Promoting joy is a powerful approach to addressing healthcare worker burnout.
Fostering meaning and purpose in staff members is the key to promoting joy in healthcare workplaces, a healthcare well-being expert says.
Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency. Burnout continues to play a leading role in the widespread healthcare workforce shortages.
Elizabeth Goelz, MD, is an internal medicine physician and associate director of the Hennepin Healthcare Institute for Professional Worklife in Minneapolis.
HealthLeaders recently interviewed Goelz to discuss the intricacies of promoting joy in healthcare workplaces. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary elements of joy in healthcare workplaces?
Elizabeth Goelz: Joy can have different meanings for different people. Creating joy directly is not a goal that I would try to pursue. It is really about cultivating a workplace where meaning and purpose thrive—that creates the space for joy to exist.
HL: What are the primary elements of meaning and purpose?
Goelz: When you think about what brings you meaning in your work or what brings you purpose in your work, is it providing quality care, is it connecting with people, is it easing the burden of suffering for others? Those are the kind of large, overarching things that are often meaningful and purposeful to healthcare personnel. Then the question is, what does that look like? Does that look like having adequate time to see patients? Does that look like having access to the right resources when taking care of patients? Does that mean having adequate support staff? Does that mean having an electronic medical record that is not obstructing the work that needs to be done?
What meaning and purpose are and what they look like to cultivate meaning and purpose are separate but related questions. It’s more about finding examples than having a dictionary definition.
HL: How can healthcare organizations make healthcare workers feel valued?
Goelz: For some people, it simply takes acknowledging their hard work. For other people, it is making time for things such as eating healthy food, or showing you value their work-life balance by not contacting them after hours, or respecting their time by not having unnecessary meetings or unnecessary emails.
There are a lot of different things that can make people feel valued. But it all comes back to creating space for meaning and purpose to thrive, and saying "thank you."
HL: Conversations about what matters most to staff can help determine projects with the best potential for creating space where joy can exist. What kind of process can promote these conversations, then translate the conversations into actions and programs?
Goelz: You need to commit to asking what matters to staff members. That is the most important step. Then you need to log the answers and reflect on the information received. It is a commitment to a culture of curiosity and change. It can take the form of asking what matters during daily or weekly team huddles, and a monthly time to reflect on the information collected, plan ideas for modifications, and reconvene to assess the progress from previous months. It can take the form of a survey. Most certainly, it includes having a point person to lead this type of work. If nobody is in charge of something like this, it simply won't get continued. Having a point person for this work says something about an organization’s commitment to a healthy workplace.
The Institute for Healthcare Improvement has a spectacular white paper on "what matters to you?" conversations. The white paper gets at the practical tools and the importance of having these conversations.
HL: Who are good candidates to be a point person in conversations about what matters most to staff?
Goelz: A chief wellness officer is the best person to do this work. A chief wellness officer can keep tabs on the work, report back to the C-Suite, and be the person who is coordinating the work. If an organization does not have a chief wellness officer, there are other people who can serve as a point person. In any organization, there are undoubtedly people who are interested in what matters to staff. Simply listening can identify who those people are. Having a point person can involve carving out a small amount of FTE for somebody to be the go-to person not only for the healthcare team but also the go-to person for the C-Suite.
In addition, there are many organizations that have wellness champions—someone from each department who stays on top of wellness work who can report back to the point person.
HL: How can healthcare organizations identify what brings meaning and purpose to healthcare professionals?
Goelz: You simply need to ask. The "what matters to you?" conversation illustrated in the IHI white paper can be a great way to go about it. Ask, log the answers, and commit to a culture of asking, recording, reflecting, changing, and repeating. Without asking, there is no other way to identify what brings meaning and purpose. We can assume that meaning and purpose is related to providing quality care. We can assume, but you must ask.
For people who are stressed or are already burning out, it is easy for them to assume that if they are not asked about meaning and purpose, then the organization does not care about it. There are a lot of things that an organization asks about, and if meaning and purpose are not being asked about, that sends a message.
HL: How can healthcare organizations create the space for joy during disruptions such as leadership changes and staffing shortages?
Goelz: First, leadership changes should always include consideration of commitment to joy and wellness prior to hiring a leader because the right leadership team is essential for prioritizing this kind of culture.
Beyond that, joy is about meaning and purpose. So, learning what creates meaning and purpose for your healthcare workers can show organizations what to prioritize during inevitable disruptions. For example, if having the appropriate amount of time to see patients is something that allows meaning and purpose to thrive, then it should be prioritized.
If having the right support staff is important, which is different for different types of organizations, then it should be prioritized. A safety net organization is going to have different staffing resource needs than a non-safety net organization, particularly when it comes to community health workers and social workers. So, prioritizing staffing around the needs of the community that the organization serves shows commitment to the meaning and purpose of the healthcare workers.
Racial disparities that existed prior to the pandemic remained problematic in the first year of the public health emergency, according to a new study.
Breast cancer screening disparities persisted in the first year of the coronavirus pandemic, and screening of some minority groups did not bounce back as well as it did for White women, according to a new study.
Breast cancer screening has the potential to detect disease at its earliest stages, when it can be treated most effectively. Racial disparities in breast cancer screening rates have been shown in earlier research. For example, data published before the passage of the Affordable Care Act showed that Black and Hispanic women without insurance were less likely to have access to mammography.
The new study, which was published online by the journal Evidence-Based Oncology, analyzes breast cancer screening rates for two periods: March 1 to Sept. 30, 2019, and March 1 to Sept. 30, 2020. The research features data from more than 14 million patient records in a multipayer database that included Medicare fee-for-service, managed Medicaid, and commercial insurance beneficiaries. The study was conducted for the nonprofit Community Oncology Alliance (COA).
The researchers examined data for five racial groups: White, Black/African American, Hispanic/Latino, Asian/Native Hawaiian/Pacific Islander, and American Indian/Alaskan Native.
The study includes several key data points.
In 2019, mammogram utilization among Asian, Hispanic, and American Indian/Alaskan Native beneficiaries was lower than utilization among White beneficiaries.
At the peak of the first COVID-19 wave in April 2020, mean monthly screening rates for White Medicare fee-for-service patients plummeted to 0.6% of eligible beneficiaries. The screening rate recovered to 6.5% of eligible beneficiaries by June 2020, which was above the pre-pandemic level of about 6.1%.
Asian, Hispanic, and American Indian/Alaskan Native women did not experience a rebound in screening rates until September 2020.
American Indian/Alaska Native women experienced the most striking screening disparities. In June 2020, screening rates for American Indian/Alaska Native women were less than half of White women. At the peak of the first COVID-19 wave in April 2020, screening rates for American Indian/Alaska Native women fell to 0.5% of eligible beneficiaries and only recovered to 3.1% in June 2020.
Pre-pandemic mammogram utilization disparities remained in September 2020 among Black (6.2%), Hispanic (4.3%), and Asian (4.5%) women.
The lead author of the study said the research is troubling for breast cancer care in general and minority women in particular. “What’s worrisome is that the combined two-year lag in screenings we are reporting will translate into not only more and more severe breast cancer cases, but that the cancer health disparities we already knew existed have remained stubbornly unmoved,” Debra Patt, MD, PhD, MBA, executive vice president at Texas Oncology and secretary of COA, said in a prepared statement.
Healthcare providers should be encouraging their patients to get routine cancer screenings, Kashyap Patel, MD, a practicing oncologist who is a co-author of the study and president of COA told HealthLeaders.
“We can have multiple interventions. At Community Oncology Alliance, we have a program called Time to Screen. Every Community Oncology Alliance practice is trying to do their best to make their patients aware of cancer screening when they come to the office. We ask about their spouses and other family members to see whether they need cancer screening,” he says.
Linguistic barriers are an issue, Patel says. “For patients for whom English is not the main language, they need explanations about cancer screening in their own language. Community Oncology Alliance has started multi-linguistic approaches, including through social media. We are trying to use a multi-pronged approach to educate patients as much as we can to make them aware about the need for screening and consequences of not getting screened.”
The Lown Institute has ranked city hospital markets and individual hospitals by racial inclusivity.
A new report uses a racial inclusivity metric to examine how well 2,800 hospitals serve people of color in their surrounding communities.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The new report from the Lown Institute uses Medicare claims and U.S. Census Bureau data in a racial inclusivity metric. Vikas Saini, MD, president of The Lown Institute, described how the racial inclusivity metric works during a webcast yesterday.
"For every hospital, we used Medicare claims data to determine the Zip codes where that hospital's patients came from. We then used that data to define the perimeter around the hospital that represents the entire area from which patients could have come. We call this the hospital community area. Once we have a hospital community area, we then use the Census data to compare the demographics of the Zip codes of where patients actually come from for a hospital to the demographics of the whole hospital community area. This let's us see which communities are being over- or under-represented for any given hospital," he said.
Using this racial inclusivity metric, the Lown Institute was able to rank hospital markets and hospitals based on racial segregation.
The following 10 cities had the most racially segregated hospital markets, with at least 50% of their hospitals falling in the most or least racially inclusive categories:
1. Detroit, when considering service to all patients, it is 90% segregated
2. St. Louis, 77% segregated
3. Kansas City, Missouri, 75% segregated
4. Atlanta, 68% segregated
5. Philadelphia, 68% segregated
6. Washington, DC, 63% segregated
7. East Long Island, New York, 61% segregated
8. Houston, 58% segregated
9. Baltimore, 56% segregated
10. Manhattan, New York, 55% segregated
The 10 most racially inclusive hospitals in the report were as follows:
1. Lakeside Medical Center, Belle Glade, Florida
2. St. Charles Madras, Madras, Oregon
3. Metropolitan Medical Center, New York
4. Boston Medical Center, Boston
5. John H. Stroger Jr. Hospital, Chicago
6. The University of Chicago Medical Center, Chicago
7. Harlem Hospital Center, New York
8. Truman Medical Center Hospital Hill, Kansas City, Missouri
9. Methodist Dallas Medical Center, Dallas
10. Grady Memorial Hospital, Atlanta
The 10 least racially inclusive hospitals in the report by rank were as follows:
2769 Palos Community Hospital, Palos Heights, Illinois
2770 St. Elizabeth Dearborn Hospital, Lawrenceburg, Indiana
2771 St. Elizabeth Fort Thomas, Fort Thomas, Kentucky
2772 Mercy Hospital South, St. Louis
2773 Peterson Regional Medical Center, Kerrville, Texas
2774 Cass Regional Medical Center, Harrisonville, Missouri
Reflections on racial inclusivity
The analysis is a reflection of structural racism in healthcare, Saini said during yesterday's webcast. "I view the data and the method as a measure of structural racism. For me, the 'structuralness' of it means that it is deeply embedded in history, patterns of residential segregation, bifurcation of the labor market, and bifurcation of the insurance market. Then you get these patterns of segregation."
Race plays a role in elective surgery, he said. "With elective surgery, although it declined in 2020 because of the pandemic, we saw a pattern. What we saw was that elective patients were drawn from whiter and wealthier areas in a hospital's surrounding community. That is not a surprise—70% of hospitals were less inclusive for elective patients than for their population as a whole. Elective surgeries are part of a selective, biased process."
Financial incentives drive racial inclusivity in healthcare, Anthony Iton, MD, JD, MPH, senior vice president of healthy communities at The California Endowment, said during yesterday's webcast. "We have constructed a market-justice-oriented healthcare system that does not respond to the needs of people—it responds to the privilege of people and their ability to pay."
Segregation in hospital markets and at individual hospitals is not the result of malicious healthcare leadership, Iton said. "When you see this over and over again, you are looking at a pattern—you are not looking at a bunch of bad actors. You are looking at a normal reaction to a set of incentives. The problem is the incentives. There are not bad people running hospitals—they are doing exactly what anybody would do under the constraints."
Thomas Sequist has been promoted from chief patient experience and equity officer to serve as the health system's top physician executive.
Boston-based Mass General Brigham has appointed the health system's first chief medical officer.
Thomas Sequist, MD, MPH, was announced as the health system's CMO last month. He has been with the health system since 1999, when he started his residency at Brigham and Women's Hospital. He still practices as a primary care physician at the hospital, and before taking on the CMO role, Sequist served as chief patient experience and equity officer at Mass General Brigham.
Sequist recently spoke with HealthLeaders about a range of issues, including leadership at Mass General Brigham, patient experience, health equity, and patient safety. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You are the first CMO at Mass General Brigham. What are your top goals in pioneering this new position?
Thomas Sequist: At a high level, the top goal that we have is to bring together the great minds that we have across our system to address some of the most pressing patient care concerns that we have in a way that we have not done in previous iterations of our organization. We want to all be driving toward a single purpose and a single set of strategies.
Diving down one layer deeper, our passion and our commitment across Mass General Brigham is going to be in the spaces of equity, patient experience, and maintaining our foundation of quality and safety. I hope that we are going to be able to substantially move the needle in the areas of equity and patient experience.
HL: What are your top goals in promoting patient safety?
Sequist: We want to maintain the ongoing excellence that we have in the hospital space, whether it is related to hospital-acquired infections or excellent outcomes related to acute myocardial infarction or congestive heart failure. We want to pioneer patient safety in spaces that are increasingly important; in particular, the ambulatory safety space.
As we move care more and more out of quaternary hospitals and into community hospitals, ambulatory centers, such as ambulatory surgical centers and medical offices, and home-based care programs, we need to parallel that movement with the development of important patient safety programs.
Ambulatory safety is a space where there is a ton of potential for us to make care even safer. It has different characteristics to it than the hospital space—it is much more episodic. A typical hospital stay is three or four days in a contained environment. Ambulatory care happens over time—it can happen over the course of months or even a year. It has many more providers and care team members involved, and much more degrees of freedom, which means it presents more challenges to patient safety. We are gearing up to address all of those challenges.
HL: What are your top goals in promoting community health equity?
Sequist: On community health equity, I separate that out between what we call health equity, which is related to the clinical delivery of care at our hospitals and offices, versus community health, which is related to a much broader concept of all of the neighborhoods we serve and how we improve their health status.
On the community health side, our top goal is to promote precision community health, which is using a data-driven approach to identifying the most pressing health concerns of a community and targeting our resources and interventions in partnership with community leaders to address those concerns. We are initially going to be focused on prevention of excess morbidity and mortality from substance use disorder and cardiovascular disease. Of course, we will not lose our attention to many of the other community health concerns, but we do want to have a targeted impact on those two areas.
On the health equity side, we have a platform called United Against Racism. This year and into the next year, our most pressing priority in the health equity space is continuing our journey of becoming an anti-racist organization. That journey takes many steps to accomplish from how we collect demographic information about our patients such as race, ethnicity, and language, to how we build out digital tools, to how we train our staff to deal with racism across our organization, to how we build care teams in primary care and staffing community health workers and social workers. We are taking a multifaceted approach to health equity, with the goal of achieving anti-racism across our organization.
HL: You have played a leadership role in the United Against Racism initiative. What have been the primary learnings from this program?
Sequist: We are about 15 months into the United Against Racism platform. Racism in healthcare is a large problem, so we are on a multi-year journey to try to have an impact.
So far, we have had an important impact in a few areas. For example, during the coronavirus pandemic, we and many others across the country noticed very early on that there was a digital access divide as telehealth stood up and people started doing video visits more regularly. We quickly noticed that many people in our Black and Latino populations were not able to access that technology and maintain their continuity of care.
We set aggressive goals to increase the enrollment rates of our Black and Latino patients into our electronic patient portal, which is the venue through which you do telehealth visits. Over the course of the past 18 months, we have seen aggressive increases in the rates of enrollment of our Black and Latino populations—more than 10 percentage point increases, which is a substantial increase in the number of patients who are now able to access the digital tools that we offer.
HL: What are your top goals in promoting patient experience?
Sequist: One of the things that we want to emphasize is that when our patients interact with our health system that they understand that they are not only going to be cared for but also cared about. It is the notion that we can provide excellent clinical delivery of care and at the same time we recognize there is much more to the patient experience. There is the care coordination. There is the empathy that we show to our patients. There is making sure that our patients have a comprehensive understanding of their care plans, so they can engage in their care in a meaningful way. We are dedicated to doing all of those things.
Another primary goal in our patient experience is going to be making sure that patients can both achieve the benefits of the scale of our health system and also not be overwhelmed by the scale of our system. That is a difficult balance to achieve. The benefit of the scale of our system is that we can treat every clinical problem of a patient—whether it is an advanced problem or a specialized problem. The diversity of the doctors, nurses, pharmacists, and staff that we have can treat a patient across the entire life span. However, with such a large and diverse system, we want patients to feel comfortable in navigating our system.
HL: How do you characterize your leadership style?
Sequist: There are a couple of things that drive me. The first is that I tend to lead through passion. I have been passionate about the things that I have been blessed to lead such as equity, community health, and quality.
The second thing about my leadership style is that I am impact-driven. The thing that matters to me the most is whether we are demonstrating that we are improving the lives of our patients and community members.
I also am someone who tends to thrive more as a leader in times of change.
After more than a decade of relatively stable medical liability premiums, rates are increasing significantly, a new report from the American Medical Association says.
Over the past three years, there has been a surge in the percentage of medical liability premiums with year-to-year increases, a new report from the American Medical Association says.
The last time there was a spike in medical liability premiums year-to-year was in the early 2000s, according to the new report. Medical liability premiums were largely stable through 2018, the report says.
The new report is based on data collected from annual rate surveys conducted by the Medical Liability Monitor(MLM), including the latest annual rate survey from October 2021. The data features "manual" premiums, which do not reflect credits, debits, dividends, or other factors that may affect the actual premiums that physicians pay for coverage.
The increases in medical liability premiums from 2019 to 2021 have added to the financial strain that physicians have experienced during the coronavirus pandemic, Gerald Harmon, MD, president of the American Medical Association, said in a prepared statement. "The medical liability insurance cycle is in a period of increasing premiums, compounding the economic woes for medical practices that struggled during the past two years of the pandemic. The increase in premiums can force physicians to close their practices or drop vital services. This is detrimental to patients as higher medical costs can lead to reduced access to care."
The new report has several key data points.
Premium decreases have become more rare over time and are now less likely than premium increases. In 2012, the percentage of premiums that decreased was 25.7%. In 2021, only 6.5% of premiums decreased.
The percentage of premiums that increased spiked after 2018, when 13.7% of premiums increased. In 2019, 26.5% of premiums increased. In 2020, 31.1% of premiums increased, which was higher than any year since 2005.
The number of large premium increases has also risen. In 2018, 3.9% of all premiums increased by at least 10%. In 2019, 3.6% of all premiums increased by at least 10%. In 2021, 7.5% of all premiums increased by at least 10%.
Twelve states experienced double-digit premium increases in 2021. Illinois led all states with the largest proportion (58.9%) of premiums that increased 10% or more, followed by West Virginia (41.7%), Missouri (29.6%), Oregon (20%), South Carolina (16.7%), Idaho (11.1%), Kentucky (7.4%), Delaware (6.7%), Washington (6.7%), Michigan (5.4%), Texas (4.9%), and Georgia (3.7%). The size of the largest premium increase in these states ranged from 35.3% in Illinois to 10% in Idaho and Washington.
There were substantial geographic variations in premiums. For example, in 2021, manual premiums for general surgeons in Los Angeles County, California, were $41,775, compared to $215,649 for general surgeons in Miami-Dade County Florida.
There also were substantial premium variations by specialty. For example, in Nassau County, New York, premiums were $32,159 for internists, $146,353 for general surgeons and $165,824 for OB/GYNs.
Interpreting the data
The upward trend in premiums is not as severe as the last "hard market," according to the new report.
"The last hard market—also referred to as the liability 'crisis'—took place about 20 years ago, in the early 2000s. It was characterized by dramatic increases in premiums. In 2003 and 2004, respectively, 77.4% and 82.1% of premiums increased from their levels in the previous ears. Some general surgeons in Miami-Dade County, Florida, faced manual premiums that increased from $110,068 in 2000 to $277,241 in 2004," the report says.
However, premiums are trending toward a hard market, the report says. "In 2019 for the first time since the last hard market, the share of premiums that increased year-to-year went up significantly. Then in 2020, an even higher proportion increased, when 31.1% of premiums went up from the previous year. In fact, this was the highest proportion observed since 2005. Once again in 2021 and despite a small dip, almost 30% of premiums increased from the previous year—the highest proportion observed since 2006."
State data indicates a hard market is forming, the report says. "According to some actuaries, we were already in the early stages of a hard market in 2020, as insurers started raising premiums in response to deteriorating underwriting results, lower loss reserve margins, and lower returns on investment. Thus, it was expected that insurers would sustain or even push for higher premiums in 2021. The 2021 MLM data suggests that this is coming to fruition. Although large increases were concentrated in certain states, small increases in premiums were more widespread. In 2020, premium increases were observed in 33 states and in 2021, they were reported in 32 states. Twenty-four states saw increases in both of those years."
For now, the ultimate direction of the medical liability market remains to be seen, the report says. "It is not atypical for there to be hard and soft markets, for premiums to go up and down, as this is part of the insurance cycle. How severe and widespread the current hard market will become—how many premiums will increase, how high they will go and whether other states will follow suit in seeing their premiums go up—is still uncertain."
Staffing shortfalls were already a concern prior to the coronavirus pandemic, but they have reached crisis levels during the pandemic, according to ECRI.
ECRI released a report today on the Top 10 patient safety concerns of 2022.
ECRI is an independent, nonprofit organization dedicated to improving the safety, quality, and cost-effectiveness of care across all healthcare settings. The organization's annual Top 10 patient safety list is developed by multidisciplinary staff at ECRI and the organization's affiliate, the Institute for Safe Medication Practices (ISMP). Patient safety concerns are also validated by scientific literature as well as ECRI and ISMP data such as accident investigations and reported medication safety problems.
The Top 10 patient safety concerns of 2022 are as follows.
1. Workforce shortages: "Even before the COVID-19 pandemic, there was a persistent shortage of clinical and nonclinical staff across the continuum. Staffing shortages have continued to increase throughout the pandemic," the ECRI report says.
2. Healthcare worker mental health problems linked to COVID-19: "An often discussed but inadequately addressed collateral result of the COVID-19 pandemic is the toll it has taken on the mental health of healthcare workers. Healthcare professionals' mental health was already at crisis level before the COVID-19 pandemic; both physicians and nurses were at risk of burnout, emotional exhaustion, or depression prior to 2020. The pandemic has now forced a reckoning with healthcare workers' mental health needs," the report says.
3. Bias and racism in addressing patient safety: "Racial and ethnic disparities have been well documented in how they affect access to care and outcomes. What is less well publicized is that disparities can even affect how adverse events are reported and responded to. … Although patients from racial and ethnic minority groups are more likely to experience an adverse event while in the hospital, providers are significantly less likely to report harmful events for patients from minority groups than for white patients. In one study, the odds of reporting patient safety events in African American patients were only 0.65 times the odds of reporting in white patients," the report says.
4. Vaccine coverage gaps and errors: "The success of any vaccine relies on correct, widespread administration to appropriate populations. Vaccine gaps and errors may harm patients or provide inadequate protection against serious diseases," the report says. The most frequently reported vaccine errors include wrong vaccine, wrong dose, and expired vaccines.
5. Cognitive biases and diagnostic error: "Cognitive biases can result in misdiagnoses by skewing how clinicians gather and interpret evidence, take action, and evaluate decisions," the report says. For example, anchoring bias occurs when clinicians stick to an initial impression despite the development of conflicting evidence.
6. Nonventilator healthcare-associated pneumonia: "Pneumonia is the most common healthcare-associated infection in the United States and is linked to substantial morbidity and mortality. Despite the attention placed on ventilator-associated pneumonia, nonventilator healthcare-associated pneumonia (NVHAP) diagnoses in the United States make up 65% of the cases, compared with 35% associated with ventilators," the report says.
7. Human factors in operationalizing telehealth: "Overlooking human factors in the design, implementation, usability, and evaluation of telehealth systems may lead to a situation mirroring what happened during the widespread adoption of electronic health records (EHRs), which caused numerous issues for providers and patients alike, including: fractured adoption, interrupted workflows, user dissatisfaction, [and] complete system failure," the report says.
8. International supply chain disruptions: "The United States heavily relies on international manufacturers to produce medical equipment, drugs, and other healthcare supplies. While medical supply and drug shortages have long been a problem in healthcare, this issue has been exacerbated by international supply disruptions resulting from the COVID-19 pandemic and other recent natural disasters," the report says.
9. Products subject to emergency use authorization: "During emergencies, the U.S. Food & Drug Administration (FDA) can issue emergency use authorization (EUA) for drugs, devices, or biologics for serious diseases or conditions when no FDA-approved alternatives are available. However, FDA requires lower levels of evidence of safety and efficacy for EUA issuance than for FDA approval," the report says. Several EUAs have been issued during the coronavirus pandemic.
10. Telemetry monitoring: "Telemetry monitoring (TM) provides real-time measurements of monitored physiologic parameters from a distance. Technological breakdowns as well as breakdowns related to clinician response increase the risk of patient harm by the disruption in identification of critical and abnormal changes in a patient's health status," the report says. Common problems with telemetry monitoring include alarm fatigue, equipment not connected as ordered, patient connected to the wrong equipment, and equipment malfunctions.
The Association for Professionals in Infection Control and Epidemiology has published an expansive report on how the United States can be better prepared for the next pandemic.
Federal, state, and local policy makers have a lot of work to do to prepare the country for the next pandemic, the Association for Professionals in Infection Control and Epidemiology (APIC) says in a new report.
The United States was inadequately prepared to respond to the coronavirus pandemic such as insufficient supplies of personal protective equipment (PPE). The country leads the world in COVID-19 deaths, with 991,260 lives lost as of today, according to worldometer.
More than a dozen infection preventionists contributed content to the new report, which APIC 2022 President Linda Dickey, RN, MPH, said requires urgent attention. "APIC is issuing this call-to-action as we all recall the nightmare of extensive supply shortages and overworked healthcare workers. Especially troubling to APIC is how many preventable infections were transmitted inside hospitals during COVID because resilience was not built into our healthcare system," she said in a prepared statement.
Sizable investments will be necessary to prepare the country to respond effectively to the next pandemic, she said. "For the U.S. to create a safer, more resilient healthcare system, policymakers should make the substantial investments recommended by the hands-on infection prevention experts who had a unique vantage point as the pandemic overwhelmed hospitals, nursing homes and clinics nationwide."
The report makes 10 recommendations to improve pandemic preparedness in the United States.
1. Improve PPE
Congress should fund research at the National Institute for Occupational Safety and Health to develop a one-size-fits-all respiratory device that can be used in healthcare facilities during infectious disease emergencies.
Congress should fund research to replace some disposable PPE with PPE that is cleanable and reusable.
2. Promote the use of masks in response to infectious disease threats
Federal, state, and local officials should recommend that the general public use masks to combat respiratory viruses.
Congress should fund research to develop standards for masks for the general public and to determine the best types of masks for different types of infectious diseases.
Federal agencies should share mask research findings with the public to generate trust in mask use to prevent the spread of respiratory viruses.
3. Improve supply chain for PPE and disinfection supplies
Federal officials should develop better processes to manage, track, and rapidly distribute PPE during a public health emergency. This effort should include greater diversity in production locations.
Federal and state officials should anticipate high demand for essential supplies and be able to meet operational healthcare demand.
Federal officials should anticipate general-public demand for supplies such as cleaning materials to make sure essential supplies are available for healthcare workers and facilities.
Government officials should research when PPE can be decontaminated for reuse by healthcare workers.
4. Infection preventionists should play prominent roles during a pandemic
Federal officials should require that infection preventionists serve on healthcare facility incident command and emergency response teams.
Federal officials should require that infection preventionists play a role in determining policies and protocols related to disease transmission at healthcare facilities such as patient placement, workflow reviews, and patient isolation.
Federal officials should require that infection preventionists serve on teams that develop crisis standard of care protocols for PPE, anti-infective therapy, and vaccinations at healthcare facilities.
Federal officials should require that an infection preventionist participate in developing an infectious disease surveillance program for healthcare facilities.
Federal officials should require that an infection preventionist should oversee the analysis and reporting of pandemic surveillance program data for a healthcare facility.
5. Properly trained healthcare workers should staff high-risk settings
The Centers for Medicare & Medicaid Services (CMS) should require nursing homes to have at least one infection preventionist.
CMS should require additional nursing home staff to be trained in infection prevention and control (IPC) to establish surge capacity during an infectious disease outbreak.
CMS should require routine mandatory surveillance for healthcare-associated infections in nursing homes.
6. Promote infection prevention and control surge capacity
Congress should provide support to healthcare facilities to ensure they have enough infection preventionists during a pandemic.
Congress should provide support to healthcare facilities to make sure IPC and employee occupational health teams can do contact tracing, conduct employee exposure testing, and implement employee vaccination programs.
Congress should provide funding to address healthcare surges during a pandemic and avoid suspension of nonurgent medical procedures, which can lead to worse outcomes for individual patients and long-term public health problems.
7. Testing and contact tracing
Congress should make sure that healthcare facilities, public health agencies, primary care providers, and the public have access to testing.
Congress should fund contact tracing administered by public health agencies and healthcare facilities to limit the spread of disease during a pandemic.
8. Data sharing and interoperability for infection surveillance data
Congress should promote methods for rapid healthcare data collection and support the sharing of data between healthcare provider electronic health records, public health agencies, federal agencies, and the public. Data sharing and interoperability boosts testing, contact tracing, and other public health strategies to prevent the spread of disease.
9. Vaccine confidence
Congress should direct federal agencies to make efforts in public health education about the benefits and effectiveness of vaccines in preventing infectious diseases.
Congress should fund research and share strategies to address vaccine misinformation.
Policy makers should fund healthcare facility IPC and employee occupational health departments to tackle vaccine hesitancy among healthcare workers.
10. Pandemic preparedness workforce capacity and training
Congress should provide funding for healthcare facilities to have enough IPC capability to support patient safety during a pandemic and have enough infection preventionists during a pandemic.
Congress should fund "just-in-time" IPC education and training for healthcare workers and the broader workforce during a pandemic.
Congress should support academic pathways at universities for infection preventionists.
Congress should fund incentives such as loan repayment programs to encourage the next generation of healthcare professionals to become infection preventionists.
The health system has several programs specifically designed to address healthcare worker well-being.
Phoenix-based Banner Health has a multifaceted approach to addressing healthcare worker well-being.
Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency. Prior to the pandemic, burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
The pandemic is straining the Banner Health workforce, Chief Clinical Officer Marjorie Bessel, MD, says. "We have all had a shared experience over the past two years with the pandemic and the toll of trying to respond to a once-in-100-years pandemic has been very difficult on the entire organization, especially on those on the frontline. We are experiencing increased levels of burnout and we are also seeing effects in other metrics that we track, such as engagement in the workplace through our employee surveys, and turnover rates, which we are seeing at unprecedented levels."
Promoting healthcare worker well-being is essential during the pandemic, she says. "I am thankful for our healthcare heroes. It is my absolute pleasure to continue to advocate and make sure that we are supporting those who have been taking care of all of us during this pandemic. I am incredibly grateful for the work that they do, and I want to make sure that we help all of them who have been providing great care under stressful conditions for more than two years."
Layered approaches to well-being
Banner Health has three primary programs that are designed specifically to address healthcare worker well-being, Bessel says.
The Well-Being Collaborative is a health system-level program with initiatives for all Banner Health employees. The collaborative has a range of supportive offerings and activities from virtual online support to physical challenges. "The idea is to approach health holistically and to offer activities to everyone," she says.
The Cultivating Happiness in Medicine (CHIM) program is targeted at physicians and advanced practice providers. CHIM has been crafted on an evidence-based, holistic model with six themes, including leadership development, social community, and individual wellness. A multidisciplinary team runs the program.
"Our oversight team looks to make sure that we are balanced and that we are doing different types of activities in each one of the six themes. The oversight team is also attuned to the voice of our customer. So, periodically, we do deep listening tours where we have conversations with the individuals we are here to support. We ask questions and try to elicit the perceived needs of people, then we slot them into our model and include them in our action plans for each year. We try to do the right kind of activities that meet the ultimate goal of improving well-being," Bessel says.
Social community events are a popular aspect of CHIM, she says. "Despite us being in a pandemic, we had more than 50% of our employed physicians and advanced practice providers participate in social community events in 2021. In 2021, there were 696 events. We provide funding for the events; we ask for physicians and advanced practice providers to lead the events themselves," Bessel says.
The Wellness in Nursing (WIN) program targets nurse well-being. "WIN is set up much like CHIM, where there is a multidisciplinary team that is heavily populated with nursing leaders who oversee a multifaceted program to help support nurses. WIN was launched about two years ago. They also have done listening tours to have conversations with nurses to learn about the types of programs that are needed. There also is some crossover and collaboration between the CHIM and WIN efforts," she says.
Recent well-being initiatives
Last year, Banner Health launched a peer-support initiative for physicians and advanced practice providers.
"We have trained individuals who volunteer to provide peer support. These volunteers are available to other individuals who need somebody to talk with. It is not a professional level of counseling, but it is more formalized and one-on-one compared to the social community events that we organize. We have 20 volunteers who have been trained to provide peer support. They receive eight hours of training, and they periodically receive virtual refresher courses. They also commit to filling out ongoing surveys so that we can make sure that the program is working well," Bessel says.
Also last year, Banner Health started creating "recharge rooms" for all healthcare workers.
"The recharge rooms are not exactly like virtual reality, where you wear a headset. These recharge rooms use immersive reality, and it is voice activated. You go into the recharge room and say, 'Elsewhere.' In the room, you experience a multi-sensorial activity. On the walls there can be pristine nature scenes and there are customized music scores that play. As you continue through the experience, the lighting changes. Each one of these scenes last for about 15 minutes, but if you start a scene and you do not like it, you can say, 'Elsewhere,' and pick a different scene from the menu. Because it is multi-sensorial, there can be individualized aromatherapy added to the experience," she says.
Measuring well-being
Banner Health uses multiple metrics to measure healthcare worker well-being, Bessel says.
"We track physician and advanced practice provider turnover. Those statistics have gone up in 2021 compared to 2020. From 2018, to 2019, to 2020, we did make some progress on turnover. The turnover statistics are a reflection of all things that lead to turnover—early retirement, people leaving for different healthcare endeavors, and people leaving healthcare all together. In addition to turnover for physicians and advanced practice providers, we use the Maslach Burnout Inventory tool—we started using that in 2018. We also have our own internal employee survey, which has two metrics that we like to track. One is the percentage of employees who recommend Banner Health as a great place to work, the other is the percentage of employees who say they are actively engaged," she says.
In 2020, female Maryland physicians earned 50% less on average than male physicians, the survey found.
A significant gender pay gap in physician compensation is persisting in Maryland, a new survey report has found.
Earlier research has shown a pervasive gender pay gap in U.S. physician compensation. A study published in December showed that through a simulated 40-year career, male physicians earn an average adjusted gross income that is about $2 million higher than female physicians.
The new survey report was produced for MedChi—The Maryland State Medical Society—by Merritt Hawkins. The physician search and consulting firm is a company of AMN Healthcare. The survey features 2020 data collected from more than 500 Maryland physicians.
The new survey report includes four key data points on the gender pay gap.
In 2020, female Maryland physicians earned 50% less on average than male physicians. The average annual income for male physicians was $320,000 compared to $213,000 for female physicians.
In 2020, female Maryland primary care physicians earned 41.2% less in average pre-tax annual income than male primary care physicians. The average pre-tax annual income for male physicians was $262,542 compared to $172,542 for female physicians.
In 2020, female Maryland physicians in surgical, diagnostic, and other specialties earned 33.5% less in average annual income than male physicians. The average annual income for male specialist physicians was $350,625 compared to $250,115 for female specialist physicians.
The gender-based pay gap changed little compared to MedChi's survey of 2016 Maryland physician compensation. In 2016, female Maryland physicians earned 49.6% less than male physicians.
The new gender-based pay gap data is discouraging, MedChi CEO Gene Ransom, JD, said in a prepared statement. "The fact that significant gender-based income disparities persist among Maryland physicians is both disappointing and perplexing. We expected to see at least some closure of this gap, but it remains as wide as ever."
The factors driving the gender-based pay gap in Maryland are unclear, James Taylor, MBA, MA, group president and CEO of AMN Healthcare's Leadership Solutions division, said in a prepared statement. "We see little difference in the employment contracts of male and female physicians. Nevertheless, the data show that female Maryland physicians earn less than males, even when specialty, hours worked, practice status, and age are factored into the equation."
The Merritt Hawkins 2019 Survey of Women in Medicine queried female physicians about what they thought were the causes of the gender-based pay gap in medicine. Unconscious employer discrimination was identified as the primary cause, followed by less aggressive or adept negotiating skills among female physicians compared to male physicians.
Other survey results
The new survey report features several other primary findings.
The data indicates the coronavirus pandemic has had a negative impact on physician compensation. Compared to 2016 average income for all Maryland physicians, 2020 average income was down 7.7%.
In 2020, Maryland physician average pre-tax annual income varied by race and ethnicity. Asian American physicians reported income of $325,000, white physicians reported income of $268,000, and African American physicians reported income of $225,000.
In 2020, employed Maryland physicians earned 26% less than physicians in independent private practice. Employed physicians earned an average pre-tax annual income of $262,000 compared to $299,000 for physicians in independent private practice.
In 2020, Maryland physicians reported that telemedicine accounted for 15% of their pre-tax income.
Maryland physicians expected telemedicine's share of their income to fall to 11% in 2021.
Maryland physicians expect only a modest percentage of their income this year will come from value-based payments. They projected that 9% of their pre-tax income will be linked to quality measures such as patient satisfaction scores and adherence to treatment protocols.
In a surprising finding, 50.3% of Maryland physicians reported that they were not professionally impacted by the pandemic. But there were disruptions because of the virus: about 5% of physicians closed their practices, 4.3% joined another practice, 3.7% were furloughed, 3% found work in another field, 1.2% were laid off, and 1.2% retired.
Researchers examined Yelp online reviews of 100 randomly selected acute care hospitals in the United States.
Based on an analysis of Yelp online reviews, acts of discrimination in the hospital setting can be categorized in six recurring patterns, including acts of commission, stereotyping, and intimidation, a recently published research article found.
Earlier research has shown that discrimination based on minority patients' race, sex, gender, sexual orientation, age, or disability generates worse health outcomes. The co-authors of the recently published research article found that Yelp online reviews provide insight into discrimination in the hospital setting that cannot be gleaned from traditional healthcare performance measures such as Hospital Compare.
The study, which was published by JAMA Network Open, is based on Yelp online reviews made from January 2011 to December 2020 of 100 randomly selected acute care hospitals in the United States.
The reviews were filtered with 31 keywords drawn from the Everyday Discrimination Scale such as race, racist, slur, threat, hate, and bias. A total of more than 10,000 reviews were collected and nearly 3,000 reviews were determined to be potentially related to discrimination. The research team identified 182 reviews that described at least one act of discrimination.
The study features several key data points.
53 reviews (29.1%) were categorized as institutional racism
72 reviews (39.6%) cited individual actors as sources of discrimination such as security guards, nurses, and physicians
89 reviews (48.9%) described acts of discrimination that occurred in clinical settings
25 reviews (13.7%) described acts of discrimination that occurred in nonclinical spaces such as lobbies
66 reviews (36.3%) included acts of discrimination by patients directed at healthcare workers
The researchers found that the acts of discrimination could be categorized in six patterns.
1. Acts of commission: "Instances in which actors showed their biases through purposeful acts of physical or verbal harassment. In extreme examples, a few reviews mentioned instances when actors violated patients' consent in carrying out abuses."
2. Acts of omission: "Acts of omission described instances in which medical care or basic needs, such as food or assistance with activities of daily living, were neglected or delayed by hospital staff. … Acts of omission frequently manifested around discussions of pain. Consumers described how a lack of attention to pain ultimately led to a missed or delayed diagnosis of an acute medical issue that was only discovered after seeking second or third opinions."
3. Dehumanizing: "Dehumanizing manifestations portrayed the consumer feeling dehumanized or devalued compared with others because of a particular personal attribute. For example, one consumer wrote, 'Why wasn't I greeted with enthusiasm, let alone greeted at all? Was it because of the color of my skin? Am I less of a person? Or was it because of age discrimination? In all my time here in the healthcare systems in [city], I’ve never once felt this invalidated.' Most frequently, consumers reported feeling dehumanized because of being ignored in a variety of settings."
4. Stereotyping: "Consumers often reported on racial and gender stereotypes that perpetuated poor health care treatment, including dismissal of symptoms and pain severity. In these scenarios, the patient came to the practitioner seeking treatment, only for their symptoms to be overlooked because of the practitioners’ prejudices and biases. These experiences occurred often among self-identified Black people and women."
5. Intimidation: "Intimidation manifested as verbal and physical tactics used by health care workers, such as threats of using specific medical protocols as punishments or intrusions into consumers' personal space, to bully and harass consumers during health care visits. Consumers reported being frightened by individual or institutional discrimination. Frequently, acts of intimidation occurred during psychiatric visits and toward self-identified women or older adults."
6. Unprofessionalism: "Discrimination described as unprofessional manifested as disrespectful or unprofessional behaviors, often including terms such as mean, rude, and condescending. In addition, several consumers noted that unprofessional individuals shared personal thoughts and opinions that expressed bias, judgment, microaggression, and macroaggression. In such instances, respondents believed that perpetrators’ negative attitude and treatment was caused by bias and in violation of the standard of care."
Interpreting the data
Institutional discrimination was present when an entire hospital or clinic was described as discriminatory, the lead author of the study told HealthLeaders.
"The reviews typically cited the hospital as the source of discrimination in these cases. A specific example was a consumer who said, 'Worst hospital ever. I went to the emergency room with my daughter, who had a non-stop running nose. Their customer service was horrible. They treated people not nice, like they were racists. I am Asian.' In that instance, the consumer cited the entire hospital. There was not just a specific nurse, receptionist, security officer, or physician. They associated the entire institution as the source of racism," said Jason Tong, MD, general surgery resident and national clinician scholar fellow, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Categorizing discrimination into patterns is helpful in addressing discrimination, he said.
"Discrimination is known as a difficult concept to study and target. Oftentimes, discrimination is thought of as a very experiential concept. However, by helping to organize discrimination into a taxonomy of recurring patterns, we can think of more effective ways to approach it. For example, as we highlight in our article, acts of omission have been used to describe a variety of patient safety issues such as medication administration errors. Importantly, people have already developed tools and approaches to types of acts of omission. So, by now thinking of acts of discrimination as another type of act of omission, we can apply pre-existing tools to address and study discrimination."
The research team deemed discrimination to be a form of patient harm, Tong said. "It goes back to the recurring patterns that we identified. The way that we did our study is we first went through many reviews, then the patterns emerged out of the data. At first, when we thought about it, a lot of the patterns seemed very familiar, and we went into the literature and found that all six of the recurring patterns had been previously described within the context of patient harm and patient safety, which is why we made the link to patient harm."