Rural residents face unique challenges to accessing healthcare such as far-flung geography, according to Dartmouth Health.
Dartmouth Health has launched an initiative to identify and address rural healthcare disparities in northern New England.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 healthcare disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
Earlier this month, Lebanon, New Hampshire-based Dartmouth Health inaugurated the Center for Advancing Rural Health Equity (CARHE).
Joanne Conroy, MD, Dartmouth Health president and CEO, said in a prepared statement that CARHE will tackle one of the biggest challenges facing the country's healthcare system.
"We have major challenges delivering—and receiving—healthcare in our rural communities. And we know that amongst our rural populations, there are those who have even greater challenges due to racism, historical marginalization, poverty, and sexual orientation. Through the work of the Center for Advancing Rural Health Equity, we strive to learn with the community what are the causes of unequal health in rural northern New England and to test solutions. The launch of the Center for Advancing Rural Health Equity is a significant step in advancing our mission to tackle these stubborn disparities head-on and ensure that our patients are fully connected to the care they deserve," she said.
People living in rural areas face unique barriers to accessing healthcare and social services, and rural geography makes it hard for health systems and social services to reach everyone who needs care, according to Dartmouth Health.
The planning process for CARHE was concentrated between January and June. Representatives on the planning team included academics, members of community-based organizations, officials from the Vermont Department of Health, and rural residents in New Hampshire and Vermont. CARHE will have four primary approaches to addressing rural healthcare disparities, according to Dartmouth Health:
Healthcare redesign: Translating knowledge into practice to meet the needs of rural populations
Research: Community-based research focused on creating evidence to support action
Community action: Community and health system partnerships crafted to meet local needs
Education: Training and the sharing of knowledge
The CARHE Leadership Council, the governing body of the center, formed in August. Members of the Leadership Council include clinicians, community leaders, educators, and researchers. The center also has a Community Advisory Council drawn from residents representing diverse populations in rural northern New England.
CARHE will be a collaborative effort, Rudolph Fedrizzi, White River Junction Public Health Services District director and chair of the center's Leadership Council, said in a prepared statement. "We are excited to work together with so many partners to establish the Center for Advancing Rural Health Equity and advance this shared vision for improving the health of our communities in meaningful ways. This collaborative approach, which draws on both expertise and lived experience, is a powerful strategy for improving the lives of all of our friends, family, and neighbors across rural New England."
Physicians are trained in optimal patient care, and when they combine that background with administrative skills, they become dynamic leaders, according to the American Association for Physician Leadership.
Angood has authored a white paper that argues physician leaders are more valuable than ever before. The white paper says physician leadership at health systems and hospitals is pivotal to improve quality, boost patient safety, achieve efficiency, and drive the transformation to value-based care.
HealthLeaders recently talked with Angood about the issues raised in the white paper. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: Why is it important to have physician perspectives included in health system and hospital leadership?
Peter Angood: Healthcare is a highly complex industry overall—arguably it is the most complex industry. There are a whole variety of clinical professionals including nurses, physician assistants, advanced practice clinicians, and pharmacists as well as nonclinical administrators. However, physicians are trained to the highest level of medical science. They are tuned in to what is best for optimal patient care in a variety of ways. So, when a physician couples that background with training and care practice experience in leadership, they become a dynamic force in terms of trying to create improvements and refinements as well as guiding healthcare organizations.
HL: What are the advantages of having a physician serve as the CEO or president of a health system or hospital?
Angood: The medical profession has continued to be viewed as a highly trusted and honorable profession by the general public as well as others inside the healthcare industry. So, when you get physicians who are well skilled in not only their clinical delivery practices but also administrative and leadership practices, they are able to achieve better performance at healthcare organizations in the CEO role. Some data suggests that physician CEOs generate 25% to 33% better performance on quality measures.
Physician CEOs bring a constellation of skills to the role, but it is the level of expertise on the clinical delivery side and the level of expertise on the administrative side that sets them apart. They are also highly respected and trusted inherently by all types of individuals both inside and outside the industry.
HL: Is there something particular about physicians that makes them a good fit for the CEO or president role?
Angood: Physicians by nature are altruistic and highly idealistic—that is what drives them to healthcare as a chosen profession. They are also highly resilient because of the long educational track and the tenacity it takes as they go through a prolonged period of career development. They gain terrific insights into the other professions that are inside the industry—both clinical and nonclinical. And they certainly gain great insights into what is the best way to deliver optimal patient care.
Physicians do not get any management or leadership training in medical school or their specialty training programs. So, it is important that physicians acquire additional skills as they embark on getting involved in different types of administrative roles.
HL: How do physicians gain those additional skills?
Angood: There is the unique physician who just has natural talents as a leader. They know how to create influence and how to stimulate others. They are natural team members who can motivate and drive teams along. But most physicians do require additional skills. They can do that without formal education by getting involved with committees or product line development. However, most will require some formal education to gain better insights as to what is required to run organizations and to be more influential as leaders.
It is not required for all potential physician leaders to do an executive master's program or a doctorate program, and there are a variety of avenues and channels to get that education and added experiences. That is part of what our organization is all about—we have 50 years of experience in providing resources that physicians need to acquire new knowledge. We also have the educational programs and credentials for physicians who want to gain added insight and skill sets.
HL: Does having physicians in the C-Suite improve medical staff engagement?
Angood: Absolutely! Healthcare is fascinating when you look at it historically and the evolution of the relationships between the medical staff as part of a hospital delivery system and how it has evolved toward today's environment. Healthcare is even more complex today because many health systems and hospitals have a combination of employed physicians as well as independent physicians. When you have physicians in the C-Suite who have trust and respect, other physicians can see and recognize that there are physicians in high levels of administration and have confidence that their interests will be understood.
HL: What are the primary core competencies for physician leaders?
Angood: As they go through their training, physicians get oriented toward being somewhat autonomous in their behaviors, and they get used to being the predominant decision-makers. So, they oftentimes need to acquire some additional competencies. Some of that starts with looking at themselves and how they behave with others. In addition to that, you must have some leadership capabilities. That includes integrity, judgment, accountability, humility, and self-control. Then you must have good skills with team building and facilitating teamwork.
Physician leaders need to be adaptable and feel comfortable with a measure of ambiguity. For some physicians, to play a leadership role they must become comfortable with being more visible. You can't just be in the background—if you are going to take on a leadership role, you must be comfortable with being on the frontline. There are also leadership technical skills such as policy, operations, risk assessment, and finance.
The American Hospital Association offers two dozen recommendations to support healthcare workers and address workforce shortages.
A new report published by the American Hospitals Association (AHA) calls on health systems and hospitals to focus on three core challenges to address the strained healthcare workforce.
Health systems and hospitals are facing widespread workforce shortages, particularly in nursing. Top healthcare executives say staffing shortages are their most pressing clinical care problem now that the crisis phase of the coronavirus pandemic has passed. Burnout has spiked during the pandemic.
The new AHA report says the healthcare workforce needs to be a top priority for health systems and hospitals. "A strong and resilient workforce is the backbone of our hospitals and health systems. There is no higher priority than ensuring that we care for the caregiver, that we make our working environment safe, and that we foster the ability for individuals to have joy in their work. While healthcare workforce challenges are not new, the pandemic has greatly exacerbated them. This national emergency demands bold, immediate action from public and private sector leaders."
Core workforce challenge 1: Reconnecting clinicians to professional purpose
Promoting a sense of professional purpose is essential to sustain the healthcare workforce, the report says. "As part of efforts to successfully recruit and retain a qualified, dedicated and diverse workforce, hospitals and health systems must create environments that consistently support meaningful work and nurture relationship-building with colleagues, patients, and families. Maximizing patient care time while minimizing administrative tasks is essential to reinspiring workers to find the joy, satisfaction, and meaning they value so highly."
There are five primary approaches to reconnect clinicians with professional purpose, the report says:
Culture: Health systems and hospitals should foster organizational cultures that are aligned with mission-driven values such as empowerment, responsiveness, and collaboration.
Determine what matters to employees: Health systems and hospitals should use employee engagement tools such as onboarding, surveys, town halls, and rounding to recognize the needs of workers and establish a work environment that they value.
Strengthen employee satisfaction: To decrease burnout and increase retention, health systems and hospitals should focus on employee satisfaction through efforts such as safe work environments, competitive compensation, adequate staffing levels, flexible scheduling, and shared decision-making
.
Support self-care: To provide high-quality care to patients, clinicians need to take care of themselves. Health system and hospital leaders should encourage clinicians to seek care for their physical and mental health. Organizations should offer educational programs as well as self-care resources that meet a range of needs.
Embrace patient-centered care: Patient outcomes and wellness should be pivotal elements for models of care. Technology should support better care and boost direct patient interaction.
Core workforce challenge 2: Provide support, training, and technology clinicians need to excel in multiple care settings
The shift in care delivery from the hospital setting has accelerated during the pandemic, the AHA report says. "The pandemic has accelerated changes in the ways care is delivered, with a wider acceptance of virtual in addition to in-person options. The settings where care is delivered also continue to expand, whether it's where patients live, in outpatient clinics, in community facilities or in hospitals. The ability to succeed in, and transition seamlessly between, a wide variety of care environments requires new skills and technologies, new flexibility in the workforce, and innovative strategies for workforce management."
There are six primary approaches to support this shift in care delivery, the report says:
Go virtual: The report calls on health systems and hospitals to seize virtual care opportunities. For example, Des Moines, Iowa-based MercyOne has launched a virtual nursing model that has a virtual nurse assist bedside nurses in monitoring patients, communicating with patients, and discharge planning. The virtual nurse program has improved patient safety and quality, enhanced communication between patients, family members, and care teams, and boosted clinician satisfaction and productivity.
Embrace technology: To automate repetitive tasks and improve clinical productivity, health systems and hospitals should launch a range of technological solutions, including natural language processing to ease documentation burdens and artificial intelligence to mine big data.
Care delivery model innovation: High-tech and high-touch approaches to care delivery models have the potential to improve quality of care and achieve staffing efficiency. For example, Partners for Nursing Staffing promotes a care delivery model with three elements: on-site care, patient monitoring equipment, and ambulatory access as well as virtual and remote care delivery.
Professional development: Foster expertise and leadership skills by offering interdisciplinary training across organizations, departments, and sites of care.
Focus on young workers: Health systems and health systems should build nursing and healthcare competencies in high schools as well as offer undergraduate scholarships.
Clinical professional training programs: Clinician and nurse education programs should promote the use of new technology, cultivate multidisciplinary care teams, and promote soft skills such as listening and empathy. These programs should also include exposure to home health services and incorporating family views in care.
Core workforce challenge 3: Recruitment, retention, and pipeline
Workforce development is crucial, the report says. "To ensure high-quality patient care now and in the future, healthcare workforce recruitment and retention must be top priorities in the short term. At the same time, developing a robust pipeline is critical to creating a sustainable long-term solution."
There are 11 primary approaches to recruitment, retention, and a robust employee pipeline, the report says:
Training options: Health systems and hospitals should work with schools, community organizations, and other healthcare organizations to offer apprenticeships and other on-the-job training opportunities.
International recruitment: Health systems such as Sioux Falls, South Dakota-based Sanford Health are recruiting nurses from overseas. These hiring programs can include housing during the transition period as well as working with international nurses to help them fit into their new communities.
Nurse training programs: In 2022, about 60 schools and hospitals have either launched or expanded nursing programs.
Promote flexibility: Offer flexibility in areas such as scheduling and remote work.
Boost upskilling: More than half of healthcare workers say they want upskilling, which can reduce financial barriers to advancing professionally.
Invest in onboarding: An effective onboarding program supports retention by establishing engagement at the time of hiring and building employee loyalty.
Inclusive workforce: Health systems and hospitals should support the efforts of medical, nursing, and allied health schools to promote diversity in their students. Health system and hospital leadership should embrace diversity, equity, and inclusion.
Offer nontraditional support: As part of recruitment and retention efforts, health systems and hospitals can offer housing grants or build affordable housing for employees. Health systems and hospitals can work with community organizations such as the chamber of commerce to find job opportunities for the spouses or partners of recruits. They can find community partners for childcare or offer on-site childcare.
Consider culture in recruitment: Health systems and hospitals should discuss the pros and cons of their community with recruits to make sure it matches their lifestyle and professional expectations.
Offer competitive financial benefits: In addition to competitive salaries, health systems and hospitals should offer financial benefits such as pay for mentoring, relocation expense assistance, and student loan assistance.
Launch in-house staffing agencies: Health systems and hospitals can have their own staffing agencies for nurses and clinicians that offer the premium pay and flexibility of travel agencies but have the stability of working for a single employer.
Dartmouth Health has taken on a leadership role for several small hospitals in New Hampshire and Vermont.
Dartmouth Health is a unique healthcare organization, with an academic medical center located in a rural area and six affiliated members, says Chief Clinical Officer Edward Merrens, MD.
HealthLeaders spoke with Merrens about a range of issues, including the health system's mission, burnout, current clinical challenges, and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What is Dartmouth Health's clinical care vision?
Edward Merrens: We are unique to have a tertiary-quaternary medical center in a rural state. We have a National Cancer Institute-designated cancer center. We have the only children's hospital in the state. We are increasingly one of the only facilities that can deliver babies as smaller hospitals retract from providing obstetrics services. We are a Level 1 trauma center.
So, we have a responsibility to the region. As we think about that, our responsibility is to be able to serve complex needs but also to ensure that the smaller hospitals have a role in their communities. They have a lot of opportunities, and we have not only served as the place where complex care happens, but we have also reached out to ensure that we can provide care at smaller hospitals as well. We have committed to complex orthopedic care at smaller hospitals, developing hospitalist programs at our critical access hospitals, connected with smaller hospitals through telehealth, and unified our emergency medicine physicians across the system.
The other things that we are doing are enhancing our care capacity coordination center to coordinate patients moving across the system in the most appropriate ways. By being responsible for the region, we have dedicated ourselves to coordinating among all the hospitals in our system, mostly critical access hospitals. We have fundamentally changed the nature of what they do by providing them with an opportunity to fill their operating rooms. It is a great experience for our clinicians and an opportunity for patients to get care close to home.
HL: In addition to telehealth, in what ways are you directly involved with your affiliated hospitals?
Merrens: They are part of our electronic health record. I work with their chief medical officers and their CEOs. We look to develop joint programs. We look to develop outreach. We have membership on their boards. So, we are a closely aligned system—we have developed several system programs. It's not just putting a Dartmouth sticker on their doors. We have developed a system pharmacy and therapeutics committee. We have ways that we try to align our clinical practices to be the same across the system. We have tried to align care.
It has been rewarding to figure out how we can develop algorithms, policies, and procedures that work across the system. We have done that in several areas, which makes it easier for patients to navigate the system and for physicians to work within it. Once you share an electronic health record, and there is one way to do things, it brings you together.
Edward Merrens, MD, is chief clinical officer of Dartmouth Health. Photo courtesy of Dartmouth Health.
HL: What is the status of physician burnout at Dartmouth Health?
Merrens: We are similar to other health systems across the country—we are dealing with not only physician burnout but also healthcare worker burnout more broadly. It is affecting everybody.
We have done a lot of things to address burnout. We developed a well-being council as well as dedicated resources and staff members for a Department of Caregiver Well-Being that incorporates physicians, advanced practice providers, and nurses. We have developed a robust employee assistance program that is available 24/7. We have gotten chaplaincy involved. We have developed lifestyle programs, including nutrition and exercise.
We also recognize that burnout is about more than having enough healthy vegetables and enough yoga. We have developed support systems for people. We are working at add more resources. We are streamlining the electronic health record. We are trying to figure out if we need new roles in the organization such as scribes and other people to make the job easier for clinicians.
We are trying to raise awareness about burnout. We are educating people, addressing needs, addressing stressors, and trying to approach the problem on all fronts.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Merrens: The clinical challenges are meeting the needs of the region, including an increasing number of patients seeking our care. We are building a new inpatient tower that will have 64 new beds and we can ramp up to 100 beds. Remarkably, at a time when other hospitals are contracting, we are building more inpatient beds.
We have a critical shortage of staffing—mainly at the nursing level but it includes radiology techs and every area of staffing. It is partly a function of the labor market—New Hampshire has one of the lowest unemployment levels in the United States. We have a unique environment to recruit people. The critical shortage of staffing is a clinical challenge. It impacts meeting patients' expectations of how they want to receive care.
The staffing crisis is not just us. One of the big problems for our 400-bed hospital is that we are struggling with finding places to discharge patients because the skilled nursing facilities and rehab facilities do not have staff, and they have limited the number of patients that they can take. So, we have got several bottlenecks in the system that make our work challenging. These bottlenecks have led us to have long-stay patients in the hospital.
HL: How is the organization addressing workforce shortages?
Merrens: We have several programs, including programs that reach out to high schools—apprenticeship programs and training programs. We are focused on the core members of the care teams who make things happen. We have had a medical assistant program for many years.
We train people to become phlebotomists because someday they will be licensed nursing assistants, then registered nurses, then nurse practitioners. We want people to focus on the stepwise growth in healthcare and what the starting point might be.
We have a health workforce readiness institute that reaches out and provides opportunities for people to be hired as employees while they are training. We have a dedicated relationship with the Colby-Sawyer College School of Nursing—they are our nursing school, and we hire as many graduates from there as we can.
Our focus has been to grow our own employees. We increased our minimum wage to $17 an hour in 2021. We may have to continue to adjust that wage. We have increased compensation for several roles, including nursing, medical assistants, LNAs, and techs.
We also have been innovative from a government standpoint. We were part of 17 organizations nationwide to receive a grant for rural healthcare workforce development. It was a $40 million grant, and we were awarded $2.5 million.
HL: What patient safety initiatives have been launched at Dartmouth Health?
Merrens: We have focused on the hospital-based and clinic-based measures that are important. We have looked at the infections that you have to be conscious of. We have reduced catheter-associated infections, central-line-associated infections, and communicable infections such as Clostridium difficile by 45% to 70% by paying attention to tracking infections and dedicating a quality team.
For example, with central-line infections, we started focusing on that area in 2019 and kept the work going through the pandemic. When we measured where we were in 2021, we had a 66% reduction in our central-line infections.
From 2018 to 2022, our urinary-catheter infection reduction was 60%.
From 2017 to 2022, we have had a 45% reduction in Clostridium difficile.
We also have an in-house team that looks at adverse events and does the root cause analysis. They look at adverse events and do the tracing to understand how those events happen.
We have an inpatient team focusing on patients who have high glucose levels and making sure that our best-practice alerts for managing sepsis are followed.
We also have thought about the safety impact on our caregivers. From 2021 to 2022, we have had a 37% reduction in blood-borne pathogen exposure such as needle sticks and exposure to blood products that happen in the emergency room and the operating rooms.
Jack Resneck Jr. says physicians will fight for the interests of their profession and their patients.
In an impassioned speech before the Interim Meeting of the American Medical Association House of Delegates, AMA President Jack Resneck Jr., MD, denounced disinformation campaigns and government interference in the patient-physician relationship.
Misinformation and anti-science rhetoric have been common during the coronavirus pandemic. Since the Supreme Court of the United States ended the right to an abortion in Dobbs v. Jackson Women's Health Organization, several states have passed laws banning abortion regardless of whether the life of the mother is threatened.
Addressing the AMA meeting on Saturday, Resneck said the country's physicians are facing unprecedented challenges. "How can a profession that put its lives on the line to lead our nation through this pandemic … that continues to fight an onslaught of medical disinformation amid increasing hostility and threats. How can we at the same time face ominous Medicare cuts as practice costs surge … as giant healthcare mergers concentrate market power … And as an ever-growing list of administrative demands pull us away from what drew us to medicine in the first place—caring for our patients."
The practicing dermatologist said he is having an emotional reaction to the threats facing physicians and their profession.
"I'm angry about how science and medicine have been politicized … about the flood of disinformation that seeks to discredit data and evidence, undermine public health, and misrepresent the wise policy of this House and our AMA's work to implement it. It began with COVID and lies meant to sew confusion and divide our nation. Lies about masking … you don't need them, so don't wear them. Lies about vaccines … they have microchips, or don't work, so don't use them. Lies about public health leaders and even frontline physicians … they're profiteering from the pandemic, so don't trust them. You are ambassadors of truth, doing the difficult work to reject these falsehoods and impart your knowledge to a weary public," he said.
Resneck said critics of physicians are misrepresenting the AMA's health equity efforts, distorting gender-affirming care, and ignoring evidence about what needs to be done to address gun violence. "You know and I know that we did not pick these fights, and that our organization isn't on any political team. The AMA is fiercely non-partisan. We have evidence-based, open debates in this House, and our actions are driven by the policies that you create. And you represent every state, every specialty, employed and independent settings, rural and urban communities. You come from every point across the political spectrum."
Physicians are willing to work with politicians, but clinicians will not be intimidated by them, he said. "We are influential individually as physicians and collectively as the AMA because we are the grown-ups in the room. We follow the evidence. Science is our North Star. And because we work with political leaders, from any party, at any time, when they are willing to help us improve the health of the nation. But make no mistake. When politicians insert themselves in our exam rooms to interfere with the patient-physician relationship … when they politicize deeply personal health decisions or criminalize evidence-based care … we will not back down. We will always stand up for our policies … for physicians … and for our patients."
Enduring the fallout of Dobbs
Resneck said the AMA has taken a stand on access to reproductive healthcare services such as abortion and contraception, adding that position is under assault.
"Since we last gathered in Chicago in June, many states have raced to criminalize abortion in the wake of Dobbs, and the drivers of disinformation have been at it again. Now they are falsely claiming that we have exaggerated or even fabricated stories about the real consequences of those laws. … Stories about patients with ectopic pregnancies, sepsis or bleeding after incomplete miscarriages, or cancers during pregnancy—patients who are suddenly unable to get the standard care that was unremarkable for decades … patients who now must, absurdly, travel hundreds or thousands of miles across the country to exercise their choice and obtain basic medical care. Denying our experience is helping prop up restrictive laws that are creating chaos—and leaving physicians in impossible positions," he said.
Resneck said abortion bans are forcing physicians to make choices between following the new laws or risking the lives of their patients. "I never imagined colleagues would find themselves tracking down hospital attorneys before performing urgent abortions, when minutes count … asking if a 30 percent chance of maternal death, or impending renal failure, meet the criteria for the state's exemptions … or whether they must wait a while longer, until their pregnant patient gets even sicker. In some cases, unstable patients are being packed into ambulances and shipped across state lines for care. To those who are forcing physicians into these ethical dilemmas, your efforts are reckless and dangerous."
"As we emerge from the worst of COVID, as practice costs have surged in the face of substantial inflation, and physicians struggle to retain staff, I can't think of a worse time for Medicare to threaten almost eight-and-a-half percent across the board payment cuts. How demoralizing! Our AMA is fighting to stop those cuts, and I'm glad to see all of medicine aligned in this effort. We must and will keep the pressure on Congress to act before the end of the year. But simply blocking every planned cut, as we've done before, isn't good enough. Physicians deserve financial stability, including automatic, positive, annual updates that account for rising practice costs. And it's time for reform of unfair budget neutrality rules that penalize doctors for things beyond our control," he said.
'Enough is enough'
Resneck expressed exasperation over misinformation and the drivers of physician burnout.
"Enough is enough. We cannot allow physicians or our patients to become pawns in these lies. All of this is exacerbating the burnout crisis in medicine. Doctors, facing threats and obstacles on so many fronts, are tired. Some are wearing down and leaving the profession they have dedicated their lives to. Telling them to be more resilient, or to do more yoga, and to enjoy a free dinner from the hospital CEO isn't going to heal the burnout. While wellness has its place, to focus solely on resilience is to blame the victim. We need to fix what's broken—and it's not the doctor."
The group representing emergency physicians and other healthcare organizations say emergency department boarding has reached "a breaking point."
The American College of Emergency Physicians (ACEP) and 34 other healthcare organizations are urging the Biden administration to hold a summit to address crisis levels of patient boarding in emergency departments.
Boarding in emergency departments occurs when there is a shortage of inpatient beds for hospital admissions or there are no beds at external facilities such as psychiatric hospitals. The Joint Commission recommends that emergency department boarding not exceed four hours; however, it has become common to have emergency department boarding for days or weeks, according to ACEP.
In a letter sent last week to President Biden, ACEP and three dozen other healthcare organizations paint a grim picture of the adverse impacts of emergency department boarding.
"In recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem—rather, from a decades-long, unresolved problem known as patient 'boarding,' where admitted patients are held in the ED when there are no inpatient beds available. While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the healthcare system have recently brought this issue to a crisis point, further spiraling the stress and burnout driving the current exodus of excellent physicians, nurses and other healthcare professionals," the letter says.
The letter details five negative effects of emergency department boarding:
1. Patient harm: "There is ample evidence that boarding harms patients and leads to worse outcomes, compromises to patient privacy, increases in medical errors, detrimental delays in care, and increased mortality," the letter says.
2. Providing care in waiting rooms: "Many emergency physicians who submitted stories reported daily numbers of boarders close to or even exceeding 100 percent of the total number of beds in their EDs, while the number of patients in the waiting room comprised up to 20 times the number of free treatment beds in which they could even be seen. In the past, that often left only hallway stretchers within the ED to care for incoming patients. But now, those too are increasingly over capacity, and so the emergency department waiting room has become the latest ad-hoc location for receiving patient care," the letter says.
3. Pediatric patients: "Unfortunately, the pediatric population is not immune to the serious ED boarding issue we are facing—particularly those with mental health conditions. During the last decade, pediatric ED visits for mental health conditions have risen dramatically. The COVID-19 pandemic led to a greater acceleration of these visits, causing several pediatric health organizations to issue a national emergency for children's mental health in 2021 and the U.S. Surgeon General to release an advisory on mental health among youth. … Multiple studies show that pediatric patients with mental health conditions who are boarded are more likely to leave without being treated, and less likely to receive counseling or psychiatric medications," the letter says.
4. Psychiatric patients: "Boarding of psychiatric patients in EDs is particularly prevalent, disproportionately affecting patients with behavioral health needs who wait on average three times longer than medical patients because of significant gaps in our healthcare system. While the ED is the critical frontline safety net, it is not ideal for long-term treatment of mental and behavioral health needs. Research has shown that 75 percent of psychiatric emergency patients, if promptly evaluated and treated in an appropriate location—away from the active and disruptive ED setting—have their symptoms resolve to the point they can be discharged in less than 24 hours. However, far too many Americans have limited options for accessing outpatient mental health care," the letter says.
5. Boarding drives burnout: "Overcrowding and boarding in the emergency department is a significant and ever-growing contributor to physician and nurse burnout, as they must watch patients unnecessarily decompensate or die despite their best efforts to keep up with the growing flood of sicker and sicker patients coming in. Healthcare professionals experiencing burnout have a much higher tendency to retire early or stop practicing all together. This increases the loss of skilled healthcare professionals in the workforce and adds more strain to those still practicing, which continues the cycle of burnout within the profession," the letter says.
Researchers find Black and Latino adults face higher barriers to timely medical care compared to White adults.
Barriers to timely medical care based on racial and ethnic disparities increased over the past two decades, according to a recent research article.
Racial and ethnic disparities impact access to healthcare. Earlier research has shown that Black and Latino people had higher lack of health insurance and cost-related unmet medical needs compared to White people from 1999 to 2018.
The recent research article, which was published by JAMA Health Forum, is based on data collected from more than 590,000 adults in the National Health Interview Survey from 1999 to 2018. The researchers examined trends in five barriers to timely medical care: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation.
The study features several key data points:
In 1999, the percentage of people reporting any of the five barriers to timely medical care was 7.3% among the Asian group, 6.9% among the Black group, 7.9% among the Hispanic and Latino group, and 7.0% among the White group
From 1999 to 2018, the percentage of adults reporting any of the five barriers to timely medical care increased for all four of the racial and ethnic groups, increasing 5.7 percentage points for Asians, 8.0 percentage points for Blacks, 8.1 percentage points for Hispanics and Latinos, and 5.9 percentage points for Whites
In 2018, compared to White adults, the proportion of adults reporting any barrier was 2.1 percentage points higher for Black adults and 3.1 percentage points higher for Hispanic and Latino adults
From 1999 to 2018, compared to White adults, Black adults experienced a 1.5 percentage point higher delay in care because of long waiting times at a clinic or medical office as well as 1.8 percentage point higher delay in care because of a lack of transportation
From 1999 to 2018, compared to White adults, Hispanic and Latino adults experienced a 2.6 percentage point higher delay in care because of long waiting times
In 2018, the overall proportion of adults reporting any barrier was 13.5%, with the adjusted prevalence among White adults at 12.9% and the proportion 2.1 percentage points higher among Black adults and 3.1 percentage points higher among Hispanic and Latino adults
From 1999 to 2018, compared to uninsured White adults, disparities in any barrier to timely medical care increased 6.6 percentage points for uninsured Black adults and 5.3 percentage points for Hispanic and Latino adults
In 2018, compared to White adults, the proportion of Hispanic and Latino adults who experienced a delay in care because of long waiting times was 4.0 percentage points higher
In 2018, compared to White adults, the proportion of Hispanic and Latino adults who experienced a delay in care because of lack of transportation was 1.0 percentage point higher
"The findings of this serial cross-sectional study of data from the National Health Interview Survey suggest that barriers to timely medical care in the US increased for all population groups from 1999 to 2018, with associated increases in disparities among race and ethnicity groups. Interventions beyond those currently implemented are needed to improve access to medical care and to eliminate disparities among race and ethnicity groups," the study's co-authors wrote.
Interpreting the data
During the study period, barriers to timely care increased significantly, with a disparity gap between White adults and Black and Latino adults, the study's co-authors wrote. "In this nationally representative study, we found that from 1999 to 2018, the overall estimated proportion of respondents who reported barriers to timely care nearly doubled, increasing from 7.1% to 13.5%, and the increase was not proportionate across the four race and ethnicity groups. During this period, differences in accessibility and availability of care between White respondents and Black and Latino respondents increased. In 2018, Black and Latino respondents were more likely to report delayed care because of lack of transportation and long waiting times at the doctor's office compared with White respondents."
The data has three health policy implications, the study's co-authors wrote:
"The increase in prevalence in barriers across race and ethnicity groups in the US indicates a worsening societal failure to deliver timely medical care. The fact that, overall, nearly 1 in 7 adults in 2018 experienced barriers to timely medical care indicates that attempts to improve access to care through improving access to insurance coverage alone may be inadequate—and may not be enough to reduce disparities. … Although increasing insurance coverage may address unmet medical needs by reducing cost, it is less clear that it removes barriers to timely medical care that are not directly related to cost."
"The growing racial and ethnic disparities in prevalence of these barriers to timely medical care suggest that the scope of national efforts to eliminate disparities in health care access should be expanded and include societal reforms beyond the health care system. This is not to say that health care−specific interventions (eg, the [Affordable Care Act], the national Culturally and Linguistically Appropriate Services) are not fundamental toward this goal, but that eliminating disparities in these indicators requires that policy interventions address nonmedical barriers to health care access and quality, including education, housing, urban planning, employment, and transportation, which disproportionately affect underserved populations."
"There are important implications from the income- and sex-stratified findings. The finding that racial and ethnic disparities were attenuated by lower income serves as an example of the pervasiveness of income inequality in access to health care, even beyond cost-related indicators. Regarding sex, although racial and ethnic disparities among women were mostly static, they had an overall higher prevalence of barriers during the study period compared with men of the same race or ethnicity. Because women face structural challenges to accessing sex-specific primary care (eg, pregnancy, menopause, gender-sensitive care), these findings add to the evidence of a need to improve women's access to primary care throughout the different stages of the life cycle."
Balcezak says that at Yale New Haven Health "nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers."
Thomas Balcezak, MD, MPH, chief clinical officer of Yale New Haven Health, recently talked with HealthLeaders on a range of issues, focusing primarily on physician burnout and workforce shortage issues, while expressing how the organization is moving healthcare forward in the communities it serves with patient safety initiatives and hospital acquisition goals to provide higher-quality care.
The transcript below has been edited for clarity and brevity.
HealthLeaders: Yale New Haven Health is in the process of acquiring three hospitals in Connecticut. What are you plans for clinical care at these hospitals?
Thomas Balcezak: We have acquired other hospitals and integrated them into the health system. For example, in 2012, we acquired the Hospital of Saint Raphael. In 2016, we acquired Lawrence and Memorial Hospital and Westerly Hospital. And in 2019, we acquired Milford Hospital. In each one of those transactions, our goals were straightforward. Connecticut is a parochial state—we like our healthcare local, and we like access to high-quality services. In these transactions and the proposed transactions for the three other hospitals, our goals are to broaden access to high-quality clinical services, to keep care to whatever extent possible local, to improve the quality of care, and to reduce the cost of care.
It comes down to cost, quality, and access. If all goes well as in the previous transactions, we believe we have an opportunity to do all three.
HL: How do you lower the cost of care in these transactions?
Balcezak: There are a couple of different ways. One is to take advantage of being a relatively large organization—we are almost $6 billion in revenue. That gives us good power in negotiation for products. It gives us access to competitive pricing on things such as drugs and supplies. So, we have some opportunities in supply chain savings.
The other way we can lower cost of care is in economies of scale for back-office services. Healthcare in general and hospitals in particular are human capital—intensive. We do not believe there is an opportunity to reduce direct caregivers—we have enhanced the staffing on the clinical side at the institutions we have acquired and integrated into the health system. There is opportunity in management structure, span of control, and back-office services.
HL: What is the status of physician burnout at Yale New Haven Health?
Balcezak: We are in a similar position as other health systems and hospitals across the country. Burnout is an issue beyond physicians—it is all of our clinical caregivers such as nurses, respiratory therapists, and pharmacists. We are seeing an epidemic of burnout in U.S. healthcare. It is something we are taking a lot of steps to address, but we do not have all of the answers.
The steps are relatively simple, but they are nuanced with a lot of efforts that are bolstering those steps. One step is making sure that we have adequate staffing, which has been a challenge. We have staffing shortages in virtually every area of our institution; just like you are seeing in other industries, we have seen growth in open positions.
Addressing staffing shortages goes well beyond salary and benefits. People want to work where they feel they are doing important work that is contributory to society. That is where healthcare has an advantage over many other industries. People go into healthcare because they want to help people—they want to help communities. It is important to be grounded in that as a health system. We need to spend more time focusing on what we are doing to improve the lives of the patients we serve and the communities we serve.
Another step is supporting the caregivers—giving them the tools that they need to deliver good care as well as reducing the barriers and the excess work that they do such as difficulties with documentation or use of the electronic medical record. There is a whole stream of work that we have been engaged in to improve day-to-day work effort, while providing employee and health resources support, so that staff have opportunity to express where their concerns are.
Pictured: Thomas Balcezak, MD, MPH, is the chief clinical officer at Yale New Haven Health. Photo courtesy of Yale New Haven Health.
HL: Give an example of an initiative you have put in place to address physician burnout.
Balcezak: One of the initiatives that we have is spearheaded by our chief medical information officer, and it is called Building Against Burnout. This initiative is specifically looking at how much time physicians are spending using the electronic medical record, particularly the "pajama time" outside of standard work hours. We have had a reduction in pajama time that can be tied directly to what our CMIO and his team has been doing to make the electronic medical record more streamlined and easier for physicians to use.
The electronic medical record is a big complaint by physicians, and it is appropriate that they are complaining about it. Technology is supposed to make lives at work easier, but what we often hear from physicians is that technology has made their work more onerous. In healthcare, we need to make documentation easier and use things such as virtual scribes to make the amount of time that physicians are spending on the electronic medical record go down.
HL: What have been your primary efforts to address workforce shortages?
Balcezak: We have made a multi-pronged effort. One of the efforts has been to make sure that we can offer a competitive salary and benefit package. We need to be competitive with more than other hospitals. We need to be competitive with other industries because it is not just healthcare that has a workforce shortage. We find ourselves competing with Amazon, retail outlets, and manufacturing organizations—we are competing at all levels of the workforce.
Right now, we have about 3,000 open FTEs that we are trying to recruit, and they are everything from pharmacists to respiratory therapists, nurses, environmental services, biomedical engineering, and clinical technicians. Virtually every position in our organization has open positions.
If you are a young person, and you are looking for a career in healthcare, the good news is there are lots of openings. There are openings at all levels, from physical therapists to occupational therapists, to all kinds of technicians, radiology, and the operating room. Every one of those positions has opportunities.
We have partnered with our local colleges to provide more educational opportunity such as scholarships for people to join the workforce. Some of our positions call for a high school diploma, and we are hiring people who do not have a high school diploma and allowing them to get a GED on the job. We have pathways for folks to get nursing degrees, and we are offering that with some tuition assistance at local colleges.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Balcezak: In many ways, it is getting back to basics. We have had growth in our length of stay. If you are not able to take care of patients in the acute phase of their illness in the most efficient way, and get their workup completed and their therapy completed in a timely way, that is a quality issue. So, we are attacking length of stay. We want to make sure that patients are not seeing delays in either diagnostics or therapeutics—that is a big deal for us now.
We are also still clearing the backlog of patients who had delays in care because of COVID. We have a backlog in screening exams—in colonoscopies. Those are burdens for population health that we are focusing on now. We are coming out of the other end of these backlogs, but we have not seen them completely cleared.
HL: Give an example of patient safety initiatives you have launched at Yale New Haven Health.
Balcezak: One of our most groundbreaking patient safety initiatives has been our work around becoming a high-reliability organization. We started this work about a decade ago—we were a relatively early adopter. The Connecticut Hospital Association created an initiative for hospitals, and we fully embraced it.
It was a galvanizing moment for our health system to get everybody involved in safety. Applying the principles of high reliability such as a deference to expertise has been permeating our organization. Rather than one initiative around falls, or one initiative around surgical-site infection reduction, we have implemented checklists and we have implemented technology for safety events. We have been addressing the most flawed part of our safety environment, which is the propensity of humans to make mistakes. The high-reliability work that we have done has taken direct aim at the frailty of humans and the fact that we are not perfect creatures.
We can talk about what we have done with technology and what we have done with human-factors engineering—those have been great individual efforts in individual error prevention. But nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers.
Outpatient practices can drive value, harness telemedicine, provide access, and promote equitable care.
Effective outpatient strategies are critical to the success of health systems, a top executive at NewYork-Presbyterian (NYP) says.
With an ever-increasing shift of care from the inpatient setting to the outpatient setting, ambulatory care has become an increasingly important sector of the U.S. healthcare industry. Annual revenue from ambulatory healthcare services is about $1 trillion, outpatient practices employ more than 7 million people, and there are more than 600,000 ambulatory care establishments, according to statista.com.
Outpatient care is essential to drive value in healthcare, says Tiffany Smith Sullivan, MPH, senior vice president and chief operating officer of physician services at NYP. "To drive value at its core, you need a patient-centered approach. We need to build teams for patients that manage complex types of care, so that we are aligned, we are communicating, and we are working with the patient to make sure that they have everything they need to remain healthy in the ambulatory setting. For example, we want a patient who is managing diabetes to not have to go to the emergency department or have an inpatient stay. That is a condition that we can manage in the ambulatory setting with community partners to help the patient get what they need to stay healthy."
Ambulatory practices have become leaders in telemedicine, she says. "You need to go back to 2020, when many of our outpatient practices were closed for in-person visits. Before 2020, we had been dragging our feet on telehealth options for our patients. We were still getting our technology up to speed. The pandemic accelerated the pace of building telehealth capabilities in the ambulatory space. While we were shut down for in-person visits, we were able to identify platforms for telehealth including phone calls and video. It was important to have telephonic visits as well as video visits for our patients who live in areas where access to high-speed Internet was not available for them. The pandemic gave us an opportunity to shift to telehealth platforms and be safe in how we provided care for patients."
NYP is committed to telemedicine in the outpatient setting, Smith Sullivan says. "We are going to continue to offer telehealth—we have about 20% of our patients wanting that option for care."
Outpatient care is essential for efficiency and access to care, she says. "Our outpatient strategies to increase efficiency include opening up access to care so that patients do not need to seek care in high-acuity settings such as the emergency department. If we are only open Monday through Friday, 8 a.m. to 5 p.m., then we are leaving out a segment of our patient population. Sickness does not only happen Monday through Friday, 8 a.m. to 5 p.m. So, we are making sure that we have extended hours and weekend hours to make sure we can provide access to our patients whenever they need care. We want them to be able to seek care in an outpatient practice, rather than seeking care in the emergency room."
NYP is trying to schedule outpatient visits within at least seven days, Smith Sullivan says. "We are identifying opportunities for expansion of primary and specialty care in areas where we see lag times. That means if you call today, how long does it take us to get you into an appointment? We have metrics for that, and we want to make sure that if we see a community that has a high lag time, we look at those trends to address where we need to place primary and specialty care resources."
The health system is expanding its ambulatory care network to improve access, she says. "We are making sure that we understand where we have significant lag times by using trend data. It can mean increased staffing such as more advanced practice providers including nurse practitioners and physician assistants in our practices. We are looking at not only the structure of the type of caregivers we have in our practices to address the needs we see in our communities but also looking at where the need is growing and shifting related to primary care and different types of specialty care."
Using ambulatory care to promote equity
Equity is one of the goals of NYP's outpatient care strategy, Smith Sullivan says. "Each community in New York City has its own different flavor and has its own underpinning resources. So, we need to make sure that we have strong partnerships in our communities and strong relationships with our patient population. We need to streamline what it takes to get in and see a provider such as having a centralized contact center, which is a process in place at NYP starting with primary care. That improves access for all of our patients."
NYP's ambulatory practices are closely linked to the community, which supports equity in care, she says. "Our strongest opportunity with our socioeconomically disadvantaged populations is to understand the community, to understand the pain points in the community, and to work with community-based organizations. For example, we have strong partnerships with faith-based organizations, school-based health centers, and programs that help people obtain healthy food. So, integrating with those programs and organizations is part of building trust in the community and making sure that care is equitable in terms of access and being able to see a provider of your choice. We need to be embedded in our communities, to be tied in with community-based organizations, and to have partnerships that are meaningful."
Expanding ambulatory care
Opening new outpatient practices remains a cornerstone of expanding ambulatory care at NYP, Smith Sullivan says. "Brick and mortar is still our biggest play in terms of the volume of patients that we see. So, we spend a lot of time and energy on where we are having bottlenecks and where we are having access issues in terms of patients not being able to get an appointment in seven to 14 days, which can mean we need an additional brick and mortar location. We also want to look at how we can open up our schedules to accommodate those patients."
Data drives decisions on opening new outpatient practices, she says. "There are several metrics that help us decide whether we should expand, where we expand, and what type of services we expand in a community. We look at lag time—how long it takes a patient to get an appointment. We look at the comments from our engagement surveys such as how long patients are staying on the phone. We look at our quality metrics to make sure our patients are getting high-quality care. If we see our physicians are overloaded, we often see a correlation to some of our quality metrics."
Recruitment statistics from 2021 show strong demand for physicians and advanced practice providers.
The market to fill physician and advanced practice provider positions is extremely competitive, according to a recent report from the Association for Advancing Physician and Provider Recruitment (AAPPR).
There are widespread workforce shortages across the country at health systems, hospitals, and physician practices. Clinical leaders say labor shortages are the Number One challenge facing their organizations.
The recent report is based on 2021 data collected from more than 175 AAPPR member organizations representing more than 23,000 employment searches. More than half of the searches were specific to physicians. The report includes several key findings:
The percentage of physician searches filled decreased for the fourth straight year
The most sought-after physician specialties were family medicine, internal medicine, and hospital medicine
The physician specialty positions that were least likely to be filled included otorhinolaryngology, dermatology, and urology
Nearly half of all physician searches were to replace a departing physician—this turnover rate has increased 16 percentage points since 2018
The proportion of clinician searches open at year end spiked in 2021, reaching 47% for physicians and 32% for advanced practice providers (APPs)
At 10% in 2021, APP turnover increased to a six-year high
The top three active searches by provider category were physician (52.0%), nurse practitioner (26.5%), and physician associate (11.2%)
The primary reasons for physician turnover at organizations with 300 to 999 providers were leaving for a similar position (74.6%), retirement (67.3%), geography (50.9%), burnout (34.6%), and compensation (30.9%)
The primary reasons for APP turnover at organizations with 300 to 999 providers were leaving for a similar position (91.7%), compensation (68.8%), geography (43.8%), burnout (33.3%), vaccination or testing requirement (18.8%), and retirement (12.5%)
Interpreting the data
The extent of clinician shortages is mainly dependent on geography and specialty, says Carey Goryl, MSW, CEO of the AAPPR. "The shortage of physicians is impacting different communities differently. If you look at rural communities, that is where we are going to see the physician shortage being felt most acutely. It also depends on the specialty. We are already starting to see certain specialties with serious shortages such as urology, where they have an aging provider workforce. When you look at the data to see who is going into urology residencies, there are not big enough numbers to have enough providers five to 10 years from now."
Future clinician shortages will be driven by geography, specialty, and burnout, she says. "The trend is taking us into an area where different patients in different communities will feel the physician shortage differently. It is going to depend on where you are and what type of provider you are trying to see. The future trend is also associated with burnout. If you have a specialty that is already stretched thin, the challenges to impact burnout, engagement, and retention point to a looming storm."
For health systems, hospitals, and physician practices, there are three primary consequences associated with physician turnover, Goryl says.
"The first impact is cost to the organization. It is very expensive to replace a physician and it is also expensive to have a physician position vacant for long periods of time. The cost to recruit and the lost income from vacant physician positions can be millions of dollars. The second impact of physician turnover is continuity of care. It hurts patients when their provider leaves and they have to create a relationship with a new physician. They may have been seeing a provider for several years, and there is a lot of historical information and relationship building that can be lost when there is this break in the continuity of care. The third impact of physician turnover is the impact on their colleagues. When a provider leaves, that means their colleagues might need to pick up additional patients or call coverage. It stretches everyone even thinner and adds to burnout."
There are no easy fixes for high clinician turnover and increasing job openings, she says. "We must look at provider retention programs that address physician concerns. We must look at why physicians and APPs leave their positions. And we need to invest in workforce planning. We must get ahead of these numbers, so they do not continue to increase. In workforce planning, we need to look at everything from retirements to employee engagement data. We need to try to forecast what is going to happen because the sooner we can start developing relationships and start recruiting to fill openings, the easier it will be to address these turnover statistics."