The Boston-based hospital is gaining ground on a racial hypertension disparity.
Community health workers are playing a leading role in addressing health equity among primary care patients at Massachusetts General Hospital, according to a presentation yesterday at the Institute for Healthcare Improvement Forum in Orlando, Florida.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 healthcare disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
Community health workers can be pivotal in efforts to address health equity, Sarah Matathia, MD, MPH, associate medical director of primary care equity at Massachusetts General Hospital said at the IHI forum. "One of the potential solutions for having diverse representation in the workforce is to include community health workers in your workforce and integrate them as part of the care team."
Community health workers are well-suited to help health systems and hospitals tackle health equity issues, she said. "Community health workers are public health workers with shared life experience, who apply that unique experience such as language or culture or specific issues such as substance use disorder. They try to provide culturally appropriate health education, and they serve as a bridge. They are able to bridge between individuals, families, and the community that they are a part of and the healthcare system."
At Boston-based Massachusetts General Hospital, community health workers are well established, Matathia said. "We are lucky to have a group of community health workers that has grown over the past 25 years. They are working in several key domains. The community health workers help find health-related social needs resources for patients, so they develop expertise in areas such as healthy food and job-finding programs. They are working on system navigation—community health workers help patients get to their appointments by calling patients and giving reminders. They provide care coordination—they help patients make appointments. And increasingly, we have been working with community health workers on models for chronic disease management."
Addressing racial hypertension disparity
Community health workers are an essential element of an effort to address a racial hypertension disparity among Massachusetts General Hospital primary care patients, she said. "We felt it was important for the program to be led by community health workers. We did not just want the community health workers to be helping with medications because we felt this was an opportunity to get to the root causes of hypertension. We incorporated more education around lifestyle, and we built modules such as why high blood pressure matters, what is too high and too low for blood pressure, how do you take blood pressure, medication adherence, nutrition, physical activity, stress management, and sleep."
The community health workers lead patient engagement in the blood pressure program, Matathia said. "We helped the community health workers in facilitating conversations by building them motivational interviewing guides and trying to put everything on one page so they could use the guidance as they were working with patients. For every patient who entered the program, they got a blood pressure cuff, the community health workers met with the patients and taught them how to use the cuff, and the community health workers helped to collect the readings. For each patient doing blood pressure monitoring, community health workers distilled those numbers down to a single value, and they could escalate to the primary care provider and the care team if there was a need for medication changes."
The blood pressure program was launched seven months ago, and so far, the results are promising, she said. "As we have been following our blood pressure control month-to-month, we have seen a 4.8% improvement in blood pressure control in our Black patient population, a 6.4% improvement in our Hispanic patient population, and 4.2% improvement in our non-English speaking population."
While there are challenges in the program such as carving out time for primary care providers to participate in the effort, progress is being made, Matathia said. "These types of initiatives can move the needle in real time, and community health workers are uniquely poised to help bridge the gaps for patients who are not as well served by traditional population health strategies."
About 233 million Americans are enrolled in health plans that cover preventive services without cost-sharing because of the Affordable Care Act.
The American Medical Association (AMA) and seven other physician groups have filed a friend-of-the-court brief defending no-cost access to preventive services under the Affordable Care Act (ACA).
The ACA, which Congress passed in 2010, requires insurers to cover preventive services without cost sharing such as deductibles for services that have "A" or 'B" ratings from the United States Preventive Services Task Force. "A" or "B" ratings indicate that a preventive service has moderate to substantial net benefits, with moderate to high certainty.
On Nov. 30, the friend-of-the-court brief was filed for Braidwood Management v. Xavier Becerra, an ACA case in the U.S. District Court for the Northern District of Texas Fort Worth Division. Braidwood and other plaintiffs in the case want U.S. District Judge Reed O'Connor to rule that insurers can impose cost sharing for preventive services.
The friend-of-the-court brief calls on Judge O'Connor to maintain the ACA's no-cost provision for preventive services. "The Court should refrain from ordering any remedy that would allow insurers to reimpose cost-sharing requirements on the millions of Americans who currently have access to no-cost preventive care. Make no mistake—that is what Plaintiffs seek," the friend-of-the-court brief says.
The physician groups that filed the friend-of-the-court brief with the AMA—known collectively as amici—are the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Medical Women's Association, the Infectious Diseases Society of America, the National Medical Association, and the Society for Maternal-Fetal Medicine.
The amici say there are several benefits from the ACA's preventive services provision. "The research is clear: no-cost preventive care saves lives, saves money, improves health outcomes, and enables healthier lifestyles. As medical professionals, amici know that preventive care can mean the difference between kicking a smoking habit or living with a heightened risk of dozens of illnesses; between taking a statin or suffering a life-changing heart attack; between providing essential prenatal care and screening or leaving children behind; and between catching a patient's cancer early or catching it after it's too late. Identifying and treating conditions before they worsen, or before they present at all, yields better outcomes for patients and saves money for the health system overall."
Improving health outcomes and bolstering the healthcare system
The AMA and the other amici argue that no-cost preventive services boost public health and the healthcare system. "An extensive body of evidence demonstrates how preventive care can help patients live long, healthy lives. Preventive services include both services aimed at the early detection and treatment of potentially fatal medical conditions and chronic diseases as well as services aimed at encouraging people to adopt healthy lifestyles," the friend-of-the-court brief says.
No-cost preventive services also reduce healthcare costs such as catching cancer in an early phase, the friend-of-the-court brief says. "Put simply, cancer is cheaper to treat at the outset than after it has metastasized."
The ACA has increased utilization of preventive services, the friend-of-the-court brief says. "Prior to the enactment of the Affordable Care Act, the majority of Americans either lacked health insurance or were enrolled in insurance plans that did not cover preventive care without cost-sharing—creating a substantial barrier to widespread use of preventive care."
ACA expanded access to preventive services
The ACA has expanded access to preventive services, the friend-of-the-court brief says. "The ACA's preventive-care requirements have generally been successful in expanding access to preventive care, and for that reason, have proven to be one of the most popular parts of the statute."
Millions of Americans have gained access to preventive services because of the ACA, the friend-of-the-court brief says. "In 2014, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services estimated that 76 million individuals gained access to preventive care without cost-sharing as a result of the ACA, either by newly enrolling in private insurance or by having already enrolled in insurance plans that shifted to covering preventive care after the ACA's enactment."
The AMA and the other amici say there are now about 233 million Americans who are enrolled in health plans that cover preventive services without cost-sharing because of the ACA.
The ACA is not perfect, but the no-cost preventive services requirement is essential, the friend-of-the-court brief says. "To be sure, the ACA's preventive care requirements are not a panacea; substantial additional work needs to be done to encourage patients to use the means provided to them to obtain these vital services. But gutting the ACA's requirements would impose further barriers, making it even harder for amici to ensure that their patients receive the requisite care."
As part of the new partnership, Bryan Health and Medline will work together to identify new strategies for enhancing patient outcomes and streamlining supply chain operations at the health system. Medline will be the exclusive provider of medical supplies for every Bryan Health hospital. Prior to the new partnership, Medline was already the provider of medical supplies for Kearney Regional Medical Center.
Medline is an ideal partner for Bryan Health, Heather Seeba, director of supply chain for the not-for-profit health system, said in a prepared statement. "Medline's proactive approach facilitated a smooth implementation, and the customer support has been incredibly responsive. We look forward to partnering with the Medline experts to optimize our operational processes and improve our supply consistency."
As part of the partnership, Medline will provide resources to help Bryan Health address clinician needs and boost operational efficiencies. Medline also will provide advanced analytics to track key metrics such as item utilization, contract compliance, price accuracy, and spending by product categories.
Medline will help Bryan Health achieve supply chain success, Megan Schwellenbach, vice president of corporate accounts at the company, said in a prepared statement. "Medline is committed to providing Bryan Health with continuously reliable, superior service. We are excited to enter into this prime vendor partnership and together develop solutions to help provide consistency and stability to its supply chain."
Westchester Medical Center Health Network's CMO says staff members ''understand the forces behind decisions if they are a part of the process.''
Renee Garrick, MD, executive vice president and chief medical officer of Westchester Medical Center Health Network (WMCHealth), says managing the health system's quaternary care hospital and balancing resources are her top challenges.
Garrick is the clinical leader for the Valhalla, New York–based health system, which features 1,700 inpatient beds at nine hospitals in the Hudson Valley. She recently talked with HealthLeaders about a range of topics, including leadership, physician burnout, clinical challenges now that the crisis phase of the coronavirus pandemic has passed, and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the main challenges of serving as CMO of WMCHealth?
Renee Garrick: There are two major issues in being the CMO of our network.
First, we are the only quaternary care hospital for this region, which spans several thousand square miles. As the major quaternary care hospital, it means we accept patients at the main hub who need high-end care that cannot be offered at the other facilities in the Hudson Valley. We are a referral hospital not just for our patients but also all hospitals in the region.
From the CMO perspective, that means there is a lot of juggling in terms of having our staff at the ready to accept patients and to be able to juggle inpatients and transfers 24/7. We must be able to do that while taking great care of the patients in our hospitals and the patients who transfer to our medical center. I spend a fair amount of my time making sure we have the best possible staff on the medical side, the nursing side, housekeeping, social work, and dietary to be able to care for a broad range of patients. I also need to make sure that the staff has the time to take care of themselves as well as patients, so their lives are balanced, and they can give the best care possible.
The other challenge is we have a lot of busy practitioners, and they have valid and important resource needs. It takes a lot to balance those needs and know that people understand that you are doing everything you can for everyone to the extent possible. That means there is some sharing that must go on. So, if surgery needs A and B, and neurosurgery needs C and D, and medicine needs E and F, they all must understand everyone's needs as a group. I expend a lot of energy making sure that people understand we are balancing resources and making sure that everyone has access to the best that is available. There's nobody who gets more than another. In the end, it all balances out.
Sometimes, people want to have an enormous amount of add-on resources, and you cannot do that if it is going to hurt a smaller department with equal need. I spend a lot of time speaking to the physicians, the medical staff, and the graduate medical staff so they can all understand how it works. Transferring patients and allocating care—and recruiting and retaining the medical staff—is a big part of what I do. It can be a challenge getting everyone to understand the greater good and the goals of the organization. It takes a lot of listening to make sure you do that well.
HL: How do you persuade colleagues to share resources?
Garrick: I try to be transparent about it. People understand the forces behind decisions if they are a part of the process. You must be aware of the staff you are working with—the medical staff, the nursing staff, and the administrative staff. You must explain your position and how you came to a decision—that is an effective way of building a coalition and having people come to an understanding of why things are being decided the way they are.
I graduated medical school in 1978. My experience has been as long as people are treated respectfully and you are honest about what can and cannot be done, the process resonates with people. A problem is created when facts are not shared, then people make up their own facts. They fill the vacuum with what they might think is the truth. It's hard to rescue the process under those circumstances.
Renee Garrick, MD, executive vice president and chief medical officer of Westchester Medical Center Health Network. Photo courtesy of Westchester Medical Center Health Network.
HL: What is the status of physician burnout at WMCHealth?
Garrick: Over the past year, we have recruited hundreds of providers. In the past three months, we have recruited 100 new nurses. So, we are a resilient organization. Part of that is we are the tertiary care referral center, and we are proud of that.
We are still dealing with COVID. But we have also been dealing with monkeypox—we have given 1,800 monkeypox vaccinations. We are thinking about polio because we are in the Northeast, where polio has had a resurgence. We also are dealing with RSV. So, our staff takes enormous pride in being at the ready and being resilient. We get so much joy out of helping patients on the nursing side and the physician side that our burnout has been less than other organizations.
A big key to physician burnout is the happiness and unanimity of purpose that we share with our nursing colleagues. Our nursing staff just ratified a new five-year contract, with overwhelming support. The core of the contract is to make it clear to our nursing staff that we have an enormous amount of respect for their skill and expertise, and we want to be able to recruit, retain, and reward the best nurses in the country. For doctors to be at their best, they work best when they have nurses who are happy by the bedside. A big part of our resiliency is we partner with an extraordinary nursing staff. That helps with how physicians cope with burnout—having a great nursing staff.
HL: What are your primary clinical challenges now that the crisis phase of the pandemic has passed?
Garrick: For us, the clinical challenges are always being ready for the next stress for the organization. Our staff had to be resilient because in the middle of COVID we had monkeypox, and we were asked by the state to be a referral center for monkeypox. We are also dealing with RSV. So, the clinical challenges are keeping the engine humming while gearing up for the next level because as a quaternary care hospital you must be able to provide basic care and get to the next level.
Right now, we are looking at high-end new radiation oncology equipment and thinking about how to move that part of our service for the region forward. That means recruitment, that means building, and that means growth and development. We are looking at building a new critical care area for the medical center to be able to serve the Hudson Valley with the highest level of care.
The clinical initiatives and clinical challenges are looking ahead to the next things we need to do to always be on the cutting edge. We are asking our people to have their feet in two worlds—the current and the future, where we are thinking about artificial intelligence and outfitting the ICU with bedside ultrasound. It's a big clinical challenge to do the day-to-day care while also planning simultaneously for the next several years to come.
HL: What are the primary efforts you have in place to address workforce shortages?
Garrick: On the medical side, we can attract some of the best physicians in the country because we provide a range of care including quaternary care. We have a good organ transplant program—we do heart, kidney, and liver. We have amazing neurosurgery and pediatric care. We have high-end care, but we are also a large network. So, at our institution, we are lucky because physicians can come to the medical center and ply their trade in complicated cases, then they can go to another hospital and be satisfied taking care of community-level conditions.
One of the advantages that we have in terms of addressing workforce shortages is there is a lot of variation in the kinds of patients that we treat, and physicians like to have the opportunity to see more than one type of patient and tackle more than one type of challenge. Over the past two years, we have credentialled more than 1,000 practitioners in our network, and the wide spectrum of the kind of patients that we see is attractive to young physicians.
We also have a lot of mentoring. When you finish your training, you still want to have somebody near your elbow as a mentor; so, if you have a question or have a complicated case, you have someone to help you. We are proud of the fact that we have a staff here that is stable—the medical staff has little turnover, and we have a lot of opportunities for mentorship. This is important for young physicians, especially the ones who trained during COVID. Our ability to provide mentors makes this network an attractive place to work.
Being an academic medical center also helps us recruit and retain physicians. Having a medical school at our main campus and being able to engage in research is a big part of recruitment and retention. The residents and fellows participate in the research as do the medical students. We love the fact that medical students stay here as residents, and some of them stay on as attending physicians.
Addressing health inequities is expected to be a top priority for employers in 2023.
Pursuing affordability of services tops seven healthcare trends for 2023, according to the Business Group on Health.
The trends are associated with the interplay of several factors, says Ellen Kelsay, president and CEO of the Business Group on Health. "While each trend relates to employer health and well-being strategies, they also exist against the backdrop of the global economy, workforce trends, innovation, and the policy and regulatory environment. As such, factors that range from provider labor shortages to the increased cost of healthcare will affect employers and employees alike in the year to come."
1. With rising healthcare costs, affordability is the leading concern for employees and employers.
Pent-up demand for healthcare services related to care delayed during the coronavirus pandemic likely will increase healthcare costs for employers in 2023. Business Group on Health survey data indicates 43% of employers have already experienced an increase in medical services linked to deferred care, with 39% of employers expecting more hikes in medical services linked to deferred care in the future. The survey data also shows cancer is the leading driver of healthcare costs, with more late-stage cancers being identified and more expensive treatment options available. In 2022, employee cost sharing for healthcare services has been stable. However, a national economic downturn in 2023 could force employers to increase health insurance premiums and out-of-pocket costs, the Business Group on Health says.
2. Workforce dynamics will impact health and well-being offerings.
Employers show an increasing awareness that employee health and well-being have a positive effect on workforce strategy, with 65% of employers reporting employee health and well-being are pivotal compared to 27% of employers five years ago. With this awareness, employers are expected to continue to invest in health and well-being initiatives in 2023. However, affordability concerns will likely lead to reconsideration of initiatives, formation of new partnerships, and crafting of collaborations with employees.
3. Addressing health inequities will be a priority for employers.
Employers are expected to use health and well-being programs to impact social determinants of health, including healthcare access, finances, and childcare. Employers are likely to expand coverage and benefits for transgender employees and employees with disabilities. Women's health could be targeted through methods such as expanded fertility benefits, focusing on maternal mortality, and increasing coverage for doula services.
4. Increased emphasis on mental and financial health of employees.
Mental health is becoming a top priority for employers and employees, with a recognition that mental health is tied to job satisfaction and several aspects of well-being such as physical and social health. In addition, the vast majority of employers have financial security initiatives as part of their well-being strategies, including establishing retirement savings, paying down debt, creating household budgets, and paying for college. Employers recognize there is an association between financial stress and employee health, productivity, and performance.
To optimize cost savings, patient experience, and health outcomes, employers are expected to continue to adopt value-based payment models. Examples of popular value-based payment models include advanced primary care, high-performance networks, accountable care organizations, and centers of excellence.
6. Telemedicine likely to continue expansion.
During the pandemic, telemedicine such as telehealth for primary and acute care, teletherapy, and telehealth for chronic condition management emerged as an alternative to in-person visits. Now, telemedicine is being widely viewed as complementary to in-person visits. According to Business Group on Health survey data, 55% of employers plan to expand their virtual health offerings in 2023.
7. Policy and regulation landscape expected to shift.
State and federal regulations for employer-sponsored health plans could change in 2023. For example, Affordable Care Act preventive services could change under court order. Large employers are expected to work with policymakers on several issues, including improving access and affordability for mental health services, women's health improvements, and transforming delivery of services through transparency and payment model reforms.
Survey data shows 45% of clinicians reported burnout in 2019, with the burnout rate rising to 60% in late 2021.
A new study found that clinician burnout spiked in the second year of the coronavirus pandemic, and the researchers identified aggravators and mitigators of burnout.
An earlier study found that emotional exhaustion increased from 31.8% of healthcare workers in 2019 to 40.4% in 2021. Emotional exhaustion is one of three scales in a widely used measure of burnout—the Maslach Burnout Inventory. Another earlier study found that physicians reporting at least one burnout symptom increased from 38.2% in 2020 to 62.8% in 2021.
The new study, which was published last week by JAMA Health Forum, is based on survey data collected from more than 20,000 clinicians. The survey data was collected between February 2019 and December 2021.
The new study features several key data points:
Burnout was reported by 45% of clinicians in 2019, 40% to 45% of clinicians in early 2020, 50% of clinicians in late 2020, and 60% of clinicians in late 2021
Higher rates of burnout were reported in chaotic workplaces (odds ratio 1.51) and settings with low work control (odds ratio 2.10)
Higher rates of burnout were associated with poor teamwork (odds ratio 2.08)
Lower rates of burnout were associated with feeling valued (odds ratio 0.22)
In the fourth quarter of 2021, the burnout rate was 36% in calm environments and 78% in chaotic environments
In the fourth quarter of 2021, the burnout rate was 39% in environments with good work control and 75% in environments with poor work control
In the fourth quarter of 2021, the burnout rate was 37% when clinicians felt valued and 69% when they did not feel valued
At the end of 2021, clinician satisfaction decreased and intent to leave increased
"Results of this survey study show that in 2020 through 2021, burnout and intent to leave gradually increased, rose sharply in late 2021, and varied by chaos, work control, teamwork, and feeling valued. Monitoring these variables could provide mechanisms for worker protection," the study's co-authors wrote.
Interpreting the data
The data reveal clinician well-being trends during the pandemic, the study's co-authors wrote.
"Levels of burnout were high and fairly stable during early 2020, with slight rises late in 2020 and a sharp rise late in 2021; likewise, intent to leave was stable at moderate levels in 2020 and 2021 until a steep rise toward the end of 2021. The lack of increase in burnout through the difficult year of 2020 is notable and may indicate a sense of determination and purpose among these professionals. However, the data show how the persistent lack of control of workload, chaotic environments, challenges with teamwork, and a lack of feeling valued by organizations may have contributed to worsening burnout and a rise in intent to leave," they wrote.
The data identify key aggravators of clinician burnout, the study's co-authors wrote. "Variables related to higher levels of burnout and intent to leave included chaotic (fast-paced) workplaces and lack of control of workload. Absolute differences in burnout between favorable and unfavorable environments were 30% or higher, which is notable. Understanding and managing work pace and modulating workload by giving clinicians greater control of their own schedules could mitigate stress seen during COVID-19 surges."
The data also identify primary mitigators of clinician burnout, the study's co-authors wrote. "Feeling valued and good teamwork were associated with favorable outcomes. How to make clinicians feel valued is being actively explored, but general principles include having a receptive leadership team who listens to frontline workers and makes tangible changes based on feedback and needs, and providing organizational support for work-life integration, as well as clinician self-care. … Good teamwork refers to not only team member camaraderie and a positive team culture, but also solid team-based care workflows that allow for efficient task-sharing and minimizing non-patient-facing tasks for clinicians."
Jason Mitchell, MD, fields seven questions about health system leadership.
One of the biggest challenges of being a chief medical officer is balancing day-to-day responsibilities with strategic planning, says Jason Mitchell, MD, SVP and chief medical and clinical transformation officer at Presbyterian Healthcare Services (PHS).
Mitchell leads more than 1,100 physicians and advanced practice clinicians. He also provides clinical oversight for the Albuquerque, New Mexico—based health system's medical staff operations at nine hospitals.
HealthLeaders recently talked with him about a range of topics, including clinical leadership at PHS, healthcare worker burnout, patient safety at PHS, and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of PHS?
Jason Mitchell: The biggest challenge is thinking about the day-to-day things you need to solve and improve, then be able to elevate and focus on strategy, so that you are looking out six months, one year, and three years. You need to be building the future for the organization. It's a big challenge because it is easy to get lost in the daily complexities and lose sight of how you get the organization to where it needs to be a couple of years out.
Fortunately, I play a large role in the strategy of the organization. I spend a lot of time bringing together clinical and administrative teams to focus on the future.
HL: How do you manage to get past the daily work and focus on strategy?
Mitchell: I have great partners in leadership who work with me on meeting this challenge. We think about what we must do and what we must transform so that three years out, we are achieving what we aspire to achieve. We spend time looking at the environment both nationally and locally, reflecting on what we want to accomplish as an organization for our community and the people we serve, and thinking about the key themes for success. Then, we go through a disciplined process to determine what work we need to do, what assets we need to create, and what are the milestones.
We start at a high level, then we engage frontline clinicians and workforce in the design process, so we design a future together. It is very deliberate.
HL: What is the status of healthcare worker burnout at PHS?
Mitchell: We are like everyone else in the country. Healthcare is hard. Healthcare was hard before the coronavirus pandemic. The pandemic has certainly changed a lot—it has changed the workforce, it has changed the support staff, it has changed clinical expectations, and many people got exhausted. We are not immune to any of that.
As you talk to our clinicians, we are a good team. Our medical staff is solid. We have a lot of tired people, but we have done a lot to support them. We did work on the physician and advanced practice clinician experience before the pandemic started, so we already had tools, processes, and teams in place to support clinicians before the pandemic began, which has helped us through the pandemic.
HL: Give a couple of examples of initiatives that you have in place to address clinician burnout.
Mitchell: One of the programs we have focused on intensely is called Relations. It is a half-day course that we have been doing for about four years. You would think in our professional education that they would teach us to be great communicators, but they do not necessarily do that. Relations is about learning to reflectively listen, to read body language, to understand the biases you bring to the table, and to practice your skills. We do role-playing. So, people can practice their skills such as reflective listening, and it has been an amazing experience. It helps in clinic and in our personal lives because it helps you listen better, which makes communication more effective and efficient. Relations helps you interact better with patients and colleagues.
Another program we have focused on is called Reset, which involves self-exploration as an individual. Again, if you think about our professional education, the amount of time for ourselves is limited. You just go, go, go through your training in medical school and residency, then you start practicing medicine and you just keep going. Reset is a multiday experience in small groups that is structured and gives you time to reflect and work on yourself. We have found that Reset has been transformative for people. It has prolonged careers for people who have been thinking about leaving medicine. It has kept people in the organization who were exhausted. And it has helped people be happy in their home lives as well.
Jason Mitchell, MD, SVP and chief medical and clinical transformation officer at Presbyterian Healthcare Services. Photo courtesy of Presbyterian Healthcare Services
HL: What are the primary elements of patient safety at PHS?
Mitchell: There are several key parts of patient safety at our health system. There is high reliability. When systems are reliant on the efforts of people, they are more successful when the high reliability processes are working.
Another piece is psychological safety and just culture. Your workforce must feel safe to report errors and to engage in process improvement. You also need to have a just culture, which is not punitive. The focus needs to be on root causes of adverse events and how you fix them.
The other piece is an absolute unwillingness to accept anything but zero harm. We have what we call our Journey to Zero Preventable Harm. We have several metrics, and we focus on them. On the executive team and the frontline, we look at those metrics all the time, and we do not just focus on Centers for Medicare & Medicaid Services metrics. There are a lot of hospital-based safety metrics, which are focused on Medicare fee-for-service patients, but they do not include Medicare Advantage, healthy adult, pediatric, or obstetrics patients. When we think about safety, it is for our entire patient population.
HL: What are the primary metrics you are following when it comes to patient safety?
Mitchell: There are several standard metrics for patient safety that we follow. We look at hospital-acquired infections such as central line–associated infections and urinary tract infections. Then we look at categories of never events such as falls with injury, retained foreign bodies, and unexpected mortality. For our Journey to Zero Preventable Harm, we have 14 metrics that fall into that initiative that we monitor on a regular basis that are standard metrics similar to the PSI 90.
HL: What are the primary efforts you have in place to address workforce shortages?
Mitchell: There are three levers—recruitment, retention, and pipeline development.
In recruitment, we focus on the culture of the organization. We are not-for-profit and based on helping people and doing the right thing. We have a great culture, and that helps us for recruitment. We recognize that many of our clinicians such as nurses want flexible schedules—they do not want three 12-hour shifts. They may want 8-hour shifts. We think about what the workforce needs for people to thrive—what does the work need to look like?
We make sure we pay based on the market or better than the market. We have competitive benefits. However, it comes back to being not-for-profit and community-based. We are an organization that people can be proud to be a part of, and that supports our recruitment.
With retention, we have a lot of focus on how our workforce thrives. We also focus on development. So, we do significant management and leadership development, whether that is for administrators or clinicians. We have many opportunities for learning and advancement because we want people to continue to grow.
We support our staff. We have Code Lavender. Frequently, bad things happen in hospitals, and as healthcare providers it hurts. We have processes in place where if something bad happens in the emergency department or another unit, we will bring in a team of people. We will bring in food. We bring in support and are there for staff members.
We have strategic plans for the workforce whether it is doctors, advanced practice clinicians, or nurses. We want to know what their needs are and make sure that we are providing for those needs. So, there is a lot of intentionality.
Pipeline development is important. We spend a lot of time out in the community. Although we are not an academic organization, we have about 2,000 students who rotate through our organization every year. We are the second largest provider of clinical rotations in New Mexico behind the University of New Mexico. Those rotations include physical therapy, respiratory therapy, doctors, nurses, physician assistants, and pharmacists. Bringing people into our organization, building relationships, and letting students learn about us is a great pipeline.
We also partner with the university and Central New Mexico Community College. If students want to get into healthcare, we want to make it easy for them to join us.
Rural residents face unique challenges to accessing healthcare such as far-flung geography, according to Dartmouth Health.
Dartmouth Health has launched an initiative to identify and address rural healthcare disparities in northern New England.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 healthcare disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
Earlier this month, Lebanon, New Hampshire-based Dartmouth Health inaugurated the Center for Advancing Rural Health Equity (CARHE).
Joanne Conroy, MD, Dartmouth Health president and CEO, said in a prepared statement that CARHE will tackle one of the biggest challenges facing the country's healthcare system.
"We have major challenges delivering—and receiving—healthcare in our rural communities. And we know that amongst our rural populations, there are those who have even greater challenges due to racism, historical marginalization, poverty, and sexual orientation. Through the work of the Center for Advancing Rural Health Equity, we strive to learn with the community what are the causes of unequal health in rural northern New England and to test solutions. The launch of the Center for Advancing Rural Health Equity is a significant step in advancing our mission to tackle these stubborn disparities head-on and ensure that our patients are fully connected to the care they deserve," she said.
People living in rural areas face unique barriers to accessing healthcare and social services, and rural geography makes it hard for health systems and social services to reach everyone who needs care, according to Dartmouth Health.
The planning process for CARHE was concentrated between January and June. Representatives on the planning team included academics, members of community-based organizations, officials from the Vermont Department of Health, and rural residents in New Hampshire and Vermont. CARHE will have four primary approaches to addressing rural healthcare disparities, according to Dartmouth Health:
Healthcare redesign: Translating knowledge into practice to meet the needs of rural populations
Research: Community-based research focused on creating evidence to support action
Community action: Community and health system partnerships crafted to meet local needs
Education: Training and the sharing of knowledge
The CARHE Leadership Council, the governing body of the center, formed in August. Members of the Leadership Council include clinicians, community leaders, educators, and researchers. The center also has a Community Advisory Council drawn from residents representing diverse populations in rural northern New England.
CARHE will be a collaborative effort, Rudolph Fedrizzi, White River Junction Public Health Services District director and chair of the center's Leadership Council, said in a prepared statement. "We are excited to work together with so many partners to establish the Center for Advancing Rural Health Equity and advance this shared vision for improving the health of our communities in meaningful ways. This collaborative approach, which draws on both expertise and lived experience, is a powerful strategy for improving the lives of all of our friends, family, and neighbors across rural New England."
Physicians are trained in optimal patient care, and when they combine that background with administrative skills, they become dynamic leaders, according to the American Association for Physician Leadership.
Angood has authored a white paper that argues physician leaders are more valuable than ever before. The white paper says physician leadership at health systems and hospitals is pivotal to improve quality, boost patient safety, achieve efficiency, and drive the transformation to value-based care.
HealthLeaders recently talked with Angood about the issues raised in the white paper. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: Why is it important to have physician perspectives included in health system and hospital leadership?
Peter Angood: Healthcare is a highly complex industry overall—arguably it is the most complex industry. There are a whole variety of clinical professionals including nurses, physician assistants, advanced practice clinicians, and pharmacists as well as nonclinical administrators. However, physicians are trained to the highest level of medical science. They are tuned in to what is best for optimal patient care in a variety of ways. So, when a physician couples that background with training and care practice experience in leadership, they become a dynamic force in terms of trying to create improvements and refinements as well as guiding healthcare organizations.
HL: What are the advantages of having a physician serve as the CEO or president of a health system or hospital?
Angood: The medical profession has continued to be viewed as a highly trusted and honorable profession by the general public as well as others inside the healthcare industry. So, when you get physicians who are well skilled in not only their clinical delivery practices but also administrative and leadership practices, they are able to achieve better performance at healthcare organizations in the CEO role. Some data suggests that physician CEOs generate 25% to 33% better performance on quality measures.
Physician CEOs bring a constellation of skills to the role, but it is the level of expertise on the clinical delivery side and the level of expertise on the administrative side that sets them apart. They are also highly respected and trusted inherently by all types of individuals both inside and outside the industry.
HL: Is there something particular about physicians that makes them a good fit for the CEO or president role?
Angood: Physicians by nature are altruistic and highly idealistic—that is what drives them to healthcare as a chosen profession. They are also highly resilient because of the long educational track and the tenacity it takes as they go through a prolonged period of career development. They gain terrific insights into the other professions that are inside the industry—both clinical and nonclinical. And they certainly gain great insights into what is the best way to deliver optimal patient care.
Physicians do not get any management or leadership training in medical school or their specialty training programs. So, it is important that physicians acquire additional skills as they embark on getting involved in different types of administrative roles.
HL: How do physicians gain those additional skills?
Angood: There is the unique physician who just has natural talents as a leader. They know how to create influence and how to stimulate others. They are natural team members who can motivate and drive teams along. But most physicians do require additional skills. They can do that without formal education by getting involved with committees or product line development. However, most will require some formal education to gain better insights as to what is required to run organizations and to be more influential as leaders.
It is not required for all potential physician leaders to do an executive master's program or a doctorate program, and there are a variety of avenues and channels to get that education and added experiences. That is part of what our organization is all about—we have 50 years of experience in providing resources that physicians need to acquire new knowledge. We also have the educational programs and credentials for physicians who want to gain added insight and skill sets.
HL: Does having physicians in the C-Suite improve medical staff engagement?
Angood: Absolutely! Healthcare is fascinating when you look at it historically and the evolution of the relationships between the medical staff as part of a hospital delivery system and how it has evolved toward today's environment. Healthcare is even more complex today because many health systems and hospitals have a combination of employed physicians as well as independent physicians. When you have physicians in the C-Suite who have trust and respect, other physicians can see and recognize that there are physicians in high levels of administration and have confidence that their interests will be understood.
HL: What are the primary core competencies for physician leaders?
Angood: As they go through their training, physicians get oriented toward being somewhat autonomous in their behaviors, and they get used to being the predominant decision-makers. So, they oftentimes need to acquire some additional competencies. Some of that starts with looking at themselves and how they behave with others. In addition to that, you must have some leadership capabilities. That includes integrity, judgment, accountability, humility, and self-control. Then you must have good skills with team building and facilitating teamwork.
Physician leaders need to be adaptable and feel comfortable with a measure of ambiguity. For some physicians, to play a leadership role they must become comfortable with being more visible. You can't just be in the background—if you are going to take on a leadership role, you must be comfortable with being on the frontline. There are also leadership technical skills such as policy, operations, risk assessment, and finance.
The American Hospital Association offers two dozen recommendations to support healthcare workers and address workforce shortages.
A new report published by the American Hospitals Association (AHA) calls on health systems and hospitals to focus on three core challenges to address the strained healthcare workforce.
Health systems and hospitals are facing widespread workforce shortages, particularly in nursing. Top healthcare executives say staffing shortages are their most pressing clinical care problem now that the crisis phase of the coronavirus pandemic has passed. Burnout has spiked during the pandemic.
The new AHA report says the healthcare workforce needs to be a top priority for health systems and hospitals. "A strong and resilient workforce is the backbone of our hospitals and health systems. There is no higher priority than ensuring that we care for the caregiver, that we make our working environment safe, and that we foster the ability for individuals to have joy in their work. While healthcare workforce challenges are not new, the pandemic has greatly exacerbated them. This national emergency demands bold, immediate action from public and private sector leaders."
Core workforce challenge 1: Reconnecting clinicians to professional purpose
Promoting a sense of professional purpose is essential to sustain the healthcare workforce, the report says. "As part of efforts to successfully recruit and retain a qualified, dedicated and diverse workforce, hospitals and health systems must create environments that consistently support meaningful work and nurture relationship-building with colleagues, patients, and families. Maximizing patient care time while minimizing administrative tasks is essential to reinspiring workers to find the joy, satisfaction, and meaning they value so highly."
There are five primary approaches to reconnect clinicians with professional purpose, the report says:
Culture: Health systems and hospitals should foster organizational cultures that are aligned with mission-driven values such as empowerment, responsiveness, and collaboration.
Determine what matters to employees: Health systems and hospitals should use employee engagement tools such as onboarding, surveys, town halls, and rounding to recognize the needs of workers and establish a work environment that they value.
Strengthen employee satisfaction: To decrease burnout and increase retention, health systems and hospitals should focus on employee satisfaction through efforts such as safe work environments, competitive compensation, adequate staffing levels, flexible scheduling, and shared decision-making
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Support self-care: To provide high-quality care to patients, clinicians need to take care of themselves. Health system and hospital leaders should encourage clinicians to seek care for their physical and mental health. Organizations should offer educational programs as well as self-care resources that meet a range of needs.
Embrace patient-centered care: Patient outcomes and wellness should be pivotal elements for models of care. Technology should support better care and boost direct patient interaction.
Core workforce challenge 2: Provide support, training, and technology clinicians need to excel in multiple care settings
The shift in care delivery from the hospital setting has accelerated during the pandemic, the AHA report says. "The pandemic has accelerated changes in the ways care is delivered, with a wider acceptance of virtual in addition to in-person options. The settings where care is delivered also continue to expand, whether it's where patients live, in outpatient clinics, in community facilities or in hospitals. The ability to succeed in, and transition seamlessly between, a wide variety of care environments requires new skills and technologies, new flexibility in the workforce, and innovative strategies for workforce management."
There are six primary approaches to support this shift in care delivery, the report says:
Go virtual: The report calls on health systems and hospitals to seize virtual care opportunities. For example, Des Moines, Iowa-based MercyOne has launched a virtual nursing model that has a virtual nurse assist bedside nurses in monitoring patients, communicating with patients, and discharge planning. The virtual nurse program has improved patient safety and quality, enhanced communication between patients, family members, and care teams, and boosted clinician satisfaction and productivity.
Embrace technology: To automate repetitive tasks and improve clinical productivity, health systems and hospitals should launch a range of technological solutions, including natural language processing to ease documentation burdens and artificial intelligence to mine big data.
Care delivery model innovation: High-tech and high-touch approaches to care delivery models have the potential to improve quality of care and achieve staffing efficiency. For example, Partners for Nursing Staffing promotes a care delivery model with three elements: on-site care, patient monitoring equipment, and ambulatory access as well as virtual and remote care delivery.
Professional development: Foster expertise and leadership skills by offering interdisciplinary training across organizations, departments, and sites of care.
Focus on young workers: Health systems and health systems should build nursing and healthcare competencies in high schools as well as offer undergraduate scholarships.
Clinical professional training programs: Clinician and nurse education programs should promote the use of new technology, cultivate multidisciplinary care teams, and promote soft skills such as listening and empathy. These programs should also include exposure to home health services and incorporating family views in care.
Core workforce challenge 3: Recruitment, retention, and pipeline
Workforce development is crucial, the report says. "To ensure high-quality patient care now and in the future, healthcare workforce recruitment and retention must be top priorities in the short term. At the same time, developing a robust pipeline is critical to creating a sustainable long-term solution."
There are 11 primary approaches to recruitment, retention, and a robust employee pipeline, the report says:
Training options: Health systems and hospitals should work with schools, community organizations, and other healthcare organizations to offer apprenticeships and other on-the-job training opportunities.
International recruitment: Health systems such as Sioux Falls, South Dakota-based Sanford Health are recruiting nurses from overseas. These hiring programs can include housing during the transition period as well as working with international nurses to help them fit into their new communities.
Nurse training programs: In 2022, about 60 schools and hospitals have either launched or expanded nursing programs.
Promote flexibility: Offer flexibility in areas such as scheduling and remote work.
Boost upskilling: More than half of healthcare workers say they want upskilling, which can reduce financial barriers to advancing professionally.
Invest in onboarding: An effective onboarding program supports retention by establishing engagement at the time of hiring and building employee loyalty.
Inclusive workforce: Health systems and hospitals should support the efforts of medical, nursing, and allied health schools to promote diversity in their students. Health system and hospital leadership should embrace diversity, equity, and inclusion.
Offer nontraditional support: As part of recruitment and retention efforts, health systems and hospitals can offer housing grants or build affordable housing for employees. Health systems and hospitals can work with community organizations such as the chamber of commerce to find job opportunities for the spouses or partners of recruits. They can find community partners for childcare or offer on-site childcare.
Consider culture in recruitment: Health systems and hospitals should discuss the pros and cons of their community with recruits to make sure it matches their lifestyle and professional expectations.
Offer competitive financial benefits: In addition to competitive salaries, health systems and hospitals should offer financial benefits such as pay for mentoring, relocation expense assistance, and student loan assistance.
Launch in-house staffing agencies: Health systems and hospitals can have their own staffing agencies for nurses and clinicians that offer the premium pay and flexibility of travel agencies but have the stability of working for a single employer.
Renee Garrick, MD, executive vice president and chief medical officer of Westchester Medical Center Health Network. Photo courtesy of Westchester Medical Center Health Network.
