Wake Forest Health Network is experiencing workforce shortages of clinical and nonclinical staff.
Workforce shortages are the primary challenge of managing Wake Forest Health Network, the president of the medical group says.
Russell Howerton, MD, is president of the medical group and senior vice president of clinical operations at Atrium Health Wake Forest Baptist. A practicing surgeon, he previously served as chief medical officer of Wake Forest Baptist Health.
Wake Forest Health Network employs about 500 physicians and advanced practice practitioners.
Howerton recently talked with HealthLeaders about a range of issues, including physician engagement, the challenges of serving as senior vice president of clinical operations at Atrium Health Wake Forest Baptist, and clinical care predictions for 2023. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the challenges of leading the Wake Forest Health Network?
Russell Howerton: Emerging from the pandemic, our greatest challenge has been the workforce at either end. Staffing the non-provider workforce and securing adequate resources for our teams to deliver the expectations we have of them has been a great challenge. At the other end, provider recruitment, retention, and burnout have been major factors.
We have learned a great deal and done a great deal to develop our pipelines and recruiting processes for the non-provider staff—clinical and nonclinical, front desk, and the backend. We have always had partnerships with those who produce that element of the workforce, but over the past couple of years, we have had to redouble our focus and intensify our efforts to strengthen those partnerships. We are not the only healthcare entity in the market for those individuals—it is ferociously competitive. We are gaining ground, but we are not where we want to be.
HL: How have you risen to the challenge of recruitment and retention in your provider workforce?
Howerton: There are many components of recruiting physicians and advanced practice practitioners. Of course, striving to have market compensation is always a core tenet—it is necessary, but it is not sufficient. Today, it is our perception that meeting the needs of physicians to feel an appropriate balance of autonomy and being securely nested in a larger system that insulates them from some of the vagaries of business practices is the task. In either direction, you can go off the rails. Certainly, you can insulate them a great deal, but you do not want to become too controlling of their daily lives and clinical activities. We feel we are striking an appropriate balance.
We are not as fully staffed as we would like, and we continue to face challenges recruiting primary care physicians. There are many new entrants and new models in the market, not just our traditional competitors. We have all recently watched primary care models for CVS and Amazon.
Creating the work environment that promotes physician engagement is a retention strategy. We also want to be the best place to work.
HL: What are the primary efforts you have in place to address burnout?
Howerton: You need to ease the barriers to giving good care. As an analogy, part of leadership's job is to make giving clinical care feel like a fish swimming downstream with the tide, not having to swim upriver against the tide simply to deliver the care that your professional standards call you to do. For better or worse, the complexities of modern care delivery and organizational structure manage to put a lot of obstacles in the way of giving clinical care. We are trying to address those obstacles.
Russell Howerton, MD, president of Wake Forest Health Network and senior vice president of clinical operations at Atrium Health Wake Forest Baptist. Photo courtesy of Atrium Health Wake Forest Baptist.
HL: What are the primary elements of physician engagement?
Howerton: Listening is essential, along with conveying that something was heard. When you listen, you will often hear much more than you can address. Physicians express broad concerns from promoting world peace to not having the parking lot swept often enough at a practice. You need to listen, hear, and act whenever possible on as many issues as possible.
HL: You serve as senior vice president of clinical operations. What are the challenges of serving in this role?
Howerton: I am responsible for several business lines and subsidiaries. I help oversee Wake Forest outpatient dialysis—we are the eighth-largest provider of patient dialysis in the nation. We operate more than 20 sites around our part of the state. It's an interesting business. It is like the hospital business in that it requires staff in place every day to care for the patients. Again, we have had an intense challenge of maintaining adequate staff to offer the services we need to provide, and the dialysis population is a non-elective population. They need to have their care whether you have staff or not.
Compared to the physician group, there is a much smaller pipeline of available individuals with knowledge in dialysis. We are using some of the same mechanisms used in large facilities but there are relatively few travelers in the dialysis world. We are actively recruiting overseas even though the lead time to onboard someone from an overseas environment is many months—it is still an overall more favorable investment than travelers.
To rise to this workforce challenge at the dialysis centers, we have adjusted our pay scales and we have broadened our recruitment searches. There is a higher labor cost in the nation today to get dialysis in real dollar terms than there was pre-pandemic. We do not envision that going away. We seek to find efficiencies and improvements in other aspects of the model.
HL: Do you have any clinical care predictions for 2023?
Howerton: I believe we will learn how telehealth will fit into the long-term model of healthcare. It clearly has a place we would not have imagined if you had asked us in January of 2020 before the pandemic.
I predict that the end of the public health emergency and the variety of approaches to the waivers and regulations that have allowed us to adopt a care model during the pandemic will lead to confusion for a couple of years.
HL: You have a clinical background as a surgeon. How has this clinical background helped you serve in physician leadership roles?
Howerton: Surgery requires a leader of a team to get the rest of the team to work together toward a common goal. That leadership skill is generally translatable to administrative leadership roles. I have a personal belief that the currency of leadership is the confidence of those you help lead that you, the leader, has confidence in them to do the job. The daily work of leadership is to build this confidence in those you help to lead, so that when you need to draw upon it, you can, and everyone can succeed.
Inappropriate prescribing of antibiotics for upper respiratory tract infections as well as coprescribing of opioids and benzodiazepines were tied to shorter primary care visits.
Shorter primary care visit time is associated with some inappropriate prescribing decisions, a new research articlefound.
Time is a key factor in primary care, with the average visit lasting 18 minutes. Survey data in previous studies has found that patients often report needing more time in primary care visits and the length of primary care visits is one of the most important factors in patient satisfaction.
The new research article, which was published by JAMA Health Forum, is based on data collected from more than 8 million primary care visits in 2017. The data features visits with more than 8,000 primary care physicians.
The researchers examined three kinds of prescribing decisions: antibiotics for upper respiratory tract infections, coprescribing of opioids and benzodiazepines, and potentially inappropriate prescribing for older adults.
The study includes several key data points:
Longer primary care visits were associated with more complex care such as more diagnoses and more chronic conditions coded
After adjusting for scheduled visit duration and visit complexity, patients who were younger, publicly insured, Hispanic, and non-Hispanic Black had shorter visits
For each additional minute of a primary care visit, the probability of an inappropriate antibiotic prescription for upper respiratory tract infections decreased by 0.11 percentage points
For each additional minute of a primary care visit, the probability of coprescribing of opioids and benzodiazepines decreased by 0.01 percentage points
There was a statistically insignificant positive association of primary care visit length and potentially inappropriate prescribing among older adults (0.004 percentage points)
Shorter primary care visit length is associated with some inappropriate prescribing decisions and affects some patient groups disproportionately, the study's co-authors wrote.
"In this cross-sectional study of primary care physician visit length, shorter visit length was associated with higher rates of inappropriate antibiotic prescribing for upper respiratory tract infections and inappropriate coprescribing of opioids and benzodiazepines for patients with painful conditions, but similar patterns were not found for other potentially inappropriate prescribing decisions. We found considerable within-physician variation in visit length, with younger, publicly insured, Hispanic, and non-Hispanic Black patients receiving shorter visits. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care," they wrote.
Interpreting the data
With shorter visit length linked to some risk of lower-quality care, the researchers focused on patient and visit characteristics that were tied to time spent with the primary care physicians, the study's co-authors wrote. "Many of these associations suggest that patients with more medical complexity or with more to discuss received more time with their physicians, which may be expected. For example, visits that included more diagnoses—an imperfect proxy for number of topics discussed—were longer, as were visits for patients with more previously recorded chronic conditions and for new patients."
The researchers were troubled by links between patient-visit characteristics and visit time that were not readily explained by differences in patient clinical need, they wrote.
"For example, patients with Medicaid insurance coverage, dual Medicare and Medicaid coverage, or no insurance coverage received significantly shorter visits than commercially insured patients despite the latter population being healthier on average. Similarly, non-Hispanic Black patients received visits that were shorter, on average, than non-Hispanic White patients seeing the same physician. These visit-level differences may accumulate over time, potentially contributing to racial disparities in how much time patients spend with their physicians each year."
Increasing the length of patient visits for upper respiratory tract infections could improve antibiotic stewardship, the co-authors wrote. "Policy makers and health system leaders wishing to advance antibiotic stewardship best practices should take note of the association between visit length and inappropriate antibiotic prescribing. Our findings suggest that lengthening upper respiratory tract infection visits may be a promising strategy to lower inappropriate antibiotic prescribing, which has been a persistent population health concern for decades."
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. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The Top 10 patient safety concerns of 2023 according to ECRI and the Institute for Safe Medication Practices are as follows:
1.Pediatric mental health crisis
Pediatric mental health has reached crisis proportions, Marcus Schabacker, MD, PhD, president and CEO of ECRI, said in a prepared statement. "Even before COVID-19, the impact of social media, gun violence, and other socioeconomic factors were causing elevated rates of depression and anxiety in children. The challenges caused by the pandemic turned a bad situation into a crisis. We're approaching a national public health emergency."
Children are now at increased risk for suicide, the new annual report says. "The increase in children experiencing extreme anxiety and depression has led to an increase in suicidal ideation, with more young people age 12 to 25 presenting to the emergency department (ED) for suspected suicide attempts. Although adolescent suicide attempts had decreased during spring 2020, the mean weekly number of ED visits for suspected suicide attempts among those age 12 to 17 was 22% higher in summer 2020 and 39% higher during winter 2021 compared with the corresponding periods in 2019."
2. Physical and verbal violence against healthcare staff
Only law enforcement and security personnel face more workplace violence than healthcare workers, according to the annual report.
The Joint Commission has made workplace violence against healthcare workers a top priority, the annual report says. "In January 2022, Joint Commission accreditation standards began requiring leadership to develop and enforce a workplace violence prevention program. Joint Commission also states that effective workplace violence programs encourage reporting incidences of threatening language and verbal abuse in addition to physical abuse."
3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine
When the U.S. Supreme Court overturned Roe v. Wade, which made maternal-fetal medicine a matter of state law, the high court created uncertainty for clinicians and their patients, the annual report says. "Although some states with abortion bans allow abortions to save the life of or prevent harm to the pregnant patient, there is often little guidance on where the line is. If clinicians wait too long, patients may suffer serious harm."
4. Impact on clinicians expected to work outside their scope of practice and competencies
Healthcare organizations have legal and ethical obligations to make sure clinical staff work within their scope of practice and competencies, but these obligations are being tested in several ways, the annual report says. "Many healthcare workers are still asked to step outside these boundaries, especially during public health emergencies and other societal circumstances such as staff shortages and turnover, increased patient volume, supply chain disruption, and rural facility closings."
5.Delayed identification and treatment of sepsis
Timely diagnosis and treatment of sepsis, which is the leading cause of death in hospitals, is crucial, the annual report says. "Intravenous antimicrobials should be administered immediately—ideally within an hour of recognition—for patients with shock and possible sepsis and for patients with a high likelihood of sepsis (including those without shock). Antimicrobials should be administered within three hours for patients with possible sepsis without shock."
6.Consequences of poor care coordination for patients with complex medical conditions
Care coordination is pivotal for patients with complex needs such as multiple chronic conditions because they often face care fragmentation, higher healthcare utilization, and worse health outcomes than other patients, the annual report says. "Improved care coordination can help mitigate these patient safety risks and preventable errors associated with common coordination pitfalls, including interprofessional communication, interoperability of health information technology (IT), medication reconciliation, test tracking and follow-up, and care transitions."
7.Risks of not looking beyond the "five rights" to achieve medication safety
The "five rights" of medication safety are right patient, right drug, right dose, right route, and right time, but they are insufficient on their own, the annual report says. "Failure to back up the five rights with high-leverage strategies and actionable procedures—or to identify which system processes failed when medication errors occur—undercuts medication safety."
8.Medication errors resulting from inaccurate patient medication lists
Inaccurate patient medication lists often occur because a patient is no longer taking a drug or a drug is omitted from the list, and healthcare organizations should have a robust system in place to address the problem, the annual report says. "Multidisciplinary medication reconciliation teams should review current processes, identify gaps and opportunities for improvement, and lead process design and redesign within the healthcare facility or practice. Team members should include executive leadership, physician champions, pharmacists, discharge planners, IT personnel, and patient safety and quality staff."
9.Accidental administration of neuromuscular blocking agents
Neuromuscular blocking agents paralyze skeletal muscles during mechanical ventilation, and they can be deadly when administered to patients who are not on a ventilator. According to the annual report, there are several causes of accidental administration of these medications, including look-alike packaging, unlabeled and mislabeled syringes, syringe swaps, and residual drug left in intravenous tubing.
10.Preventable harm due to omitted care or treatment
According to the annual report, missed care has several negative consequences, including complications such as pressure injuries, increased length of stay, and decreased patient satisfaction. "Some of the most common predictors of missed care include inadequate staffing levels; increased workload; poor work environment; limited staff experience, education, or competency; lack of material resources; poor communication; poor care transitions; limited skills mix of staff on the unit; and lack of teamwork," the report says.
As the number of long COVID cases grows, healthcare providers need to learn more about these patients.
Long COVID patients experience increased risk for several cardiovascular conditions in the year after coronavirus infection, a new research article found.
Long COVID, also known as post-COVID-19 condition (PCC), is defined as having new, returning, or ongoing health issues more than four weeks after an initial infection, according to the Centers for Disease Control and Prevention. Symptoms that lead to a diagnosis of long COVID include fatigue, cough, loss of taste or smell, shortness of breath, neurocognitive difficulties, and depression.
The new research article, which was published by JAMA Health Forum, features data collected from 13,435 long COVID adult patients and a control group of 26,870 adults without COVID-19. The data was drawn from national commercial insurance claims along with laboratory results and mortality data from the Social Security Administration's Death Master File and Datavant Flatiron data.
The research article has several key findings:
The long COVID patients experienced increased healthcare utilization for cardiac arrhythmias (relative risk 2.35).
The long COVID patients experienced increased healthcare utilization for pulmonary embolism (relative risk 3.64).
The long COVID patients experienced increased healthcare utilization for ischemic stroke (relative risk 2.17).
The long COVID patients experienced increased healthcare utilization for coronary artery disease (relative risk 1.78).
The long COVID patients experienced increased healthcare utilization for heart failure (relative risk 1.97).
The long COVID patients experienced increased healthcare utilization for chronic obstructive pulmonary disease (relative risk 1.94).
The long COVID patients experienced increased healthcare utilization for asthma (relative risk 1.95).
Risks for these conditions were higher for long COVID patients who were hospitalized during the acute phase of coronavirus infection compared to long COVID patients who were not hospitalized.
The long COVID patients also experienced increased mortality, with 2.8% of long COVID patients dying compared to 1.2% of individuals in the control group. This translated to an excess death rate of 16.4 per 1,000 individuals.
The long COVID patients in the study were at significantly higher risk for adverse outcomes in the year after initial infection, the research article's co-authors wrote. "This case-control study leveraged a large commercial insurance database and found increased rates of adverse outcomes over a 1-year period for a PCC cohort surviving the acute phase of illness. The results indicate a need for continued monitoring for at-risk individuals, particularly in the area of cardiovascular and pulmonary management."
Interpreting the data
Even for adults who are not hospitalized, long COVID patients are at risk for serious conditions and mortality, the study's co-authors wrote.
"Based on published literature, the most common symptoms experienced by individuals with PCC include fatigue, headache, and attention disorder. While these symptoms are concerning, results from this study also indicated a statistically significant increased risk for a range of cardiovascular conditions as well as mortality. While these risks were heightened for individuals who experienced a more severe acute episode of COVID-19 (ie, requiring hospitalization), it is essential to note that most individuals (72.5%) in the cohort did not experience hospitalization during the acute phase."
As the number of long COVID cases grows, healthcare providers need to learn more about these patients, the study's co-authors wrote. "Gaining additional insight into the risks and trajectory of the disease is essential for clinicians caring for these individuals, especially a need for primary prevention for individuals at higher risk. At a health-systems level, it is also necessary to develop resources and guidance for individuals at risk for serious complications."
The study has significant implications, they wrote. "From a health policy perspective, these results also indicate a meaningful effect on future healthcare utilization, and even potential implications for labor force participation. Gaining knowledge on the scope and trajectory of PCC is relevant for policy makers, given the recent guidance by the US Department of Health and Human Services that classifies 'long COVID' as a disability if it substantially limits major life activities."
Physicians need to be able to trust the people who are leading them, chief clinical officer says.
Transparency and creating an environment that promotes autonomy, mastery, and purpose are essential in physician engagement, the chief clinical officer of Mercy Health-Lima says.
Matthew Owens, MD, chief clinical officer of Mercy Health-Lima, is a practicing physician specializing in physical medicine and rehabilitation. Mercy Health-Lima, part of Bon Secours Mercy Health, is anchored by St. Rita's Medical Center in Lima, Ohio.
HealthLeaders recently talked with Owens about a range of issues, including physician engagement, quality improvement initiatives, and patient experience. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You have oversight of Mercy Health Physicians-Lima. What are the keys to success in supervising a physician group?
Matthew Owens: Leading a large medical group is an honor I do not take lightly. There are many pressures that our physicians and our advanced practice clinicians face every day while they are delivering care.
Maintaining an engaged clinician workforce is probably the most critical factor in achieving success in care delivery. If I do not have a workforce that is engaged in the work they are doing each day, it is difficult to do the work that the medical group is required to do.
HL: What are the primary elements of physician engagement?
Owens: Physicians are a highly motivated, competitive, and self-driven group of people. Most will perform at a high level if they are provided with the environment to allow them to excel. One of the most critical elements to physician engagement is transparency in leadership. Physicians need to be able to trust the people who are leading them. I try to be highly transparent—sometimes to a fault. I want to allow our physicians to feel engaged with the plans of the organization.
Beyond transparency and thinking about factors that promote strong engagement, I often refer to three major principles that I picked up from a book called Drive by Daniel Pink. In that book, Pink says people intrinsically want to do things that matter, and there are three principles that are important to allow people to shine. You need to grant them autonomy, mastery, and purpose. When I am thinking about leading physicians, if I can be transparent, then constantly work to give physicians an environment that promotes autonomy, mastery, and purpose, I know that the physician colleagues that I lead will perform at a high level.
HL: What are the primary challenges of serving as a chief clinical officer?
Owens: As we emerge from the stressors of the pandemic, I am struck by the pace of change and the pressures to manage that change. So much of what we do feels different than pre-pandemic.
We have an evolving set of challenges in healthcare. There are workforce shortages. There are mobility challenges in the workforce. There are inflationary pressures. There are regulatory burdens. And, frankly, there is a lot of gamesmanship among our nation's insurance providers. Those are all factors that immediately come to mind that impact the daily delivery of care to those that we serve.
HL: How are you rising to these challenges?
Owens: We are having to think about doing things in a different way than we used to in the past. We look toward different strategies for staff recruitment—it is not just the recruitment of physicians, it is the recruitment of the care teams surrounding physicians. Candidates are looking for something a little bit different than before the pandemic, and if we do not adapt to that then we are going to see ourselves falling behind. Once they are here, we must figure out what the key elements are to retain that workforce.
Healthcare organizations in this country are in a difficult spot. The inflationary pressures are certainly apparent as in any industry, but unfortunately reimbursement changes are not keeping up with the inflationary pressures. So, we must be wise about our expenses—we must manage those expenses tightly.
Regarding regulatory burdens, there are a lot of new regulations being released on a regular basis, particularly during the pandemic. It has complicated our ability to be efficient with how we are using our workforce—we have a lot of pressures from various groups to try to live up to the standards they have set.
Matthew Owens, MD, chief clinical officer of Mercy Health-Lima. Photo courtesy of Bon Secours Mercy Health.
HL: What is Mercy Health-Lima doing to recruit and retain clinicians?
Owens: At Mercy Health-Lima, we are blessed to be leaders of a large, progressive regional referral center in a relatively rural area of Ohio. While that is not the setting that every physician seeks during a job search, we have a strong track record of retaining our physicians for a long time once they settle into practicing here. We are surrounded by several wonderful small cities and communities that are filled with wonderful people who seek our care, and that becomes endearing to our clinicians.
The landscape for recruitment is challenging right now. We know there is a physician shortage across the country. Our biggest sell is to convince clinicians to come and take a look at what we have to offer, to see how progressive our medical center is, then show them how nice it can be to live in our communities.
Regarding retention, we specifically work to ensure that our providers feel they have the tools needed to be successful. We also recognize the gravity of burnout and the emotional scar that the pandemic left on our care teams. We are healing together—we have developed a few methods of intervention that we hope provide members of our care teams a path to recovery. For example, we have a Life Matters platform that allows our providers to reach out if they have specific concerns related to mental health or burnout, or more broadly if they have specific life concerns and need help tracking down resources in the community.
We also have a program called Caring for Colleagues, where there are several of our physician colleagues across the ministry who have volunteered to provide their cell phone numbers so any care team member can call them at any hour of the day or night and receive counseling.
HL: What are the keys to success for quality improvement initiatives?
Owens: Transparency and communicating a clear "why" behind a quality improvement initiative are probably the most important factors to being successful. If I cannot communicate a compelling reason why a quality initiative should take priority in the minds of our care team members, it will certainly not gain traction.
HL: Give me an example of a quality initiative you have led.
Owens: As we emerged from the pandemic, we were finding that we had a high rate of catheter-associated urinary tract infections. That was partly related to long lengths of stay of COVID patients. We wanted to get those catheter-associated infections back under control. We brought together several physician and nursing leaders from across our healthcare market. We explained the "why" in a transparent way, and we asked them for action steps that would impact the hospitals that they lead. What was great as an outcome was getting buy-in right away, which helped us decrease those infections precipitously over the past six months.
HL: What are the keys to success in patient experience?
Owens: Our patients expect great care, and they are moved by how we make them feel. The soft skills of medicine such as body language and empathy are critical in every single patient interaction. As patients seek greater and greater awareness of their care plans, we must strive to keep them feeling like they are partners in their health.
The most basic thing is ensuring that our providers have the clinical skills and the knowledge base to be successful. That is the absolute baseline level that we would expect. The next level we would expect is the soft skills. I want a clinician in our market to walk into a room and not only make the patient feel they know what they are talking about but also make the patient feel like they are heard and they want to come back and see that provider again. That's how we convince our community that we are providing them a great patient experience. When patients leave feeling they have been heard and they have been truly cared for, and they leave thinking they want to come back, they go home and tell the rest of the community about that experience. Our providers also become more successful in attracting patients because of that experience.
So, we have programming that tries to teach soft skills to our providers. We try to go beyond the clinical knowledge base and make sure our providers are exposed to a curriculum that allows them to engage soft skills when they are interacting with patients.
The vast majority of healthcare executives surveyed said workforce will have a significantly negative or negative impact on growth strategies this year.
Workforce issues loom large for healthcare C-Suite executives, according to a new survey report from Guidehouse and the Healthcare Financial Management Association (HFMA).
Workforce shortages are widespread in the healthcare sector. In an annual survey published last month by the American College of Healthcare Executives, workforce challenges were the Number One concern of 2022.
The new survey report from Guidehouse and HFMA features data collected from 182 healthcare executives, 80% of whom were C-Suite leaders such as CEOs, CFOs, and COOs. The survey asked the executives five questions.
1. What impact is your workforce having on your 2023 growth strategy?
62% of survey respondents said the state of their workforce is expected to have a significantly negative impact on 2023 growth strategy
34% of survey respondents said the state of their workforce is expected to have a negative impact on 2023 growth strategy
Only 1% of survey respondents said the state of their workforce is expected to have a significantly positive impact on 2023 growth strategy
The workforce is a pivotal concern at healthcare organizations, the survey report says. "Labor is the root cause of delays in care delivery innovation. Clinician burnout, staff resignations, executive retirements, and equity issues now define many health system work environments. Fundamental changes in culture, work redesign, and workforce development are essential for providers to thrive in the new healthcare economy."
2. By how much do you project staffing to increase or decrease in the following areas?
Advanced practitioners:
55% of survey respondents expect staffing of advanced practitioners to increase by as much as 10%
34% of survey respondents expect staffing of advanced practitioners to increase by 10% or more
Behavioral and mental health providers:
45% of survey respondents expect staffing of behavioral and mental health providers to increase by as much as 10%
36% of survey respondents expect staffing of behavioral and mental health providers to increase by 10% or more
Physicians:
60% of survey respondents expect staffing of physicians to increase by as much as 10%
23% of survey respondents expect staffing of physicians to increase by 10% or more
Nurses:
47% of survey respondents expect staffing of nurses to increase by as much as 10%
31% of survey respondents expect staffing of nurses to increase by 10% or more
Contractors and travelers:
41% of survey respondents expect staffing of contractors and travelers to decrease by 10% or more
24% of survey respondents expect staffing of contractors and travelers to decrease by as much as 9%
19% of survey respondents expect staffing of contractors and travelers to increase by as much as 10%
15% of survey respondents expect staffing of contractors and travelers to increase by 10% or more
Healthcare organizations should not limit their primary recruitment strategies to physicians, the survey report says. "As organizations determine the best way to establish themselves as preferred providers, they may find they need fewer physicians to achieve these goals. Adding more behavioral health providers, social workers, and case managers to the team could help take pressure off overloaded medical professionals while giving patients the right support in the right setting, including in the home."
Health systems cannot continue to rely on contractors and travelers, Thomas Zenty III, a national adviser at Guidehouse, said in a prepared statement. "Health systems are struggling to afford the vast increase in the need for contractors and traveling clinicians. As their short-term contracts come to an end, leading organizations are finding attractive ways to keep these caregivers on full-time and integrate them into the business."
3. By how much do you project patient volumes to increase or decrease over the next 12 months?
Outpatient:
54% of survey respondents expect outpatient volume to increase by as much as 10%
41% of survey respondents expect outpatient volume to increase by 10% or more
Inpatient:
17% of survey respondents expect inpatient volume to decrease by 10% or more
24% of survey respondents expect inpatient volume to decrease by as much as 9%
35% of survey respondents expect inpatient volume to increase by as much as 10%
21% of survey respondents expect inpatient volume to increase by 10% or more
Patient volumes are an area of volatility for health systems as the country emerges from the coronavirus pandemic, Richard Bajner, Guidehouse partner and payer-provider leader, said in a prepared statement. "Most health systems are still experiencing volumes below pre-COVID levels, resulting in sizable market challenges. These shifts should inform strategic growth efforts that are focused on person-centered care, such as excellence in ambulatory services, to create sustainable business models that attract and retain patients while driving financial resiliency in an era of volatility."
4. What are your expectations for emergency department (ED) and elective procedure volumes?
ED volume:
55% of survey respondents expect ED volume to increase by as much as 10%
32% of survey respondents expect ED volume to increase by 10% or more
Elective procedure volume:
56% of survey respondents expect elective procedure volume to increase by as much as 10%
26% of survey respondents expect elective procedure volume to increase by 10% or more
The expectations for ED and elective procedure volumes are optimistic given market conditions, the survey report says. "Fundamental changes are contributing to unpredictability in the demand for emergency room visits, inpatient volume, ambulatory surgery procedures, outpatient visits, length of stay, case mix index, virtual care, and more. In turn, almost universally, hospitals and health systems are facing financial and operational instability like never before."
5. Please select the area your organization is projecting the greatest percentage budget increase in the next 12 months.
20% of survey respondents said digital engagement and virtual care
18% of survey respondents said revenue cycle automation
17% of survey respondents said investing in physician organizations
16% of survey respondents said managed services and outsourcing partners
13% of survey respondents said merging or acquiring strategic assets
10% of survey respondents said cybersecurity
5% of survey respondents said home care or hospital at home
Digital engagement, virtual care, and automation are top priorities for healthcare organizations, Zenty said. "With growth in labor and supply costs, many leaders are turning to purposeful artificial intelligence, automation, and digital care strategies to improve engagement and efficiency. Successful organizations are reevaluating their digital connectivity capabilities to ensure patients and caregivers know how to access and use patient portals, EHRs, and other technologies, as well as to streamline corporate and non-clinical services."
Mainly due to a shortage of primary care providers, millions of Americans do not have access to a usual source of primary care.
With more funding, Federally Qualified Health Centers would be well-suited to filling a gaping primary care gap, according to a recent report from the National Association of Community Health Centers (NACHC).
More than 100 million Americans do not have access to primary care, mainly due to a shortage of primary care providers in their community, the report says. The report deems these Americans as medically disenfranchised.
Federally Qualified Health Centers, also known as Community Health Centers, have a vital role to play in serving this medically disenfranchised population, Rachel Gonzales-Hanson, interim president and CEO of NACHC, said in a prepared statement. "The primary care gap is deepening in underserved communities across our nation, and Community Health Centers are vital to filling in those gaps by providing critical routine healthcare services. The COVID-19 pandemic only illuminated existing healthcare inequalities in the most vulnerable areas of our nation, making it crystal clear the important role of health centers."
The NACHC report highlights a national crisis, she said. "The Closing the Primary Care Gap report illustrates an unfortunate picture of medically underserved Americans with a disproportionately higher risk of harm from preventable diseases—and one-quarter of them are children. Expanding access to primary healthcare must be a national priority."
In addition to the findings that 100 million Americans do not have access to primary care and one-quarter of them are children, the report has several key findings:
Only 11% of the medically disenfranchised population is uninsured, which indicates that lacking access to primary care is not mainly related to insurance.
More than half of the medically disenfranchised population has an income below 200% of the Federal Poverty Level. These people may not be able to afford traveling long distances to access care.
Without community health centers, 15 million more people would likely not have access to primary care.
The number of medically disenfranchised people has doubled since 2014.
Investments are needed to reduce the medically disenfranchised population, the report says. "Access to primary care in medically disenfranchised communities can be improved through strategic investments, such as incentives for primary care practitioners to train and work in medically underserved communities and additional funding for Community Health Centers to expand their network of providers."
Addressing the shortage of primary care providers is crucial, the report says. "Gaps in primary care persist due to a nationwide primary care provider shortage that is driven by increased medical specialization and an uneven distribution of providers. Clinical trainees are pursuing increased specialization, which has led to a decline in the proportion of medical students and residents entering primary care. … Both primary care providers and specialists are more concentrated in highly populated urban areas that are home to higher-income, majority-insured populations. This pattern leaves fewer providers to care for rural communities that are more sparsely populated and may have a lower median household income. A variety of factors are also leading to consolidation, and clinic closures across the landscape of primary care practices are exacerbating the problem of unequal distribution."
More federal funding for Community Health Centers is needed to not only open more clinics but also to keep pace with inflation, the report says. "While the Community Health Center fund has increased by 14% since 2015, medical care inflation has risen by 25%, leading to a 9.3% decrease in federal health center funding in real terms."
Community Health Centers are geared toward providing services in underserved communities, the report says. "Health centers place an emphasis on culturally competent care and intentionally recruit providers who are underrepresented in the medical profession and those who reflect the cultural diversity of their community. This results in providers who represent the diverse racial, ethnic, and linguistic backgrounds of the communities they serve. Continued investments in these programs are necessary to sustainably grow the number of providers working in medically underserved communities and to strengthen the primary care workforce of the future."
Primary care is an essential component of the country's healthcare system, the report says. "Primary care providers can treat the common cold, ensure healthy childhood development, prevent future illness, manage chronic conditions, and connect patients to specialty services. Having a usual source of primary care is associated with decreased emergency department use and lower healthcare costs throughout the lifetime. On the other hand, a lack of access to primary care can weaken the public health response to future pandemics and could have dire consequences for patients, especially those facing compounding access barriers."
Community Health Centers should be part of the solution to the country's primary care crisis, the report says. "Health centers have a proven track record of filling primary care gaps in underserved communities, making them well-positioned to fill that need for the more than 100 million Americans who remain medically disenfranchised. The health center program has grown in the last five years to serve more patients and expand specialty services such as behavioral health, dental, and vision services in medically underserved communities. With sufficient resources, the health center program can expand into more underserved communities and continue to close the gap in primary care for America’s medically disenfranchised population."
The author of a new book expects the challenges facing healthcare before and during the coronavirus pandemic to persist for years.
Healthcare organizations should focus on four areas as they emerge from the coronavirus pandemic, the author of a new book says.
Healthcare organizations faced several challenges going into the pandemic, including the rise of consumerism and adoption of value-based payment models. The pandemic introduced new challenges such as widespread workforce shortages and severe financial problems.
Thomas Lee, MD, a primary care physician at Brigham and Women's Hospital in Boston and chief medical officer at Press Ganey, offers prescriptions for healthcare organizations in his new book, Healthcare's Path Forward. "The reason why I wanted to write this book is because we have been through a lot over the past few years, and I am hoping the pandemic will be winding down, but the fact of the matter is the stresses that became explicit the last few years are not going away in many ways. I wanted to come up with the path forward that we need to be pursuing in order to meet the challenges," he told HealthLeaders.
Drawing on the collective knowledge of colleagues inside and outside Press Ganey, Lee says there are a set of basic activities that healthcare leaders have to have in mind now that the crisis phase of the pandemic has passed. "One is building trust in the workforce. Second is building trust among patients. Third is developing a deeper and broader sense of patient safety. Fourth is understanding what consumerism really means—how do you build trust among people when they are not directly in front of you."
1. Building trust in the workforce
The first path forward is building trust in the workforce, Lee says.
"One definition of trust that I like is confidence that you are going to be treated fairly in circumstances you have not even thought of yet. We need everyone working in our healthcare organizations to feel that way about their organization. To do that, the organization and its leaders have to show that they understand what is important to the people working there, that they are authentic, and that they have a plan for making sure that the workers are taken care of. Those are the three key elements of trust building with the workforce," he says.
If healthcare workers trust their organization, it can promote pride and other positive factors, Lee says. "Data shows us that of course you have to pay people better, of course you have to try to do what you can to staff adequately, but the factor that is actually the main determinant of whether people in the workforce stay with your organization is the pride that they feel. It is the teamwork. It is the sense of inclusion. It is the culture. These are much more powerful determinants of whether people stay or go. This may sound like rhetoric, but it is supported by our data."
2. Building trust among patients
Patients want to know that their healthcare providers are well organized and efficient, Lee says. "Turning to patients, yes, patients do care about what their clinicians are like—are they showing empathy, are they coordinating with other clinicians, are they communicating well? But research from the past few years has shown that other things matter, too. The thing I would focus on is friction before the patient visit—chaos can shake patients' trust in the system. They want to know that their caregivers have their act together."
3. Developing a deeper and broader sense of patient safety
Attentiveness to patient safety is a crucial path in the way forward, he says. "Whether it is inpatient or outpatient, if patients see anything that shakes their confidence that things are excellent in terms of their safety, then they can't trust the whole system."
There needs to be a deeper sense of patient safety, Lee says.
"One of my favorite examples comes from the United Kingdom, where the nurses in one set of hospitals argued for switching to a disinfectant that did not smell like a disinfectant. After they switched, the patient experience declined, and there were increased complaints about cleanliness. That's because without the smell of the disinfectant, people did not feel safe. So, the thing that I emphasize is that we not only have to worry about keeping patients safe from physical harm but also keep them safe from emotional harm. We have to make them feel safe."
4. Understanding consumerism
For consumerism and people making choices, healthcare leaders must understand what builds trust among consumers, he says. "Managing what they see online, giving them lots of information such as comments and pictures, then giving them consistency by exporting those comments and pictures to third-party websites—it seems obvious that we are going to be moving in this direction, and some organizations are getting there faster than others."
Healthcare organizations need to revolutionize their customer service capabilities, Lee says. "Healthcare needs to go through what banking went through. Many of us can remember being agitated about whether we would get out of work in time to get to the bank to deposit a check. Now, there are digital interfaces to conduct banking. We need to get to the same place in healthcare, where consumers can get things done 24 hours a day, but we are not all going to get there at the same time, and organizations that get there faster are going to have advantages."
At Scripps Health, clinicians play an essential role in supply chain decision making.
Engaging clinicians is pivotal in healthcare supply chain such as value analysis and standardization initiatives, the top supply chain executive at Scripps Health says.
Cecile Hozouri, MBA, has been corporate vice president of supply chain at Scripps since 2010. She joined the San Diego-based health system as a supply chain manager in 2003.
HealthLeaders recently talked with Hozouri about a range of issues, including the keys to supply chain success, conducting value analysis for products, and enlisting clinicians in supply chain decision making. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary elements of supply chain success?
Cecile Hozouri: First and foremost, you need an effective supply chain team. I have a very engaged team that helps solidify and support the supply chain across the organization and helps get changes done.
Another piece is a collaborative approach with clinicians. We are constantly connected with someone from the medical staff, the nursing teams, advanced practice nurses, or even our chief operating executives to have conversations about something we are thinking about doing.
At its best, supply chain is a vehicle for change. The Scripps executive team supports us in seeking change. All of our top executives are very supportive of moving forward with change. This is where the collaborative relationship with our clinicians is crucial. The only way we are going to achieve success with a change is if clinicians are doing it with us.
HL: What are the primary challenges of serving as corporate vice president of supply chain at Scripps?
Hozouri: For the past three years with the coronavirus pandemic, we have had significant challenges in the supply chain. That includes everything from raw materials, to specialty products, to the simplest plastic products such as syringes and basins. We have been able to tackle the most critical supply shortages by working directly with our nurses and clinicians who utilize these products and determine the best options for substitutions while their primary manufacturers are unable to produce the original products. It has been a challenging three years, and it continues to be challenging.
While we have managed those challenges with the supply disruptions and backorders, we are also combatting supply cost increases. We have had multiple conversations with our vendor partners to strategize what we can do together to offset those increases.
HL: How do you rise to the challenge of increased costs?
Hozouri: I have a very effective strategic sourcing team and contractual team that supports this piece. We have an integrated supply chain with our clinicians, which helps us manage costs. When it comes to cost increases, we are bringing those vendors to the table. When it comes to a physician-specific product, we make the physicians aware of what the cost increases look like, and they help us with that. They may choose another product.
HL: Do you work with a group purchasing organization?
Hozouri: We utilize a group purchasing organization called HealthTrust. They provide a wide variety of supply and service standardization opportunities for us. They have a full portfolio of commodity, service, and specialty product contracts that have been negotiated at great rates.
Cecile Hozouri, MBA, corporate vice president of supply chain, Scripps Health. Photo courtesy of Scripps Health.
HL: How do you conduct value analysis?
Hozouri: We have a clinical value analysis governance structure that is chaired by our physician leaders at Scripps. And within our own supply chain department, we have a clinical team that is made up of nurses with backgrounds in surgery, cardiac care, critical care, and med-surg. Our nurse team works closely with our service line leaders and connects with our nursing departments to review supply utilization data specific to their areas of expertise. Those reviews are centered on quality metrics and supply variation across our health system.
Our supply chain team also supports the clinical service lines in new product and technology requests, and they review how new requests may support our patient experience. Our collaboration with the clinical service lines is designed to choose the best products for the best patient outcomes at the best price possible.
HL: How is supply chain management organized at Scripps?
Hozouri: We have a very connected supply chain at Scripps. We have a corporate office function that has our contracting, procurement, and value analysis team. Then we have operations and logistics teams that work directly with our hospitals and clinics. Logistics supports all product and equipment needs for our standard processes such as ordering, receiving, and inventory management.
HL: How do you include clinicians in supply chain decision making?
Hozouri: Involving our clinicians is critical to our supply chain processes. On a daily basis, our logistics team or our nurses in value analysis work very closely with our service line physicians and nurses to address product disruptions. The physicians and the nurses review our recommended product substitutions if the manufacturers are unable to produce their usual products. We need their feedback to make sure that the substitutions can support patient care.
Clinicians also support us on cost-reduction initiatives, and clinicians review standardization efforts with our supply chain teams. For example, our emergency department clinicians came forward and asked about disposable devices that are used once and thrown away. We looked into that opportunity, and they were right—we were spending a lot of money on disposable products and there was a lot of waste. With their help and collaboration, we achieved more than $1 million in savings.
HL: How do you engage clinicians when there are supply disruptions?
Hozouri: We usually have physician leaders within the service lines that we connect with. We also have a physician executive at each one of our hospitals that provide other point persons for us to go to. Overall, when we are dealing with a supply disruption, we reach out to the physicians and nurses in that service line and talk with them about the backorders and the items we need to substitute. We pick up the phone. We send emails. We share product information. We send out substitute products that they can touch and feel to make sure things are OK to substitute.
HL: How do you convince clinicians to standardize supplies?
Hozouri: When we do standardization projects, we work with clinicians as a group. For example, when we come forward with standardization ideas in surgery, we bring those ideas to the surgeons as a group and see whether they are willing to take a look at changes. Getting the physicians to the table has not been a challenge for our supply chain team. We have been working very well together, and providing the necessary data to make decisions has been an effective way to get clinicians to the table.
A Hancock Regional Hospital executive says workforce shortages are going to be a long-term challenge in healthcare.
Now that the crisis phase of the coronavirus pandemic has passed, healthcare providers need to adapt to the "new normal," a hospital chief medical officer says.
Julia Compton, MD, recently succeeded Michael Fletcher, MD, as CMO of Hancock Regional Hospital in Greenfield, Indiana. Before taking on the CMO role, she served as president of the Hancock Physician Network, which employs about 100 clinicians. Her clinical background is in radiation oncology.
Compton recently talked with HealthLeaders about a range of topics, including physician leadership, physician engagement, and clinical care predictions for 2023. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: Now that the crisis phase of the pandemic has passed, what are the primary clinical challenges at Hancock Regional Hospital?
Julia Compton: The biggest challenge is making sure that we have enough staff to take care of patients.
The other big piece is that there is a new normal and we have to adapt. That's tough. We need to pivot because what patients want has changed with the pandemic. For health systems like ours, we must pivot to the need of the patient. Traditional medical models are not going to be what patients want going forward. We will see that patients want much more individualized care. They want time with their physician.
HL: What are the primary elements of this new normal in addition to patients wanting more individualized care and more time with their physicians?
Compton: It's learning to utilize artificial intelligence. Learning to utilize data that not only helps the physician but also helps the patient. It's looking around and saying, "Who has built some of this capacity better that can help with patient care?" Physicians have never wanted to spend their time in the electronic medical record, and that is where traditional medicine has gone. What we are going to see is a pivot away from that. There is going to be more face-to-face time with patients, which could mean using more direct primary care models and other new models of care. It also could involve addressing the social determinants of health to help physicians provide the type of care that patients need.
Julia Compton, MD, chief medical officer of Hancock Regional Hospital. Photo courtesy of Hancock Health.
HL: What are the primary challenges of serving as CMO of Hancock Regional Hospital?
Compton: The biggest challenge we are facing now is labor shortage and how that is impacting not only our hospital but also all hospitals in central Indiana. The labor shortage is tremendous. Like many hospitals, we have a lot of agency nursing supplementing our nurses. We are trying to create a new opportunity where travel nurses may want to remain and become a part of Hancock Health.
On the floors and ICUs, we are seeing that nurses are young. They are brand new. They are fresh out of school. A lot of them did not have clinical training because of COVID, so what the nurses are trained to do now is very different than traditional nurses prior to COVID. Nurses that would have been doing the lead in terms of training have retired. All of this has a massive ripple effect on our physicians and advanced practice providers in terms of influencing burnout and concerns about patient safety.
HL: Are you experiencing physician shortages?
Compton: Recruiting physicians has become difficult. We are finding our best recruitment is from friends of friends. Person-to-person relationships and recommendations are crucial. But what we are seeing is that there are just not a lot of physicians out there. For us, the need for hospitalists is high. The need for certain subspecialties such as gastroenterology is high. Those physicians are very difficult to recruit now.
HL: How are you rising to that physician recruitment challenge?
Compton: We are looking to our own doctors to contact friends or colleagues who they would want to invite to our hospital. We have started offering a recruitment bonus to doctors who have candidate recommendations. There is a recruitment bonus if a candidate interviews and a recruitment bonus if a candidate is hired.
In our physician recruitment, we are accentuating the positives of working at Hancock Regional Hospital. Our hospital is relatively unique in that it is in a suburb area near Indianapolis, meaning that we have a smaller state feel but you are 20 minutes from the big city. So, we are big enough to be interesting, innovative, and cutting-edge, but small enough for physicians to have an impact on the community.
HL: What are the key elements of physician engagement at Hancock Regional Hospital?
Compton: During the pandemic, our doctors united and became engaged on every level to move the organization forward, to have a cohesive plan, and to have an incredibly fast and innovative response to COVID.
We had a new meeting three times per week with our doctors from noon to 1 p.m., and there was a lot of idea sharing. More than 90% of our doctors were engaged in those calls. We created triage clinics. We created respiratory clinics. We stood up monoclonal antibody infusion centers. We created several surge protocols. That engagement piece has continued. We want to keep that momentum going.
Instead of having a call three times per week, we have a call monthly. We also have other avenues to keep our physicians engaged. For example, we are inviting physicians to participate in large strategy sessions. All physicians and advanced practice practitioners are invited. The meeting is held from 7 to 8:30 a.m. We delay the start of clinics until that meeting is over, which provides everybody with the opportunity to participate.
HL: What are the keys to success for physician leadership?
Compton: People assume that physicians are natural leaders, and they are natural leaders in their own offices. But when you ask a physician to go into physician leadership at a higher level in the organization such as outside their own service line, one of the biggest keys to success is that you can no longer think as an individual. Instead, if a decision is made or if we implement a new strategy, there will be a ripple effect that impacts many people, and the many must be considered.
As physicians, we are taught to focus on a problem and to immediately solve it, and there are a small number of outcomes from the solution. In physician leadership, when you start working at different levels of an organization, you realize there is rarely one answer to a problem. There are many pros and many cons with every decision, and you must think through those pieces.
In addition to moving from thinking as an individual to thinking about the many, physician leaders need to learn how to listen very well. Physicians are used to having the answer—we need to have the answer if we have a very sick patient. In physician leadership, you find that there are many answers and there are many incredible brains around the table. In physician leadership, you are not always going to be the one who has the answer.
HL: Do you have any clinical care predictions for 2023?
Compton: One thing will be living with a new normal of labor shortages. Many people have been hoping it would end, but I don't think it is going to end. It is something that we will all have to adapt to and figure out how to manage the workforce differently.
Innovation is my second prediction. We are already starting to see big players innovate in healthcare. It will be interesting to see what Amazon does after some of its recent purchases in the healthcare arena. I assume they will be able to do things well, including virtual medicine. The opportunity for us at the hospital level to innovate will become even more important in 2023 and going into 2024.
There is going to be considerable healthcare fatigue in 2023. During the pandemic, ambulatory clinicians had difficulties they had to deal with and that was also true on the inpatient side. So, each type of physician and each type of advanced practice practitioner has seen COVID through a different lens, and now clinicians are genuinely tired.
There is going to be an increased emphasis on mental health in 2023, not only adult mental health but also child mental health.
The last prediction I would make is that we are going to see an increase in cancer diagnoses and chronic disease diagnoses. Patients are becoming sicker, and a lot of that has to do with the annual wellness visits that so many people either put off or could not get scheduled during the pandemic. As people get back into cancer screening and annual wellness visits, we are going to see a sicker patient population not only from chronic disease but also with oncologic diagnoses.
Matthew Owens, MD, chief clinical officer of Mercy Health-Lima. Photo courtesy of Bon Secours Mercy Health.
Cecile Hozouri, MBA, corporate vice president of supply chain, Scripps Health. Photo courtesy of Scripps Health.
