WellSpan Health has established an extensive tiered huddle system, revamped patient safety reporting system, and culture of safety.
WellSpan Health has made significant gains in patient safety over the past three years.
Patient safety includes medical errors that impact patients and "near misses" that could have reached patients. Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System.
York, Pennsylvania-based WellSpan Health reassessed the health system's approach to patient safety in 2020, says Michael Seim, MD, senior vice president and chief quality officer.
"We looked at our long-term goal to focus on zero harm to patients and zero harm to team members. As part of our annual plan, our board of directors set a goal to make measurable outcome improvements and reduce safety events that reach patients. We started to focus on our methodology. We understand that most errors that reach a patient are because of system and process design flaws. No one goes into healthcare to harm people—it is about poorly designed systems. So, we spent a lot of time building our management structure and training our leaders in the theory of lean management. Then we spent time getting input from our 20,000 team members to develop a lean management system that connected our frontline team members to our CEO every day," he says.
The results have been impressive.
WellSpan Chambersburg Hospital: more than 260 days central line-associated bloodstream infection (CLABSI) free
WellSpan Waynesboro Hospital: last CLABSI was prior to 2012
WellSpan Gettysburg Hospital: more than 250 days CLABSI free and more than 100 days catheter-associated urinary tract infection (CAUTI) free
WellSpan Ephrata Community Hospital: more than 980 days CLABSI free
WellSpan Good Samaritan Hospital: more than 830 days CLABSI free
At WellSpan York Hospital, the Open Heart ICU and Surgical ICU have been both CAUTI free for the past year
Safety event reporting
WellSpan has committed to having an extensive tiered-huddle system, where every team member huddles every morning, Seim says. "Every team member is engaged in some type of huddle, where any safety event, harm event, or near miss gets elevated upto our CEO. We trained all 20,000 team members in patient safety and in recognizing risk or harm to patients. We trained all team members in problem solving and root-cause problem solving. The concept is that everyone owns patient safety in our health system."
The frontline huddles are connected to the entire management team, he says. "The second tier of huddles is managers and directors, who elevate concerns from the frontline team members. Then our regional vice presidents huddle; and, ultimately, the vice presidents' huddle reports to our CEO huddle. Every day, we connect any safety concern that a frontline team member identifies all the way up to our CEO."
The health system also has a revamped formal reporting system for patient safety, Seim says. "We rebranded our patient safety process to remove any punitive characteristics for team members—we wanted them to feel psychological safety. We rebranded to putting safety first and called the reporting system "Safety First." We are striving to get the number of events that our team members identify to increase in our Safety First system. We wanted them to not only report errors but also proactively report areas where someone could be potentially harmed."
In 2020, there were 20,000 safety events reported. Over the past year, 42,000 Safety First events have been reported, he says.
Team members can also find out what has happened after they report a safety issue, Seim says. "We created an opportunity for team members to request feedback on how we resolved an issue. A lot of times, team members had felt it was not worth putting in a report because it just went into a black box and disappeared. In the new process, team members can request follow-up from the manager of a unit to find out what we have done to prevent an error from reaching a patient."
Promoting a culture of safety
WellSpan has promoted a culture of safety, with active involvement of the leadership team, Seim says. "Our board sets our annual plan goals, including zero harm to patients and zero harm to team members. We use the lean methodology of sharing data openly. Every two weeks, we have a leadership review of our annual plan goals, which includes patient harm. We have a weekly call every Monday with every manager in the organization where we share information about safety."
The health system has created a culture where patient safety catches are celebrated, he says. "We have what we call a Heads Up, Speak Up Award, where we recognize team members who stop the line for a potential harm event before it reaches a patient. We have had national recalls for products when our team members have stopped the line because there was a safety issue. One was with a fall mat that was slippery when wet. We celebrate the best catches of the year during our annual quality forum. We talk about quality and safety, and we celebrate opportunities to improve patient safety and quality."
The experience of two healthcare worker well-being programs implemented during the coronavirus pandemic generates recommendations.
The architects of two healthcare worker well-being programs launched at the beginning of the coronavirus pandemic share lessons learned in a new journal article.
Healthcare workers nationwide were already showing signs of distress and burnout before the pandemic. Earlier research showed that physicians experiencing at least one burnout symptom rose from 38.2% in 2020 to 62.8% in 2021.
The new journal article, which was published by JAMA Psychiatry, focuses on well-being programs launched by Columbia University Irving Medical Center (CopeColumbia) and the University of California-San Francisco (UCSF Cope).
CopeColumbia and UCSF Cope shared several characteristics such as being led by departments of psychiatry. CopeColumbia featured a model of peer support and education. UCSF Cope provided triage, assessment, and treatment services to all workers at the health system.
The new journal article offers nine lessons learned from the well-being programs.
1. Prepare for a future crisis: Healthcare organizations should prepare now for future crises, the journal article's co-authors wrote. "In addition to building a robust well-being program, healthcare systems must incorporate explicit plans for supporting mental health into future disaster preparedness. These plans require investment in a mental health workforce that has capacity and flexibility to respond during disasters."
2. Embrace structural change: Healthcare organizations should enact structural changes to boost well-being, the journal article's co-authors wrote. "Workplace well-being is largely dependent on structural factors. After the initial shock of managing the fear and uncertainty of a novel deadly virus, we found that sessions emphasizing individual well-being and coping strategies without adequately addressing (or at least acknowledging) structural barriers to wellness evoked negative responses. For example, the impact of lack of childcare resources clearly impacted healthcare worker experience of burnout during the pandemic."
3. Promote compassionate leadership: Healthcare organizations need compassionate leadership to achieve positive cultural change, the journal article's co-authors wrote. "The central role of leadership in creating a sense of safety and shared purpose was repeatedly highlighted—not only at the top but across all layers of administration. … We believe that leaders should obtain training in compassionate leadership following the principles of trauma-informed care: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and attention to culture, historical, and gender issues. We believe that leaders should be evaluated by their ability to prioritize well-being and mental health, in addition to productivity."
4. Deploy dedicated resources: Healthcare organizations need to have dedicated resources to address healthcare worker well-being such as financial and personnel resources, the journal article's co-authors wrote. "Both systems in the initial phase of the crisis mobilized clinicians eager to volunteer time to support their colleagues to rapidly create these programs. However, as our medical centers reopened, it became clear that meeting the varied needs of workers across complex health systems requires ongoing investment from the larger institution, rather than relying on individual volunteers or departmental resources."
5. Address equity and justice: Healthcare organizations need to address equity and justice to boost healthcare worker well-being, the journal article's co-authors wrote. "The disproportionate toll of the COVID-19 pandemic on historically racialized and economically marginalized populations is well documented. Clinicians caring for these populations are faced with the consequences of societal inequities that limit their ability to care optimally for patients and contribute significantly to moral injury. Within the healthcare workforce, the stresses of the pandemic were also unequally experienced. For example, productivity declined among women compared with men in academia."
6. Importance of psychiatry leadership: Well-being program leadership teams should include psychiatry professionals, the journal article's co-authors wrote. "We strongly believe that psychiatry should hold a formal role within any system-wide well-being effort in healthcare. Because well-being exists along a spectrum, our programs benefited from psychiatry leadership who could facilitate consideration of the range of mental health issues that often co-occur with significant work stressors and burnout, integrate evidence-based therapeutic approaches into well-being efforts, and facilitate access to clinical care."
7. Partnerships are pivotal: Well-being programs should be built on partnerships and trust, the journal article's co-authors wrote. "Human resources groups were key partners in both institutions and must be engaged early in any crisis response. Collaboration between departments and units, such as Faculty Affairs, the Office of Work Life, employee assistance programs, as well as between academic and hospital programs that have historically functioned in silos, were critical to our successful efforts to support well-being, build trust, and overcome stigma."
8. Craft worker-focused opportunities: In addition to individual treatment, well-being programs should offer a range of resources for self-help and stress management, the journal article's co-authors wrote. "To increase employee access to mental health services in ways that provide reassurance about confidentiality, institutions should consider contracting with insurance providers with robust mental health coverage and/or partnering with companies that have remote telemental health and facilitate care for employees and their family members to be delivered both within and outside the medical center."
9. Address mental health stigma: Healthcare organizations should strive to reduce the stigma associated with mental health support and treatment, the journal article's co-authors wrote. "Many interventions intentionally focus on burnout—rather than mental health—to avoid the stigma associated with mental illness. … We recommend that institutions launch mental health destigmatization campaigns to encourage all staff to seek treatment when needed, connected with scalable low-resource interventions. Hospital privilege processes should not include any questions regarding mental illnesses or treatment, but rather focus on current ability to perform occupational duties."
AdventHealth expects Central Florida population growth of about 6% over the next four to five years, with a related increase in demand for healthcare services.
Meeting the challenge of population growth in Central Florida is the top priority of the new chief clinical officer of the AdventHealth Central Florida Division South Region.
In March, Victor Herrera, MD, became chief clinical officer and senior vice president for AdventHealth Central Florida Division South Region, which features 10 hospitals. His prior positions at AdventHealth include serving as chief medical officer and vice president of AdventHealth Orlando, the flagship hospital of the Altamonte Springs, Florida-based health system. He also served as medical director of continuing education at the health system.
HealthLeaders recently talked with Herrera about a range of issues, including medical education, quality improvement initiatives, and change management. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What is your top priority in serving as chief clinical officer of AdventHealth Central Florida Division South Region?
Victor Herrera: The population in Central Florida is growing. In the next four to five years, we anticipate that we will have about 6% population growth. We estimate that will be 150,000 to 200,000 new people in this area. I see getting ready for this population growth as our top priority. From a healthcare perspective, we expect an increase in demand for healthcare services.
The population growth will bring pressure in terms of building our access points, creating an infrastructure that meets the needs of that growth, and thinking about our workforce. Coming out of the coronavirus pandemic, there have been constraints related to workforce, and we are in the process of thinking through our pipeline for providers. We need to not only hire more people but also change the way people work, so we can take care of more patients without increasing the burden on care teams in a way that is unsustainable.
HL: How do you plan to rise to the challenge of making sure you have the workforce to serve this growing population?
Herrera: We will have to pursue innovation in how we deliver care. We anticipate that we are going to do more things outside of the hospitals. We are going to see more care at home. When it comes to the care model, it is going to look very different five years from now. We are going to redefine hospital care—it is the only way that we can match the demand for services.
Obviously, technology is going to have to be one of the tools that we are going to have to leverage as part of this transformation. There is the potential to use artificial intelligence and machine learning. We need to remove the burden that is associated with tasks that are tedious and take a lot of time for our workforce. We can probably automate many of these tasks, which will free up time for frontline healthcare workers to deliver care. It can also improve satisfaction in the workforce.
Currently, nurses spend up to 40% of their time documenting and doing tasks that we believe we can automate. So, it's not just about adding more people. It is about changing the work of the people we have already, so they have the capacity to see more patients.
Victor Herrera, MD, chief clinical officer and senior vice president for AdventHealth Central Florida Division South Region. Photo courtesy of AdventHealth.
HL: You have experience in medical education. What are the primary qualities of a good medical educator?
Herrera: We have a large medical education footprint in our health system, and we continue to grow it. We are training the next generation of physicians, and our goal is that most of those physicians will stay with us. When it comes to the key qualities of a good medical educator, things have changed a lot. If I go back to when I was a medical student, most of the knowledge that I was acquiring came from attending physicians and faculty. I would ask them questions, and that is how I learned.
The world has changed. There is so much information now that we need to know and be able to find. We cannot just rely on individual educators to pass along that knowledge. We need to teach our trainees how to use the tools that exist, so they can go on their own and find information. In 2023, a good medical educator understands what information tools exist and focuses their training of students and residents on how to use those tools to find information. In addition, a good medical educator teaches clinical judgment, which continues to be a core area.
HL: What are the primary elements of advancing population health?
Herrera: We need to leverage artificial intelligence and machine learning to characterize the populations that we serve. We need to have access to data and focus on the outcomes we are trying to influence. We need to focus on the predictors of outcomes. Artificial intelligence and machine learning will give us the ability to process data and find signals that were not obvious to us in the past. This will take us to a new level of delivering on the promise of population health. This is a big opportunity—how we can leverage technology to understand data to have predictive value for our patients.
HL: What are the keys to success in quality improvement initiatives?
Herrera: When we talk about quality improvement, we need to go beyond a particular care team and saying their quality needs to be better. As leaders, we need to get to the root cause of why we are getting the results that we are getting. Sometimes, we fail to think that way. If we are not getting the results we are hoping for, there is a reason for that. There are drivers or incentives that prevent you from achieving what you want to achieve.
The root causes are often not obvious, and sometimes we jump into quality improvement initiatives without understanding those drivers. Understanding root causes is the key to quality improvement.
HL: What are the keys to success in change management?
Herrera: It is similar to quality improvement. You need to understand the drivers of what you want to change. In addition, you need to have good communication with everyone who is involved. You need to get to the front line and determine why we are doing what we are doing. So, you need to find root causes and establish communication all the way to the front lines.
HL: What is your approach to team leadership?
Herrera: You need to create psychological safety among your team members. You need to create an environment where people feel comfortable telling you what they think. In healthcare, we take care of patients, and taking care of patients comes with a high bar in terms of expectations. We are always trying to achieve excellence in everything that we do. At the same time, we need to create an environment where people feel it is OK to fail. If we are not getting the results that we need right away, my leadership style is to say that is OK; otherwise, you will stop innovating. If you are going to innovate, you need to feel comfortable with the idea that innovations may not work the first time.
My leadership style is to push my team to think outside the box, to try new things, and to innovate. You are not going to get your team to innovate if you do not create psychological safety.
The increase in physician turnover was greatest from 2010 to 2014, rising from 5.3% to 7.2%.
The annual physician turnover rate increased significantly between 2010 and 2018, according to a recently published journal article.
Physician turnover was defined as physicians moving to a new practice or leaving the practice of medicine. Physician turnover has several negative consequences, including the cost of replacing physicians who leave a practice, interruption of continuity of care, and reducing access to care such as for rural patients.
The recent journal article, which was published by Annals of Internal Medicine, is based on a new method of gauging physician turnover through Medicare billing records. The analysis compared turnover rates by physician, practice, and patient characteristics.
The journal article features several key data points.
The annual physician turnover rate rose from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and rose to 7.6% in 2018
From 2010 to 2014, most of the increased turnover rate was due to physicians who stopped practicing, with an increase from 1.6% to 3.1%
Younger physicians were more likely to move to a new practice, with 5.6% of physicians between 35 years old and 44 years old moving in a given year, and 2.6% of physicians 65 years old or older moving in a given year
Older physicians were significantly more likely to leave practice, with 9.8% of physicians 65 years old or older leaving practice compared to 1.4% of physicians 35 to 44 years old leaving practice
Physicians in rural areas were more likely to move than physicians in urban areas (5.1% vs. 3.9%) and more likely to leave practice (3.3% vs. 2.7%)
Female physicians were more likely to move and leave practice than male physicians
Compared to physicians in larger practices, physicians in solo or 2-physician practices were less likely to move or leave practice
Physicians seeing a higher proportion of dual-eligible (Medicare and Medicaid) patients were more likely to move (top vs. bottom quartile: 4.2% vs. 3.9%) and more likely to leave practice (top vs. bottom quartile: 3.5% vs. 2.9%)
Among specialties, hospitalists had the highest annual moving rate (5.4%), followed by surgical specialists (4.5%) and primary care physicians (4.0%)
Among specialties, obstetrician-gynecologists had the lowest annual moving rate (3.5%)
Among specialties, hospitalists had the highest annual rate of leaving practice (3.6%), followed by primary care physicians, obstetrics-gynecology, and hospital-based physicians (ranging from 3.1% to 3.2%)
Among specialties, medical specialists (2.0%) and surgical specialists (2.4%) had the lowest annual rates of leaving practice
The increase in turnover rates between 2010 and 2018 is significant, and it poses challenges for healthcare providers and patients, study co-author Lawrence Casalino, MD, PhD, emeritus professor of public health, Department of Population Health Studies, Weill Cornell Medical College, told HealthLeaders.
"You have to look at the percentage change and the absolute numbers. The change in the absolute numbers—5.3% to 7.6%—does not seem that large, but it is still one out of 13 physicians leaving medicine or moving to another practice. That is fairly high, and it is close to the other studies that have looked at physician turnover. It is expensive for a practice or a health system if a physician leaves. When they have to look for a new physician, there are several costs involved. It is also bad for patient care, particularly for patients who have had a physician for a long time," he said.
Interpreting the data
The finding that physician turnover is higher in rural areas than urban areas is concerning, Casalino said. "Rural areas are already short on physicians in primary care and specialties. In addition, people in rural areas are usually poorer and sicker than people in urban areas."
The finding the physicians with higher proportions of dual-eligible patients have relatively high turnover rates is also concerning, he said. "To the extent that dual-eligible and poorer patients are sicker, they need their doctors even more."
Financial and clinical pressures likely contribute to the physician turnover rates of physicians with higher proportions of dual-eligible patients, Casalino said. "It's common knowledge that practices that have high percentages of dual-eligible or otherwise poor patients have lower revenue than other practices. So, they take in less money, but to provide good care for poorer and sicker patients, it takes more time and money for physicians to provide that care. There is more financial and clinical pressure on physicians in practices that have a high poor patient mix."
Multiple factors likely explain why physician turnover is higher for women than men, he said. "On average, female physicians are younger than male physicians, and younger physicians are more likely to move to another practice. Women also are involved in more care of children and elderly parents, and they may not be as tied to a particular practice as men. They may have to leave because they cannot make their schedule of caring for other people work with their practice, and they have to go somewhere else that has the schedule they need."
The COVID-19 pandemic exposed several weaknesses in public health emergency preparedness such as insufficient centralized coordination at the federal level.
The frequency of pandemics on the scale of the COVID-19 pandemic is likely to increase and preparedness planning needs to improve, according to a position paper from the American College of Physicians (ACP).
The COVID-19 pandemic exposed several weaknesses in public health emergency preparedness, the position paper says. At the federal level, those weaknesses included insufficient centralized coordination, inadequately defined responsibilities, and an under-resourced national stockpile of supplies such as personal protective equipment. Other weaknesses included the failure to have a widespread testing and tracing system to contain the outbreak.
The ACP position paper, which was published today in Annals of Internal Medicine, makes 13 recommendations to improve public health emergency preparedness.
1. The federal government should have a comprehensive pandemic preparedness and response plan that is evidence-based and includes input from qualified professionals. Congress should provide adequate funding for pandemic preparedness.
2. Health equity should be a top priority for policy makers and public health officials in pandemic planning to diminish health disparities.
3. Federal and state agencies should have consistent and timely communication about risk and evidence-based strategies to address a pandemic as recommended in the ACP's earlier position paper, "Modernizing the United States' Public Health Infrastructure." Physicians have a key role to play in communicating evidence-based prevention and treatment strategies, and they should contribute to pandemic communications at the federal, state, tribal, and local levels. Efforts must be made to dispel misinformation and to boost trust in the healthcare system.
4. There should be a congressionally funded national public health data infrastructure that can support real-time data sharing between public and private public health stakeholders.
5. Efforts should be undertaken to secure and improve the healthcare supply chain. There should be funding to have sufficient personal protective equipment and other essential supplies in the Strategic National Stockpile.
6. Public policy should promote first-responder capacity and training as well as surge capacity at healthcare facilities. Education and training is needed to bolster the healthcare workforce, including physicians, nurses, and public health practitioners. Federal, state, and private agencies involved in licensing or work visas should be prepared to use volunteer physicians and other healthcare workers to meet labor demand during public health emergencies.
7. There should be a reserve of healthcare workers including physicians and public health professionals in healthcare settings to counsel, diagnose, treat, and monitor patients during a public health emergency.
8. Safety and well-being should be promoted during public health emergencies. Government agencies and medical institutions should partner to craft emergency preparedness plans that foster patient health, safety, and welfare. Government agencies and medical institutions should protect the safety and well-being of healthcare workers during a public health emergency.
9. Public and private payers should provide financial support to healthcare providers during public health emergencies, particularly in underserved communities. This financial support is essential because of increased costs and decreased revenues during pandemics.
10. Efforts should be made to decrease infection in workplaces, especially for essential workers. There should be federal mandates for workplace protections for essential workers during public health emergencies.
11. There should be universal access to sick leave with paid time off to allow workers to address personal or family illnesses, injury, or other medical conditions.
12. There should be public-private partnerships to speed vaccine development and distribution during a pandemic. Clinical trials should include all populations such as racial minorities and children.
13. Vaccines should be used based on recommendations from the Centers for Disease Control and Prevention as well as the agency's Advisory Committee on Immunization Practices. Vaccines should be distributed equitably, with priority place on high-risk people such as healthcare workers. Physicians should promote vaccination among their patients.
There is an urgent need to improve pandemic preparedness, the co-authors of the ACP position paper wrote. "As our global society continues to be ever more interconnected, and climate change is worsening, evidence suggests that more frequent and severe pandemics are on the horizon. Now is the time to take action and make preparations before the next pandemic happens. Policymakers must learn from the experience of the U.S. with COVID-19—both the good and the bad—and draw from it to inform a robust, comprehensive, and unified national pandemic preparedness plan."
Although men account for the majority of physicians, the proportion of female physicians in the workforce increased from 30% in 2010 to 37% in 2022.
The U.S. physician workforce increased 23% from 2010 to 2022, according to a census conducted by the Federation of State Medical Boards (FSMB).
The census, which was published this week by the Journal of Medical Regulation, is the seventh biennial census conducted by the FSMB. The census features data on physician workforce trends, including the number of licensed physicians, medical degree type, specialty certification, sex, and age.
Census data was drawn from the FSMB's Physician Data Center. The census covers physicians with full unrestricted licenses to practice in the 50 states and the District of Columbia in 2022.
The census includes several key data points.
The number of physicians has increased from 850,085 physicians in 2010 to 1,044,734 physicians in 2022. The physician-to-population ratio has increased from 277 physicians per 100,000 people in 2010 to 313 physicians per 100,000 people in 2022.
Most physicians (89%) have a Doctor of Medicine (MD) degree, with 11% of physicians having a Doctor of Osteopathic Medicine (DO) degree. From 2010 to 2022, the number of physicians with a DO degree increased 89%, compared to an 18% increase in the number of physicians with an MD degree.
Physicians holding specialty certifications has increased, with 77% of physicians board-certified in 2010 and 85% of physicians board-certified in 2022.
In 2022, physicians had graduated from 2,200 medical schools in 169 countries. Most physicians (77%) graduated from U.S. or Canadian medical schools. The largest percentage of international medical graduates attended medical schools in India (21%).
Although men account for the majority of physicians, the proportion of female physicians in the workforce increased from 30% in 2010 to 37% in 2022.
The mean age of physicians has increased from 50.7 years old in 2010 to 51.9 years old in 2022. From 2010 to 2022, there was a 54% increase in the number of physicians aged 60 years and older.
In 2022, female physicians were younger than male physicians: 31% of female physicians were under 40 compared to 20% of male physicians, and 19% of female physicians were 60 or older compared to 38% of male physicians.
Interpreting the data
The new census report shows significant changes in the physician workforce, Humayun Chaudhry, DO, president and CEO of the FSMB, said in a prepared statement. "The data in the 2022 census illustrates how dramatically the physician population has grown and diversified since 2010. The FSMB census continues to be an important tool in helping medical regulators and healthcare policymakers stay informed of physician workforce trends as they consider ways to encourage public safety and physician wellness."
The census and demographic data highlight concerning trends, the co-authors of the Journal of Medical Regulation article wrote. "The nation's healthcare system faced several hurdles during the COVID-19 pandemic and prolonged challenges remain as aging in the general and physician populations create increased demand for healthcare resources and amplify workforce supply concerns."
However, the journal article's co-authors identified several "reasons to be cautiously optimistic."
The country is at the forefront of advances in medical technology and more students are enrolling in medical schools.
During the coronavirus pandemic, many physicians and other clinicians showed resilience and an ability to adapt to changing circumstances.
Also during the pandemic, medical licensing boards demonstrated the ability to respond to a crisis such as through expedited licensure.
The expansion of telehealth since the beginning of the pandemic has boosted access to healthcare services.
The U.S. healthcare system will have to rise to daunting challenges in the years ahead, the co-authors of the journal article wrote. "As the nation progresses through the demographic and digital transformations ahead, striking a balance between meeting the healthcare needs of an aging population and the wellness concerns of an often-overworked physician will be difficult but essential."
Clarity is crucial to the success of medical groups, the chief medical officer of Monument Health says.
Physician groups should have a clear definition of who they are, says Brad Archer, MD, chief medical officer of Rapid City, South Dakota-based Monument Health.
Archer has been CMO of Monument Health since September 2017. Prior to joining Monument Health, he was chief clinical officer at University of Iowa Health Alliance. His prior experience includes serving as executive medical director of MercyCare Community Physicians.
HealthLeaders recently talked with Archer about a range of topics, including the challenges of serving as CMO of Monument Health, physician group leadership, and value-based care. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Monument Health?
Brad Archer: Initially, going back about six years ago when I got here, the biggest challenge was the lack of structure, which led to a lack of engagement from the physician staff. So, we have focused on building our culture starting with building a consistent structure that sought to generate physician input on a regular basis as opposed to an ad hoc basis. We worked on the leadership infrastructure.
We have also created an atmosphere of psychological safety and transparency in terms of error reporting and process improvement.
Our geography is a challenge. We have a large region to cover without any other population centers nearby. There are no other hospitals or health systems to share some of the responsibility that comes with our geography. Our healthcare partners are in places such as Sioux Falls, Billings Clinic, and Denver, which are quite distant from us, so one of our challenges is providing the latest and best care for our patients given that we have distant healthcare partners.
Another challenge we face is that we have a disproportionate government payer mix. So, in addition to the large geography, we have some issues with affordability.
HL: Do you have a high percentage of Medicare and Medicaid patients?
Archer: Yes, and we have a high percentage of government payers in general. For us, that also includes the Indian Health Service, which is a significant component of our tertiary referral base. For the tribes, we are their tertiary facility. Like all government payers, IHS is paying us below our costs to provide services.
HL: How are you rising to the challenge of having government payers that do not cover the totality of your costs?
Archer: It is a challenge, and it got worse with COVID with the increase in supply chain costs and the increase in labor costs. We are having to be careful as we look at our expansion into different service lines. So far, the payer mix has not kept us from launching new service lines, but it is a consideration. Like a lot of places, we are becoming leaner in terms of our efficiency. As we maintain and improve quality, we are looking to do so in a way that is most efficient and financially feasible.
We are getting better with our revenue cycle—connecting our clinical teams to our revenue cycle and finance teams to achieve the best possible financial outcome for patients. We do not want to burden patients with unnecessary medical bills or expenses because we did not get prior authorization or because we did not document in a way that resulted in a reimbursement denial.
Brad Archer, MD, chief medical officer of Monument Health. Photo courtesy of Monument Health.
HL: Your previous experience includes serving as executive medical director of MercyCare Community Physicians. What are the keys to success in physician group leadership?
Archer: You need a clear definition of who you are as a physician group and how you do things. You need to put these definitions in writing. I tell young physicians who are considering joining a physician group to make sure the organization has a clear mission, a committed leadership structure, and an operational structure that reflects the organization's values and leadership structure. Clarity is crucial to a successful medical group.
The CMO of a successful medical group needs to function like an air traffic controller. You need to navigate people to get things done and stick to it.
HL: What are the primary elements of physician engagement?
Archer: It goes back to structure. You need to create a structure that is consistent and has physicians involved on a regular basis. I always say the worst thing you can do with physicians is to try to not bother them much then have ad hoc meetings where you ask their opinion. Under those circumstances, physicians will often feel that they do not get follow-up. The consistency of the governance structure and the inclusion of all the operational decisions within the organization on the physicians' agenda are essential. You do not want to make assumptions or bypass the physician leadership.
There are different ways to conduct physician engagement. At Monument Health, we are fully integrated with our non-physician leadership in a way that provides open dialogue for our decisions with physicians.
HL: What role do physicians play in administrative leadership at Monument Health?
Archer: When I got here, there was a separate physician group and seeking input was primarily on an ad hoc basis. We dissolved that group and chose a fully integrated model. So, we have medical directors at every level of service in a market-based operational structure.
We have the system-level operations structure, then each market has their own unique operational structure. Within those markets, there are physicians who are paired at the director level and the vice president level in every department. So, we have department-specific medical directors who are paired with their department directors, and we have executive medical directors who are paired with the operational vice presidents. These leaders are engaged in all of the decision-making.
HL: You have a large rural population. What are the keys to success in providing value-based care in this kind of an environment?
Archer: With value-based care, you need to change information systems and the workflows to more of a proactive management, where we are focusing on our panel of patients that we are responsible for and trying to predict their needs ahead of time. We need to make sure patients are getting preventative care and not be reactive. In our case, this is particularly challenging because tertiary care is a big part of our value in the region, and it is largely reactive and emergent care. We must do tertiary care well while we shift our focus to managing populations and focusing on population health. Traditionally, our data systems have not supported that type of management as readily as we would like them to.
Things are getting better now. Claims information that we can get from the Centers for Medicare & Medicaid Services and other payers that are promoting value-based contracts is certainly helpful. But we must alter our workflows, particularly in our primary care clinics, in order to accommodate a value-based approach to care.
One of the keys to success is contractual, where you seek to appropriately document and code your patients' conditions. That is a separate component of success that is not inherently part of a general medical education or of a medical practice necessarily.
Another factor is having the appropriate access, which is a challenge for us and many other health systems across the country. Primary care access is not always easy, and in rural areas such as ours it can be even more challenging. In particular, when you are trying to do outreach and to get people to come in, we have some distance to cover to bring people in to see their providers. So, transportation becomes a challenge for us.
HL: What are the primary elements of patient safety at Monument Health?
Archer: First and foremost, it is about promoting a just culture and getting our errors reported, including near misses. These are opportunities for us to learn and improve our processes.
To support a just culture, we have a good quality assurance structure in place. We have the correct technology and data tools to provide opportunities for improvement. We also have promoted the lean methodology.
About 371,000 Americans die annually after a false negative diagnosis for a serious illness, according to researchers.
False negative diagnoses are likely the largest source of death linked to medical errors in the United States, a new research article found.
The U.S. National Academy of Medicine says improving diagnosis is a "moral, professional, and public health imperative." In a 2015 report, the National Academy of Medicine estimated that most Americans have at least one diagnostic error in their lifetime that can lead to "devastating consequences."
The new research article, which was published by BMJ Quality & Safety, extrapolates total false negative diagnoses that result in death or permanent disability from "The Big Three" disease categories for misdiagnosis with serious harm: vascular events, infections, and cancers. The researchers focused on 15 diseases in The Big Three categories: stroke, venous thromboembolism, arterial thromboembolism, aortic aneurysm/dissection, myocardial infarction, sepsis, pneumonia, meningitis/encephalitis, spinal abscess, endocarditis, lung cancer, breast cancer, colorectal cancer, melanoma, and prostate cancer.
The study features several key findings:
About 795,000 Americans suffer death or permanent disability after a false negative diagnosis for a serious illness at an ambulatory clinic, emergency department, or inpatient setting, with 371,000 deaths and 424,000 permanent disabilities
The 15 serious diseases that were the focal point of the study account for 50.7% of deaths and permanent disabilities linked to false negative diagnoses
Five of the 15 diseases that were the focal point of the study account for 38.7% of deaths and permanent disabilities linked to false negative diagnoses: stroke, sepsis, pneumonia, venous thromboembolism, and lung cancer
The overall average diagnosis error rate was estimated at 11.1%
The disease with the highest rate of death and permanent disability linked to false negative diagnosis was stroke, which was missed in 17.5% of cases
Interpreting the data
The study is the first rigorous national estimate of death and permanent disability linked to diagnostic errors, David Newman-Toker, MD, PhD, lead investigator of the research and director of the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence said in a prepared statement.
"Prior work has generally focused on errors occurring in a specific clinical setting, such as primary care, the emergency department, or hospital-based care. These studies could not address the total serious harms across multiple care settings, the previous estimates of which varied widely from 40,000 to 4 million per year. The methods used in our study are notable because they leverage disease-specific error and harm rates to estimate an overall total," he said.
Efforts to improve diagnosis should focus on diseases accounting for the greatest number of serious misdiagnosis-related harms and with high diagnostic error rates, Newman-Toker said. "A disease-focused approach to diagnostic error prevention and mitigation has the potential to significantly reduce these harms. Reducing diagnostic errors by 50% for stroke, sepsis, pneumonia, pulmonary embolism, and lung cancer could cut permanent disabilities and deaths by 150,000 per year."
There is an urgent need for more research designed to examine diagnostic errors and point to possible solutions, he said. "Funding for these efforts remains a barrier. Diagnostic errors are, by a wide margin, the most under resourced public health crisis we face, yet research funding only recently reached the $20 million per year mark. If we are to achieve diagnostic excellence and the goal of zero preventable harm from diagnostic error, we must continue to invest in efforts to achieve success."
The researchers found conservative estimates of serious harm from diagnostic errors compelling, the study's co-authors wrote. "Even with the most conservative assumptions about disease incidence or disease-specific harms, we estimated the number affected [patients] to be over 500,000. The number of affected patients is large, and this makes diagnostic error a pressing public health concern."
Diagnostic errors could be the most deadly medical errors in U.S. healthcare, the co-authors wrote. "Our results suggest that diagnostic error is probably the single largest source of deaths across all care settings (~371,000) linked to medical error."
A joint steering committee will identify projects and track the progress of projects.
Riverside Health System and UVA Health have formed a strategic alliance to generate benefits in complex care, medical education, care coordination, and clinical research, the Virginia-based health systems announced last week.
The top executives at the health systems say the organizations are joining forces from positions of mutual strength, including strong financial standing. The agreement provides UVA Health with a 5% ownership stake of Riverside.
"The question that often comes up is, how is an alliance like this superior to a straight up merger? This alliance allows us to focus on our communities and our unique missions in a way that gives strength to both health systems, but that does not require a merger. We feel it is the best of both worlds—we gain the strengths of each institution while allowing us to focus on the needs of our local populations," says Michael Dacey, MD, Riverside's president and CEO.
The overall goal of the alliance is to improve the quality of care for nearly 2 million people in Eastern Virginia, he says. "The types of resources that are being committed fall into a number of categories. Certainly, there are some financial resources, but it's not about the money because both health systems are doing well financially. It is more about the expertise and the coordination of care."
A primary goal of the alliance is to keep complex care local, says K. Craig Kent, MD, CEO of UVA Health and executive vice president for health affairs at University of Virginia. "We believe all care should be delivered locally. With this alliance, 95% of care should be able to be provided locally. There will be rare instances when someone has to leave Eastern Virginia for something incredibly complex, but the idea is to partner with Riverside to provide as much complex care locally as possible. That is one of the underlying concepts of the alliance."
An example of collaboration on complex care and care coordination in the alliance is transplant medicine, Dacey says. "Riverside is not going to do organ transplantation, but UVA Health is one of the best transplant centers in the world. If we can help coordinate patient care and get patients into the transplant process earlier, that will help save lives, and all of the pre- and post-transplant care can be done locally."
As part of the alliance, UVA Health will have a transplant coordinator for Eastern Virginia, Kent says.
"In terms of solid organ transplantation, 90% of the work involved for patients is the pre-operative evaluation and the post-operative care. All of that can be performed extraordinarily well in Eastern Virginia by Riverside. The other 10% of the care can be provided by UVA Health. Patients that need transplantation are complex patients and care coordination is critically important. Part of our alliance is making sure that we have our teams working together closely, so patients can be cared for in the best possible way," he says.
Boosting clinical research is an important element of the alliance, Dacey says. "One of the things that we both have a joint interest in is research, particularly clinical trials. Riverside has a large number of patients. We have about 1.2 million ambulatory visits annually. A lot of those people would benefit from access to clinical trials, and the opportunity to work with UVA Health on clinical trials is one of the things we were attracted to."
Medical education is another key component of the alliance, Dacey says. "At Riverside right now, we have our own residencies in family medicine, emergency medicine, and obstetrics. We hope to grow both the number of residencies such as adding internal medicine next year and the opportunities for the residents to work with the resources at UVA Health, whether it be developing research projects or sharing faculty back and forth. We hope to grow those areas of medical education, particularly at the residency level."
Bolstering residencies is part of Riverside's strategy to address physician workforce shortages, he says. "There is a huge shortage of doctors coming, probably a shortage of 80,000 to 100,000 doctors nationally in the next 10 years. The problem is not necessarily medical schools, it is the ability to train at the post-graduate level. By growing residencies above what we have right now, we hope to help address that problem. Where a resident trains is the most important determining factor for where they end up practicing medicine. So, we feel growing residencies in Virginia will help with the physician workforce in Virginia, and UVA Health can clearly assist us in that effort."
Riverside and UVA Health are ideal partners, Dacey says. "We both share the same mission and values, which is to do what is best for our patients. We are both committed to providing the right care, at the right place, at the right time. So, it was a cultural fit. In addition, our medical staffs already collaborate in several areas in terms of specialty referrals back-and-forth. So, we already had pre-existing clinical relationships. Plus, there is the world-class reputation of UVA Health combined with the substantial patient base of Riverside, which was an additional attraction from Riverside's standpoint."
UVA Health and Riverside will each retain their governance and administrative structures, but there will be a formal mechanism to manage the alliance, he says. "We will have a joint steering committee, where members from UVA Health and members from Riverside will jointly identify projects and track the progress of projects, whether that is in clinical areas, educational areas, or clinical research areas."
The American Medical Association says financial and administrative pressures on physicians are driving the shift away from independent practices.
Physicians are less likely to work in private practices than they were a decade ago, according to a new Physician Practice Benchmark Survey conducted by the American Medical Association (AMA).
The AMA launched its first Physician Practice Benchmark Survey in 2012. The surveys, which are published every other year, are nationally representative of post-residency physicians who provide at least 20 hours of patient care per week. The latest survey, which was conducted from September to November 2022, features data collected from 3,500 physicians.
The results of the latest survey reflect financial and administrative pressures on physicians, AMA President Jesse Ehrenfeld, MD, MPH, said in a prepared statement.
"The AMA analysis shows that the shift away from independent practices is emblematic of the fiscal uncertainty and economic stress many physicians face due to statutory payment cuts in Medicare, rising practice costs, and intrusive administrative burdens. Practice viability requires fiscal stability, and the AMA's Recovery Plan for America's Physicians is explicit in calling for reform to our Medicare payment system that has failed to keep up with the costs of running a medical practice."
The Physician Practice Benchmark Survey released yesterday has several key data points in four areas.
1. Practice ownership
From 2012 to 2022, the proportion of physicians who work in private practices fell from 60.1% to 46.7%
From 2012 to 2022, the proportion of physicians who work in a hospital-owned practice increased from 23.4% to 31.3%
In most specialties in 2022, the proportion of physicians in private practice ranged from 41.2% for general surgeons to 49.7% for radiologists
In 2022, the specialty outliers for physicians in private practice were emergency medicine physicians at 37.0% and surgical subspecialists at 63.3%
The primary reason cited for hospital and health system acquisition of physician practices was the need to negotiate higher payment rates with payers, with 46.1% of survey respondents saying this reason was very important and 33.4% saying this reason was important
2. Practice size
From 2012 to 2022, the proportion of physicians working in practices with 10 or fewer physicians decreased from 61.4% to 51.8%
From 2012 to 2022, the proportion of physicians working in practices with 5 to 10 physicians decreased from 21.4% to 19.0%
From 2012 to 2022, the proportion of physicians working in practices with fewer than 5 physicians decreased from 40.0% to 32.8%
From 2012 to 2022, the proportion of physicians working in practices with at least 50 physicians increased from 12.2% to 18.3%
3. Practice type
In 2022, single-specialty practices represented the largest proportion of physicians (41.8%) followed by multi-specialty group practices (26.7%), solo practices (12.9%), and a direct employment or contracting relationship with a hospital (9.6%)
Over the past decade, the proportion of physicians in multi-specialty practices and a direct employment or contracting relationship with a hospital have increased about 4 percentage points
Over the past decade, the proportion of physicians in solo practices and single specialty group practices has decreased about 4 percentage points
At more than 50% of physicians in 2022, obstetricians/gynecologists, anesthesiologists, and radiologists had the largest proportion of physicians who practice in single specialty practices
At 27.8% of physicians in 2022, general internists were least likely to work in a single specialty practice
Psychiatrists and general internists were the most common specialties working in solo practices in 2022 at about 22% of physicians
4. Employment status
In 2022, 49.7% of physicians were employees and 44.0% were practice owners
In 2012, 41.8% of physicians were employees and 53.2% of physicians were practice owners
Brad Archer, MD, chief medical officer of Monument Health. Photo courtesy of Monument Health.
