. Our goal from there is to get the patient out the door with their discharge instructions in less than 30 minutes."
Advice for other emergency departments
Teamwork is crucial to improve emergency department efficiency, Handler says. "Maria and I speak frequently throughout the day. We observe what is happening in the emergency department into the early evening to make sure things are going smoothly. There is a HIPAA-compliant text service called TigerConnect that we use with all of our stakeholders. If there is a delay in one area, we get a message out and the person responsible for that area—whether it is lab, radiology, transport, or logistics—does their best to rectify the problem. Without teamwork and an eye on the ball, things can fall apart quickly."
Emergency department teams need to care about efficiency and their patients, Aponte says. "You need to care about the initiatives that you are doing and care for the people doing the work. You also need to provide patient-centered care. When someone comes to the emergency room, it can be scary for them. They are very anxious when they arrive. You need to care about the efficiency model and care about what is right. We cared enough that we knew that our time numbers were not meeting our expectations."
Patient satisfaction can be a powerful motivator for emergency department staff when conducting efficiency initiatives, Handler says. "One of the things that got us the biggest buy-in and gave us momentum was when the staff saw how happy the patients were and how much easier the encounter became because the patient was not upset, frustrated, or disappointed. Patients get dissatisfied if they sit in a waiting room for hours before being seen. The encounter goes so much more smoothly when you have a happy patient in front of you instead of an angry one."
The survey found 73% of adults feel that the healthcare system fails to meet their needs in some way.
Two-thirds of U.S. adults surveyed by The Harris Poll reported that managing healthcare is "overwhelming" and "time-consuming."
The survey was conducted by The Harris Poll on behalf of the American Academy of Physician Associates (AAPA). The survey, which features data collected from more than 2,500 adults, was conducted from Feb. 23 to March 9.
The survey was conducted to get the patient perspective on U.S. healthcare, AAPA CEO Lisa Gables, CPA, said in a prepared statement. "So much has changed in healthcare since the pandemic, and the focus has largely been on the strain that healthcare teams are experiencing. Certainly, we have to address that as we know it impacts the resiliency and strength of our healthcare workforce. However, AAPA wanted to understand from the patient perspective what is and isn't working in healthcare today."
The survey generated several key findings:
Survey respondents reported that they spend the equivalent of an eight-hour workday per month coordinating healthcare for themselves and/or loved ones
The survey found 73% of adults feel that the healthcare system fails to meet their needs in some way
The survey found 71% of adults are concerned that the demands on healthcare providers are onerous
The survey found 68% of adults worry that healthcare workforce shortages will impact patients
The survey found 66% of adults reported that healthcare providers appear to be more rushed than in the past
The survey found 47% of adults believe their healthcare providers are burned out or overburdened
Nearly one-third of survey respondents reported feeling rushed during a healthcare appointment
The survey found that 61% of adults only seek healthcare services when they are sick
The survey found 44% of adults have skipped or delayed care in the past two years, with 40% saying the reason was concern about cost
The survey found 64% of adults want healthcare providers to spend more time understanding them, with 49% of survey respondents reporting that healthcare providers do not always listen to them
The survey found 67% of adults reported that their health would improve if they worked regularly with a healthcare provider they trusted
The survey found 54% of adults would feel more comfortable working with a healthcare provider who shares their background
The survey found 54% of adults reported that their health would improve if healthcare providers helped them figure out the healthcare system
The survey shows patients are struggling with the healthcare system, which can impact health outcomes, John Gerzema, CEO of The Harris Poll, said in the survey report. "What struck me from the research we conducted on behalf of AAPA is how clearly the findings demonstrate how the system itself is getting in the way of people being able to take care of themselves as well as the ones they love. The system is costly, confusing, and it takes too long to get needed care. The result is that people want to engage with it less which can lead to even more health problems—both physical and mental."
Difficulty engaging with healthcare providers has negative consequences, the survey report says. "Most adults admit that they only seek care for themselves when they are sick and delaying care or skipping it altogether is an all-too-common occurrence. This often comes with consequences: Many adults who have skipped or delayed care say they experienced negative impacts as a result. Forgoing care is not only detrimental in the case of a major health concern, but also prevents people from undergoing routine preventative care. In addition, the negative impacts often extend beyond patients themselves: Many of those who have helped someone coordinate care say their life was negatively impacted in some way as a result of helping someone navigate the healthcare system."