University of Michigan Health and Newark Beth Israel Medical Center have increased hand hygiene compliance significantly.
The results of two technology-based hand hygiene improvement initiatives were presented this week at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
In the hospital setting, hand hygiene is critically important to reduce hospital-acquired infections and to prevent surgical-site infections post-operatively. Despite the benefits of hand hygiene, achieving hand hygiene compliance among healthcare workers can be problematic.
In August 2018, Ann Arbor, Michigan-based University of Michigan Health switched from using static charts to monitor hand hygiene compliance to using electronic dashboards to visualize hand hygiene compliance in real time at its 1,100-bed campus. The technology-based initiative uses business intelligence software to generate weekly and monthly compliance reports that can be filtered by hospital unit and role such as environmental services and nursing.
A month after the initiative was launched, hand hygiene compliance at 19 hospital units improved from the high 80% range to 95%. Compliance rates dropped to 86% in March 2021 because the program was paused during the coronavirus pandemic, but compliance has risen to 98% as of April 2023 through reintroduction the dashboards and real-time data sharing.
Covert observers play a crucial role in the hand hygiene efforts, says Marissa Yee, MPH, an infection preventionist at University of Michigan Health. "We have covert observers who are trained to monitor hand hygiene. They walk around the hospital and look for hand hygiene opportunities, which focus on entry into a patient room or into a bay area as well as when a healthcare worker exits these areas. The covert observers can enter their hand hygiene observation data through a web-accessible database on their phones or iPads."
Once the data goes into the database, it is fed into the business intelligence software, which automatically refreshes the online dashboards, so staff can access their most current hygiene compliance, she says. "Staff can look at their hospital unit, environmental services unit, patient food and nutrition services, and any ancillary department. We want people to be able to access their data in real time, so they have many opportunities throughout a month to review their hand hygiene compliance. The business intelligence software has allowed us to get real-time data out to frontline staff as well as leadership throughout the institution so they can remind staff about hand hygiene during daily management huddles."
With the technology, the health system can target hand hygiene interventions, Yee says. "This initiative has allowed us to see whether we need to target specific shifts, units, or roles throughout the institution. We can educate staff on a timely basis because we can see what we are observing in real time."
Staff members have easy access to the hand hygiene compliance data, she says. "The dashboards are available on the health system website. There are different filters to view a specific unit or department, specific months, and our adult hospital or our children's and women's hospital. Staff can subscribe to a dashboard on a daily, weekly, or monthly basis with a particular filter and have the dashboard pushed to their email."
Newark Beth Israel Medical Center initiative
Newark Beth Israel Medical Center, a 665-bed hospital based in Newark, New Jersey, that is operated by RWJBarnabas Health, launchedan automated hand hygiene monitoring system in 2019.
After a 21-day baseline period in February 2022, the hospital deployed the automated hand hygiene monitoring system in eight adult inpatient units covering about 200 patient rooms. The monitoring system senses every opportunity for hand hygiene and counts actual dispenses of hand sanitizer to compute the compliance rate. Data from the intervention was collected from March 2022 to April 2023. During the intervention period, the median hand hygiene rate rose in all units, ranging from a 67% to 132% improvement compared to baseline. The average percent increase over baseline across the eight adult inpatient units was 98%.
As part of the intervention, the infection prevention team enlisted hand hygiene champions and unit managers who shared real-time data about their units during daily safety huddles with hospital leadership and during shift changes. The role of hand hygiene champions and unit managers in the initiative is focused on looking at hand hygiene behavior, says Ndubuisi Eke-Okoro, MSc, an infection preventionist and epidemiology specialist at Newark Beth Israel Medical Center.
"Taking full ownership of our hand hygiene is one of the tools to prevent hospital-acquired infections. Hand hygiene champions and unit managers cross check as soon as a healthcare provider or any healthcare worker is about to approach a patient space. That creates an awareness of hand hygiene when working in a patient space," he says.
Hospital leaders have played a pivotal role in the initiative, Eke-Okoro says. "As part of our journey to being a high-reliability organization, we have made hand hygiene a priority. As soon as we initiated the electronic monitoring system, all infection prevention departments announced the hand hygiene performance of the facility during the daily safety huddles. The senior leadership gave responsibility to unit leaders to announce hand hygiene compliance in their daily huddles. All leaders got involved if hand hygiene was going in the wrong direction."
A new study has found that very few patients hospitalized with alcohol use disorder are prescribed appropriate medications such as naltrexone.
Hospitalizations for alcohol use disorder (AUD) are an opportunity to begin treatment with medications for AUD (MAUD) but only a small percentage of patients receive MAUD within 30 days of discharge, a new study found.
About 29 million U.S. adults have AUD, and alcohol is a factor in more than 140,000 deaths per year, according to the National Institute on Alcohol Abuse and Alcoholism. Several AUD medications, including naltrexone, acamprosate, and disulfiram, have had U.S. Food and Drug Administration approval for decades.
The new study, which was published today in Annals of Internal Medicine, is based on AUD hospitalization data in 2016. The researchers examined more than 28,000 AUD hospitalizations for more than 20,000 unique patients.
The study features three key data points:
Only 0.7% of patients began MAUD treatment within two days of discharge
Only 1.3% of patients began MAUD treatment within 30 days of discharge
The most predictive demographic factor for MAUD treatment linked to an AUD hospitalization was younger age—18 to 39 years old versus more than 75 years old (adjusted odds ratio 3.87)
"In this national sample of eligible Medicare Part D beneficiaries who had not been treated recently and were hospitalized for AUD in 2016, MAUD treatment was rarely initiated during hospital discharge or follow-up care and was more likely among younger patients and those with involvement of psychiatry or addiction medicine," the study's co-authors wrote.
Interpreting the data
Clinicians are missing an opportunity to treat AUD patients, the study's co-authors wrote. "Hospitalizations allow for engagement with healthcare resources, such as clinicians and social workers, that may otherwise be difficult to access, and health vulnerability experienced by patients during hospitalizations may provide motivation for behavior change. Initiation of MAUD treatment should involve a long-term treatment plan, and if this is not feasible during hospitalization then referral for outpatient treatment may be a preferred alternative. However, the low rate of MAUD treatment initiation within 30 days of discharge indicates that initiation during follow-up rarely occurs."
MAUD is an effective treatment for AUD, the co-authors of an editorial accompanying the study wrote. "Currently recommended medications include naltrexone and acamprosate, which were approved by the U.S. Food and Drug Administration in 1994 and 2004, respectively, after showing benefits to patients with moderate to severe AUD. In recent meta-analyses, compared with placebo, naltrexone reduced the risk for return to heavy drinking (51% vs. 61%), whereas acamprosate reduced relapse in patients who had recently become abstinent (62% vs. 75%)."
The reported rates of MAUD treatment for patients hospitalized with AUD is "startling low," the editorial co-authors wrote. "Might there be legitimate reasons for this result? We do not think so. Although 90% of the patients had secondary diagnoses of AUD, the researchers recognized that AUD diagnoses affect hospital care and excluded patients identified as being in remission. Patients with a primary diagnosis of AUD had higher rates of initiation, but initiation rates were in the single digits."
Jesse Ehrenfeld acknowledges there are many challenges in healthcare, but he is optimistic.
Physicians are facing many challenges, including the fallout from a long pandemic, barriers to care, Medicare reimbursement cuts, and workforce shortages, says Jesse Ehrenfeld, MD, MPH, the new president of the American Medical Association.
Ehrenfeld, a practicing anesthesiologist in Wisconsin, was inaugurated as the 178th president of the AMA last week. He succeeded Jack Resneck Jr., MD.
This week, HealthLeaders talked with Ehrenfeld about a range of issues, including the top priorities of his AMA presidency, health equity, and physician shortages. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the top priorities for your AMA presidency?
Jesse Ehrenfeld: After three long years of dealing with the coronavirus pandemic, people are burned out in a lot of jobs but especially those of us who work in healthcare. We have had the COVID pandemic and a pandemic of bad information. Doctors and nurses have an important job to keep people healthy, but we have a healthcare system that is in crisis.
There are many barriers to care. We have insurance companies that are denying necessary care for patients. We have workforce issues where many doctors are saying they are going to reduce their hours or retire. We have Medicare cuts that are threatening the viability of practices. And, increasingly, we have legislators who are trying to impact the practice of medicine through acts that are being passed across the country.
We have to make sure that we can support physicians in recovering from the pandemic, and that is why the AMA adopted the Recovery Plan for America's Physicians. It is our top priority to make sure we are committed to rebuilding the nation's healthcare system.
HL: What are the top threats in the medical profession?
Ehrenfeld: We have real challenges around physician burnout. We have a Medicare payment system that is unsustainable and threatens healthcare access for seniors. We continue to have threats to safe care through the inappropriate expansion of scope of practice. We have real challenges around administrative hassles such as prior authorization, which places burdens on patients and practices as well as creates delays in care for individual patients. Those are the things that are continuing to threaten how we keep Americans healthy.
Jesse Ehrenfeld, MD, MPH, president of the American Medical Association. Photo courtesy of the AMA.
HL: What are some of the primary steps that need to be taken to advance health equity?
Ehrenfeld: Health equity is a priority for the AMA. Certainly, as we look at how care is delivered, we recognize there is much more that we need to do. As the first openly gay person to hold the office of AMA president, issues of LGBTQ health and equity are close to my heart and have long been a focus of my work in medicine.
The AMA continues to push forward a lot of work in this area. We need to make sure care is advanced in ways that eliminates longstanding inequities and improves outcomes for patients who have been historically marginalized. It requires us to address structural racism in the healthcare system. It requires us to equip physicians with the knowledge and the tools to confront health inequities and advance health equity across all aspects of the healthcare system.
There are important cases before the U.S. Supreme Court that likely will be decided this month, including the consideration of race in higher education admissions that will include medical schools. We have concerns about limiting the ability to consider race as a factor in admissions to colleges and medical schools, which could affect the ability to have a diverse physician workforce that we know impacts patient outcomes.
HL: How do you feel about being the first openly gay person to serve as AMA president?
Ehrenfeld: It is an exciting moment for the AMA. I know there are people in the country who are struggling because they happen to be gay or identify as LGBTQ, and I hope the visibility that I bring to my leadership of the AMA—the nation's oldest and most influential physician group—can give these people some hope and sense of possibility. I want to make sure that all patients can get the healthcare that they need, but that is only going to be possible if physicians and patients are able to make decisions together without the interference of lawmakers telling us how to do our jobs and second-guessing the science behind medicine.
HL: By multiple accounts, the labor market for physicians is tighter than ever. What can be done to reduce physician shortages?
Ehrenfeld: We need to make sure that we can expand the physician workforce. There are steps that we have long advocated for to expand the number of training slots particularly at the graduate medical education level as well as the expansion of medical school classes. These are important advocacy points at the AMA to make sure that we have the physician workforce that can meet the needs of our patients.
The AMA has invested significantly in our accelerating change in medical education portfolio of programs and grants over the past decade. We are trying to not only expand the workforce but also to transform how we train doctors today to make sure they can take care of patients tomorrow.
HL: Can physician assistants and nurse practitioners help address physician shortages?
Ehrenfeld: Absolutely! We strongly support physician-led, team-based care. Each team member has unique knowledge and makes valuable contributions to enhance patient outcomes. I experience this every week when I put on scrubs and go into an operating room to work with nurse anesthetists and anesthesia assistants.
However, it is important to point out that nurse practitioners and physician assistants, while valuable members of the team, are not a replacement for physicians and never will be. Removing physicians from a care team only results in higher costs and lower quality of care.
HL: What can be done to address physician burnout and mental health conditions among physicians?
Ehrenfeld: Unfortunately, we are at a crisis point. There continues to be stigma around accessing mental health services for physicians. Following the passage of the Dr. Lorna Breen Health Care Provider Protection Act last year, which is a bill we strongly supported, we continue to push for regulatory and legislative solutions to make sure we can direct more resources and more funding to support the mental health needs of physicians.
It is important to point out that the fundamental cause of physician burnout is not individual physicians having failures. It is working in a system that is ill-equipped to support the practice of medicine, and we need to have reform at the system level. We need to reduce burdens such as prior authorization and other administrative hassles that do not add value to what we do as care providers. We need to make it more enjoyable to practice medicine to reduce the burnout that people are experiencing.
HL: Are there things that health systems, hospitals, and physician practices can be doing to reduce physician burnout?
Ehrenfeld: Absolutely! The AMA has resources that can help health systems, hospitals, and practices address burnout. They can change workflows. They can reimagine how work is performed to better leverage tools and technologies. They can get physicians back in front of patients and reduce the amount of time they are doing administrative tasks.
HL: In your inaugural address, you said you embraced optimism regarding the challenges facing the medical profession. Why are you an optimist about these challenges?
Ehrenfeld: There are a lot of challenges, but I have seen physicians across the nation step up in incredible ways over the past three years in spite of the challenges and unbelievably difficult circumstances. They have been on the frontlines, working day in and day out to keep people healthy and to save lives. Among the residents and the medical students I work with, I see optimism and enthusiasm.
At the AMA, I know we can have an impact. I know that we can make things better for all Americans, and I look forward to leading the AMA over the next year.
Despite our healthcare system being in crisis and despite so many of my colleagues being at their breaking point, I am optimistic about the future. We can get this right.
The expansion of Williamson Medical Center will add 50 beds to the hospital.
The $200 million expansion of Franklin, Tennessee-based Williamson Medical Center includes medical staff and service line growth, says Andy Russell, MD, MBA, chief medical officer of Williamson Health.
A board-certified emergency medicine physician, Russell was named CMO of Williamson Medical Center in 2018. He served as an emergency medicine physician at Williamson Medical Center starting in 2004 and was promoted to medical director of the hospital's emergency department in 2010.
HealthLeaders recently talked with Russell about a range of topics, including the challenges of serving as CMO of Williamson Health, safety and quality, and issues related to the expansion of Williamson Medical Center. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Williamson Health?
Andy Russell: The biggest challenge but also the most fun challenge is working in the constantly changing landscape of healthcare. The speed at which things were changing during the pandemic was unlike anything I had experienced before. That experience gained during the pandemic combined with the rapidly evolving technological advances means that the fast pace of a continually changing healthcare environment is here to stay.
At this point, my days are filled with projects focused on continual improvement to our patient safety initiatives such as hospital-acquired infections and fall prevention. We are developing new and higher-acuity service lines. We are incorporating more technology in areas such as telemedicine. We are onboarding new physicians and much more. No two days are the same.
HL: How do you rise to the challenge of a rapidly changing healthcare landscape?
Russell: You must remain flexible and nimble. I'm constantly participating in webinars and attending presentations to learn about the newest technology to help keep us at the forefront of an ever-changing landscape.
HL: In what ways are you focusing efforts on safety and quality now that the crisis phase of the coronavirus pandemic has passed?
Russell: We never lost focus on safety and quality during the pandemic. Safety and quality were at the forefront of everything we did during the pandemic, but we did have to shift and modify policies frequently throughout the pandemic as things changed. Obviously, COVID was a novel disease—something we had never dealt with before. While we had policies in place to deal with various infectious diseases, we were constantly having to shift and change as new information about COVID came out. Some of our policies and procedures that we had in place for years had to be modified.
Coming out of the pandemic, we now have many new staff members who do not know how we did things prior to COVID. We are constantly re-evaluating our quality and safety metrics. We are looking at where we were historically and where we are now, and we are continually adjusting where needed.
Over the past few months, we have put in initiatives and protocols for hand hygiene, central lines, urinary catheters, and order sets for pre-operative and post-operative care. These efforts have been focused on reducing infections within the hospital and making this a safer place for the patients.
HL: You have been involved in a $200 million expansion project for Williamson Medical Center. How is the expansion project impacting recruitment of medical staff?
Russell: The expansion project has brought a whole new energy to the hospital, which has been fantastic coming out of the pandemic. It's nice to have something new and positive for everybody to experience. Staff are excited to come to the hospital.
We have been focused on expanding several service lines, including cardiology, obstetrics-gynecology, the neonatal intensive care unit, critical care, and the emergency department. We are growing our primary care clinics as well as our orthopedic group. We have hired several doctors in each one of those specialties.
The mission of our health system sells itself to new physicians. Franklin is a great place to live and a great place to work. People want to come here and work in the community they live in and take care of the patients they see every day in the community.
We have two new orthopedic surgeons joining this year. We have brought in three new cardiologists. We have three new OB/GYN physicians. We have two new neonatologists and new neonatal nurse practitioners who have started in the past year. We will be bringing on two new providers in the emergency department by the end of the year. With the growth of the hospital, we must expand the medical staff to keep up with the patient volume.
HL: With a healthcare workforce shortage across the country, how have you risen to the medical staff recruitment challenge?
Russell: That is an ongoing process. While we have better staffing levels than we did a year ago, we are still not where we want to be. We have been rising to the challenge with increased salaries, improved benefits, flexible scheduling, and promoting our vision and expansion project.
Andy Russell, MD, MBA, chief medical officer of Williamson Health. Photo courtesy of Williamson Health.
HL: You mentioned service line growth. How has the expansion project affected service line development?
Russell: We are expanding our bed count by more than 50 beds, and we knew we were going to have to increase the staff to handle the increase in patient volume. Obviously, with the expansion and increased staffing there is increased cost, and we must increase revenue to cover those costs. Some of the service lines grow themselves such as the emergency department. With the continued growth of the community, emergency room visits have increased, and we have had to hire new emergency physicians.
At the same time, with more people in the ER, you have more patients with conditions such as chest pain who need cardiology services. There are more pregnant women who need obstetrics services. There are more patients who need surgical procedures. With the increased population in the area, that drives volume throughout the hospital, and we are trying to meet the needs of the community. We have been developing service lines to meet those needs.
HL: You have served on Williamson Medical Center's Medical Executive Committee. How does the committee function?
Russell: I have been involved in the Medical Executive Committee for about 15 years. For the first 10 years, I was involved in the MEC as a function of my role in the emergency department. Since I have moved into the CMO role, I have been involved in the MEC in more of an administrative capacity.
Williamson Medical Center is a physician-driven and physician-directed hospital. The MEC sets medical policies and procedures. The committee oversees the medical credentialling of clinical staff. The MEC reviews the professional practice evaluations of all new physicians as well as ongoing professional practice evaluations to make sure that our staff is up-to-date on the latest advances in medical care. The MEC also serves as the disciplinary board for our medical staff.
HL: What role do physicians play on the MEC?
Russell: The committee is made up of 100% physicians. Our chief of staff is the chair of the MEC. The CEO and I are non-voting members of the committee. The physicians on the committee are the ones setting medical policies and standards for the hospital.
HL: You have a clinical background in emergency medicine. How has this clinical background helped you serve in the CMO role?
Russell: Working in the ER, you get to know everybody in the hospital. I worked in the ER last night, and I worked with general surgeons, I worked with obstetrics, I worked with internal medicine doctors, and I worked with cardiology. I had to go to two different floors in the hospital to take care of patients who were not doing well, so I get to work with staff all over the hospital.
In emergency medicine, you learn about how the different hospital departments work together to make one, unified organization. In my time working in the emergency department, I have developed a network of colleagues across all of the specialties in the hospital. It has taught me how to work together and develop compromises. When I am in the ER, I am constantly calling doctors, and it is almost always with bad news. I need them to come to the ER to see a patient, or I need to admit a patient they need to work with the following day. I must be able to explain situations to them, so they understand the patient's needs. I have learned how to have difficult conversations.
Moving into the CMO role, I must bring people together and bring different departments together. I am continuing to build relationships and allowing everybody to work together for the greater good of the hospital.
A new survey developed at One Brooklyn Health gathers valuable data that shines light on equity for the health system's patients.
One Brooklyn Health is implementing a health equity initiative that focuses on patient experience.
Health equity has emerged as one of the pressing issues in healthcare. Last year, Health equity was proposed as the fifth element of a Quintuple Aim to guide healthcare improvement efforts.
At One Brooklyn Health, the Brooklyn, New York-based health system has launched the DEI Outreach Program to help address health equity, says Gwendolyn Lewis, DNP, RN, principal investigator at One Brooklyn Health and vice president of ambulatory care at Interfaith Medical Center in Brooklyn.
"This project started so that we could look at how health equity impacts the patient experience as well as health outcomes. We started with focus groups that included members of the community and patients. They shared with us their experiences with facilities in north-central Brooklyn. Based on the feedback that we received, we developed a 10-question survey. We partnered with CipherHealth, so the surveys could be sent out electronically to patients who were discharged from either the inpatient setting or outpatient setting," she says.
The survey, which is called the Brooklyn Health Equity Index, is different than other patient experience surveys, Lewis says. "We take this tool a step further than Press Ganey's tool regarding patient experience. Press Ganey's tool does not address whether a patient is discriminated against. Press Ganey's tool does not address whether the patient's needs beyond a hospitalization or a clinic visit are taken into consideration. The Press Ganey tool does not address whether the patient could comply with the medical regimen that was decided in either their hospital or outpatient encounter. Our survey tells us what real-life experiences are like. For example, did the doctor look at how difficult it is for the patient to apply what they have been told?"
The Brooklyn Health Equity Index has been deployed in two stages, she says. In the first stage, more than 4,000 surveys were sent to One Brooklyn Health patients. In the second stage, more than 10,000 surveys were sent out to One Brooklyn Health patients.
The Brooklyn Health Equity Index is collecting key data, says K. Torian Easterling, MD, MPH, senior vice president of population and community health as well as chief strategic and innovation officer at One Brooklyn Health.
"For us to address injustice, we must be able to shine a light on it. We must be intentional about trying to identify where injustice is showing up, so that we can ensure that our patients are having the best experience that will lead to optimal health. That is the big picture. This survey put us in the right direction of getting there. We can identify where there might be inequities and where there might be negative experiences. Then, it is on us as a health system to apply the right kinds of tools to address those gaps," he says.
One Brooklyn Health is committed to the long journey required to address health equity, Easterling says. "Before the new survey, we were using our performance improvement activities and working with our chief quality officer to achieve practice improvement in our ambulatory centers and inpatient units. Our previous surveys did not ask questions like this new survey. They did not ask about getting treated unfairly. They did not ask about whether the care team recognized patients in a warm and welcoming way. So, while we are in the initial phase of making sure the new survey is valid, our next step is going to be to couple the new survey with practice improvement activities."
Previous equity work at One Brooklyn Health
Some practice improvement through a health equity lens has already been done at One Brooklyn Health, Easterling says. "We have been ensuring that individuals have the resources they need to improve their care. We have the Diabetes Center of Excellence, and we have been removing barriers to make sure that patients have access to continuous glucose monitors and are able to test their blood sugar on a regular basis. We are doing this while being responsive to our patients' needs. Our nurse practitioners can engage patients on a timely basis."
The health system has been using technology to address health equity, he says. "We have also been using MyChart—a digital technology that allows the patient to interact with their physician or nurse practitioner in real time. Patients can get a response without having to visit an office."
These kinds of efforts are systematically removing barriers and ensuring that all patients have good quality care, Easterling says.
"One, we are listening. Two, we are making sure we are incorporating the ways in which patient experience is important. Three, we are making sure our practice overall is standard in a way that matches the services offered in any other health system. Four, we are using our data. Our data is important because that is going to be the roadmap to continue to improve upon the type of work that we are doing. We are collecting race and ethnicity data. We are collecting social determinants of health data. These are the ways we are advancing health equity and eliminating health inequities in the health system."
Recently published research shows that about 13% of people are aware of the 988 Suicide & Crisis Lifeline.
More efforts are needed to raise awareness about the 988 Suicide & Crisis Lifeline, says Andrew Sassani, MD, corporate vice president and chief medical officer of California behavioral health services for Magellan Health.
The 988 Suicide & Crisis Line was launched last July. Formerly known as the National Suicide Prevention Lifeline, the 988 Suicide & Crisis Line offers free and confidential support to people facing a suicide crisis or emotional distress.
Awareness of the 988 Suicide & Crisis Line lags far behind awareness of 911, Sassani says. "Certainly, there is more awareness now than there was a year ago, when the line was being born. But even though awareness is more than it used to be, the line is not commonly known to the extent that it should be. As research recently showed, about 13% of people are aware of the 988 line, whereas everybody is aware of 911. People know 911 probably from the time they are 5 or 6 years old. We are certainly far from that level of awareness about 988."
Despite the lack of awareness, the 988 line is making a difference for people in behavioral health crises, he says. "If we look at the data of how many calls and texts have been made to 988, we are on track to reach about 5 million contacts by the line's one-year anniversary. That is a promising sign, but the fact that the awareness is less than 15% points to additional efforts needing to be made for awareness."
Raising awareness about 988
New approaches need to be developed to raise awareness about the 988 line, Sassani says.
"NBC used to have 'The More You Know' public service announcements. We need a nationwide campaign of these kinds of public service announcements to make people aware of the availability of 988. We cannot rely on individual healthcare providers or other people 'in the know.' Mental health providers know about 988 and perhaps they will tell their patients about 988. The fact that only 13% of the population is aware of 988 is partly due to the absence of a wide campaign with the specific goal of raising awareness across the nation about 988."
A national approach to raising awareness about the 988 line is crucial, he says. "There have been local efforts to raise awareness by media and healthcare providers, but there has not been a general, nationwide campaign to raise awareness. Television and social media campaigns would be helpful."
988 fills a critical need
Being able to call 988 is an easy way to access help when people are facing a behavioral health crisis. Sassani says.
"Many of the calls to 911 are for when a fire breaks out, a car accident happens, or some other physical emergency occurs, and a dispatcher sends an ambulance, fire trucks, or police officers to the scene. The 911 dispatchers are not mental health or substance abuse savvy. The 988 line was created to specifically be able to handle the calls or texts that are made related to mental health and substance abuse crises. The skillset of deciphering and dispatching resources for a fire is quite different than the skillset for dealing with someone experiencing a behavioral health crisis. So, the 988 line was specifically created to be able to address behavioral health calls more professionally by trained dispatchers," he says.
In addition to having 988 operators trained to address behavioral health crises, the operators play a key role in connecting people to local services, Sassani says. "When a call or text is made to 988, depending on how the communication transpires, one of the best parts of 988 is that a transfer can be made to a local resource, so a local professional in mental health or substance use can take the call or text, then engage with the person and provide needed services."
The 988 operators are prepared to deal with behavioral health crises, he says. "When someone calls 911, a dispatcher picks up and says, 'What is your emergency?' When someone calls 988, the operator knows that the incoming call is going to be related to a mental health or substance use crisis. That's why you call 988—you don't call 988 to say that a fire has broken out. The 988 operators are trained and skilled to process and engage a person in a mental health or substance use crisis in a professional way to help that person get out of the crisis mode. The goal is to stabilize the person then hand them off to a behavioral health provider who can provide services."
The American Medical Association has created or strengthen policies to promote public health and advocate for new laws and regulations.
The annual meeting of the American Medical Association's House of Delegates this week included the adoption of several new policies on issues ranging from medical education to gun violence.
The AMA's House of Delegates is the policy-making body of the organization, with physicians, residents, and medical students representing every state and medical specialty. Working through a democratic process, delegates reach a national physician consensus in areas including public health, science, ethics, and government.
The following are 10 new AMA policies adopted by the House of Delegates:
Children's mental health: The House of Delegates declared that children's mental health and barriers to mental healthcare access for children are in a state of national emergency that requires urgent attention. The new policy calls on the AMA to work with other stakeholders to increase the mental health workforce to address the limited access to mental health services for children.
Race and education: With the U.S. Supreme Court expected to rule on affirmative action this month, the House of Delegates declared that the consideration of race in undergraduate and medical school admissions is necessary to promote diversity in the physician workforce. "Efforts to do away with affirmative action undermine decades of progress in creating a diverse physician workforce and will reverse gains made in the battle against health disparities," AMA President Jesse Ehrenfeld, MD, MPH, said in a prepared statement.
Diversity, equity, and inclusion efforts at medical schools: The House of Delegates modified its Continued Support for Diversity in Medical Education policy to state that DEI efforts are essential in medical training. The delegates also voted to oppose any local, state, or federal actions that attempt to limit DEI initiatives, curriculum requirements, or medical education funding. "Diversity among healthcare professionals promotes better access to healthcare, improves healthcare quality for underserved populations, and helps physicians better meet the unique needs of each patient," the AMA said in a prepared statement.
Body mass index as a measure in medicine: The House of Delegates clarified how BMI should be used as a measure in medicine. The new policy is based on an AMA Council on Science and Public Health report that found BMI is an imperfect method of measuring body fat because it does not account for differences across racial and ethnic groups, genders, and age-span. The new policy directs physicians to use BMI in conjunction with other measures, including measurements of visceral fat, body adiposity index, body composition, relative fat mass, and waist circumference.
Overdose reversing medications: The House of Delegates voted to encourage states and communities to adopt legislation and policies to make overdose reversal medications accessible to staff, teachers, and students in educational settings. The House of Delegates also voted to support development of alternatives to naloxone to treat synthetic opioid-induced respiratory depression and overdose. Finally, the House of Delegates voted to increase the availability of naloxone and other safe and effective overdose reversal medications by supporting the availability, delivery, procession, and use of mail-order overdose reversal medications.
Firearm background checks and sales of multiple firearms: The AMA considers firearms violence as a public health crisis. The House of Delegates adopted a policy to advocate for federal and state regulations that prevent inheriting, gifting, or transferring ownership of firearms without adhering to requirements for background checks, waiting periods, and licensure requirements. The House of Delegates also voted to advocate for state and federal regulations to prevent the sale of multiple firearms to the same purchaser within five business days.
Extreme risk protection orders: Currently, more than 20 states allow law enforcement, family or household members, and/or intimate partners to ask courts to enact extreme risk protection orders (ERPOs) to temporarily remove firearms from high-risk individuals. The House of Delegates voted to support laws that include medical professionals as people who can ask a court to prevent an individual who is at risk of harm to themselves or others from purchasing or possessing firearms.
Social media and firearm violence: The House of Delegates voted to create a policy aimed at addressing social media posts that glorify firearm violence. "Under the new policy, the AMA will call on all social media sites to vigorously and aggressively remove posts that contain videos, photographs, and written online comments encouraging and glorifying the use of firearms," the AMA said in a prepared statement.
Medicinal psychedelics: The AMA is concerned about lawmakers in some states embracing the use of psychedelics or entactogenic agents such as psilocybin to treat psychiatric conditions. In response, the House of Delegates adopted a policy to advocate against the use of psychedelics or entactogenic agents except in uses that have received Food and Drug Administration approval or uses prescribed in approved investigational studies. The House of Delegates also voted to support more research into psychedelics or entactogenic agents with the scientific integrity and regulatory standards in place to evaluate other drug therapies.
Hazardous chemicals: In response to several recent train derailments that resulted in hazardous chemical spills, the House of Delegates voted to advocate for strengthening regulations for the transportation of hazardous materials. "Under the new policy, the AMA will advocate for regulations that prioritize public health and safety over cost. The new policy also supports efforts to hold companies responsible for chemical spills by making them liable for the healthcare costs incurred by individuals exposed to hazardous chemicals," the AMA said in a prepared statement.
Inpatients benefit from good communication with doctors and nurses, and they want to know the clinical staff is communicating and coordinating care.
In general, the primary elements of patient experience include healthcare access and treating patients as people rather than consumers, says David Williams, MD, chief clinical officer and senior vice president at UnityPoint Health.
Williams has been the top clinical executive at UnityPoint since May 2020. Prior to working in his current role, he was president and CEO of UnityPoint Clinic and UnityPoint at Home. Before joining UnityPoint more than two decades ago, his work experience included serving as regional medical director for Iowa Health Physicians.
HealthLeaders recently talked with Williams about a range of topics, including the primary challenges of serving as chief clinical officer at UnityPoint, home healthcare services, and how clinicians are involved in administrative leadership at UnityPoint. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as chief clinical officer of UnityPoint?
David Williams: My mind goes right to COVID. We are more than three years into the pandemic, and it has taken a toll on our caregivers—doctors, nurses, and advanced practice providers. Specifically, you see COVID fatigue in the general public and in our workforce. It has led to significant workforce challenges. We have doctors and nurses who have been on the brink for a long time, and several are choosing to leave the profession.
In addition to the impact of COVID is workplace violence. I have been in healthcare for well over 25 years, and I have never experienced the incivility that we are seeing toward our caregivers. This puzzles me, and we are working to keep our team members safe.
HL: How are you rising to these challenges?
Williams: For the workforce challenges, I have to give credit to our chief nursing officer, Dr. D'Andre Carpenter, who is my dyad partner. We are looking at nursing workforce differently. We do not think the traditional nursing staffing model is going to come back. We do not think we are going to have enough staff for that model. So, we are developing a collaborative care model to have nurses work together to take care of populations of patients. We want to use our resources to the best of our ability.
We are using technology with both the nursing and physician workforce. One example is telehospitalists. During the pandemic and to the present time, I do not think we would have had enough hospitalists across our three states and nine regions to take adequate care of patients without telehospitalists. By using telehospitalists, we have been able to unlock resources particularly in some of our rural communities that we would not have been able to serve otherwise.
With workplace violence, we have taken a unified approach. We have three states and nine regions, and workplace safety has traditionally been handled at the local level. We now have a systemwide task force with clinical leaders as well as public safety leaders to come up with solutions. Some of it is limiting access points to our facilities. The other piece is training our staff with de-escalation training to recognize patients and family members who may be in an agitated state and de-escalate potentially violent situations. We are taking a multi-pronged approach.
HL: You previously served as president and CEO of UnityPoint at Home. For health systems, what are the main opportunities in home health care services?
Williams: Home health care is kind of a hidden gem. We spend a lot of time as health system leaders talking about our hospitals and clinics—we do not spend enough time talking about what we can do in the home. People define home health traditionally—they think of things like durable medical equipment and traditional home-based services.
What we have been able to do is expand the scope of home health. We have a suite of care-at-home services now, including hospital at home, palliative care at home, skilled nursing at home, and primary care at home. When you think about home health, patients want to be taken care of as close to home as possible. They are going to have the best care experience at home surrounded by loved ones, and it is also going to be a setting with the lowest cost of care.
We not only provide traditional home care services but also think about what else we can do in the home. That is where people want to be.
David Williams, MD, chief clinical officer and senior vice president at UnityPoint Health. Photo courtesy of UnityPoint Health.
HL: You have played a patient experience leadership role in the past. What are the keys to success in achieving a positive patient experience?
Williams: In our industry, there is a big debate about whether we should call people patients or consumers. I do not think either term works—we should call people as people. They want to be treated as people. They want us to treat them the way they treat their family members and loved ones.
Access is huge—we must focus on access. Virtual access is becoming crucial. For example, we are focusing on ways people can access us through their cellphones.
One example of boosting patient experience is at UnityPoint Clinic, where our front desk staff has been rebranded. We had a contract signing ceremony for all of them. Their new title is experience specialist, so they know the No. 1 thing we need them to do is to show people who come to our clinics how much they matter.
In the inpatient setting, the key to patient experience is communication—not just communication with nurses, not just communication with doctors. It is very easy for patients and family members to feel the difference between care on a weekday and care on a weekend. Showing them that our teams are talking and collaborating with each other is the key to patient experience in the inpatient setting.
HL: What are the main clinical care challenges in rural health?
Williams: Staffing problems are throughout the industry, but they are exacerbated in rural health. I live in the state of Iowa, and we also serve the states of Illinois and Wisconsin, and all three states are very rural. We have problems recruiting providers, particularly in obstetrics and behavioral health. We have problems with recruiting nursing staff. We have problems in recruiting for sub-specialties. We must do the best we can to stretch those resources.
We have a tendency to have one specialist such as an obstetrician in a small town in Iowa. What we are trying to do is at least provide them virtual groups because what tends to happen is you have one doctor in a specialty, and they are on call 365 days a year. They do not get a break. We try to team them up with doctors who might work a couple of towns away to form a virtual group to provide some coverage and collegiality. We have found this to be effective in extending careers in some of our small towns.
Telehealth is part of the answer to rising to rural health challenges. We have expanded sub-specialty care in rural areas via telehealth.
HL: How is UnityPoint staffing clinicians at rural hospitals?
Williams: In addition to forming virtual groups, we are utilizing to the best of our ability advanced practice providers in our rural hospitals. We also have several residencies at rural hospitals and that is key. If you can get young doctors in training to work in these communities, many of them fall in love with their towns. They decide they want to practice in a rural setting.
HL: How are clinicians involved in administrative leadership at UnityPoint?
Williams: We have a dyad leadership model throughout our organization in the clinic setting, the hospital setting, and the home care setting. We pair clinical leaders such as doctors, nurses, and advanced practice providers with operational leaders.
One thing we have done that is unique is we realized we needed additional training for our physician leaders. About 10 years ago, we started a physician leadership academy in partnership with the American Association for Physician Leadership. We bring in their faculty and train cohorts of our promising physician leaders. We have trained more than 100 doctors in this program, and I am one of them. I was in the first cohort. Some of these doctors go on to receive master's level training. Many of these doctors move into leadership roles throughout our institution. I am proud of how physicians are engaged directly in leadership at our health system.
Our hospitals have traditional medical executive committees and medical staff leadership. In UnityPoint Clinic, we have a group that is called the Physician Governance Council. It is a group of mainly physicians and some advanced practice providers in all of our regions that are our highest physician governance body. They are instrumental in not only clinical operations but also in strategy.
We also have physicians on the health system's board of directors and regional boards of directors. So, clinicians are involved in governance throughout our health system.
Researchers find younger, Black non-Hispanic, publicly insured, and male patients are at highest likelihood of being the subject of an electronic behavioral alert.
Patient behavioral alerts in electronic medical records designed to mitigate workplace violence may perpetuate systemic inequities, according to a recent research article.
In a poll funded by the American College of Emergency Physicians, two-thirds of emergency physicians and 70% of nurses said they had been physically assaulted at work in the prior year. Patients were perpetrators in 97% of the workplace violence incidences in the poll. The poll found hitting, spitting, and punching were the most common kinds of physical assaults.
The recent research article, which was published in Annals of Emergency Medicine, features data collected from nearly 3 million emergency department visits at 10 EDs from 2013 to 2022.
The study includes several key data points:
Out of the 2,932,870 ED visits, 6,775 (0.2%) generated electronic behavioral alerts for 789 patients
Out of the ED visits with electronic behavioral alerts, 5,945 (88%) were determined to have a safety concern involving 653 patient perpetrators
Among patients with safety-related electronic behavioral alerts, the median age was 44, 66% were men, and 37% were Black
In subsequent ED visits, patients with safety-related behavioral alerts had higher rates of discontinuance of care (7.8% versus 1.5% for patients with no alert) such as leaving without being seen
The most common incidents that prompted electronic behavior alerts were physical abuse (41%) or verbal abuse (36%)
Black non-Hispanic patients were more likely to be the subject of an electronic behavioral alert than White non-Hispanic patients (odds ratio 2.60)
Patients younger than 45 were more likely to be the subject of an electronic behavioral alert than patients 45 to 64 years old (odds ratio 1.41)
Male patients were more likely to be the subject of an electronic behavioral alert than female patients (odds ratio 2.09)
Publicly insured patients were more likely to be the subject of an electronic behavioral alert than commercially insured patients (Medicaid, odds ratio 6.18)
The data indicates electronic behavioral alerts may perpetuate bias against historically marginalized groups, the study's co-authors wrote. "In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities."
Interpreting the data
ED clinicians may make biased decisions about agitated patients, the study's co-authors wrote.
"When agitation occurs, clinicians are required to rapidly diagnose potential causes and intervene to minimize any physical danger, apply verbal and behavioral techniques to deescalate behavior, and assess the need for any coercive measures such as physical restraints. … This combination of physical danger with a need for quick decision making may lead to reinforcement of biases during agitation events. Indeed, emergency clinicians have expressed frustration and negative attitudes toward individuals with substance use and mental illness, and racial and ethnic minorities are particularly vulnerable to negative outcomes in the ED," they wrote.
Electronic behavioral alerts may increase bias and discrimination, the study's co-authors wrote. "Electronic behavioral alerts with frequent notifications may only exacerbate biases given that we found their disproportionate application to sociodemographic minorities. Moreover, the fact that patients with electronic behavioral alerts have higher rates of care discontinuance suggests the possibility that these patients are treated differently or more quickly dismissed."
The data shows that workplace violence is a serious issue, but the best interventions to address specific patients are unclear, the study's co-authors wrote. "What remains unknown is what form and timing these interventions should have, which appropriately balance the risks to safety and mitigate propagating disparities. These interventions may take the form of focused meetings with patients outside of the acute encounter, auditing of electronic behavioral alert placement to ensure accuracy and fairness, continuing review to assess further need of the electronic behavioral alert as the risk of violence decreases, and removal of potentially biased or stigmatizing language."
Jack Resneck Jr., MD, spotlights the challenges and victories of his year-long presidency of the American Medical Association.
In the final speech of his American Medical Association presidency on Friday, Jack Resneck Jr., MD, offered his assessment of the U.S. healthcare system to the AMA House of Delegates.
Resneck, who is a practicing dermatologist based in San Francisco, gave a wide-ranging speech that included assailing prior authorization hurdles, criticizing the Medicare payment system, and shining light on threats to reproductive healthcare. He will be succeeded as AMA president this month by Jesse Ehrenfeld, MD, MPH, who is a Wisconsin-based anesthesiologist.
The AMA was founded in 1847. The physician-led organization convenes more than 190 state and specialty medical societies as well as other key stakeholders.
The following are highlights of Friday's speech:
"I'm sure some of the headlines about burnout stop you in your tracks—they certainly keep me up at night. One in five physicians plans to leave their practice within two years, while one in three are reducing their hours. Only 57 percent of doctors today would choose medicine again if they were just starting their careers."
"We never turn our backs on our patients because that's not who we are. And we carry that same stubborn resolve and tenacity into our advocacy work. That means fighting for the long overdue fixes to a broken Medicare payment system, and obnoxious prior auth abuses, even when policymakers have neglected the problems for decades. That means defending against scope expansions that put patients at risk, even when it requires gearing up again and again in state after state. That means confronting medical disinformation in the news and on social media, even when its growth feels overwhelming."
"No, I can't sugarcoat the very real threats. I’m still appalled by the Medicare cuts. What on Earth was Congress thinking? Practices are on the brink. Our workforce is at risk. Access to care stands in the balance. We absolutely must tie future Medicare payments to inflation, and we're readying a major national effort to finally achieve Congressional action."
"Shame on political leaders, fueling fear and sewing division by making enemies of public health officials, of transgender adolescents, of physicians doing anti-racism work, and of women making personal decisions about their pregnancies."
"I'm also deeply disappointed by our nation's lack of progress to address the public health crisis of gun violence. Preventable and needless homicides and suicides continue, and the political inaction is atrocious."
"You wouldn't know it from social media, but after some unfortunate detours, most patients are turning back to their trusted physicians for our insights and expertise about science and medicine."
"You wouldn't know it from 20 state legislatures racing to criminalize abortion and rob women of access to reproductive health care, but most people in this country support our policies and the fundamental rights of patients to make their own decisions about their health."
"You wouldn't know it from health insurers still bullying us with prior auth delays and denying care, but policymakers from both parties are onto these schemes, the momentum has shifted, and they’re not going to allow this nonsense anymore."
"In our country, and in our profession, we don't agree on everything, but we agree on enough things to pursue the shared things that we care about. Together. And let us not forget that those pursuits have generated some big and small wins tied to the AMA Recovery Plan for America's Physicians."
"Our Congressional advocacy played a key role in legislation to extend Medicare telehealth coverage."
"We have enormous privilege to do this work. We share a love for what we do—to help, to cure, to listen, to solve, to heal, to lead. And we have a responsibility to our patients and to the health of this nation. We are the keepers of an important tradition … a flame that must not be extinguished. Our profession is counting on us to get this right. Our patients are depending on us to continue this fight. We will not let them down."