Strong medical groups function as a network, with clinicians knowing and talking with each other.
Leading a large medical group requires careful listening, understanding the issues, and achieving alignment on key priorities, says RWJBarnabas Health's Andy Anderson.
Anderson has been executive vice president, chief medical officer, and chief quality officer of the West Orange, New Jersey-based health system since May 2022. He previously served as president and CEO of the Combined Medical Group of RWJBarnabas Health and Rutgers Health. Prior to joining RWJBarnabas, Anderson served as executive vice president and system chief medical officer of Aurora Health Care in Wisconsin.
Anderson recently talked with HealthLeaders about a range of issues, including the challenges of leading clinical care at RWJBarnabas, the keys to generating a positive patient experience, and the primary elements of physician engagement. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of RWJBarnabas?
Andy Anderson: The opportunity is to truly build an integrated health system, and our health system is interested in being one system and one family. Having all of our individual pieces and parts come together for a seamless experience for our patients while we are serving our communities and having our communities become healthier is key.
The challenge is having a common vision and mission as well as achieving good outcomes together. The biggest levers we are pulling are having system incentives and having everyone rally around the most important things: the patient experience and quality outcomes. If everyone is centered on those important things, we will be able to come together as an integrated health system.
HL: How are you rising to the challenge of being a fully integrated organization?
Anderson: There are three important levers. One is making sure that we have the right culture. We need a culture where people can speak up for safety, people are working well together on teams, and people are working on continuous quality improvement. The second lever is having strong leaders who are engaged and accountable, with engaged team members who are working together to achieve the best outcomes. The third piece is transparency of data. We need to make sure people know how they are doing. We need to make sure people know how the health system is doing and whether we are making progress on key initiatives. It helps create positive energy when you are making progress.
Andy Anderson, MD, MBA, executive vice president, chief medical officer, and chief quality officer of RWJBarnabas Health. Photo courtesy of RWJBarnabas Health.
HL: What are the primary challenges of serving as chief quality officer of RWJBarnabas?
Anderson: Part of that challenge is making sure there is focus because there are a lot of different areas that can be worked on at once. If you do not focus on the most important areas, then it is hard to move things forward. We have picked some areas where we know we have opportunities to improve based on the data such as prevention of hospital-acquired infections.
So, having focus, clear priorities, goals, and incentivizing everyone around those goals creates alignment, where the whole health system is moving forward together to improve outcomes.
HL: You served as president and CEO of the Combined Medical Group of RWJBarnabas Health and Rutgers Health. What are the keys to success in leading a large medical group?
Anderson: Leading a large medical group requires careful listening and an understanding of what the issues are; then you need to achieve alignment on key priorities. In the work we are doing on patient experience and quality, having clear direction on the key outcomes that we are trying to achieve is crucial. You need to create the vision of where we want to go, set common outcomes such as having a great patient experience and making sure care is coordinated, and make sure that you have created an integrated network within the medical group.
One of the most powerful motivators for a medical group is to have your clinicians be interconnected, know each other, and trust each other. You need a network that is centered around the patients. A high-functioning medical group is going to be tightly interconnected, and it is going to coordinate and integrate care for patients.
HL: How do you establish a network within a medical group?
Anderson: Some of that is people truly getting to know each other, seeing each other, and talking to each other. Clinicians need to have a comfort level to pick up the phone and call a colleague. It also goes back to the common outcomes that we are all trying to achieve together—great patient experience and great quality outcomes. Having everyone centered on those common outcomes brings everyone together. Having a network of positive and trusting relationships is critical. You must foster that and make sure that people are comfortable talking with each other.
HL: What are the primary elements of physician engagement?
Anderson: Physicians are very interested in being leaders. Allowing them to take on leadership roles, then coaching and developing them is very engaging. You need to create career paths for physicians to take on roles, whether it is leading a committee or an initiative, or moving up into an administrative role.
The other important part of physician engagement is two-way communication. You need to make sure physicians understand the priorities of the health system, then listen to them. You want good feedback, and you want to understand the issues at the front line. Sometimes, it comes down to an individual practice and the pain points in that practice, and how you can help solve those pain points. Effective two-way communication is very engaging for physicians as well as the knowledge of the health system, what the priorities of the health system are, and how the physicians can contribute to those priorities.
HL: What are the keys to generating a positive patient experience?
Anderson: Listening to the patients very purposefully and understanding what their priorities are is important. We need to listen to any issues that they may identify while they are in our hospitals or other facilities. Then you need to close the loop. If there is an issue that we hear about with an individual patient, we need to close the loop on that issue right away—it makes a big difference for that individual.
I was rounding recently, and we had a patient who was not sure who their doctor was going to be because their current doctor was retiring. After rounds, we talked immediately with the care team, who went back to the patient and helped the patient understand the transition to a new doctor.
So, closing the loop with an individual patient makes an enormous difference for that person. More broadly, we need to understand what the themes are by listening to patients. We need to find out if there are themes emerging about the environment, the food, how much patients know about their day in terms of procedures or tests they are going to have, and whether their doctor and nurses are communicating appropriately. Just getting that information by listening to our patients is impactful to improve the patient experience.
In addition, employee engagement is the underlying way you can improve the patient experience. If your employees are excited to be at work, they are happy to be at work, and they are centered on mission and purpose, then they are going to deliver the best possible care to our patients. So, focusing on our employees is a critical part of being successful with our patient experience.
HL: What is the role of clinicians in organizational administration at RWJBarnabas?
Anderson: It is very important to have the voices of physicians, nurses, and other clinicians—those who are doing the work and delivering the care. It is much better when there is communication, understanding, and coordination with those clinicians. To have a health system that is truly effective and efficient, that clinician voice is critical.
We have purposefully engaged our nurse leaders and our physician leaders. They typically co-lead our quality, safety, and patient satisfaction projects with dyad nurse leadership and physician leadership driving initiatives. It is powerful and great role-modelling.
Part of how we have organized ourselves is through service lines such as cancer, neurology, cardiovascular, and pediatrics. The model for those service lines is to have a dyad leadership team with an administrator and a clinician. Having a clinician be a co-leader of a service line is one of the examples of how we have clinicians involved in administrative leadership.
Another example is that each of our hospitals has a chief medical officer and a chief nursing officer. They are very much at the table and often leading initiatives, particularly quality, safety, and patient satisfaction. They are the leaders for those initiatives and make sure that we are making progress.
The overuse of antibiotics has been linked to antibiotic resistance and antibiotic-associated adverse effects.
A multifaceted antibiotic stewardship initiative for respiratory conditions at Intermountain Health urgent care clinics resulted in a significant reduction in antibiotic prescribing, a new research article found.
Most antibiotic prescriptions in the United States are made in outpatient settings and as many as 30% of those prescriptions may be unnecessary. Antibiotic overuse has been linked to antibiotic resistance and antibiotic-associated adverse effects.
The research article, which was published by JAMA Network Open, is based on data collected from nearly 500,000 urgent care encounters at 38 urgent care clinics and one telemedicine clinic operated by Intermountain Health. The data was collected during a 12-month baseline period from July 1, 2018, to June 30, 2019, a 12-month intervention period from July 1, 2019, to June 30, 2020, and a 12-month sustainability period from July 1, 2020, through June 30, 2021.
The intervention was based on the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship. The intervention incorporated all four of the CDC core elements, including the following:
1. Education for clinicians and patients: Education for clinicians included an urgent care antibiotic stewardship champion who served as a peer-to-peer resource for clinicians, a handbook that included guidelines, and monthly update lectures at regional urgent care meetings. Education for patients included a symptomatic therapies checklist and a patient-facing antibiotic stewardship webpage.
2. Electronic health record tools: Clinicians had EHR tools such as receiving azithromycin prescribing justification alerts in the EHR and the addition of delayed antibiotic prescriptions in the EHR.
3.Clinician antibiotic prescribing dashboard: This dashboard included all clinicians and clinics, which allowed for peer comparison.
4. Media campaign: Intermountain Health launched a media campaign that included television and radio interviews, print media such as newspaper articles, and Facebook and Twitter posts.
In addition to the four CDC core elements, Intermountain Health designed a quality measure financial incentive for urgent care clinicians. The financial incentive gave clinicians increased compensation if they prescribed antibiotics in less than 50% of respiratory illness encounters.
The study generated several key data points:
Clinicians prescribed antibiotics for respiratory conditions for 47.8% of encounters in the baseline period and 33.3% of encounters in the intervention period.
In the first month of the intervention, antibiotic prescribing decreased 22% and antibiotic prescriptions fell 5% monthly during the intervention.
Among clinicians who were working in both the baseline and intervention periods, 95% decreased their prescribing of antibiotics for respiratory conditions.
During the baseline period, 38.5% of clinicians prescribed antibiotics for more than 50% of respiratory condition encounters. During the intervention period, 10.2% of clinicians prescribed antibiotics for more than 50% of respiratory condition encounters.
There was no statistically significant decrease in patient satisfaction when comparing the baseline and intervention periods.
The was no statistically significant increase in hospitalizations within 14 days of an urgent care encounter when comparing the baseline and intervention periods.
"The findings of this quality improvement study indicated that an [urgent care] antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for [urgent care] antibiotic stewardship," the study's co-authors wrote.
Interpreting the data
The research shows that outpatient antibiotic stewardship programs can be successful, the study's co-authors wrote. "This study adds to growing evidence about effective outpatient stewardship programs, including those focused on [urgent care] settings. Features of successful programs include the use of audit and feedback, clinician and patient education, EHR tools, and peer comparison or benchmarking."
The urgent care antibiotic stewardship initiative made gains beyond the reduction in prescribing for respiratory conditions, the study's co-authors wrote. "In addition to reductions in the overall rate of antibiotic prescribing for respiratory conditions, several other areas of antibiotic prescribing improved, including the use of azithromycin and delayed prescriptions. Because these areas were explicitly targeted by components of our intervention, they likely represent changes in clinical practice and were sustained beyond the intervention period."
The finding that there were no statistically significant changes in patient satisfaction and patient safety is noteworthy, the study's co-authors wrote. "This is important because of the relatively large reduction in antibiotic use for respiratory conditions that occurred with the intervention. Our observation that patient satisfaction scores were stable may provide reassurance to clinicians that practicing antibiotic stewardship is not associated with unintended consequences in patient satisfaction and other important dimensions of clinical care, including visit duration, both of which have been cited as barriers to mitigating antibiotic overuse."
The Cancer Equity Project will initially focus on three initiatives.
Total Health, the largest provider of free oncology continuing education in the United States, has launched the Cancer Equity Project, a nonprofit organization designed to promote health equity in cancer care.
Cancer disparities include incidence, mortality, morbidity, and stage at diagnosis, according to the National Cancer Institute (NCI). Contributing factors to cancer disparities include social determinants of health, behavior, biology, and genetics, the NCI says.
The overall mission of the Cancer Equity Project is to promote health equity in cancer patients, so everyone can live their lives to the fullest, says Sharon Gill, executive director of the nonprofit. "We want to elevate the voice of underrepresented groups in cancer care. We will be looking at the disparities in cancer care and bringing them to the forefront. We want everyone to have a fair shot."
There is a need for an organization such as the Cancer Equity Project because there are many serious cancer disparities, she says. "Black women are 40% more likely to die from breast cancer than White women. Black men have a prostate cancer death rate that is more than twice the rate for White men. Hispanic children are 20% more likely to die of leukemia than non-Hispanic White children. Men living in the poorest U.S. counties have a colorectal cancer death rate that is 35% higher than men in affluent counties."
Total Health is well-positioned to help address cancer disparities, Gill says. "We have access to data and information. Total Health works with the medical community, and the Cancer Equity Project is going to be focusing on the patient community. We want to impact healthcare disparity numbers."
Initiallly, the Cancer Equity Project will be focusing on three initiatives.
1. Healthcare Provider Certificate Program
The SEEK Color Certificate Program will provide training to healthcare providers focused on inherent biases, Gill says.
"In terms of the disparities in cancer care, one of the things we know is that there are inherent biases in the healthcare system, and what we are trying to do is educate healthcare providers on the inherent biases. These are not malicious—just inherent. The certificate program is working in tandem with diversity, equity, and inclusion (DEI) experts and DEI speakers to talk about some of the barriers. It could be unconscious bias or unconscious microaggression," she says.
The Cancer Equity Project will be bringing DEI speakers who can help draw attention to how doctors are interacting with patients and how patient questionnaires are written, Gill says. "We want to expose to the medical community that there are differences in how a Black patient may respond to a doctor. There are differences when Black patients are asked about their medical history—they may not have those answers based on cultural and economic status. We are going to train doctors to understand how to work with underrepresented groups."
Healthcare providers can earn a certificate by participating in three workshops, she says.
2. Patient education
The Cancer Equity Project has developedCompass Cancer Journey Mapsto help cancer patients have educated shared decision-making conversations with their healthcare teams, Gill says. "When you go to a doctor, you often only have 15 minutes to talk—whether they are an oncologist or a primary care physician. You have a limited time to speak with your doctor. What we have found is that if you are an uneducated patient about your condition, the doctor will make decisions for you."
The Compass Cancer Journey Maps will arm patients with information about next steps and expectations, she says. "So, when you go to your doctor, you can have an intelligent and educated conversation. At that point, you can make decisions together with your doctor because you will be more informed. Doctors do not have the time in their office visits to give you much information, so we are trying to give patients the information that they need."
3. Clinical trial
The Cancer Equity Project is launching the EBONY-B001 clinical trial, which will focus onyounger Black Women with early, hormone receptor-positive clinically high-risk but genomic low-risk breast cancer. The goal of the clinical trial is see whether this patient population can avoid chemotherapy by using ovarian function suppression in combination with endocrine therapy.
The EBONY-B001 clinical trial will address an unmet need in cancer research, Gill says. "Of the people who are taking part in clinical trials, a small percentage of those people are Black women. Many Black women do not have access to cutting-edge medication that is coming out; or, worse, medications are developed that are not necessarily suitable for Black women or other patients from underrepresented groups."
"Even the most highly qualified and competent physicians in the U.S. may face a medical liability claim in their careers," the AMA president says.
A new analysis from the American Medical Association (AMA) shows that 31.2% of physicians have been sued for medical liability claims.
Most lawsuits for medical liability claims do not result in the finding of a medical error, according to the AMA. From 2016 to 2018, 65% of claims were dropped, dismissed, or withdrawn; and for the 6% of claims decided by a trial verdict, 89% were won by the defendant.
Many physicians will face lawsuits during their careers, but they practice medicine despite the risk, AMA President Jack Resneck Jr., MD, said in a prepared statement. "Even the most highly qualified and competent physicians in the U.S. may face a medical liability claim in their careers, however, getting sued is not indicative of medical errors. All medical care comes with risks, yet physicians are willing to perform high-risk procedures that offer hope of relief from debilitating symptoms or life-threatening conditions."
The new analysis is based on the AMA's 2016-2022 Physician Practice Benchmark Surveys. The benchmark surveys are nationally representative and include paid and unpaid claims.
The new analysis features several key findings:
The longer physicians practice medicine, the higher their risk of a medical liability claim. For physicians over the age of 54, 46.8% have faced a lawsuit. For physicians under age 40, 9.5% have faced a lawsuit.
Medical specialty accounts for the largest variation in lawsuits, with surgical specialties generally facing the highest risk and internal medicine subspecialties generally facing the lowest risk. The specialties at highest risk of lawsuits include obstetricians-gynecologists, with about 62% of physicians being sued during their careers, and general surgeons, with about 60% of physicians being sued during their careers. The specialties at lowest risk of lawsuits include allergists and immunologists, with 7% of physicians being sued during their careers, and hematologists and oncologists, with 8% of physicians being sued during their careers.
Lawsuits also vary by physician gender. Female physicians are at lower risk of being sued than their male counterparts. About 24% of female physicians have been sued during their career compared to about 37% of male physicians having been sued during their career. Female physicians had 42 claims per 100 physicians compared to 75 claims per 100 physicians for male physicians.
Medical liability claim reform is needed, the AMA said in a prepared statement. "Given the heavy cost associated with a litigious climate and the significant financial toll it takes on the nation's healthcare system, the AMA continues to work with state and specialty medical associations and other stakeholders in pursuit of both traditional and innovative medical liability reforms that strike a reasonable balance between the needs of patients who have been harmed and the needs of millions of Americans who need affordable, accessible medical care."
Interpreting the data
There is a strong association between longer-term claim frequency and physician age, the new analysis says. "Physicians under the age of 40 are 15.6 percentage points less likely and those over 54 are 21.9 percentage points more likely to have ever been sued than their age 40-54 counterparts. These differences are almost identical when controlling for other factors. This age-risk relationship is not surprising given that older physicians have been practicing for a longer period of time and thus have had more exposure to risk."
Specialty is a key factor in the likelihood of a physician being sued, the new analysis says. "In both the short and longer term, the widest variation in liability risk comes from specialty. Among the strongest and most consistent results is that OB/GYNs, general surgeons, orthopedic surgeons and other surgeons have a much higher incidence of claims. Of OB/GYNs, 62.4% have been sued in their careers, followed by 59.3% of general surgeons. Controlling for other factors, OB/GYNs and general surgeons are 33.6 and 28.6 percentage points more likely than general internists to have ever been sued."
In the short term, female physicians have been at lower risk of being sued than their male counterparts, the new analysis says. "Women were less likely to have been sued in the prior year than men. Notably, this gender differential grew over time. In the 2016-2018 period, 2.8% of men were sued in the previous year, compared to 1.6% of women. There was no change over time for men in 2020-2022, but the likelihood that women received a claim fell to 0.9%. … There are a number of reasons why women are less likely to be sued. In terms of short-term risk, they tend to practice in less risky specialties and provide fewer hours of patient care."
At UW Health, the process to address medical errors is not punitive.
When medical errors occur, health systems must learn from the experience and conduct root cause analyses, says Aimee Becker, MD, MBA, chief medical officer of UW Health.
Becker has been CMO of the Madison, Wisconsin-based health system since August 2018. Prior to her role as CMO, she served as the interim chair for the UW School of Medicine and Public Health Department of Anesthesiology. Previously, she served as chief of anesthesia and director of operating rooms at the William S. Middleton Memorial Veterans Hospital in Madison.
HealthLeaders recently talked with Becker about a range of topics, including the challenges of serving as CMO at UW Health, clinical care quality and patient safety, and the role of physicians in healthcare administration at UW Health. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of UW Health?
Aimee Becker: Broadly speaking, the challenges we face at UW Health are similar to other healthcare organizations. We are navigating financial headwinds and we are feeling challenges with inflationary pressures. Additionally, workforce shortages pose a significant challenge, particularly as we are still feeling the impact of the coronavirus pandemic.
Addressing the staffing shortages is one of our highest priorities, and linked to this is the well-being of our workforce. This is so critical. Our healthcare teams have had to weather a lot of stress and changes stemming from the pandemic and supporting them has been and continues to be a top priority. As an organization, we recognize the challenges our care teams face, and we want to ensure that we are supporting them not only through staffing but also across the full spectrum. When considering the challenges we face as an organization, we must start with the well-being of the individuals that make it work.
HL: How are you supporting the well-being of your staff?
Becker: It is through multiple measures and many different levels. We have a team dedicated to well-being across our organization. We have a strong physician partner—our chief wellness officer, who works specifically on the well-being of our physicians and advanced practice providers as well as our residents and fellows.
Through the pandemic, we developed several resources. At baseline, our leaders are very engaged with our frontline teams, and they spend a lot of time rounding to hear from and learn from our frontline teams. We want to know what their issues and barriers are and try to mitigate those. We developed a robust, cross-functional multidisciplinary team for peer support. We have employee well-being resources across an entire portfolio of different options, whether that is peer support, confidential mental health services, or our response to stressful incidents. It is a multipronged approach to well-being.
HL: You are responsible for clinical care quality and patient safety at UW Health. What are the primary elements of clinical care quality?
Becker: We are fortunate in that we have a strong quality and safety team that reports up through our chief quality officer, who is a physician. Associated with this, we have robust structures and processes to support our goal of achieving remarkable healthcare outcomes. All of this is tied to our operational framework. So, our management triads and dyads are key to engaging our frontline team members.
Quality and safety are part of the work that we do every day, and each one of us is responsible for quality and safety, and we are accountable to our patients and each other. So, while we have excellent patient care outcomes, we are dedicated to continuous improvement. We have set expectations for our behaviors at work, and we empower our frontline teams to lead improvement work, stop the line when necessary, and hold each other accountable.
HL: What are some of the primary mechanisms for ensuring patient safety at UW Health?
Becker: How we interact with each other is important. We know that respectful work environments are safe patient care environments. How we operate day to day and communicate is key. We have a real-time management structure, where we huddle with our teams to ensure patient safety and to address issues. We have quality improvement initiatives that are always evolving to make sure that we are targeting the patient care needs of today.
HL: How do you handle medical errors?
Becker: It is important to have a just culture. As an organization, we are going down that path formally. You must have a process around evaluating errors that is non-punitive, and you must be able to learn from your mistakes and identify the root causes. We have a robust root cause analysis structure that is aimed at understanding all of the root causes. In addition to that, we have the infrastructure to address and mitigate medical errors.
We have a reporting system for medical errors, near misses, and any safety concerns. This is a key ingredient of our quality and safety portfolio. Anyone can put a concern into the reporting system.
Aimee Becker, MD, MBA, chief medical officer of UW Health. Photo courtesy of UW Health.
HL: What role do clinicians play in healthcare administration at UW Health?
Becker: At UW Health, physicians play a significant role in healthcare administration. We have physicians engaged in healthcare administration at many levels. To start, we have a physician CEO. For our inpatient operations, we have a triad model for our hospital leadership that includes a physician leader, a nursing leader, and an administrative leader. For our ambulatory operations, we have dyad partnerships that include a physician and either an administrator or nurse leader, depending on the location. The aim of the collaboration is not for physicians to take over the roles of our administrative and nursing leader partners—the intent is to support operations and patient care with physician input.
HL: In general, do you think physicians are playing a greater role in healthcare organization administration?
Becker: In short, yes. I hope we have shifted from the past, when physicians viewed hospital administration separately as "the suits." Certainly, physicians provide valuable administrative leadership in healthcare.
Very often, our physician leaders continue to take care of patients. That lends a lot of credibility to the broader patient care team, and it gives physician leaders a unique perspective when they are directly engaged in patient care.
HL: You led clinical care at UW Health during the pandemic. What were your primary learnings from this experience?
Becker: The silver lining with all the COVID challenges is that we learned so much. First, as a healthcare organization, we learned that we could weather a storm by being in it together. The tremendous collaboration across all aspects of the organization was inspiring during very tough times. We also learned that despite being a large integrated academic health system we can be flexible and nimble when the situation calls for it. This will continue to be important as we face ongoing headwinds.
We also learned the value of telemedicine. Our patients and our care teams appreciate this, and we learned the value of working from home. The flexibility has been important for our workforce. Having the flexibility to work from home has improved the work-life balance. Working from home is not for everybody, but the fact that the option exists when the work is applicable and our team members can have a say in that is empowering.
HL: You have a clinical background in anesthesiology. How has this background helped prepare you to serve in the CMO role?
Becker: For me, patient care is my first love. I love being an anesthesiologist, which has taught me a lot of things. First, getting to care for patients is a privilege, and with that privilege comes obligations and responsibilities, including continual improvement. Being an anesthesiologist has taught me that patient care is a team sport, and that each one of us on the team wants to be valued and respected for our unique contributions to patient care.
Working as an anesthesiologist has also taught me that there is no room for "us versus them" in patient care. In healthcare, there are many opportunities for us-versus-them situations, and we strive to mitigate that. For example, as we think about the importance of being valued and respected for the unique contributions to patient care, emergency department care is different from inpatient care, and each of those are unique and valuable, but neither is better than the other or more important than the other.
You need to value and respect everyone's contributions; but more broadly, we need to promote that we are all in this together for patient care. There is no us-versus-them scenario that I can think of that improves patient care.
The coronavirus pandemic compromised the ability of hospitals to work on patient safety, the president and CEO of The Leapfrog Group says.
During the coronavirus pandemic, hospitals lost ground on patient safety, says Leah Binder, president and CEO of The Leapfrog Group.
The Leapfrog Group recently released the watchdog organization's spring 2023 Hospital Safety Grades. There are fewer "A" grades and more "B" grades largely because of an increase in three hospital-acquired infections: Methicillin-resistant Staphylococcus aureus, central line-associated bloodstream infections, and catheter-associated urinary tract infections.
The pandemic compromised the ability of hospitals to work on patient safety, Binder says. "Hospitals had a great deal of difficulty managing a public health emergency while also maintaining vigilance on patient safety. They were somewhat overwhelmed and, in some cases, very overwhelmed by the response to the coronavirus pandemic, and that caused them to be unable to handle some of the important day-to-day business of running a hospital. What we need to do is make sure hospitals can be more resilient in the future, so they are able to manage both a public health emergency and their day-to-day business, which includes protecting the lives of patients."
Leapfrog also noted patient experience scores at hospitals declined, she says. "A hospital was not a great place to be during the pandemic. As a patient, you usually could not have your family visit. Frequently, there were either serious restrictions on visitors or no visitors allowed. That had a major impact on patient experience. It also had an impact on workforce experience—I have heard from many nurses that not having families in the room was demoralizing for them. They had no feedback, and they did not have the extra set of eyes that families provide when caring for patients."
Uncertainty associated with the pandemic along with changing rules and regulations created a stressful environment in hospitals, which had a negative impact on patient experience, Binder says. "What we saw from that is patients reported their experience declined. The declines we saw in patient experience were serious declines. Patients reported not being comfortable with the medications they were prescribed and poor nurse communication. There is research that correlates those kinds of patient experiences with outcomes. So, it is something that we must watch closely, and it is something we will be tracking as we look at the recovery from the pandemic."
In the spring 2023 Hospital Safety Grades, 29% of hospitals received an "A," 26% received a "B," 39% received a "C," 6% received a "D," and less than 1% received an "F." While the performance is similar to recent Leapfrog Hospital Safety Grades, there was slippage, she says. "There are slightly more 'B' hospitals than there were in the last rounds and fewer 'A' hospitals. That is directly related to some of the challenges we saw in infection rates and other safety factors."
Binder says she expects improvement in the next round of Hospital Safety Grades. "We definitely have seen a major setback that has to be turned around immediately. That said, I am optimistic that hospitals will turn it around. They will improve. They know how to do it, and they want to do it."
Factors supporting the hospital-at-home trend include an aging population, advances in technology, and the search for more value in healthcare.
The Ohio State University Wexner Medical Center is bullish on hospital-at-home care.
The Medicare waiver for 24-hour nursing in hospital-at-home care has been extended until December 2024. With waivers granted by the federal government since the beginning of the coronavirus pandemic, more than 100 health systems across 37 states have launched hospital-at-home programs.
Ohio State launched its Hospital Care at Home program in January. The Medicare waiver for 24-hour nursing in hospital-at-home care is a good sign, says Rachit Thariani, chief administrative officer for Ohio State's Post-Acute and Home-Based Care Division. "In general, I feel confident that payers will cover this care. However, because this is still a somewhat evolving model of care, this two-year window provides a great opportunity for all of us who are in this space to comprehensively assess the value that this program creates. The value equation is always going to be the cost at which we provide the care and the quality and outcomes associated with this program."
Hospital-at-home programs need to generate data that shows the programs are effective, he says. "If the healthcare industry and the folks who are in this space can design and generate that evidence, we can prove that it is comparable to alternative models. Then I feel good about the fact that we will continue to see payers and the Centers for Medicare & Medicaid Services make this part of the mainstream of how healthcare is delivered."
There are four factors that indicate hospital-at-home care will be a trend in the future, Thariani says.
"First, you can look at the demographic changes and the aging population. Currently, about 17% of our population is above the age of 65. It is projected by 2040 that we will see about 81 million people who will be above the age of 65. It is one of the fastest growing segments of our population, and if you think about the needs of that population, hospital at home is perfectly suited to that population."
"The second piece is technology, which has come a long way and it is getting further and further advanced. That allows us to do things in the home that were not possible even five years ago. The advances in technology will help deliver higher acuity care models in the home."
"Third, there is a constant search for higher value in healthcare. Value is better outcomes at a comparable or lower cost point. As health systems and other players in healthcare such as payers and employers search for higher value, models such as hospital at home will be extremely interesting to them."
"Fourth, we have some large health systems making significant investments in hospital at home, so it is not something that we should under-estimate because those investments help develop the processes and technologies. Those investments help create a significant infrastructure that we can deploy for this model and understand its true efficacy."
Ohio State's hospital-at-home model
The Centers for Medicare & Medicaid Services (CMS) launched its Acute Hospital Care at Home program more than three years ago. Ohio State has embraced the CMS model, Thariani says. "In our hospital-at-home model, we have modeled it around what the CMS waiver permits. A patient needs to originate either in the emergency department or an inpatient setting and we can discharge them early to home. … The requirements are that there should be a daily provider visit, which could be completed by a physician remotely or an advance practice provider or a nurse practitioner in person. There is also a requirement for two daily visits completed in person by a registered nurse and potentially by an emergency medical technician. The requirements also state that we have access to care providers 24/7 for patients who are admitted to the program."
To provide staffing for Ohio State's Hospital Care at Home program, the organization has partnered with Dispatch Health, he says. "They recruit the physicians, nurse practitioners, and registered nurses for us. They are the ones who are seeing patients in the home. The services that Ohio State provides directly include pharmacy dispensing services, durable medical equipment, and physical, occupational, and speech therapy. It is kind of a hybrid model that includes clinicians who are employed on our behalf by Dispatch Health and certain services that we can provide."
Dispatch Health provides a 24-7 command center that is staffed by registered nurses, Thariani says. The command center oversees remote patient monitoring and interacts with the patients virtually.
Dispatch Health plays a key role in remote patient monitoring and patient data collection, he says. "As part of our relationship with Dispatch Health, they work with a remote patient monitoring company. When a patient is transferred to hospital at home, each patient receives a cellular-enabled tablet, and the tablet can constantly gather patient readings and vital signs. All of the documentation goes into our electronic medical record system—Epic. So, the data either goes directly into Epic, or when the in-home care team is with the patient, they go into Epic and conduct documentation. Our folks back in the hospital can understand what is going on with a patient at any given point in time."
Ohio State is collecting data for several hospital-at-home metrics, Thariani says. "CMS requires three metrics—patient volume, care escalation rates (how many patients were admitted into the hospital-at-home model but had to be brought back to the hospital), and mortality. However, we are working toward capturing a more comprehensive set of metrics. These include operational metrics such as length of stay and additional quality metrics such as readmission rates, infection rates, and falls. We are also collecting patient experience metrics such as patient satisfaction."
Phoenix Children's Hospital is also successful in retaining clinicians.
With an aggressive growth strategy, Phoenix Children's Hospital has been able to recruit and retain significant numbers of clinicians.
There is a tight clinician labor market nationwide. "The physician recruitment market is tighter than ever," Tara Osseck, regional vice president of recruiting at Jackson Physician Search, told HealthLeaders earlier this year.
Phoenix Children's Hospital is expanding from one hospital to three hospitals. Phoenix Children's Hospital—East Valley Campus is expected to open this summer. Phoenix Children's Hospital—Arrowhead Campus is slated to open next year. As part of the growth effort, Phoenix Children's has increased the organization's medical group from 25 to 34 divisions, and the surgical department has increased from 27 to 90 surgeons.
"The growth of the medical group has been based on numerous factors. Number One is the growth of the system—moving from a single hospital to three hospitals sometime in the next 12 to 14 months has driven the need for the overall growth. If we were not growing the system, we would not have had to worry about growing the number of clinicians," says Daniel Ostlie, MD, surgeon-in-chief and chair of surgery.
Phoenix Children's has powerful selling points for clinician recruits, says Jared Muenzer, MD, physician-in-chief. "Whenever I interview anywhere from senior leaders on the business side to senior leaders on the clinical side to junior physicians, I start with the most amazing things about Phoenix Children's Hospital are people and potential. The potential is looking at where Phoenix Children's fits in the Southwest—you look at our level of competition and we own the tertiary and quaternary market of children's healthcare in this region. It makes us a place that people are interested in. They want to hear about it."
In terms of people, Muenzer says part of the reason Phoenix Children's draws clinicians is world-class training programs. "Our faculty come from training programs at the best children's hospitals in the country. Then you add the layer that we have grown our training programs from the mid-teens to close to 30 fellowship programs, and we have been growing our own clinicians over the past decade. It's feeding on itself now, which puts us in a great position. We are still able to recruit clinicians despite a tight labor market."
High patient volumes across a range of specialties are also a selling point in clinician recruitment, Ostlie says. "We have a significant advantage because of the volume and population that this children's hospital supports with very little competition in our market. There is a small local children's hospital, but they don't really pose any market competition. I can hire a general surgeon and that person is going to be very busy. We can go out and hire a neurologist who focuses on mobility or rare diseases and because of the population that we have here—a million children—we know that neurologist is going to see patients that fit the specialty."
Phoenix Children's is also able to recruit clinicians in subspecialties, Ostlie says. "We just recruited a surgeon from Nebraska who specializes in osteogenesis imperfecta, which is brittle bone disease. We know we can bring her here, we can put her in an established orthopedics division, and she is going to be able to grow the osteogenesis imperfecta program just because of location—the airport is easy to get to—and we have a million kids here already. We also have all of the supporting structures such as genetics and orthopedic surgery that will allow her program to grow in a way that it would not be able to grow in other places."
Clinician retention
Annual evaluations help Phoenix Children's to retain clinicians, Muenzer says. "When Dan and I took over about seven years ago, one of the things we did not have was a way to evaluate and reward our clinicians every year. Now, we have a yearly evaluation program for all of our providers across the entire enterprise. For our over 750 clinicians, which is both physicians and advanced practice providers, they get evaluated every year, and that evaluation has an impact on their compensation. It allows us the opportunity to try to remain competitive in the market. The evaluations also give clinicians the sense that their accomplishments are being recognized."
Retention is also about empowering clinicians, Muenzer says. "Dan and I have 34 divisions, and we have empowered leaders to not only go out and recruit the number of providers they need but also the specialists and subspecialists they need to build a book of business in areas such as neurology, gastroenterology, and orthopedics. We gave them the power to build those programs. By doing that, it empowers those leaders to say, 'This is my book of business as a leader, and Dan and Jared give me the authority and the power to go out and build my program.'"
Phoenix Children's wants providers to have every opportunity to grow and mature and to be what they want to be, which boosts retention, Muenzer says. "For example, if you want to be a world-class clinical provider and deliver world-class clinical care and that is what your goal is, that is OK. If you want to be a researcher, if you want to be a medical director, if you want to build programs, if you want to be an educator, if you want to be a division chief, all of those tracks are available at this organization to all of our providers."
Pfizer Global Supply features 36 manufacturing sites, 11 distribution and logistics centers, and 31,000 manufacturing and distribution workers.
Scale is a primary way Pfizer has been rising to supply chain challenges during the coronavirus pandemic and as the crisis phase of the pandemic has passed, says Martina Ryall, vice president for strategy and operational excellence at Pfizer Global Supply.
The pandemic disrupted healthcare supply chains around the world. In the early stage of the pandemic, health systems and hospitals struggled to secure essential supplies such as personal protective equipment.
Pfizer has an impressive supply chain scale, Ryall says. "Today, Pfizer Global Supply consists of 36 manufacturing sites, 11 distribution and logistics centers, and 31,000 manufacturing and distribution colleagues who essentially enable supply to patients around the world. On an annual basis, we supply more than 50 billion doses across 180 countries, and we have hundreds of partnerships with manufacturing organizations and suppliers."
Scale allows Pfizer to minimize supply chain risk, she says. "One of the primary ways that we are reducing the risk of supply chain disruptions is through scale. We scale our operations and diversify our network. For example, we use multiple suppliers to minimize the risk of supply interruptions for essential medicines. So, instead of relying on a few suppliers in a particular region, we have a broader ecosystem or web around the world."
Supply chain resiliency is a top goal for Pfizer, Ryall says. "We are building in resiliency by establishing parallel supply chains through the United States and Europe. We also go to the traditional levers as well—implementing inventory management strategies that support thoughtful and purposeful over-production in certain areas of essential medicines. We also have a workforce that we can scale and flex depending on the need."
Supply chain lessons learned from the pandemic
The pandemic presented challenges and opportunities for Pfizer's supply chain, she says. "During the pandemic, one of the key things was being able to leverage our speed, our scale, and our science. However, the pandemic has shown us that so much remains outside of our control. Rather than try to navigate all of the volatility, our teams try their best to act proactively. One of the things that we learned was that while volatility may be disruptive, it is also a catalyst for us to engineer new and innovative ways of doing our work."
Pfizer's supply chain had to navigate chaos and complexity during the pandemic, Ryall says. "While it was uncomfortable, it did force us to grow in directions that we may not have dreamt of otherwise. We started to see a lot of new opportunities and better ways to get to our patients. Embracing that chaos and volatility is part of our "light speed" culture through which we have evolved operations to move with speed, eliminate unnecessary work, and trust each other to make decisions so we can get breakthroughs to the patients."
The pandemic has driven change in Pfizer's supply chain, she says. "We have learned that we could put in place nimble structures and a network of trusted and reliable suppliers. We had teams of interconnected problem solvers. We also harnessed digital tools—they are becoming a critical part of our manufacturing supply chains. In the past two years, digital technologies have enabled tremendous improvement in our service and cycle times because you can see the data. So, we are putting all of those learnings into practice."
Embracing drone deliveries
Drones have been an "exciting endeavor" for Pfizer, Ryall says. "It has given us access to remote locations that we were never able to get to before. We have partnered with Zipline. It has been a fantastic partnership that has enabled us to deliver to many remote areas during the pandemic. One of the first countries for the partnership was Ghana. We were able to reach communities in Ghana with poor road access—there were geographic features that impeded our traditional distribution methods."
Drone deliveries are part of Pfizer's long-term supply chain strategy, she says. "Drones were something that we were already working on before the pandemic, but the pandemic amplified drones as a method of delivery. Rather than it being a one-off method of delivery, drone shipments are something that we want to embrace and embed as one of our methods of reaching patients. Zipline is a pioneer in delivering medical products in remote areas, and we want to advance this partnership to other remote areas of the world. Drones are here to stay, and they will grow in terms of use."
Indiana University Health's vice president of supply chain has three decades of experience in purchasing roles.
Indiana University Health is working closely with suppliers to limit the impact of inflation at the Indianapolis-based health system, says Sam Banks, chief procurement officer and vice president of supply chain.
Prior to joining IU Health, Banks worked at medical device manufacturers for nearly 14 years, most recently serving as vice president of global procurement at Wright Medical Group. He also worked for nearly two decades at Honda, mainly in purchasing leadership roles.
HealthLeaders recently talked with Banks about a range of subjects, including coping with inflation, supply chain challenges at IU Health, and engaging physicians in supply chain. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How are you coping with inflation in your purchasing efforts?
Sam Banks: Inflation is tough for us. IU Health committed to the state of Indiana that we were not going to raise prices for five years. So, we do not have a lot of ability to absorb inflation. So, we are seeking significant cost savings this year.
We are working closely with our suppliers to make sure they understand that we need to push back on cost increases, and they need to find ways to take cost out. In some areas and contracts, we have protection against inflation or at least a cap on prices. That has saved us in quite a few situations.
We are trying to change the way we are working with our suppliers. We are engaging with their leadership teams, so they understand our current situation and our future plans. We want them to know we are a good partner as we continue to grow and continue to try to consolidate the supply base. We are also digging into their financials to understand the actual costs of their products. I am a firm believer that the better we understand how their products are made and their input costs, the better our ability is to push back on cost increases.
We are also asking suppliers about ways they can help us. If we are doing things that drive inefficiencies into their operations, we want to know that. Allowing suppliers to say something that is less than positive to the customer gives them the freedom to be honest with us.
Sam Banks, chief procurement officer and vice president of supply chain at IU Health. Photo courtesy of IU Health.
HL: What are the primary challenges of serving as chief procurement officer and vice president of supply chain at IU Health?
Banks: I joined IU Health last year, right as we were coming out of COVID. My whole supply chain experience has been almost 20 years with Honda and another 14 years in the medical device world, so IU Health has been a big change for me. When I started at IU Health, it was clear that the team was fatigued, and we were understaffed due to workforce shortages.
I was fortunate that my boss, who is the senior vice president of systems services, is a great leader and he understood what it took to get me onboarded and up-to-speed quickly. He had also put some good leaders directly under me, so I am fortunate to have a great team that reports directly to me that knows leadership and supply chain.
One of the biggest things that we struggle with is trying to find the right talent and dealing with attrition. We are challenged to compete in the marketplace because many organizations are raising salaries. So, we are trying to make sure that we have a great total offering—not just wages.
We are also challenged in supplies. The backorder situation and the disruption is getting better, but these challenges still exist. It has started to transition away from not as many backorders to more conversations with suppliers about cost increases.
Finally, our struggle is with data. We have a ton of data, but we do not have an efficient way to use it, process it, analyze it, and visualize it to help us drive our business to make it better. We need to start looking at process improvement, becoming more efficient, and taking our supply chain expertise to the next level.
HL: How have you been rising to the data management challenge?
Banks: We have been working closely with our information technology colleagues. We are also working closely with our third-party suppliers—they are getting us a lot of data and we are pushing them to help us understand how to use their services better and optimize the relationships. We are working to see how we can use that data to drive our business forward.
We are also looking internally at how we can write reports and to make sure that we have the right people in the right spots with access to the right data.
HL: Do you have a group purchasing organization?
Banks: We use Vizient. The GPO works on our behalf and negotiates national contracts to leverage the volume of not only our health system but also other health systems to get us the most competitive price offering that we can get. What a lot of people might not understand is that we use the GPO's suite of data for spend management and benchmarking. We also use the GPO's suite of data for our clinical side, with safety, quality, and efficiency metrics.
HL: IU Health has an integrated service center. What are the primary elements of this facility?
Banks: The ISC is a 296,000 square foot facility. About 150,000 square feet is warehouse and distribution. We use that space to stock between 30 and 90 days of inventory of more than 3,300 products. About 40% of our supplies flow through the ISC. The main functions there are warehousing and distribution. It is also a supply chain headquarters—it is where leadership sits as well as purchasing, business analytics, value analysis, and strategic sourcing. We just added pharmacy, so soon our pharmacy folks will be working out of that building and doing the pharmaceutical piece of our business there.
HL: How do you engage physicians in the supply chain?
Banks: We work closely with our clinical effectiveness team—they are our main liaison with the physicians. We participate in the physician-led councils. We bring physicians opportunities and they help us decide which direction we want to go. For example, we may have a category that has six suppliers, and we want to take that down to three suppliers, while maintaining safety, quality, and delivery with improved cost.
For example, we will have a physician-led council on orthopedics. We will talk about preferred suppliers and product usage. Doctors will give us feedback on how things are going. We will say this is how we are performing to the contract; and if there is an initiative that we have to work with the supplier or change suppliers, that conversation will occur with the physician-led council.
Sometimes, physicians will help us with supplier negotiations. It can be helpful to have physicians in those conversations.
We also have collaborative groups and nursing councils, which has been critical for us the last couple of years as backorders have come up and there has been a need for substitution. We are able to work closely with those nursing councils and collaborative groups to quickly decide whether a substitute is appropriate or not.