Physician reimbursement from Medicare decreased 29% from 2001 to 2024, according to the American Medical Association.
The proposed 2.8% physician payment cut in the 2025 Medicare Physician Fee Schedule is not sustainable, the CMO of a New Jersey-based health system says.
On July 10, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for the Physician Fee Schedule that would reduce the conversion factor for physician reimbursement from $33.29 this year to $32.36 next year. The conversion factor is the number of dollars assigned to a relative value unit (RVU), which is a key element of physician payment by Medicare.
If the payment cut is adopted in the 2025 Physician Fee Schedule final rule later this year, it would be the fifth consecutive year that physicians experienced a reimbursement cut from Medicare.
Physician reimbursement from Medicare decreased 29% from 2001 to 2024, according to the American Medical Association.
The proposed 2025 reimbursement cut would have a significant negative impact on health systems, hospitals, and physician practices, says Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer at RWJBarnabas Health.
"The cost of healthcare is rising," Anderson says. "There is clearly inflation in our economy, and having the reimbursement go down is absolutely the wrong direction. The Physician Fee Schedule model is not sustainable if the reimbursement is going to be cut. Reimbursement needs to keep pace with inflation and the cost of healthcare."
Medicare physician payment cuts are hitting the bottom line of healthcare organizations, according to Anderson.
"It handcuffs our health systems and hospitals to make the investments they need to make in infrastructure as well as to provide a fair wage to employees including physicians," Anderson says. "These reimbursements cuts are not going to help healthcare grow over time."
To cope with the reimbursement reduction trend, health systems, hospitals, and physician practices must reduce costs and find efficiencies, Anderson says, adding that these efforts include stewardship of services and resources, such as laboratory tests, radiology tests, and pharmaceuticals.
"We need to question ourselves and make sure we are using our resources judiciously," Anderson says.
According to Anderson, another area where health systems and hospitals can contain costs is throughput—moving patients through hospitals as efficiently as possible.
"Some of that is through better discharge planning," Anderson says. "Some of that is through better throughput in our emergency rooms. We need to focus on throughput efficiency while being safe at the same time."
In addition to proposing a 2.8% physician payment cut next year, CMS predicts that the Medicare Economic Index, which is the measure of physician practice cost inflation, will increase by 3.6% in 2025. The gap between the reimbursement cut and inflation places a significant financial burden on healthcare providers, according to Anderson.
"Medicare needs to match inflation with reimbursement and to make sure that this gap is not widening," Anderson says. "It is creating stress points financially on our healthcare system, and that is not a sustainable model."
After the pandemic, 78% of healthcare facilities report anesthesia staff shortages. Here's how to fix it.
The country is grappling with a critical shortage of anesthesia staff and several steps need to be taken to address the problem.
A recent article published in the journal Anesthesiology detailed the extent of the anesthesia staff shortage and offered solutions to rise to the challenge. According to the article, before the coronavirus pandemic, 35% of healthcare facilities reported an anesthesia staff shortage. Two years after the pandemic, the percentage of healthcare facilities reporting an anesthesia staff shortage rose to 78%, the article says.
"For me, the biggest challenge of the anesthesiologist shortage is patient safety," says Gulshan Sharma, MD, MPH, senior vice president and chief medical and innovation officer at The University of Texas Medical Branch at Galveston. "It's a different ballgame when you are putting a patient under anesthesia. You want to make sure you have a talented team of anesthesia professionals who can help manage the patient."
There are three primary strategies to address the anesthesia staff shortage, according to Sharma.
"One strategy is to make sure that anesthesiologists are paid fairly based on the market, which is one thing we have done to improve recruitment and retention," Sharma says. "A second strategy is to support anesthesiologist well-being, which is something we are working on. A third strategy is to staff low-risk areas with outside agencies. We have pursued all three of these strategies at UTMB over the past couple of years."
Tackling the problem
There are no short-term solutions, but several steps need to be taken to address the shortage of anesthesia staff, the lead author of the Anesthesiology article says.
A critical step is increasing the number of training positions for anesthesiologists, says Amr Abouleish, MD, MBA, professor of anesthesiology at UTMB.
"One approach is to increase the number of training positions in existing programs, which is my preference," Abouleish says. "The challenge is funding those positions—they are not free positions and residents need to be paid."
At this point, the Centers for Medicare & Medicaid Services does not pay for these positions, so hospitals must pay for them, according to Abouleish. The good news is that with anesthesiology staffing tight, CMOs and other healthcare leaders can make a good argument that funding resident positions actually saves money for hospitals because they don't have to hire costly locum tenens staff.
"Another approach is starting brand new training programs," according to Abouleish. "A lot of the new programs are partners in a nontraditional sense. We have a paradigm shift, where facilities such as HCA Healthcare hospitals and companies such as North American Partners in Anesthesia are partnering to create residency programs."
This is a paradigm change because residency programs have traditionally been at academic institutions or private practices.
Healthcare organizations need to promote retention of anesthesiologists and certified registered nurse anesthetists (CRNAs), Abouleish says.
"One of the things we must do is reduce burnout," according to Abouleish. "We are short people. And when we hire locum tenens anesthesiologists, they usually are not on call. In 2021, my department's anesthesiologists averaged five to six in-house calls per month. That was tolerable, but it contributed to burnout."
According to Abouleish, burnout is a hard problem because until hospitals recruit new anesthesiologists, existing clinicians are taking on too much call.
"UTMB has been addressing burnout—we have increased compensation to make our positions more attractive to boost recruitment, which makes us less stretched thin," Abouleish says.
Another retention strategy is to increase opportunities for anesthesiologists and CRNAs to have flexible schedules or part-time hours, Abouleish says.
As young anesthesiologists grow their families, healthcare organizations need to promote work-life balance as well as have flexible and part-time positions available to them, according to Abouleish, who added that when female anesthesiologists have a baby, they should be allowed to come back and work part-time.
Part-time positions are also important for anesthesiologists and CRNAs who are close to retirement, Abouleish says, adding that part-time positions can be the difference between anesthesia professionals leaving for retirement or staying at a reduced capacity for several years.
Hospitals need to effectively manage Non-Operating Room Anesthesia (NORA) sites and place them close to operating rooms, according to Abouleish. NORA sites include cardiac catheterization labs, gastrointestinal and endoscopy suites, and interventional radiology suites.
"At a freestanding children's hospital, NORA sites are almost 50% of the anesthetizing sites required," Abouleish says. "At UTMB, NORA sites are almost 30% of the anesthetizing sites. There has been an explosion of NORA sites."
Geographic isolation of anesthesia sites challenges understaffed anesthesiology teams, according to Abouleish.
"If I were to build a new hospital today, I would have all interventional patients on the same floor," Abouleish says, "the pulmonary lab, the gastrointestinal lab, the cath lab, interventional radiology, and operating rooms all on the same floor."
The new diagnostic test determines the level of activation of a patient's immune system, which reflects whether the patient has sepsis.
A Baton Rouge, Louisiana-based hospital has generated positive results such as reduced cost of care from using a new artificial intelligence-driven early diagnosis tool for sepsis.
Sepsis is the body's extreme reaction to an infection that can result in tissue damage and organ failure. Annually in the United States, there are at least 1.7 million adult hospitalizations for sepsis and at least 350,000 deaths from the condition, according to the Centers for Disease Control and Prevention.
Our Lady of the Lake Regional Medical Center, which is part of Baton Rouge, Louisiana-based Franciscan Missionaries of Our Lady Health System, has adopted IntelliSep, an AI-driven sepsis diagnostic testing system developed by San Francisco-based Cytovale Inc. IntelliSep gained Food and Drug Administration approval in January 2023.
IntelliSep determines the presence or absence of sepsis by measuring the activation of a patient's immune system, says Catherine O'Neal, MD, CMO at Our Lady of the Lake Regional Medical Center.
"As a patient approaches severe sepsis and septic shock, the immune system is more activated," she says. "IntelliSep measures the range of activation from a patient who is not activated at all to a patient who has a highly activated immune system against an infection. Highly activated patients tend to be more likely to have septic shock."
IntelliSep is one of several AI-driven sepsis diagnostic tools that have been developed in recent years. Other AI-driven sepsis diagnostic tools include the following:
Steripath, which decreases blood culture contamination to increase sepsis testing accuracy
Sepsis Immunoscore, which is an AI and machine learning software that is designed for rapid diagnosis and prediction of sepsis
Targeted Real-Time Early Warning System, which is an algorithm developed at Johns Hopkins Medicine that is integrated into electronic health records and is designed for early recognition of sepsis
Benefits of using IntelliSep
Our Lady of the Lake Regional Medical Center has generated several benefits from using IntelliSep.
The sepsis diagnostic test has improved efficiency in the emergency department, O'Neal says.
"It is getting patients through the emergency department more efficiently," she says. "You want your testing to pinpoint what is wrong with a patient as quickly and accurately as possible. The test can tell us within 10 minutes whether the patient is seriously ill from an infection or the patient is not infected at all and not seriously ill. By pinpointing who needs care faster, we can be more efficient with the rest of our testing and get patients through the ED faster."
IntelliSep has decreased the number of blood cultures taken at the hospital, says Christopher Thomas, MD, vice president and chief quality officer at Franciscan Missionaries of Our Lady Health System.
"Because we are concerned about sepsis and its high mortality in the United States, the Centers for Medicare & Medicaid Services tells us that every patient with a suspected infection must get blood cultures," he says. "If you don't know who is going to get sick, and you can't tell the difference between a patient with an activated immune system and a patient who does not have an activated immune system, then they all should get blood cultures."
Over the eight months that Our Lady of the Lake Regional Medical Center has used IntelliSep, the hospital has spared 1,800 patients from getting blood cultures, Thomas says.
"That's a big deal because it is a procedure," he says. "Not getting a blood culture is a big deal to me. It takes about eight minutes to collect each blood culture and you must do it perfectly. About 2% of the time, a blood culture comes back positive for an infection because of bacteria on the skin."
IntelliSep has reduced cost of care, Thomas says.
"We know from a study that we are saving patients who receive the IntelliSep test an average of $1,400," he says. "That comes from not having to prescribe an expensive antibiotic. That comes from avoiding blood cultures. That comes from patients spending less time in the hospital."
A recent study published in Academic Emergency Medicine found that IntelliSep correctly identified which patients did not have sepsis 98% of the time, making it an essential tool for clinicians to rule out sepsis and explore alternative diagnoses.
The accuracy of the test has been a boon at Our Lady of the Lake Regional Medical Center, O'Neal says. The impact of IntelliSep is similar to an electrocardiogram, she says, noting an electrocardiogram can tell a clinician whether a patient is having a heart attack or just has chest pain from another source such as indigestion.
"IntelliSep generates similar benefits," O'Neal says. "A patient may have an abscess, but IntelliSep can tell us whether we have time to observe the patient or let the patient go home. If IntelliSep indicates that a patient has sepsis and we identify it early, we can save lives through early intervention. We now have a tool that tells us who needs intervention quickly, just like the electrocardiogram tells us whether a patient is having a heart attack and needs care immediately."
Generating results
Data shows that IntelliSep has had a positive impact on patients and operations at Our Lady of the Lake Regional Medical Center, Thomas says.
The hospital conducted 1,800 less blood cultures in six months than the facility did in a six-month span a year ago
Since adopting IntelliSep, the hospital has saved nine days of nurse staffing time
Length of stay for sepsis patients in the ICU has been reduced by two days
Since adopting IntelliSep, the hospital has reduced sepsis mortality by 20%
"From the quality-of-care standpoint, we have never seen this kind of reduction in mortality at our hospital," O'Neal says. "It is hard to move the needle on saving lives."
The top clinical officers at Allegheny Health Network, UW Health, and Houston Methodist have made physician well-being a primary focus.
With a nation-wide shortage of physicians worsening, physician well-being programs are essential for retention and recruitment.
Physician burnout remains a concern across the country, and it spiked during the coronavirus pandemic. In a 2021 survey of physicians conducted by the American Medical Association, Mayo Clinic, Stanford University School of Medicine, and the University of Colorado School of Medicine, 62.8% of physicians reported experiencing burnout symptoms, which was up from 38.2% the previous year.
Health systems and hospitals have launched a range of interventions to improve physician well-being. The efforts range from initiatives to address basic needs such as taking meal breaks to more advanced approaches including improving efficiency of practice such as support for coding and billing.
The following HealthLeaders stories show how three health systems are addressing the well-being of physicians and other staff members.
1.Allegheny Health Network wellness program is improving the well-being of clinicians and nurses: AHN's wellness program started by focusing on basic problems such as making sure staff were taking meal breaks and staying hydrated. Several well-being initiatives that the health system adopted during the coronavirus pandemic have become permanent such as a peer support program. More recent well-being initiatives at AHN include hiring a wellness officer for each institute on the medical staff and creating an advanced practice provider council.
2.UW Health is following best practices for physician well-being: The Madison, Wisc.-based health system is using Stanford Medicine's well-being survey and implementing the Stanford Medicine Model of Professional Fulfillment. UW Health's physician well-being programs focus on a culture of wellness, efficiency of practice, and personal resilience.
CCO Hoda Asmar says the health system improved sepsis care during the first two years by focusing on two processes, including early administration of antibiotics.
After committing to improve sepsis care in 2021, Providence has significantly reduced deaths over the past three years.
Sepsis is an extreme response to infection, and it can lead to tissue damage, organ failure, and death. At least 1.7 million Americans develop sepsis annually, and one third of patients who die in U.S. hospitals have sepsis during their hospitalization, according to the Centers for Disease Control and Prevention.
"Sepsis care is a key focus for us," says Hoda Asmar, MD, MBA, executive vice president and chief clinical officer at Providence. "We have made significant strides, and we will continue to make strides. This is something we are going to be working on for years to come, and we are saving lives."
Asmar says Providence focused on two processes during the first two years:
The health system has more than doubled use of a standardized order set for sepsis patients. The primary elements are blood work and tests used to diagnose sepsis, administration of antibiotics, intravenous fluid resuscitation, and management of hypotension. Providence now uses the order set for 76% of patients presenting with sepsis and hopes to raise that rate to 80%.
The health system is also setting a goal to have the first antibiotic administered within one hour of identifying a patient with sepsis. It’s currently meeting this goal for 77% of patients, with a target of 80%.
Asmar says those efforts helped reduce sepsis deaths from 2021 through 2023.
"Our end goal is to be at a rate better than expected mortality," she says. "The way we measure sepsis mortality is the ratio between observed mortality and expected mortality. The expected mortality comes from a benchmark based on the acuity of the patients we see. We want to be better than 1.0 on the sepsis mortality ratio of observed mortality and expected mortality."
In 2021, Providence ended the year with a sepsis mortality observed-to-expected ratio of 1.11. In 2022, that ratio was 1.04, and in 2023 the ratio was 0.90.
Last year, the health system saved an estimated 1,250 lives of sepsis patients, Asmar says.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer at Providence. Photo courtesy of Providence.
New plans to save more lives
Asmar says Providence is now focusing on four more areas to improve sepsis care:
The health system is looking at gaps between its care performance and the Centers for Medicare & Medicaid Services' (CMS) sepsis bundle expectations, which include early antibiotic use, timing of blood cultures, fluid resuscitation, and management of hypotension.
Providence is looking at sepsis care through a health equity lens. Nationally, several patient populations experience worse sepsis outcomes than white patients, including Black patients and Hispanic patients. The health system wants to solve the unique challenges of vulnerable populations and is working on educational tools in languages other than English. A primary goal is to educate vulnerable populations about sepsis and sepsis care such as seeking care early.
The health system is also focusing on early intervention. The earlier that clinicians can identify sepsis and intervene, the fewer complications and deaths. Providence is focusing on key settings such as emergency departments and urgent care centers. One strategy involves using the EHR to monitor vital signs such as blood pressure, heart rate, and respiratory rate and give clinicians an early warning when sepsis is detected.
Providence is also using the EHR to manage care for patients who are admitted to a hospital for a different diagnosis but show signs of sepsis or septic shock.
"This is an ongoing journey," Asmar says. "There is not just one goal. We want to decrease harm and save lives. We are proud of our achievement in 2023, and 2024 is trending in the right direction to be below expected sepsis mortality."
The health system has focused on catheter-associated urinary tract infection, central line-associated bloodstream infection, Clostridium difficile, methicillin-resistant Staphylococcus aureus, and colon and hysterectomy surgical site infections.
Indiana University Health (IU Health) has significantly reduced healthcare-associated infections through a series of initiatives over the past six years.
On a daily basis, 1 in 31 of hospitalized patients in the United States has at least one healthcare-associated infection, according to the Centers for Disease Control and Prevention. Healthcare-associated infections have several negative impacts, including increased length of stay, hospital readmissions, and morbidity and mortality.
Healthcare-associated infections are a key element of patient safety, which is a top concern for CMOs. Health system and hospital CMOs can learn from IU Health's success in reducing healthcare-associated infections.
Over the past six years, IU Health has focused on several healthcare-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), Clostridium difficile (C. diff), methicillin-resistant Staphylococcus aureus (MRSA), and colon and hysterectomy surgical site infections.
Efforts to reduce these healthcare-associated infections at the health system have decreased these patient harms by nearly 50%, says Christopher Weaver, MD, MBA, senior vice president and chief clinical officer at IU Health.
"In 2017, we had more than 700 of these events. In 2023, we had 382 of these events," Weaver says.
According to Weaver, data and standardization have played key roles in IU Health's healthcare-associated infection initiatives.
"We have focused on good, clean, timely, and actionable data both in outcomes and processes. We have looked at data that shows how we are performing in care bundles," Weaver says. "We have also looked at our standardization of processes and supplies."
National benchmark data indicated IU Health could improve its healthcare-associated infection performance, Weaver explains.
"We looked at national benchmarks for these infections that gave us good data and recognition about the harm that these infections cause," Weaver says. "We were not performing at the level where we wanted to perform."
Christopher Weaver, MD, MBA, is senior vice president and chief clinical officer at IU Health. Photo courtesy of IU Health.
Healthcare-associated infection initiatives
To reduce CAUTIs, IU Health has focused on the care bundle for urinary tract catheters, educating staff on the insertion of catheters as well as the daily care for catheters, Weaver says.
"We started with standardizing the insertion kits—making sure that we had the same insertion kits across the health system, with all of the appropriate supplies in an easily used format," Weaver says. "When someone opens a kit, they have everything they need to insert a catheter."
For CAUTIs as well as CLABSIs, the health system has tried to limit the use of catheters whenever medically appropriate.
"We put a process in place for non-invasive urinary collection devices that avoided the use of invasive catheters. This effort had a tremendous impact in reducing CAUTI events across the health system," Weaver says. "We make sure we do not use urinary-tract and central-line catheters for the sake of convenience."
Daily chlorhexidine gluconate bathing has helped reduce CLABSI events, according to Weaver, adding patients or families were refusing the bathing, which decreased bathing percentages.
"We changed the language from saying it was a bath to saying it was a treatment, which has been more readily welcomed by the patients and just part of their standard care," Weaver says.
IU Health has strived to be more consistent in its efforts to reduce C. diff infections, Weaver says.
"We have standardized the testing of patients for C. diff. We have made sure patients have a positive indication for C. diff, so we are conducting better stewardship of patients who develop C. diff," Weaver says. "When we have a patient with C. diff, we optimize our isolation of the patient to limit the spread of the infection."
The health system has also bolstered efforts to promote hand hygiene and hand-washing among care team staff, which has helped decrease the spread of C. diff and MRSA, Weaver says.
"We also established a process for isolating patients with MRSA infection to drive those numbers down," Weaver says.
To reduce colon and hysterectomy surgical site infections, IU Health has looked "upstream" to focus on patients who are at high risk for a surgical site infection, Weaver says.
"We made sure patients were optimized before it was time for their surgery to decrease the likelihood of infection," Weaver says. "We evaluated patients who were at high risk for an infection and tried to get their medical issues under control. For example, we made sure we were managing diabetes and were giving nutritional supplements for patients at high risk."
The health system also made sure clinical staff were following care bundles for preoperative care, intraoperative care, and postoperative care. In addition, clinical staff focused on daily care of wounds after surgery, Weaver says.
Implementation tips
Weaver explains there is no "special trick" for avoiding these infections to take care of the problem and drive infection rates to near zero.
"In reality, much of the work involves conducting the basics of care and making sure all of our team members understand the importance of infection prevention," Weaver says.
As IU Health posted gains in some of its healthcare-associated infections, it was crucial to maintain those improvements before moving on to other initiatives, Weaver says.
"We were able to improve our performance on CAUTI, CLABSI, and C. diff, and it was important to keep that data in front of us to stay at an optimal level of performance," Weaver says. "Then we shifted our focus to more infections such as MRSA and colon and hysterectomy surgical site infections."
Sean Reinhardt says being successful in his new role includes admitting he does not have all the answers.
Humility is an essential quality for CMOs, the new CMO of Doylestown Health says.
Sean Reinhardt, MD, began his tenure on June 3 at the Doylestown, Penn.-based health system, which features Doylestown Hospital, a 247-bed community teaching hospital with more than 435 physicians in over 50 specialties. He has held several leadership positions at the hospital, including lead physician for the cardiology group, director of the medicine department, and president of the medical staff.
"You need to realize that you do not have all the answers, but there are people around you who probably do have the answers if you bring them in the loop," he says. "You need to lean on other people to help. You need to approach challenges humbly, and say, 'How can I make this better, and who can help me find the solution?'"
There are other qualities that can help a CMO succeed, Reinhardt says.
"It also helps to have a history with the organization, which helps you support the culture," he says. "You obviously must have people skills—you are not going to do well as a CMO if you can't work well with others. You must have good organizational skills because there is a lot thrown at you."
Sean Reinhardt, MD, is CMO of Doylestown Health. Photo courtesy of Doylestown Health.
At this early stage in holding the CMO role, Reinhardt says he has two primary priorities.
First, he wants to promote care quality at Doylestown Health.
"Quality is the center of everything we do," he says. "Nothing happens without good patient care."
"Our medical staff is robust and focuses on the quality of the doctors," he says. "We take very seriously any deviation from quality care, and deviations are investigated in a formal process and dealt with in a timely manner."
Reinhardt says quality is included in patient care metrics.
"Quality is reviewed regularly when we follow various metrics of performance, including door-to-balloon time for the cath lab and door-to-needle time for stroke," he says. "Everyone needs to be invested in improving quality."
Second, Reinhardt is playing a role in merger talks with Penn Medicine.
"Successfully completing that merger is a top clinical priority," he says. "If the merger goes through, success would be defined by maintaining our unique culture while garnering Penn Medicine's strengths and scale."
Reinhardt has clinical experience as a cardiologist, which he says helped prepare him to serve in the CMO role.
"As a specialty, cardiology has many different facets," he says. "There is noninvasive cardiology, which shares a lot of characteristics with primary care. There is interventional cardiology, which is much more procedural-based and involves interactions with surgeons, so I have a surgical background. Cardiology is a great place to develop experience and master the medical issues that come before a CMO."
Promoting patient safety
Reinhardt says he has three priorities when it comes to patient safety.
"My primary approaches to promoting patient safety are to make it the center of our culture, to make sure everyone knows it is essential to our culture, and to make it easy for people to report patient safety issues," he says. "We also need to address patient safety issues and to constantly re-evaluate how we are doing on patient safety. So, it is a continuous process, where you foster a culture of patient safety."
Like other hospitals, Doylestown Hospital has several metrics to evaluate performance on patient safety, such as hospital-acquired conditions, Reinhardt says. Patient safety is addressed at the highest levels of the organization, including a monthly Patient Safety Committee meeting.
Reinhardt says the health system makes an effort to avoid being punitive so that staff will feel more comfortable reporting patient safety issues.
"Everyone understands patient safety reporting is conducted so patients can receive better care," he says. "We all make mistakes. We all have bad days. Everyone knows that the patient safety reporting system is designed to have a teaching moment, where we can all learn."
Leading a medical staff
Reinhardt says his leadership style is focused on working together.
"Being collaborative is the only way to work with a medical staff," he says. "All physicians are very accomplished, and they are not going to be convinced by just saying, 'I told you so.' You must establish a collaborative environment, where physicians feel like solutions are developed with them at the table."
To do this, he says, a CMO must also be an effective intermediary.
"As the CMO, I am here to act as an interface between the administration and the clinical staff," he says. "When someone brings me a problem or challenge, my first reaction is how can I help them fix the issue, whether it is an administrator with a question about the medical staff or vice versa. I am the link between the two sides. I need to be able to speak both languages, so there is communication between the administration and the medical staff."
The hospital wants clinicians to know quickly when scans show unexpected or emergent results.
Massachusetts General Hospital has launched an innovative patient safety initiative to promote the timely communication of radiographic results.
Patient safety is a top priority for CMOs. Patient safety concerns at health systems and hospitals include healthcare-associated conditions such as infections and medical errors.
"As CMO, I believe there is no higher priority than patient safety and the culture we build around it," says William Curry, MD, CMO of Massachusetts General Hospital, Massachusetts General Physicians' Organization, and Mass Eye and Ear.
Massachusetts General Hospital, which is a part of the Mass General Brigham health system, recently established a policy and process for the acknowledgment of clinically significant radiographic results, Curry says.
"A well-known issue in patient safety internationally is communicating results of scans to the appropriate responding clinician and closing the loop so you know that the responding clinician knows about critical or unexpected results," Curry says.
For example, a doctor may have a patient in the office on a Friday and be worried about pneumonia. A chest X-ray or CT scan is ordered for Saturday morning. While there may be pneumonia identified on that scan, there may also be something else identified such as a pulmonary embolism, which is an emergency.
Massachusetts General Hospital is setting up a system that is resilient to confirm that the ordering clinician or whomever is covering for that clinician gets results promptly. Subsequently, one of the clinicians can carry out the right action for the patient.
Massachusetts General Hospital has created the technology infrastructure for radiologists to reach out and get closed-loop responses from clinicians whether the situation is emergent or important, Curry adds.
"We also require Epic-based documentation of the receipt of scans by the responding clinician within 30 minutes to two weeks, depending on the urgency of the scenario and the need to protect the patient," Curry says. "Once the ordering clinician acknowledges receipt of a scan, the next step is to make sure the appropriate action is taken and documented."
According to Curry, there should be no patients who have had an image with an urgent, critical, or surprising result where the entire loop between acknowledgment of receipt of the scan and appropriate clinical follow-up is not carried out and documented.
"This is an exciting initiative, and it takes some of the burden off providers who worry about what they are missing," Curry says. "The goal is to make a system for managing images that is more resilient than anything we have done before."
William Curry, MD, is CMO of Massachusetts General Hospital, Massachusetts General Physicians' Organization, and Mass Eye and Ear. Photo courtesy of Mass General Brigham.
Promoting a culture of safety
Massachusetts General Hospital's patient safety philosophy is to be relentlessly patient-oriented, according to Curry.
"We want to create patient safety systems that are resilient to make sure that we are putting our providers in the best position to use their knowledge and their skills to deliver the safest possible care," Curry says. "The key for us is to be relentlessly focused on every step of the patient journey to create the systems that prevent safety events from occurring."
Curry and other hospital leaders are constantly showing that patient safety is a priority.
"We consistently message about patient safety and put it first in our communications," Curry says. "We open every meeting with an assessment of patient safety. We review patient safety events at the institution as broadly as we possibly can—we are responsive to every patient safety event. We almost beg for reporting—there is no amount of patient safety event reporting that is too much."
The health system uses RLDatix's RL6 patient safety reporting platform.
"We share patient safety reporting throughout Mass General Brigham," Curry says. "We can learn from each other in an immediate way. If there is a safety event that occurs at Massachusetts General Hospital, the other hospitals in our health system can learn from our analysis of the event in real time."
There are as many as 27,000 patient safety events reported at Massachusetts General Hospital annually. "We revel in the high number of safety events that are reported," Curry says.
Patient safety partner
RLDatix recently announced the creation of the RLDatix Safety Institute, and Curry hopes the vendor partner will help Massachusetts General Hospital improve patient safety performance.
"I hope the RLDatix Safety Institute can help us address the known and the unknown issues in patient safety," Curry says. "We learn from a volume of events, and we learn from each other. There is no single patient safety issue in particular that I am hoping to learn about from the safety institute—I am eager to see what kind of data they generate."
Millie offers midwife-led care to patients with low-risk or moderate-risk pregnancies.
Millie, a maternal care clinic based in Berkeley, Calif., features a midwife-led care model with doulas also providing support to patients.
A report published earlier this month by The Commonwealth Fund provides insights into the U.S. maternal mortality crisis. The report found that the United States has a higher maternal mortality rate than 13 other high-income countries. The report shows that the United States and Canada have the lowest supply of midwives and obstetrician-gynecologists among the high-income countries, and OB/GYNs outnumber midwives in the United States, Canada, and Korea.
Millie's model of care features collaboration and innovation, says Amy Kane, MD, medical director at the maternal care clinic.
"The model involves midwifery care with the support of a trained doula," she says. "Our doulas play the role of a support person in collaboration with the team. Our doulas provide prenatal and postpartum support, but they are not present at a birth."
Millie works in collaboration with physicians whenever patients have conditions that make them high risk, Kane says.
"We do not provide direct physician care, but we have strong relationships with the maternal-fetal medicine groups in the community, private OB/GYN groups in the community, and hospitalists who provide OB/GYN care," she says. "So, our midwives always have the support that they need, and our patients always have the support they need. If a patient develops a high-risk pregnancy, our midwives can hand them off directly to a physician for their care."
For most pregnancies, the most important Millie team member is the midwife, Kane says.
"The patient has a midwife who sees the patient throughout their pregnancy and the postpartum period," she says. "Most patients have the same midwife for all of their visits, but patients also get the opportunity to see other midwives on the team. Midwife visits are both in-person and virtual."
Tech support is one of the innovative elements of Millie's care model.
"One of the special things about Millie is the educational resources on our app," Kane says. "Even when you have longer prenatal visits like we do, there is never enough time to teach patients as much as they need to know. So, providing educational resources is critical. It is hard to get the right information—the Internet is vast, and it is hard for patients to find reliable sources of information."
Millie has an effective care model because the clinic is setting up a situation where patients are cared for by clinical professionals who are appropriate for the level of care that the patients need, says Mark Simon, MD, MMM, CMO at Ob Hospitalist Group.
"They have midwives involved to deliver care for low-risk patients and medium-risk patients," he says. "They can make an OB/GYN available for high-risk patients and any surgical interventions. They have the doulas engaged from a support perspective, which makes a lot of sense."
The Commonwealth Fund report indicates the importance of midwives in maternal care, Simon says.
"An interesting finding of the report is that the United States is one of the countries that has the lowest supply of midwives," he says. "If you look at how we have obstetrical care providers in this country, we are heavily physician focused. A country like Norway, which has one of the lowest maternal mortality rates, has essentially the same number of obstetricians per live births as the United States, but they have 15 more midwives per 1,000 births."
Midwives should play a larger role in U.S. maternal care, Simon says.
"I am a physician, and physicians provide great care in obstetrics, but physicians are not the be all and end all in maternity care," he says. "Clearly, the numbers indicate that we need more clinicians such as midwives providing maternity care in this country to help address maternal mortality and morbidity. Midwives are part of the solution, and they should be adopted more frequently than they are today. Hopefully, we are moving in that direction."
A higher reliance on midwives in maternal care would help address a shortage of obstetricians in the United States, Simon says.
"We just do not have enough physicians practicing obstetrics in this country," he says. "It takes a long time to train physicians, and relying on obstetricians alone is not the most effective way to deal with our maternal mortality and morbidity crisis. A better model is to have physicians working in concert with midwives."
Generating results
Data indicates Millie's model of care is driving good clinical outcomes.
The C-section rate among Millie's low-risk, first-time mothers is 21.7% compared to the national rate of 26.3%
Millie's patients have a low preterm birth occurrence rate at 3.01% compared to the national rate of 10.49%
Millie's patients experience a low birthweight rate at 3.66% compared to the national rate of 8.52%
Compared to OB/GYN-led clinics, Millie has a lower cost of care, according to Anu Sharma, MS, Millie CEO and founder.
"Clinical studies and the experience of peer nations has shown that midwifery-led care leads to fewer C-sections and other interventions for low-to-moderate risk pregnancies," she says. "Midwifery-led care is also less expensive than OB-led care in terms of staffing costs."
Millie excels at early detection and management of risk, which lowers costs, Sharma says.
"In addition to C-sections, other drivers of cost are related to poor management of care and late detection of risks," she says. "These result in readmissions, preterm births, NICU stays, and unnecessary emergency room usage."
As OhioHealth came out of the coronavirus pandemic, its quality and safety team decided there was a need to do an entire reset across the health system.
OhioHealth has made becoming a high-reliability organization a top priority for the 16-hospital health system.
High reliability was pioneered in the aviation and nuclear energy industries. At health systems, hospitals, and physician practices, it includes focusing on patient safety and limiting medical errors.
OhioHealth launched its high-reliability effort a year ago, saysTeresa Caulin-Glaser, MD, senior vice president and chief clinical officer of the health system.
"As we came out of the coronavirus pandemic, our quality and safety team decided that we needed to do an entire reset across the health system," she says. "The goal was to get everybody back into understanding what we needed to be focusing on and working together across the health system to create a high-reliability organization."
At health systems, the foundation of high reliability is safety, but becoming a high-reliability organization generates widespread benefits, Caulin-Glaser says.
"When you focus on safety, you are automatically improving your quality," she says. "You are automatically improving your service to the patient. You are improving the culture of the organization to be safety-first. Financially, you gain a benefit because you do not have unnecessary hospital readmissions, long lengths of stay, or errors that are costly for the organization and the patients."
Teresa Caulin-Glaser, MD, is senior vice president and chief clinical officer of OhioHealth. Photo courtesy of OhioHealth.
Taking the first step
Driving high reliability at a health system starts with education, Caulin-Glaser says.
"The messaging and importance of this initiative came from Steve Markovich, our president and CEO," she says. "His message was: Everybody is training. If you were an executive, you were training. If you were working in accounting, you were training. Everyone in the organization was training on universal skills for high reliability."
OhioHealth has been training employees on several universal skills:
S.T.A.R.: Employees are encouraged to stop, think, assess, and react.
Make a 50-second connection: Caregivers are encouraged to make a connection with their patients in the beginning of a clinical interaction. For example, a provider can ask how the patient is feeling and about family members. The goal is to know important things about the patient and focus attention on the patient.
Speak up: Staff members have been trained to validate and verify everything they do that touches patients. For example, if a caregiver is administering medication, they are expected to validate and verify that they have the right patient, the right medication, the right timing of administration, and the right dose. In an operating room, if a surgeon asks for an instrument and a nurse is not sure that they heard the request clearly, the nurse is expected to stop and ask a clarifying question to make sure the right instrument is provided.
Communicate clearly: For example, if a patient is in the emergency room, then is transferred to a medical floor in the hospital with direction to receive 325 mg of aspirin, the nurse receiving the patient should ask whether the patient needs 325 mg of aspirin. The nurse is repeating the direction and asking the emergency room staff to verify the prescribed medication.
Practice empathy: Team members should make empathetic statements such as, "I hear you are not feeling well today, and you had a bad night with little sleep." All employees should listen to patients' concerns and acknowledge them.
Caulin-Glaser says the education program is working.
"About 90% of the leaders across OhioHealth have received high-reliability training," she says. "Our goal is to have 70% of our associates—more than 15,000 people—trained by the end of this month. We want to have 100% of our associates trained by the end of September. High reliability is part of our onboarding training."
The value of reporting systems
OhioHealth has established a daily tiered huddle process to report on four kinds of events: patient safety incidents, workplace injuries, workplace violence, and anything that needs to be escalated to senior leadership.
Tier 1 huddles are conducted with frontline healthcare workers.
Tier 2 huddles feature frontline leaders, who try to resolve issues that arise in the Tier 1 huddles.
Tier 3 huddles address issues that are escalated from Tier 2 huddles, with managers and directors in attendance.
Tier 4 huddles handle issues escalated from Tier 3 huddles, with hospital presidents and their leadership committees in attendance.
Tier 5 huddles are held at noon and address the most serious and repetitive issues reported by the other tiers, and participants include the chief clinical officer, president and CEO, chief operating officer, chief nursing executive, chief information officer, and the vice president of quality and safety.
"Our tiered huddles have helped us to find out what is happening in the health system and to proactively address issues," Caulin-Glaser says. "We are having fewer repetitive issues, and we are getting ahead of issues."
OhioHealth also has an online platform for staff members to report patient safety events. The platform is easy to access and use, Caulin-Glaser says. Over the past year, the health system has experienced a 30% increase in patient safety event reporting.
Safety teams review all safety event reports, and there is a review process for any safety events that are considered serious, Caulin-Glaser says.
"If there are events that we feel need a deep dive, we conduct a root cause analysis that is sent to senior leaders, who determine what we have learned and what actions are going to be put in place," she says.
Expected improvements
OhioHealth has lofty expectations for the impact of its high-reliability initiative.
"Our quality will improve, and we have already seen quality gains," Caulin-Glaser says. "We have been working on high-reliability skills to reduce the mortality rate in our hospitals, and we have seen that number improve. We expect to decrease unnecessary infections such as central line infections and catheter infections. We are expecting to see a reduction in surgical site infections because staff are being more careful."
The health system is expecting to see gains in patient satisfaction, Caulin-Glaser says. They’re hoping that patients will report that they were heard in the hospital and that all members of their team understood the care plan, she says.
In addition to reducing hospital readmissions, length of stay, and costly errors, OhioHealth is expected to reap other financial benefits from its high-reliability initiative, Caulin-Glaser says.
"By establishing high reliability in our outpatient clinics, we hope to be treating patients proactively, so they do not require hospitalization, which should reduce expenses for the patients as well as the organization," she says. "If we become known as a high-reliability organization, it should drive more patient volume to the organization, which will increase revenue."
Teresa Caulin-Glaser, MD, is senior vice president and chief clinical officer of OhioHealth. Photo courtesy of OhioHealth.