Research shows that female physicians spend more time with patients compared to their male counterparts.
Payment models that emphasize productivity and volume of patients seen are a primary cause of the physician gender pay gap, a healthcare finance professor says.
A recent Doximity report found a significant gender pay gap among physicians, with male doctors earning $110,000 more than their female counterparts. This represents a 26% gender pay gap in 2022, compared to a gender pay gap of 28% in 2021.
"There is increasing attention and research in this area. In the most recent research published in the New England Journal of Medicine, the study found that female primary care physicians earn less for the care that they provide but spend more time with their patients than their male colleagues," says Richard Priore, ScD, MHA, a clinical associate professor in the Department of Health Policy and Management at Tulane University.
The New England Journal of Medicine study found that female primary care physicians spent 15.7% more time with patients compared to their male counterparts. "The challenge for female physicians is they are spending more time with their patients and getting paid less," Priore says.
Female physicians appear less inclined to bow to the financial pressure of productivity-based business models at physician practices, he says. "Physicians have increasingly been put into a business mode, where there is pressure to see more patients in less time. My suspicion is that female physicians have not responded to this pressure in the same way male physicians have."
The physician gender pay gap is not the result of female clinicians putting in less effort than male clinicians, Priore says. "The New England Journal of Medicine study found that female physicians are not working less than their male counterparts—they are working just as hard as men are."
Payment reform is part of the solution to fixing the physician gender pay gap, he says. "We need to fundamentally change the way that physicians and hospitals are paid, and we need to increasingly pay for outcomes such as clinical outcomes and managing chronic conditions to keep patients out of the hospital. We need to address this issue to focus on wellness, prevention, and primary care."
More work needs to be done to understand the physician gender pay gap problem and to find solutions, Priore says. "There needs to be more research in the area in order to understand the problem. There needs to be more media attention and national research, whether it is from the National Institutes of Health or private foundations looking into this. We need to find out more about other underlying reasons for the physician gender pay gap. There also needs to be more senior leaders in health systems asking the question and being prepared to address the answers, especially if the answers are unpopular or do not paint the health system in a good light."
Previous research had found an increase in healthcare-acquired infections at hospitals during the coronavirus pandemic.
Hospital inpatients with COVID-19 have had much higher rates of healthcare-acquired infections (HAIs) than hospital inpatients without COVID-19, a new research article shows.
Previous research that compared data from 2019 to 2020 found that there was an increase in HAIs at hospitals. That research found higher infection rates for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.
The new research article, which was published by JAMA Network Open, features data collected from more than 5 million hospitalizations between 2020 and 2022 at 182 inpatient facilities operated by the HCA Healthcare health system. The researchers documented cases of CLABSI, CAUTI, MRSA, and Clostridioides difficile (Cdiff) among COVID-19 inpatients and inpatients without COVID-19.
The study includes several key findings:
The incidence of CLABSI was nearly 4-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
The incidence of CAUTI was 2.7-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
The incidence of MRSA was 3.0-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
For Cdiff, there was no significant difference in infection rates for COVID-19 inpatients and non-COVID-19 inpatients
COVID-19 inpatients had a mean 8.2-day length of stay compared to a mean 4.7-day length of stay for non-COVID-19 inpatients
"In this cross-sectional study of hospitals during the pandemic, HAI occurrence among inpatients without COVID-19 was similar to that during 2019 despite additional pressures for infection control and healthcare professionals. The findings suggest that patients with COVID-19 may be more susceptible to HAIs and may require additional prevention measures," the study's co-authors wrote.
Interpreting the data
A key finding of the study is that HAI rates for non-COVID inpatients did not increase at HCA Healthcare during the pandemic, the lead author of the research article told HealthLeaders.
"There have been some prior publications that say, 'Hospital infection rates have gone up since COVID.' The inference is that hospitals took their eye off the ball, or they were not as safe as they used to be. Until this study, no one had looked to see whether it was true that everybody was getting more infections or whether it was the introduction of a new population of patients that caused the infection rate to go up. In fact, our paper shows that for the non-COVID population, infection rates have been stable. It turns out that COVID patients are at high risk for hospital-acquired infections," says Kenneth Sands, chief epidemiologist at HCA Healthcare.
It would not be fair to say that COVID patients got worse care, he says. "They are just a new patient population, and the risks of infection had never been documented before. Now that they are documented, it provides the opportunity to start being aware of the higher risk and taking the appropriate extra steps."
The next step for researchers is to determine why COVID patients are at higher risk for hospital-acquired infections, Sands says.
COVID-19 inpatients drove the increase of HAIs during the pandemic, the study's coauthors wrote. "Our findings are consistent with previous reports that the occurrence of HAIs increased during the COVID-19 pandemic, reversing a multiyear national trend of improving performance regarding hospital infection. However, our subanalysis revealed that this increase in the overall infection rate appeared to be entirely due to the occurrence of HAIs in the COVID-19 population. Patients without COVID-19 had rates of HAIs that would be expected based on the incidence observed before the pandemic."
Three factors could have accounted for higher rates of HAIs among COVID-19 inpatients compared to non-COVID-19 inpatients, the study's co-authors wrote:
The COVID-19 inpatients had a longer length of stay, which is associated with higher risk of developing a HAI
Healthcare workers assigned to COVID-19 units may have had reduced resources and altered workflows
A decrease in infection prevention performance among COVID-19 inpatients could have been due to risks associated with this high-risk population
HAI rates among COVID-19 inpatients improved over time, the study's co-authors wrote. "While HAI rates were higher in the COVID-19 population, the occurrence of CLABSI, MRSA, and CAUTI in this population decreased over the course of the pandemic from 2020 to 2022. This is likely reflective of both improving practice in the management of COVID-19 as well as the decreasing acuity and length of stay in this population over time."
The new chief medical officer of Meritus Medical Center faces multiple challenges, including making the hospital the best care provider at the lowest cost possible.
While rural health has its challenges such as access, it is fulfilling because of the close connections between caregivers and patients, the chief medical officer of Meritus Medical Center says.
Atchuthanand Budi, MD, was named CMO of the Hagerstown, Maryland-based hospital in January. He previously served as associate chief medical officer of the medical center and was a physician-owner of a pediatrics practice for 20 years.
HealthLeaders recently talked about a range of issues with Budi, including the challenges of serving as CMO, learning about team-based care in neonatal intensive care units, and how running a pediatrics practice prepared him for physician leadership roles. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What do you anticipate will be your primary challenges in serving as CMO of Meritus Medical Center?
Budi: I have multiple challenges. We are changing the way healthcare is seen in many ways. One is that we as an organization want to make healthcare more cost-effective, so we want to be the best care provider at the lowest cost possible.
Two, we are working on the equity of healthcare access for every person in our county and surrounding areas, which is a challenge because a lot of people are not able to access healthcare for reasons such as lack of transportation. We are addressing those issues by providing clinics in remote areas so people can come to us.
Three, we have changed our hospitalist program. Previously, we were working with a contracted group; now, all of the hospitalists are employed by Meritus. Hospitalists see about 80% of the patients in the hospital. We hired some providers from the contracted group, and we hired a lot of people across the region and some from across the country.
Another challenge is we have a medical school launching, which is part of our organization, and we want to make sure that we have enough specialties and enough bandwidth so the medical students can be trained.
HL: How do you plan to rise to these challenges?
Budi: I have been in medicine for about 41 years, and I ran a private practice for about 20 years. Plus, I have been involved in several leadership roles. All of this experience gives me confidence that I can handle all of my challenges simultaneously. Running a private practice involved fiscal responsibility, and I want to make sure the cost of caring for patients is not prohibitive. Running a private practice also gives me the ability to be agile and move according to the needs of the community. The fact that I have served in leadership roles gives me an edge to face my challenges.
The most important thing is I have a great team of administrators and physician leaders who are helping me deal with challenges.
Atchuthanand Budi, MD, chief medical officer of Meritus Medical Center. Photo courtesy of Atchuthanand Budi.
HL: You serve a largely rural population. What are the primary challenges of serving a rural population?
Budi: Serving a rural population has more heart-warming situations than challenges. There are challenges such as healthcare access. But the feedback you get is positive and heart-warming because you are much closer to the population, and everyone knows you.
Washington County, unlike other rural areas, is fairly contained, and that is one of the reasons why we want to make our regional medical center the best place for people to get services, so , we are expanding our specialty services to make sure that we can take care of every need of the patients in our area.
Because people in the community know our providers, serving in a rural area is much more rewarding from a medicine standpoint because you make connections at a personal level.
HL: How do you rise to the access challenge with a rural population?
Budi: Instead of having offices around the hospital, we have opened multiple satellite offices for primary care in remote areas, so people can access them. We have used mobile clinics to reach people, especially for vaccinations.
HL: You have worked in neonatal intensive care units. What did you learn about team-based care working in that setting?
Budi: In my view, the neonatal intensive care unit is the best place to learn about team-based care. For example, if you have a pre-term baby weighing less than 2 pounds, you need respiratory therapists, you need nursing, you need a social worker, you need the parents, and you need the entire hospital network to help that baby grow in the best environment with the least possible complications. You also need the pharmacy because the drug dosing and the medications are unique for newborns. The social worker plays a key role by keeping everybody together and working with the parents. The case managers make sure all of the insurance companies are onboard.
I have seen that working together brings much better results for the baby, the family, and the hospital.
HL: You were a physician and owner at a pediatrics practice. How did this experience help prepare you to serve in physician leadership roles?
Budi: There were six providers in the group—four physicians and two nurse practitioners. I was the junior provider—the three other physicians were much older than me. I took over running the practice and also took over getting involved in building our own office. I worked with the nurses, the secretarial staff, the office manager, and my physician and nurse practitioner colleagues. I also dealt with different insurance companies to negotiate contract terms. I worked with different vaccine manufacturing companies to get the best rates on the best vaccines for our pediatric patients. I learned about public speaking.
I ran a practice successfully for more than 20 years, which gives me an edge in dealing with different groups of people. As CMO, I am working with different sets of people but in much larger numbers. All of the things I learned from running a practice helped give me the tools to be a good chief medical officer.
HL: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical care challenges facing Meritus Medical Center?
Budi: We have delved deeper into the inequities in healthcare in our region. We have a person who has been running the data and finding out where the main inequities have been. For example, in diabetes care, we have been looking at care for white and non-white patient populations as well as English-speaking and non-English-speaking patient populations. We have seen that diabetic care is poorer for non-English speaking and non-White populations. So, we are working on that.
We also found that the rate of breastfeeding is much lower in non-white and non-English-speaking populations, and we are trying to educate them. We are making sure that all information is available in English and Spanish in our hospital, which was not the case before.
There is also the challenge of the shortage of physicians and nurses, which we are seeing across the nation, and we are facing the same challenge. We have been able to maintain nursing staffing—we have a nursing school in our community, which helps us recruit nurses on a regular basis. We have a physician shortage in some specialties and in primary care, which is part of the reason we decided to start a medical school. We will have medical students who will train with us for several years, and a significant number of them will stay in our community. The medical school is set to open in 2025, and it will be called the Meritus School of Osteopathic Medicine.
HL: What advice would you offer to other physicians who may be interested in administrative leadership roles such as CMO?
Budi: The administrative role of the CMO should not be viewed that you are just a part of the administration. The chief medical officer should be the conduit between the medical staff of the hospital and the administrative staff. It is also ideal to hire a CMO from the community rather than outside the community. In my case, I know most of the hundreds of physicians in this community either at a personal level or because I have been involved in credentialling them. Having these relationships makes it easier for me to build bridges and make the communication much smoother.
A recent report found that 42% of U.S. adults are obese.
Obesity should be addressed through a multi-modal management approach involving a range of healthcare providers including primary care physicians, obesity specialists, nutritionists, and counselors, a liver disease specialist says.
Obesity rates have increased steadily over the past decade and now 42% of U.S. adults are severely overweight, according to a recent report from NORC at the University of Chicago.
Obesity is a serious problem in the United States, says Tejas Joshi, MD, director of liver diseases at Marshall Health. "It is a growing issue. Ten years ago, one-third of Americans were normal weight, one-third were over-weight, and one-third of them were obese. A recent study showed 42% of the U.S. adult population is suffering from obesity. As we look to 2030, we expect 50% of U.S. adults will be obese."
Obesity is related to several medical conditions, he says. "The severity of the obesity problem is directly linked to the health conditions associated with obesity. There are consequences, and some of the consequences are going to be in different formats—mechanical, metabolic, and neurological. One mechanical consequence is sleep apnea, which causes difficulty in sleeping. Another mechanical consequence is added weight on joints leading to arthritis. Metabolic consequences include conditions such as diabetes, high cholesterol, and fatty liver disease. A neurological consequence is depression."
Obesity has also been linked to a dozen kinds of cancer, including gastrointestinal, urinary, and pancreatic cancers, Joshi says.
Many healthcare providers should be involved in helping obese patients achieve weight loss, he says. "Optimally, we should approach obesity through multi-modal management via various providers—primary care, obesity specialists, nutritionists, counselors, as well as education from specialists that the patient may be seeing secondary to obesity-related consequences. So, if you are seeing a heart specialist because you have cardiovascular disease on top of obesity, the multi-modal management approach includes the heart specialist talking about a cardiac-health diet and weight loss. If you are seeing a hepatologist because you are suffering from fatty liver disease not related to alcohol, then the hepatologist should be involved in educating, counseling, and putting referrals in."
Through multi-modal management, we can achieve meaningful weight loss and address the obesity epidemic, Joshi says. "Your primary care provider could be the one to prescribe medicines, provide you with information, and put referrals in. A nutritionist could talk about various diets. When it comes to counselors, we must recognize that obesity plays a role in depression—depression can worsen obesity in some cases and obesity can drive depression."
Relatively new medications are a step forward in efforts to address obesity, he says. "GLP-1 agonists are one of the newest classes of medication that has achieved Food and Drug Administration approval for the treatment of obesity. There are more of these GLP-1 agonists as a class—even more are entering Phase 3 clinical trials. These drugs are a good addition to the treatments that healthcare providers have to battle the obesity epidemic."
Ozempic, which is FDA-approved for treatment of diabetes, is a GLP-1 agonist that should not be prescribed to treat obesity, Joshi says. "In the case of Ozempic, we have to prescribe medications based on their FDA-approved indications. If you have a patient who is diabetic who also has obesity, then if you started them on Ozempic one of the effects is weight loss. But providers should be prescribing medicines based on their FDA-approval."
Lifestyle changes are essential to address obesity, he says. "In lifestyle, we have to recognize appropriate times to eat and when not to eat. For example, you probably should not eat a couple of hours prior to sleeping. We need to recognize healthy foods—those that are not complex carbohydrates. We need to recognize that given the illness you are currently suffering from, there may be a specific diet scientifically shown to benefit that condition. Exercise is important. It is recommended that we get about 150 minutes per week of moderate-intensity exercise such as brisk walking 30 minutes a day."
In Joshi's practice, FibroScan, an ultrasound-based diagnostic tool that measures liver scarring, has helped influence patients' behaviors, he says. "I plan to publish a study that shows FibroScan motivated my patients to lose weight. We had patients who we diagnosed with FibroScan. We gave them educational material. We had them return in 90 days. And just learning that their liver was affected by their lifestyle choices and their weight was a motivating factor. On return, we had these patients re-examined, and they had lost weight. Their sugar numbers had gone down. FibroScan helped motivate them."
About 37 million Americans have kidney disease, according to the American Kidney Fund. About 800,000 Americans are living with kidney failure, and nearly 570,000 of those people are on dialysis, the American Kidney Fund says.
Dialysis centers nationwide are facing workforce shortages among the nurses who run the centers and the technicians who operate the dialysis machines, says Robert Provenzano, MD, a nephrologist at Ascension St. John Hospital in Detroit and a co-author of a recent journal article on using a calculated risk score to monitor blockages in vascular access for dialysis known as hemodialysis vascular access stenosis.
"The workforce in dialysis centers has always been challenging. … During COVID, the dialysis nurses faced a major challenge, not only from all the masking and personal protective equipment, but also from a very high acuity rate. In other words, their patients were very sick, and they started dying in very large numbers. As a matter of fact, for the first time in 30 years, the number of people on dialysis dropped. That's how significant the mortality was. So, the nurses who were both emotionally and physically overwhelmed just went elsewhere. They went to hospitals, which also had shortages. The hospitals can afford to pay more," he says.
Hemodialysis vascular access stenosis is a primary complication of dialysis, and it requires labor intensive efforts to monitor the condition, Provenzano says.
"The protection of vascular access is so important that the Centers for Medicare and Medicaid Services, which is the primary funder of dialysis services, has mandated that all patients receive surveillance. Surveillance is a very broad term, and they leave it up to the providers of dialysis care to determine what surveillance is. For the most part, dialysis centers do a physical examination on the access. A physical exam on the access is where you examine it, you touch it, you palpate it, and you listen with your stethoscope and try to make a determination whether there's a blockage," he says.
Physical examinations are a burden for the nursing staff at dialysis centers, Provenzano says. "Often, the caregivers doing the physical exam are the nurses who are understaffed, very busy, and they don't have the time to do it. So, it often isn't done. As a result, providers have adopted other methods of doing surveillance. One is an ultrasound that is usually conducted by a technician. They can see if there's a blockage. The problem with that technique is it's very expensive and it also slows down operations in the dialysis unit."
Using a calculated risk score, which estimates the probability of a vascular access blockage on a scale of 1 to 10, with higher scores indicating higher risk, helps dialysis center nurses to focus on fewer patients, he says.
"There are typically about 100 patients in each dialysis unit. If a nurse is running around trying to figure out which one of those 100 patients needs attention for their access, it's more efficient for the nurse to know which of those 100 actually has a problem. What this technology does is it shows the seven people who are going to have an event. So, the nurse can focus on seven instead of the other 93, and just make a simple referral to the vascular surgeon or the interventional radiologist to prevent the blockage. So, it takes just a few minutes instead of hours and hours."
Combining the calculated risk score with a physical examination is an effective way to conduct vascular access surveillance, Provenzano says. "When you have the people who are identified by the algorithm as a high risk for blockage, then those few people have a physical exam to verify whether there's evidence that a blockage exists. So, they build on each other to improve the positive predictive aspect of the process."
More than two-thirds of healthcare organizations do not have succession plans for physician retirements.
Healthcare organizations should be bracing for a wave of physician retirements, according to a new white paper from Jackson Physician Search.
A report published by the Association of American Medical Colleges in 2022 found that nearly half of physicians were more than 55 in 2021. As a result, more than two of five of physicians will be at least 65 within the next 10 years.
"Even more staggering than that is we are seeing physicians choosing to retire early, due in part to burnout, the influence of the pandemic, reprioritizing lifestyle, and having the financial stability to retire earlier than they planned for. The retirement of physicians is going to result in a significant loss of clinical expertise and experience, which is going to have an impact on healthcare," says Helen Falkner, a regional vice president of recruiting at Jackson Physician Search.
The new white paper is based largely on a physician retirement survey that Jackson Physician Search conducted with physicians and administrators in November and December 2022. The survey has several key findings:
While physicians believe six months notice of retirement is adequate, administrators prefer one to three years of notice.
The majority of physicians plan to work part-time or contract somewhere else rather than fully retire. Most administrators believe retiring physicians are leaving medicine entirely.
Burnout is the top reasons cited by physicians for retirement, but administrators believe age is the top reason for physician retirement.
About 25% of physician survey respondents reported that COVID-19 had pushed them to want to retire early, and 60% of those still plan to do so.
As early as age 50, some physicians are cutting back their working hours.
When physicians were asked what factors would encourage them to delay full retirement, 58% said they would delay retirement if they could work part-time and 52% said they would delay retirement if they could have flexible schedules.
More than two-thirds of healthcare organizations do not have succession plans for physician retirements.
The white paper has five key takeaways for healthcare organization administrators:
Start retirement conversations with physicians when they reach age 55
Conduct physician retention efforts and burnout mitigation
As physicians approach retirement age, give them several options to ease workload and improve work circumstances
Consider ways to keep aging physicians engaged such as teaching opportunities
Adapt to the needs of younger physicians by revising job descriptions and compensation packages
Physician retention plans
There are five primary elements of physician retention plans, Falkner says:
"It is important to note that retention starts at recruitment. The number one indicator of turnover is poor cultural fit. So, for organizations as they are interviewing, if the organization has a strong culture, low turnover, and good communication between physicians and management, those are elements that should be emphasized in the hiring and recruitment process. Organizations should be hiring for fit versus hiring to fill positions. Hiring for fit is going to be one of the best ways that organizations can have a good chance at retaining."
"Organizations should provide personal growth opportunities for physicians. Burnout is at an all-time high, and it is critical as an administrator to keep a pulse on the physician staff and offer opportunities to explore things outside of the physicians' day-to-day clinical responsibilities such as medical mission work and volunteer work."
"Just as important as personal growth opportunities are career advancement opportunities such as clinical or administrative leadership positions. Again, it comes back to knowing your physician staff—the better you know your staff, the better you will be able to find ways for those physicians to challenge themselves."
"Administrators need to provide their physicians with a good work-life balance. It is important to have open conversations with physicians and to take a collaborative approach so that you can develop mechanisms that will help physicians better achieve work-life balance. Tied into work-life balance is encouraging time off. It can help physicians deal with the pressures of their job and allows them to spend more time with family."
"The level of compensation is always going to play a role in your ability to retain physicians. For physicians, many of them are saddled with significant debt, and any effort to boost compensation will help you retain physicians. For those organizations offering career advancement opportunities, that is a great way to offer more compensation for a physician who steps into an administrative or blended administrative-clinical role."
Holding retirement conversations
When administrators initiate retirement conversations with physicians, the best advice is to approach the conversation early in an open and transparent way, then the conversation should be revisited often, says Tara Osseck, a regional vice president of recruiting at Jackson Physician Search.
"Administrators need to give physicians the space and opportunity to talk about their retirement plans in an environment that is not threatening. You do not want the physician to feel the organization is trying to push them out the door. Administrators should provide assurance that the physician is not going to be sidelined and offer the opportunity to work part-time," she says.
Understanding a physician's retirement motivations and plans post-retirement can help an administrator to offer options and, in certain circumstances, convince the physician to keep working in some capacity, Osseck says. "As physicians are eager to discuss and consider options to lighten their workload such as a reduced schedule, reduced patient load, and elimination of call, they also are eager to leave a legacy in some way. For many physicians, that may be in the form of teaching or mentorship, which can be an asset for an organization."
Succession planning
A crucial part of succession planning for retiring physicians is to share knowledge between the retiring physician and the new physician, Falkner says. "A successful physician succession plan includes the developmental processes and systems to facilitate the transfer of knowledge from the retiring physician and the new physician. That can involve creating documentation, sharing standard operating procedures, creating access to patient records, and encouraging communication and collaboration between the retiring physician and the new physician."
There are several other key factors in succession planning, she says:
Goal setting: You need to identify the goals of your succession plan and make a business case for why it is important to your organization.
Research and forecasting: Understanding the recruitment needs when a physician retires can include gathering data on your current physicians such as demographics and specialties. Data can help administrators create a timeline that estimates when physicians are likely to retire.
Due diligence: Administrators should meet with stakeholders and develop job descriptions. Key stakeholders should include not just the retiring physician but also physicians who are remaining.
Mentorship and leadership training: Administrators should provide opportunities for new physicians to ensure a smooth transition. This can involve pairing a new physician with an experienced physician, providing on-the-job training, and offering continuing education opportunities.
Contingency planning: Even the best succession plan can have gaps. Ideally, you want to have a pipeline of candidates who are ready to work, but it is also important to have an established relationship with a locum tenens agency that can help to quickly fill openings in the short-term.
The primary supply chain function is to ensure availability of supplies, equipment, and services at the best available rates, the top supply chain officer at RWJBarnabas Health says.
The key to success in healthcare supply chain management is balancing effectiveness and efficiency, says Bob Taylor, MBA, senior vice president of supply chain for RWJBarnabas Health.
Taylor has been senior vice president of supply chain at the West Orange, New Jersey-based health system since July 2017. His prior experience includes serving as assistant vice president of supply chain at Birmingham, Alabama-based UAB Health System for nearly a decade.
HealthLeaders recently talked with Taylor about a range of issues, including the challenges of serving as the top supply chain officer at RWJBarnabas Health, balancing competing needs that impact supply chain, conducting value analysis, and involving clinicians in supply chain decision-making. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the top supply chain officer at RWJBarnabas Health?
Bob Taylor: RWJBarnabas Health, the largest, most comprehensive academic health system in New Jersey, relies on the vitality of our supply chain to deliver safe and effective care every day. This entails monitoring and managing a multifaceted network of resources across our 12 facilities with a service area covering eight counties with five million people. My charge is to maintain the delicate balance of creating efficiency and effectiveness in our supply chain to meet the many, and sometimes competing, needs within our organization. As our health system transitions to value-based care—and amid ongoing difficulties in the global healthcare supply chain—we are challenged to sustain a function that is optimized for exceptional value while continuing to deliver smoothly on patient outcomes.
HL: How do you balance the competing needs within the health system that impact supply chain?
Taylor: Supply chain sits at the intersection of cost, quality, and outcomes. We have a primary function of ensuring availability of supplies, equipment, and services at the best available rates. This must be balanced with ensuring that those items are of high quality and deliver the outcomes that are expected to improve patient care. If we purchase products that are inexpensive but low quality, they may result in poor patient outcomes, which ultimately will translate to cost elsewhere in the healthcare continuum. We are also in a natural tension with our partners as we are looking to reduce cost of care while most supplier partners are looking to increase revenues. This sometimes necessitates looking at new vendor relationships or making broader commitments to fewer vendors to secure value.
Bob Taylor, MBA, senior vice president of supply chain at RWJBarnabas Health. Photo courtesy of RWJBarnabas Health.
HL: How is the supply chain managed at RWJBarnabas Health?
Taylor: Like most hospital systems, our supply chain is complex and interconnected. We take a highly strategic, data-driven approach to managing our procurement process to ensure best practices and to enhance quality and patient outcomes in the most fiscally responsible way possible.
Our core corporate function includes strategic sourcing and contracting, value analysis, capital equipment procurement, procure to pay, and "final mile" management of delivering goods and services to our clinicians and patients. Using data and analytics solutions not only give us the ability to see the bigger picture, but they also enable us to optimize and increase efficiency, while eliminating waste.
Our function is supported by a team of more than 400 people who are committed to delivering exceptional service and value as well as improving the quality of patient care.
HL: How do you conduct value analysis?
Taylor: We have a robust value analysis function across the system comprised of experienced clinicians. The value analysis team collaborates with the many councils, collaboratives, and physician groups to help select the most clinically appropriate products based on clinical evidence and efficacy. Once products are selected the strategic sourcing and contracting team negotiates the contract details for execution.
HL: Tell me about your group purchasing organization.
Taylor: Our system uses a GPO to purchase most of our commodity goods. In some cases, where it makes sense, we contract directly with suppliers.
HealthTrust Purchasing Group is the GPO. Like all GPOs, HPG contracts with suppliers on behalf of the aggregate GPO membership, and as a member we can access the agreements for our use. As our health system is large, we can also frequently further negotiate more favorable pricing with GPO suppliers.
Now that the crisis phase of the pandemic has passed, what are the primary supply chain challenges at RWJBarnabas Health?
While the pandemic's crisis phase is somewhat over, we are still experiencing enormous disruptions that are putting the supply chain function under risk. As the global shortage on healthcare supplies continues, vendors are working to build resiliency, which can lower risk but result in higher costs.
Our team takes a proactive approach to integrate strategies and best-in-class practices to optimize scarce resources, alleviate shortages, and expand capacity quickly. The ability to increase efficiency and manage costs while making sure our dedicated and skilled medical practitioners have the resources to do their jobs is key for us.
HL: How do you involve clinicians in supply chain decision-making?
Taylor: Our supply chain is highly integrated and involves RWJBarnabas Health clinicians throughout the process. We collaborate with our clinical leaders on an ongoing basis and have created formalized cross-functional and specialty-focused teams across our initiatives. For example, our doctors, nurses, and other clinical team members actively participate in product selection, compliance management, managing use of supplies, and more. Their ability to help us understand the exact resources they need to practice medicine adds tremendous value and efficiency.
HL: What are the primary keys to success in supply chain management?
Taylor: Right now, it is crucial for us to have flexibility and the ability to pivot as things change. This also makes it more important than ever to engage and collaborate with our internal partners across the system.
I think of the supply chain in terms of having two main branches: One is effectiveness, which means doing the right thing. The other is efficiency, which means doing things right. It is crucial to strike a balance between the two.
If we are only efficient, we could end up doing all the wrong things just very efficiently, which does not add value. If we are only effective, we may do all the right things but do them so poorly that we again do not add value. Both efficiency and effectiveness are required and in balance to do the right things the right way.
In quality improvement initiatives, empower frontline leaders to help inform the priorities, chief medical officer says.
The biggest quality improvement initiative at UNC Hospitals has been advancing the journey to high reliability, says Chief Medical Officer and Vice President of Medical Affairs Thomas Ivester, MD, MPH.
Ivester has been chief medical officer and vice president of medical affairs at UNC Hospitals since April 2017. Previously, he served as medical director and physician service leader for obstetrics at UNC Hospitals, based in Chapel Hill, North Carolina.
HealthLeaders recently talked with Ivester about a range of topics, including his top challenges at UNC Hospitals, quality improvement, and patient safety. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of UNC Hospitals?
Thomas Ivester: The general challenges of chief medical officers tend to be that we are often saddled with vast areas of responsibility such as quality and the medical staff. At the same time, we don't always have clear lines of authority, especially since employment relationships can be different and different areas of the organization have different reporting relationships. In addition, we don't often have purview over revenue-generating activities, which can hinder our influence.
At UNC Hospitals, I have a couple of challenges. One is we have grown significantly over the past couple of decades, and our organizational structure particularly on the medical staff side has not necessarily kept up in terms of modernizing. That is a priority for me—getting the medical staff better organized to execute.
At the same time, we have also grown substantially as a system, which means governance over our big priorities is informed and influenced by a lot of other entities that were not a part of us 20 years ago. There are several positives that go along with that, but it also introduces several challenges in terms of governance and decision-making.
HL: How have you risen to the challenge of organizing the medical staff?
Ivester: We have done several things. One of my first activities was to revamp and standardize the job descriptions of each level of medical directorship and physician service leader at the institution. I had to make those job descriptions and their associated responsibilities and lines of accountability clear.
I have also had to engage an effective cascade throughout the medical staff to make sure that organizational priorities are disseminated all the way to the front line and that we are also being informed by what frontline leaders are observing and having a pathway of getting it back up to the senior levels of the organization.
Another key strategy is learning to delegate more effectively, and that is a skill that I am still learning. We need to enable and empower a group of lieutenants to help to execute and lead strategy across the multiple domains that I have to oversee.
HL: How have you risen to the growth of the organization and the challenge of governance?
Ivester: I have been forging relationships with my CMO colleagues across the health system, so that we can connect one-on-one or in small groups. We also convene as a larger group at a monthly roundtable to discuss topics that cut across our organization, to present ideas and to work together to solve challenges.
Thomas Ivester, MD, MPH, chief medical officer and vice president of medical affairs at UNC Hospitals. Photo courtesy of UNC Hospitals.
HL: What are the keys to success in implementing quality improvement initiatives?
Ivester: One of the keys for us has been to focus on a finite number of priorities. That relies upon the principle that we truly believe we can do anything, but we certainly cannot do everything. So, we need to select the right priorities and de-select the priorities that are not right for the moment.
We also work diligently to empower our frontline leaders to help inform the priorities. We try to enable those local leaders to identify and select their local priorities from our broader strategy, so initiatives are much more relevant to the folks that they are overseeing at their local unit, clinic, or area of service.
Finally, the engagement piece is critical. We do that by supporting the work of frontline leaders including our medical directors with project resources. We set clear expectations. We provide the right data at the right time. We make commitments that last longer than the current fiscal year.
HL: Give an example of a quality improvement initiative you have been involved in at UNC Hospitals.
Ivester: Our biggest quality initiative has been the launch of what we call Carolina Quality, which is our multi-year strategy that forms the foundation of our journey to high reliability. This is based on a full commitment to the tenets of just culture, daily huddles, leadership rounds, and safety reporting. This is all supported by a robust data strategy and ongoing optimization of care team and patient experience.
This is the biggest quality initiative in our history, and it is based on things we already do. We just need to do them better and in a more integrated way.
HL: What are the keys to success in implementing patient safety initiatives?
Ivester: In a lot of ways, they are similar to implementing quality initiatives. Oftentimes, our safety initiatives are focused on faster, more agile decision-making and change management. That requires gathering a guiding coalition, with clear accountability and expectations as well setting timelines for execution.
It is also important to continually remind folks of the "why." There must be a compelling reason for doing what we are doing. The "how" becomes infinitely easier if you can get people to understand and buy into the "why."
HL: Give an example of a patient safety initiative you have been involved in at UNC Hospitals.
Ivester: Probably the most important thing for us was implementing our daily safety huddles. We did this a couple of years ago in the middle of the pandemic. This has been a fantastic platform, and we borrowed ideas from many colleagues across the country to develop our system. It starts in the morning with more than 300 Tier 1 safety huddles taking place across the entire medical center. They are escalating issues around operations, quality, and safety to a Tier 2 huddle that involves director-level leaders across the institution. Ultimately, it culminates in our Tier 3 safety huddle that occurs daily at 10 a.m. and involves every member of our executive team hearing every escalation from the preceding 24 hours.
We have demonstrated that we are able to solve between 85% and 90% of escalated issues within the same day, often within just a few hours. Every other issue is resolved within one to two weeks, or it is converted into an improvement project.
Along with the huddles, we have instituted a formal mechanism for managing the array of root cause analyses that are taking place across the institution, so that performance is being monitored and we are executing with far greater fidelity through enhanced accountability.
HL: You have a clinical background in obstetrics and gynecology. How has this clinical background helped you serve in physician leadership roles?
Ivester: Having a clinical background does lend substantial credibility to physician leadership roles. Whether you are a CMO, a quality leader, or serving in another role, to be able to demonstrate that you are still rolling up your sleeves and can work alongside colleagues in a clinical arena can be helpful. The variety of my practice in obstetrics gives me insights into several areas. I work in the inpatient setting. I work in the operating room. I do imaging. So, I have insights into the work of clinical folks across the spectrum of clinical venues.
HL: How would you characterize your leadership style?
Ivester: I tend to be relational. I connect directly with people in smaller, more intimate settings where we have an opportunity to get on the same page as well as understand one another's priorities and concerns. I work to find common ground.
I certainly do not mind at all being on stage and trying to rally the troops. I am a visionary person and work a lot on strategy. I try to coalesce people under a unifying vision, but I make sure that vision is not just mine. It reflects the input of folks across a unit or the institution. I want to strike a balance between inclusiveness and consensus. However, there are times when I need to step in and make an executive decision.
Another piece is I put a lot of thought in trying to connect seemingly disparate priorities or areas of work, then try to find a common ground. It has helped me to bring together folks from across the institution, and it gets back to operating under a unified vision or set of goals.
Ivester is a contributor to the HealthLeaders Exchange. The HealthLeaders Exchange community is a private idea-sharing network for senior executives in hospitals, health plans and physician organizations. To join, please visit theHealthLeaders Exchange LinkedIn page.
Pediatric experts from 15 different specialties and departments collaborate to make teen's fourth liver transplant a success.
A fourth liver transplant for a Montana teenager was an exercise in clinical leadership, care coordination, and team-based care, the surgeon who led the care team says.
Standard liver transplant teams involve several care team members, including care coordinators, nursing staff, surgeons, anesthesiologists, blood bank, and hepatologists. In this case, the care team consisted of pediatric experts from 15 different specialties and departments across Children's Hospital Colorado, including cardiac surgeons and a dialysis team.
Seth was 17 when he had his fourth liver transplant more than a year ago. When he was 2 years old, he was diagnosed with a genetic liver disease known as progressive familial intrahepatic cholestasis. At 8, Seth was diagnosed with a type of liver cancer known as hepatocellular carcinoma, which led to his first liver transplant.
Unfortunately, a complication with his liver and a critical illness compromised the first and second liver transplants. After the third liver transplant, Seth and his family were able to return to a normal life, and he lived for about 8 years without serious complications. But in November 2021, his artery clotted and he developed infected bilomas that were not responsive to medical management or interventional radiology treatment.
It is extremely uncommon to conduct four liver transplants in a patient, Michael Wachs, MD, chief of abdominal transplant surgery at Children's Hospital Colorado, told HealthLeaders. "The reason I thought it was reasonable to do was the first three transplants were conducted close together—they were all part of an initial complication and getting Seth through that. Then he had a period of years when he did well. In my mind, I grouped the first three transplants he had as a young child as his first transplant experience, so the fourth transplant was more like doing a second transplant."
The possibility of complications expanded the care team, he says. "In this case, because it was the fourth transplant, we were concerned about the outflow of the liver, which is only a couple of centimeters from the diaphragm and the heart. We had put a stent in during the previous transplant and that was going to have to come out. Then we were going to have to suture the new liver above where the stent used to be. So, we were going to be very close to the heart and we had to coordinate with the cardiac surgeons and the cardiac bypass team—the team that runs the bypass pump."
Dialysis was also a possibility, Wachs says. "It was pretty clear that if it was a tough operation, we were most likely going to have to do dialysis in the operating room, so we had to bring in a dialysis team, which is a group of nurses that runs the dialysis machine and the nephrologists determine how much dialysis the patient needs."
Logistics were also a challenge, he says. "It was not a live donor transplant—it was going to be a deceased donor transplant—we never knew when it was going to happen. … To have all of our people ready at any given time, we had to have more than one person from each team in on the plan. For example, if the main cardiac surgeon was not on call that day and we had the perfect immunologic organ, we wanted to have a backup cardiac surgeon. So, not only were there more groups involved, there was duplication of effort to make sure there was always going to be somebody available."
Collaboration was one of the keys to success in Seth's fourth liver transplant, Wachs says. "There is always collaboration among the groups that are involved in transplants, but we were communicating with the other teams that are not typically involved in a liver transplant. It is not just asking for their help—you need to ask for their opinions. So, I sat down several times with the cardiac surgeons and the radiologists to try to anticipate what we were going to do first, second, and third, and when we might need the heart surgeons. We talked with them about whether we could get the stent out, and what were the options if we had to go around it. We worked through those various steps and drew them out almost like you draw out a playbook in a football game. That was the primary collaboration—everybody talked about how the operation would go if we ran into particular situations."
Team-based care was pivotal, he says. "A good team functions by having leadership where you find good people to surround yourself with, and you let them brainstorm, you ask them questions, and you let them use their expertise to help you do the best that you can. I do not believe in a top-down approach. The old-fashioned surgery approach is the surgeon being the captain of the ship. That's great when the ship is going down—somebody must be in charge. But most of the time, when you want things to go well, the better approach is to have a level playing field of colleagues, where you put together a team of colleagues that work well together and complement each other. Then you plan out what you are going to do. Everybody gets the credit when it goes well. Everybody shares the blame when it does not go well."
Clinical leadership was also crucial, Wachs says. "My approach to clinical leadership is to lead from behind, which involves putting good people together, giving everyone a chance to speak, then once everyone has been heard, putting things together in a way that makes sense. Collaborative leadership is how we conduct transplant operations."
In survey data, 80% of primary care physicians and 64% of patients reported they would prefer to conduct future visits in-person rather than via telehealth.
Although most primary care physicians and patients were satisfied with telehealth visits during the coronavirus pandemic, majorities of both populations prefer in-person visits in the future, according to a new research article.
Many in-person medical visits were not possible during the early phase of the pandemic, and telehealth visits increased sharply. The future of telehealth visits after the pandemic is unclear.
The new research article, which was published today by Health Affairs, features survey data collected from 337 primary care physicians and 1,417 patients. The physician survey was conducted from Feb. 12 to May 24, 2021. The patient survey was conducted from April 30 to May 11, 2021.
The study includes several key findings:
80% of primary care physicians reported that they would prefer to conduct future patient visits in-person rather than via telehealth
64% of patients reported that they would prefer to conduct future visits in-person rather than via telehealth
60% of physicians reported that the quality of telehealth visits was inferior to in-person visits; 29% reported quality was equivalent
33% of patients reported that the quality of their video visits was inferior to in-person visits; 51% reported quality was equivalent
The most common reason given for lower quality of telehealth visits compared to in-person visits was the lack of a physical examination (92% of physicians and 90% of patients)
90% physicians and patients reported that telehealth visits went well during the pandemic
45% of physicians reported rapport was worse by video than by in-person visits
20% of patients reported rapport was worse by video than by in-person visits
52% of physicians reported very or somewhat frequent difficulties with video or audio quality, 39% of physicians reported they very or somewhat frequently had Internet connectivity difficulties, and 34% of physicians reported the video platform or software did not work well
Regarding their most recent video visit, 23% of patients reported that they had difficulties with video or audio quality, 17% of patients reported they had Internet connectivity difficulties, and 18% of patients reported that the video platform did not work well
Older patients, patients with lower educational attainment, and Asian patients were more likely than other patients to prefer in-person visits over telehealth visits in the future
"We found that telemedicine was widely accepted and appreciated by patients and physicians early in the COVID-19 pandemic; however, majorities of both groups expressed a preference for in-person visits in the future. … More physicians see the quality of care by video as inferior, with concerns about limitations on physical examinations that are mirrored by patients. Investing in tools that enhance the virtual physical may be beneficial both in their own right and in terms of facilitating virtual care when needed," the study's co-authors wrote.
Interpreting the data
The study suggests a diminished role for telehealth in primary care after the pandemic, the study's co-authors wrote. "Few physicians indicated a preference to continue telemedicine as their main modality of care, although many saw a role for a small share of care provided this way, particularly for mental health. In parallel, few patients would choose a video visit if in-person visits were available. … Results suggest that in the long term, telemedicine can play a role in providing access to care during health emergencies, but it will likely play a smaller role in primary care, at least in the immediate future, with a focus on patients who prefer or need this modality and on specific conditions such as behavioral health."
The quality of care in telehealth visits is a concern for primary care physicians, the co-authors wrote. "Most physicians felt that the quality of care provided by video was generally worse than what they could provide in person, even in a pandemic. That said, perception of quality varied across visit types, with behavioral health seen as largely equivalent. Further, the most common concern about quality was the lack of a physical exam. Together this evidence suggests that perception of quality may vary even within categories such as management of chronic conditions, such that visits for which a physician feels a physical exam is important are the least likely to be seen as high quality in the video setting."
Patients were less concerned about quality of care in telehealth visits, the co-authors wrote. "Results may reflect the fact that patients were evaluating only a single visit and thus made a more neutral judgment in the absence of more experience, or perhaps that they did not face cumulative burdens from video care in the way that physicians may have. Consistent with this idea, for patients, quality of care in the video setting was linked to the appeal of virtual care in the future. Because concerns about quality were connected to not having a physical exam, this reinforces the possibility that some kinds of care are better suited to video care even from the patient's perspective and that improvements to home tools such as blood pressure cuffs could improve perceived or actual quality from the patient side and facilitate willingness to seek virtual care when appropriate."
The study found that there could be concerns about a "digital divide," the co-authors wrote. "What we did find is that older respondents, those with less education, and those who were Asian were less likely to want to continue using video visits. This is consistent with concerns about a 'digital divide' in telemedicine use that favors those who are younger, wealthier, and White, both in the COVID-19 pandemic and more broadly."