Dartmouth Health has taken on a leadership role for several small hospitals in New Hampshire and Vermont.
Dartmouth Health is a unique healthcare organization, with an academic medical center located in a rural area and six affiliated members, says Chief Clinical Officer Edward Merrens, MD.
HealthLeaders spoke with Merrens about a range of issues, including the health system's mission, burnout, current clinical challenges, and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What is Dartmouth Health's clinical care vision?
Edward Merrens: We are unique to have a tertiary-quaternary medical center in a rural state. We have a National Cancer Institute-designated cancer center. We have the only children's hospital in the state. We are increasingly one of the only facilities that can deliver babies as smaller hospitals retract from providing obstetrics services. We are a Level 1 trauma center.
So, we have a responsibility to the region. As we think about that, our responsibility is to be able to serve complex needs but also to ensure that the smaller hospitals have a role in their communities. They have a lot of opportunities, and we have not only served as the place where complex care happens, but we have also reached out to ensure that we can provide care at smaller hospitals as well. We have committed to complex orthopedic care at smaller hospitals, developing hospitalist programs at our critical access hospitals, connected with smaller hospitals through telehealth, and unified our emergency medicine physicians across the system.
The other things that we are doing are enhancing our care capacity coordination center to coordinate patients moving across the system in the most appropriate ways. By being responsible for the region, we have dedicated ourselves to coordinating among all the hospitals in our system, mostly critical access hospitals. We have fundamentally changed the nature of what they do by providing them with an opportunity to fill their operating rooms. It is a great experience for our clinicians and an opportunity for patients to get care close to home.
HL: In addition to telehealth, in what ways are you directly involved with your affiliated hospitals?
Merrens: They are part of our electronic health record. I work with their chief medical officers and their CEOs. We look to develop joint programs. We look to develop outreach. We have membership on their boards. So, we are a closely aligned system—we have developed several system programs. It's not just putting a Dartmouth sticker on their doors. We have developed a system pharmacy and therapeutics committee. We have ways that we try to align our clinical practices to be the same across the system. We have tried to align care.
It has been rewarding to figure out how we can develop algorithms, policies, and procedures that work across the system. We have done that in several areas, which makes it easier for patients to navigate the system and for physicians to work within it. Once you share an electronic health record, and there is one way to do things, it brings you together.
Edward Merrens, MD, is chief clinical officer of Dartmouth Health. Photo courtesy of Dartmouth Health.
HL: What is the status of physician burnout at Dartmouth Health?
Merrens: We are similar to other health systems across the country—we are dealing with not only physician burnout but also healthcare worker burnout more broadly. It is affecting everybody.
We have done a lot of things to address burnout. We developed a well-being council as well as dedicated resources and staff members for a Department of Caregiver Well-Being that incorporates physicians, advanced practice providers, and nurses. We have developed a robust employee assistance program that is available 24/7. We have gotten chaplaincy involved. We have developed lifestyle programs, including nutrition and exercise.
We also recognize that burnout is about more than having enough healthy vegetables and enough yoga. We have developed support systems for people. We are working at add more resources. We are streamlining the electronic health record. We are trying to figure out if we need new roles in the organization such as scribes and other people to make the job easier for clinicians.
We are trying to raise awareness about burnout. We are educating people, addressing needs, addressing stressors, and trying to approach the problem on all fronts.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Merrens: The clinical challenges are meeting the needs of the region, including an increasing number of patients seeking our care. We are building a new inpatient tower that will have 64 new beds and we can ramp up to 100 beds. Remarkably, at a time when other hospitals are contracting, we are building more inpatient beds.
We have a critical shortage of staffing—mainly at the nursing level but it includes radiology techs and every area of staffing. It is partly a function of the labor market—New Hampshire has one of the lowest unemployment levels in the United States. We have a unique environment to recruit people. The critical shortage of staffing is a clinical challenge. It impacts meeting patients' expectations of how they want to receive care.
The staffing crisis is not just us. One of the big problems for our 400-bed hospital is that we are struggling with finding places to discharge patients because the skilled nursing facilities and rehab facilities do not have staff, and they have limited the number of patients that they can take. So, we have got several bottlenecks in the system that make our work challenging. These bottlenecks have led us to have long-stay patients in the hospital.
HL: How is the organization addressing workforce shortages?
Merrens: We have several programs, including programs that reach out to high schools—apprenticeship programs and training programs. We are focused on the core members of the care teams who make things happen. We have had a medical assistant program for many years.
We train people to become phlebotomists because someday they will be licensed nursing assistants, then registered nurses, then nurse practitioners. We want people to focus on the stepwise growth in healthcare and what the starting point might be.
We have a health workforce readiness institute that reaches out and provides opportunities for people to be hired as employees while they are training. We have a dedicated relationship with the Colby-Sawyer College School of Nursing—they are our nursing school, and we hire as many graduates from there as we can.
Our focus has been to grow our own employees. We increased our minimum wage to $17 an hour in 2021. We may have to continue to adjust that wage. We have increased compensation for several roles, including nursing, medical assistants, LNAs, and techs.
We also have been innovative from a government standpoint. We were part of 17 organizations nationwide to receive a grant for rural healthcare workforce development. It was a $40 million grant, and we were awarded $2.5 million.
HL: What patient safety initiatives have been launched at Dartmouth Health?
Merrens: We have focused on the hospital-based and clinic-based measures that are important. We have looked at the infections that you have to be conscious of. We have reduced catheter-associated infections, central-line-associated infections, and communicable infections such as Clostridium difficile by 45% to 70% by paying attention to tracking infections and dedicating a quality team.
For example, with central-line infections, we started focusing on that area in 2019 and kept the work going through the pandemic. When we measured where we were in 2021, we had a 66% reduction in our central-line infections.
From 2018 to 2022, our urinary-catheter infection reduction was 60%.
From 2017 to 2022, we have had a 45% reduction in Clostridium difficile.
We also have an in-house team that looks at adverse events and does the root cause analysis. They look at adverse events and do the tracing to understand how those events happen.
We have an inpatient team focusing on patients who have high glucose levels and making sure that our best-practice alerts for managing sepsis are followed.
We also have thought about the safety impact on our caregivers. From 2021 to 2022, we have had a 37% reduction in blood-borne pathogen exposure such as needle sticks and exposure to blood products that happen in the emergency room and the operating rooms.
Jack Resneck Jr. says physicians will fight for the interests of their profession and their patients.
In an impassioned speech before the Interim Meeting of the American Medical Association House of Delegates, AMA President Jack Resneck Jr., MD, denounced disinformation campaigns and government interference in the patient-physician relationship.
Misinformation and anti-science rhetoric have been common during the coronavirus pandemic. Since the Supreme Court of the United States ended the right to an abortion in Dobbs v. Jackson Women's Health Organization, several states have passed laws banning abortion regardless of whether the life of the mother is threatened.
Addressing the AMA meeting on Saturday, Resneck said the country's physicians are facing unprecedented challenges. "How can a profession that put its lives on the line to lead our nation through this pandemic … that continues to fight an onslaught of medical disinformation amid increasing hostility and threats. How can we at the same time face ominous Medicare cuts as practice costs surge … as giant healthcare mergers concentrate market power … And as an ever-growing list of administrative demands pull us away from what drew us to medicine in the first place—caring for our patients."
The practicing dermatologist said he is having an emotional reaction to the threats facing physicians and their profession.
"I'm angry about how science and medicine have been politicized … about the flood of disinformation that seeks to discredit data and evidence, undermine public health, and misrepresent the wise policy of this House and our AMA's work to implement it. It began with COVID and lies meant to sew confusion and divide our nation. Lies about masking … you don't need them, so don't wear them. Lies about vaccines … they have microchips, or don't work, so don't use them. Lies about public health leaders and even frontline physicians … they're profiteering from the pandemic, so don't trust them. You are ambassadors of truth, doing the difficult work to reject these falsehoods and impart your knowledge to a weary public," he said.
Resneck said critics of physicians are misrepresenting the AMA's health equity efforts, distorting gender-affirming care, and ignoring evidence about what needs to be done to address gun violence. "You know and I know that we did not pick these fights, and that our organization isn't on any political team. The AMA is fiercely non-partisan. We have evidence-based, open debates in this House, and our actions are driven by the policies that you create. And you represent every state, every specialty, employed and independent settings, rural and urban communities. You come from every point across the political spectrum."
Physicians are willing to work with politicians, but clinicians will not be intimidated by them, he said. "We are influential individually as physicians and collectively as the AMA because we are the grown-ups in the room. We follow the evidence. Science is our North Star. And because we work with political leaders, from any party, at any time, when they are willing to help us improve the health of the nation. But make no mistake. When politicians insert themselves in our exam rooms to interfere with the patient-physician relationship … when they politicize deeply personal health decisions or criminalize evidence-based care … we will not back down. We will always stand up for our policies … for physicians … and for our patients."
Enduring the fallout of Dobbs
Resneck said the AMA has taken a stand on access to reproductive healthcare services such as abortion and contraception, adding that position is under assault.
"Since we last gathered in Chicago in June, many states have raced to criminalize abortion in the wake of Dobbs, and the drivers of disinformation have been at it again. Now they are falsely claiming that we have exaggerated or even fabricated stories about the real consequences of those laws. … Stories about patients with ectopic pregnancies, sepsis or bleeding after incomplete miscarriages, or cancers during pregnancy—patients who are suddenly unable to get the standard care that was unremarkable for decades … patients who now must, absurdly, travel hundreds or thousands of miles across the country to exercise their choice and obtain basic medical care. Denying our experience is helping prop up restrictive laws that are creating chaos—and leaving physicians in impossible positions," he said.
Resneck said abortion bans are forcing physicians to make choices between following the new laws or risking the lives of their patients. "I never imagined colleagues would find themselves tracking down hospital attorneys before performing urgent abortions, when minutes count … asking if a 30 percent chance of maternal death, or impending renal failure, meet the criteria for the state's exemptions … or whether they must wait a while longer, until their pregnant patient gets even sicker. In some cases, unstable patients are being packed into ambulances and shipped across state lines for care. To those who are forcing physicians into these ethical dilemmas, your efforts are reckless and dangerous."
"As we emerge from the worst of COVID, as practice costs have surged in the face of substantial inflation, and physicians struggle to retain staff, I can't think of a worse time for Medicare to threaten almost eight-and-a-half percent across the board payment cuts. How demoralizing! Our AMA is fighting to stop those cuts, and I'm glad to see all of medicine aligned in this effort. We must and will keep the pressure on Congress to act before the end of the year. But simply blocking every planned cut, as we've done before, isn't good enough. Physicians deserve financial stability, including automatic, positive, annual updates that account for rising practice costs. And it's time for reform of unfair budget neutrality rules that penalize doctors for things beyond our control," he said.
'Enough is enough'
Resneck expressed exasperation over misinformation and the drivers of physician burnout.
"Enough is enough. We cannot allow physicians or our patients to become pawns in these lies. All of this is exacerbating the burnout crisis in medicine. Doctors, facing threats and obstacles on so many fronts, are tired. Some are wearing down and leaving the profession they have dedicated their lives to. Telling them to be more resilient, or to do more yoga, and to enjoy a free dinner from the hospital CEO isn't going to heal the burnout. While wellness has its place, to focus solely on resilience is to blame the victim. We need to fix what's broken—and it's not the doctor."
The group representing emergency physicians and other healthcare organizations say emergency department boarding has reached "a breaking point."
The American College of Emergency Physicians (ACEP) and 34 other healthcare organizations are urging the Biden administration to hold a summit to address crisis levels of patient boarding in emergency departments.
Boarding in emergency departments occurs when there is a shortage of inpatient beds for hospital admissions or there are no beds at external facilities such as psychiatric hospitals. The Joint Commission recommends that emergency department boarding not exceed four hours; however, it has become common to have emergency department boarding for days or weeks, according to ACEP.
In a letter sent last week to President Biden, ACEP and three dozen other healthcare organizations paint a grim picture of the adverse impacts of emergency department boarding.
"In recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem—rather, from a decades-long, unresolved problem known as patient 'boarding,' where admitted patients are held in the ED when there are no inpatient beds available. While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the healthcare system have recently brought this issue to a crisis point, further spiraling the stress and burnout driving the current exodus of excellent physicians, nurses and other healthcare professionals," the letter says.
The letter details five negative effects of emergency department boarding:
1. Patient harm: "There is ample evidence that boarding harms patients and leads to worse outcomes, compromises to patient privacy, increases in medical errors, detrimental delays in care, and increased mortality," the letter says.
2. Providing care in waiting rooms: "Many emergency physicians who submitted stories reported daily numbers of boarders close to or even exceeding 100 percent of the total number of beds in their EDs, while the number of patients in the waiting room comprised up to 20 times the number of free treatment beds in which they could even be seen. In the past, that often left only hallway stretchers within the ED to care for incoming patients. But now, those too are increasingly over capacity, and so the emergency department waiting room has become the latest ad-hoc location for receiving patient care," the letter says.
3. Pediatric patients: "Unfortunately, the pediatric population is not immune to the serious ED boarding issue we are facing—particularly those with mental health conditions. During the last decade, pediatric ED visits for mental health conditions have risen dramatically. The COVID-19 pandemic led to a greater acceleration of these visits, causing several pediatric health organizations to issue a national emergency for children's mental health in 2021 and the U.S. Surgeon General to release an advisory on mental health among youth. … Multiple studies show that pediatric patients with mental health conditions who are boarded are more likely to leave without being treated, and less likely to receive counseling or psychiatric medications," the letter says.
4. Psychiatric patients: "Boarding of psychiatric patients in EDs is particularly prevalent, disproportionately affecting patients with behavioral health needs who wait on average three times longer than medical patients because of significant gaps in our healthcare system. While the ED is the critical frontline safety net, it is not ideal for long-term treatment of mental and behavioral health needs. Research has shown that 75 percent of psychiatric emergency patients, if promptly evaluated and treated in an appropriate location—away from the active and disruptive ED setting—have their symptoms resolve to the point they can be discharged in less than 24 hours. However, far too many Americans have limited options for accessing outpatient mental health care," the letter says.
5. Boarding drives burnout: "Overcrowding and boarding in the emergency department is a significant and ever-growing contributor to physician and nurse burnout, as they must watch patients unnecessarily decompensate or die despite their best efforts to keep up with the growing flood of sicker and sicker patients coming in. Healthcare professionals experiencing burnout have a much higher tendency to retire early or stop practicing all together. This increases the loss of skilled healthcare professionals in the workforce and adds more strain to those still practicing, which continues the cycle of burnout within the profession," the letter says.
Researchers find Black and Latino adults face higher barriers to timely medical care compared to White adults.
Barriers to timely medical care based on racial and ethnic disparities increased over the past two decades, according to a recent research article.
Racial and ethnic disparities impact access to healthcare. Earlier research has shown that Black and Latino people had higher lack of health insurance and cost-related unmet medical needs compared to White people from 1999 to 2018.
The recent research article, which was published by JAMA Health Forum, is based on data collected from more than 590,000 adults in the National Health Interview Survey from 1999 to 2018. The researchers examined trends in five barriers to timely medical care: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation.
The study features several key data points:
In 1999, the percentage of people reporting any of the five barriers to timely medical care was 7.3% among the Asian group, 6.9% among the Black group, 7.9% among the Hispanic and Latino group, and 7.0% among the White group
From 1999 to 2018, the percentage of adults reporting any of the five barriers to timely medical care increased for all four of the racial and ethnic groups, increasing 5.7 percentage points for Asians, 8.0 percentage points for Blacks, 8.1 percentage points for Hispanics and Latinos, and 5.9 percentage points for Whites
In 2018, compared to White adults, the proportion of adults reporting any barrier was 2.1 percentage points higher for Black adults and 3.1 percentage points higher for Hispanic and Latino adults
From 1999 to 2018, compared to White adults, Black adults experienced a 1.5 percentage point higher delay in care because of long waiting times at a clinic or medical office as well as 1.8 percentage point higher delay in care because of a lack of transportation
From 1999 to 2018, compared to White adults, Hispanic and Latino adults experienced a 2.6 percentage point higher delay in care because of long waiting times
In 2018, the overall proportion of adults reporting any barrier was 13.5%, with the adjusted prevalence among White adults at 12.9% and the proportion 2.1 percentage points higher among Black adults and 3.1 percentage points higher among Hispanic and Latino adults
From 1999 to 2018, compared to uninsured White adults, disparities in any barrier to timely medical care increased 6.6 percentage points for uninsured Black adults and 5.3 percentage points for Hispanic and Latino adults
In 2018, compared to White adults, the proportion of Hispanic and Latino adults who experienced a delay in care because of long waiting times was 4.0 percentage points higher
In 2018, compared to White adults, the proportion of Hispanic and Latino adults who experienced a delay in care because of lack of transportation was 1.0 percentage point higher
"The findings of this serial cross-sectional study of data from the National Health Interview Survey suggest that barriers to timely medical care in the US increased for all population groups from 1999 to 2018, with associated increases in disparities among race and ethnicity groups. Interventions beyond those currently implemented are needed to improve access to medical care and to eliminate disparities among race and ethnicity groups," the study's co-authors wrote.
Interpreting the data
During the study period, barriers to timely care increased significantly, with a disparity gap between White adults and Black and Latino adults, the study's co-authors wrote. "In this nationally representative study, we found that from 1999 to 2018, the overall estimated proportion of respondents who reported barriers to timely care nearly doubled, increasing from 7.1% to 13.5%, and the increase was not proportionate across the four race and ethnicity groups. During this period, differences in accessibility and availability of care between White respondents and Black and Latino respondents increased. In 2018, Black and Latino respondents were more likely to report delayed care because of lack of transportation and long waiting times at the doctor's office compared with White respondents."
The data has three health policy implications, the study's co-authors wrote:
"The increase in prevalence in barriers across race and ethnicity groups in the US indicates a worsening societal failure to deliver timely medical care. The fact that, overall, nearly 1 in 7 adults in 2018 experienced barriers to timely medical care indicates that attempts to improve access to care through improving access to insurance coverage alone may be inadequate—and may not be enough to reduce disparities. … Although increasing insurance coverage may address unmet medical needs by reducing cost, it is less clear that it removes barriers to timely medical care that are not directly related to cost."
"The growing racial and ethnic disparities in prevalence of these barriers to timely medical care suggest that the scope of national efforts to eliminate disparities in health care access should be expanded and include societal reforms beyond the health care system. This is not to say that health care−specific interventions (eg, the [Affordable Care Act], the national Culturally and Linguistically Appropriate Services) are not fundamental toward this goal, but that eliminating disparities in these indicators requires that policy interventions address nonmedical barriers to health care access and quality, including education, housing, urban planning, employment, and transportation, which disproportionately affect underserved populations."
"There are important implications from the income- and sex-stratified findings. The finding that racial and ethnic disparities were attenuated by lower income serves as an example of the pervasiveness of income inequality in access to health care, even beyond cost-related indicators. Regarding sex, although racial and ethnic disparities among women were mostly static, they had an overall higher prevalence of barriers during the study period compared with men of the same race or ethnicity. Because women face structural challenges to accessing sex-specific primary care (eg, pregnancy, menopause, gender-sensitive care), these findings add to the evidence of a need to improve women's access to primary care throughout the different stages of the life cycle."
Balcezak says that at Yale New Haven Health "nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers."
Thomas Balcezak, MD, MPH, chief clinical officer of Yale New Haven Health, recently talked with HealthLeaders on a range of issues, focusing primarily on physician burnout and workforce shortage issues, while expressing how the organization is moving healthcare forward in the communities it serves with patient safety initiatives and hospital acquisition goals to provide higher-quality care.
The transcript below has been edited for clarity and brevity.
HealthLeaders: Yale New Haven Health is in the process of acquiring three hospitals in Connecticut. What are you plans for clinical care at these hospitals?
Thomas Balcezak: We have acquired other hospitals and integrated them into the health system. For example, in 2012, we acquired the Hospital of Saint Raphael. In 2016, we acquired Lawrence and Memorial Hospital and Westerly Hospital. And in 2019, we acquired Milford Hospital. In each one of those transactions, our goals were straightforward. Connecticut is a parochial state—we like our healthcare local, and we like access to high-quality services. In these transactions and the proposed transactions for the three other hospitals, our goals are to broaden access to high-quality clinical services, to keep care to whatever extent possible local, to improve the quality of care, and to reduce the cost of care.
It comes down to cost, quality, and access. If all goes well as in the previous transactions, we believe we have an opportunity to do all three.
HL: How do you lower the cost of care in these transactions?
Balcezak: There are a couple of different ways. One is to take advantage of being a relatively large organization—we are almost $6 billion in revenue. That gives us good power in negotiation for products. It gives us access to competitive pricing on things such as drugs and supplies. So, we have some opportunities in supply chain savings.
The other way we can lower cost of care is in economies of scale for back-office services. Healthcare in general and hospitals in particular are human capital—intensive. We do not believe there is an opportunity to reduce direct caregivers—we have enhanced the staffing on the clinical side at the institutions we have acquired and integrated into the health system. There is opportunity in management structure, span of control, and back-office services.
HL: What is the status of physician burnout at Yale New Haven Health?
Balcezak: We are in a similar position as other health systems and hospitals across the country. Burnout is an issue beyond physicians—it is all of our clinical caregivers such as nurses, respiratory therapists, and pharmacists. We are seeing an epidemic of burnout in U.S. healthcare. It is something we are taking a lot of steps to address, but we do not have all of the answers.
The steps are relatively simple, but they are nuanced with a lot of efforts that are bolstering those steps. One step is making sure that we have adequate staffing, which has been a challenge. We have staffing shortages in virtually every area of our institution; just like you are seeing in other industries, we have seen growth in open positions.
Addressing staffing shortages goes well beyond salary and benefits. People want to work where they feel they are doing important work that is contributory to society. That is where healthcare has an advantage over many other industries. People go into healthcare because they want to help people—they want to help communities. It is important to be grounded in that as a health system. We need to spend more time focusing on what we are doing to improve the lives of the patients we serve and the communities we serve.
Another step is supporting the caregivers—giving them the tools that they need to deliver good care as well as reducing the barriers and the excess work that they do such as difficulties with documentation or use of the electronic medical record. There is a whole stream of work that we have been engaged in to improve day-to-day work effort, while providing employee and health resources support, so that staff have opportunity to express where their concerns are.
Pictured: Thomas Balcezak, MD, MPH, is the chief clinical officer at Yale New Haven Health. Photo courtesy of Yale New Haven Health.
HL: Give an example of an initiative you have put in place to address physician burnout.
Balcezak: One of the initiatives that we have is spearheaded by our chief medical information officer, and it is called Building Against Burnout. This initiative is specifically looking at how much time physicians are spending using the electronic medical record, particularly the "pajama time" outside of standard work hours. We have had a reduction in pajama time that can be tied directly to what our CMIO and his team has been doing to make the electronic medical record more streamlined and easier for physicians to use.
The electronic medical record is a big complaint by physicians, and it is appropriate that they are complaining about it. Technology is supposed to make lives at work easier, but what we often hear from physicians is that technology has made their work more onerous. In healthcare, we need to make documentation easier and use things such as virtual scribes to make the amount of time that physicians are spending on the electronic medical record go down.
HL: What have been your primary efforts to address workforce shortages?
Balcezak: We have made a multi-pronged effort. One of the efforts has been to make sure that we can offer a competitive salary and benefit package. We need to be competitive with more than other hospitals. We need to be competitive with other industries because it is not just healthcare that has a workforce shortage. We find ourselves competing with Amazon, retail outlets, and manufacturing organizations—we are competing at all levels of the workforce.
Right now, we have about 3,000 open FTEs that we are trying to recruit, and they are everything from pharmacists to respiratory therapists, nurses, environmental services, biomedical engineering, and clinical technicians. Virtually every position in our organization has open positions.
If you are a young person, and you are looking for a career in healthcare, the good news is there are lots of openings. There are openings at all levels, from physical therapists to occupational therapists, to all kinds of technicians, radiology, and the operating room. Every one of those positions has opportunities.
We have partnered with our local colleges to provide more educational opportunity such as scholarships for people to join the workforce. Some of our positions call for a high school diploma, and we are hiring people who do not have a high school diploma and allowing them to get a GED on the job. We have pathways for folks to get nursing degrees, and we are offering that with some tuition assistance at local colleges.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Balcezak: In many ways, it is getting back to basics. We have had growth in our length of stay. If you are not able to take care of patients in the acute phase of their illness in the most efficient way, and get their workup completed and their therapy completed in a timely way, that is a quality issue. So, we are attacking length of stay. We want to make sure that patients are not seeing delays in either diagnostics or therapeutics—that is a big deal for us now.
We are also still clearing the backlog of patients who had delays in care because of COVID. We have a backlog in screening exams—in colonoscopies. Those are burdens for population health that we are focusing on now. We are coming out of the other end of these backlogs, but we have not seen them completely cleared.
HL: Give an example of patient safety initiatives you have launched at Yale New Haven Health.
Balcezak: One of our most groundbreaking patient safety initiatives has been our work around becoming a high-reliability organization. We started this work about a decade ago—we were a relatively early adopter. The Connecticut Hospital Association created an initiative for hospitals, and we fully embraced it.
It was a galvanizing moment for our health system to get everybody involved in safety. Applying the principles of high reliability such as a deference to expertise has been permeating our organization. Rather than one initiative around falls, or one initiative around surgical-site infection reduction, we have implemented checklists and we have implemented technology for safety events. We have been addressing the most flawed part of our safety environment, which is the propensity of humans to make mistakes. The high-reliability work that we have done has taken direct aim at the frailty of humans and the fact that we are not perfect creatures.
We can talk about what we have done with technology and what we have done with human-factors engineering—those have been great individual efforts in individual error prevention. But nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers.
Outpatient practices can drive value, harness telemedicine, provide access, and promote equitable care.
Effective outpatient strategies are critical to the success of health systems, a top executive at NewYork-Presbyterian (NYP) says.
With an ever-increasing shift of care from the inpatient setting to the outpatient setting, ambulatory care has become an increasingly important sector of the U.S. healthcare industry. Annual revenue from ambulatory healthcare services is about $1 trillion, outpatient practices employ more than 7 million people, and there are more than 600,000 ambulatory care establishments, according to statista.com.
Outpatient care is essential to drive value in healthcare, says Tiffany Smith Sullivan, MPH, senior vice president and chief operating officer of physician services at NYP. "To drive value at its core, you need a patient-centered approach. We need to build teams for patients that manage complex types of care, so that we are aligned, we are communicating, and we are working with the patient to make sure that they have everything they need to remain healthy in the ambulatory setting. For example, we want a patient who is managing diabetes to not have to go to the emergency department or have an inpatient stay. That is a condition that we can manage in the ambulatory setting with community partners to help the patient get what they need to stay healthy."
Ambulatory practices have become leaders in telemedicine, she says. "You need to go back to 2020, when many of our outpatient practices were closed for in-person visits. Before 2020, we had been dragging our feet on telehealth options for our patients. We were still getting our technology up to speed. The pandemic accelerated the pace of building telehealth capabilities in the ambulatory space. While we were shut down for in-person visits, we were able to identify platforms for telehealth including phone calls and video. It was important to have telephonic visits as well as video visits for our patients who live in areas where access to high-speed Internet was not available for them. The pandemic gave us an opportunity to shift to telehealth platforms and be safe in how we provided care for patients."
NYP is committed to telemedicine in the outpatient setting, Smith Sullivan says. "We are going to continue to offer telehealth—we have about 20% of our patients wanting that option for care."
Outpatient care is essential for efficiency and access to care, she says. "Our outpatient strategies to increase efficiency include opening up access to care so that patients do not need to seek care in high-acuity settings such as the emergency department. If we are only open Monday through Friday, 8 a.m. to 5 p.m., then we are leaving out a segment of our patient population. Sickness does not only happen Monday through Friday, 8 a.m. to 5 p.m. So, we are making sure that we have extended hours and weekend hours to make sure we can provide access to our patients whenever they need care. We want them to be able to seek care in an outpatient practice, rather than seeking care in the emergency room."
NYP is trying to schedule outpatient visits within at least seven days, Smith Sullivan says. "We are identifying opportunities for expansion of primary and specialty care in areas where we see lag times. That means if you call today, how long does it take us to get you into an appointment? We have metrics for that, and we want to make sure that if we see a community that has a high lag time, we look at those trends to address where we need to place primary and specialty care resources."
The health system is expanding its ambulatory care network to improve access, she says. "We are making sure that we understand where we have significant lag times by using trend data. It can mean increased staffing such as more advanced practice providers including nurse practitioners and physician assistants in our practices. We are looking at not only the structure of the type of caregivers we have in our practices to address the needs we see in our communities but also looking at where the need is growing and shifting related to primary care and different types of specialty care."
Using ambulatory care to promote equity
Equity is one of the goals of NYP's outpatient care strategy, Smith Sullivan says. "Each community in New York City has its own different flavor and has its own underpinning resources. So, we need to make sure that we have strong partnerships in our communities and strong relationships with our patient population. We need to streamline what it takes to get in and see a provider such as having a centralized contact center, which is a process in place at NYP starting with primary care. That improves access for all of our patients."
NYP's ambulatory practices are closely linked to the community, which supports equity in care, she says. "Our strongest opportunity with our socioeconomically disadvantaged populations is to understand the community, to understand the pain points in the community, and to work with community-based organizations. For example, we have strong partnerships with faith-based organizations, school-based health centers, and programs that help people obtain healthy food. So, integrating with those programs and organizations is part of building trust in the community and making sure that care is equitable in terms of access and being able to see a provider of your choice. We need to be embedded in our communities, to be tied in with community-based organizations, and to have partnerships that are meaningful."
Expanding ambulatory care
Opening new outpatient practices remains a cornerstone of expanding ambulatory care at NYP, Smith Sullivan says. "Brick and mortar is still our biggest play in terms of the volume of patients that we see. So, we spend a lot of time and energy on where we are having bottlenecks and where we are having access issues in terms of patients not being able to get an appointment in seven to 14 days, which can mean we need an additional brick and mortar location. We also want to look at how we can open up our schedules to accommodate those patients."
Data drives decisions on opening new outpatient practices, she says. "There are several metrics that help us decide whether we should expand, where we expand, and what type of services we expand in a community. We look at lag time—how long it takes a patient to get an appointment. We look at the comments from our engagement surveys such as how long patients are staying on the phone. We look at our quality metrics to make sure our patients are getting high-quality care. If we see our physicians are overloaded, we often see a correlation to some of our quality metrics."
Recruitment statistics from 2021 show strong demand for physicians and advanced practice providers.
The market to fill physician and advanced practice provider positions is extremely competitive, according to a recent report from the Association for Advancing Physician and Provider Recruitment (AAPPR).
There are widespread workforce shortages across the country at health systems, hospitals, and physician practices. Clinical leaders say labor shortages are the Number One challenge facing their organizations.
The recent report is based on 2021 data collected from more than 175 AAPPR member organizations representing more than 23,000 employment searches. More than half of the searches were specific to physicians. The report includes several key findings:
The percentage of physician searches filled decreased for the fourth straight year
The most sought-after physician specialties were family medicine, internal medicine, and hospital medicine
The physician specialty positions that were least likely to be filled included otorhinolaryngology, dermatology, and urology
Nearly half of all physician searches were to replace a departing physician—this turnover rate has increased 16 percentage points since 2018
The proportion of clinician searches open at year end spiked in 2021, reaching 47% for physicians and 32% for advanced practice providers (APPs)
At 10% in 2021, APP turnover increased to a six-year high
The top three active searches by provider category were physician (52.0%), nurse practitioner (26.5%), and physician associate (11.2%)
The primary reasons for physician turnover at organizations with 300 to 999 providers were leaving for a similar position (74.6%), retirement (67.3%), geography (50.9%), burnout (34.6%), and compensation (30.9%)
The primary reasons for APP turnover at organizations with 300 to 999 providers were leaving for a similar position (91.7%), compensation (68.8%), geography (43.8%), burnout (33.3%), vaccination or testing requirement (18.8%), and retirement (12.5%)
Interpreting the data
The extent of clinician shortages is mainly dependent on geography and specialty, says Carey Goryl, MSW, CEO of the AAPPR. "The shortage of physicians is impacting different communities differently. If you look at rural communities, that is where we are going to see the physician shortage being felt most acutely. It also depends on the specialty. We are already starting to see certain specialties with serious shortages such as urology, where they have an aging provider workforce. When you look at the data to see who is going into urology residencies, there are not big enough numbers to have enough providers five to 10 years from now."
Future clinician shortages will be driven by geography, specialty, and burnout, she says. "The trend is taking us into an area where different patients in different communities will feel the physician shortage differently. It is going to depend on where you are and what type of provider you are trying to see. The future trend is also associated with burnout. If you have a specialty that is already stretched thin, the challenges to impact burnout, engagement, and retention point to a looming storm."
For health systems, hospitals, and physician practices, there are three primary consequences associated with physician turnover, Goryl says.
"The first impact is cost to the organization. It is very expensive to replace a physician and it is also expensive to have a physician position vacant for long periods of time. The cost to recruit and the lost income from vacant physician positions can be millions of dollars. The second impact of physician turnover is continuity of care. It hurts patients when their provider leaves and they have to create a relationship with a new physician. They may have been seeing a provider for several years, and there is a lot of historical information and relationship building that can be lost when there is this break in the continuity of care. The third impact of physician turnover is the impact on their colleagues. When a provider leaves, that means their colleagues might need to pick up additional patients or call coverage. It stretches everyone even thinner and adds to burnout."
There are no easy fixes for high clinician turnover and increasing job openings, she says. "We must look at provider retention programs that address physician concerns. We must look at why physicians and APPs leave their positions. And we need to invest in workforce planning. We must get ahead of these numbers, so they do not continue to increase. In workforce planning, we need to look at everything from retirements to employee engagement data. We need to try to forecast what is going to happen because the sooner we can start developing relationships and start recruiting to fill openings, the easier it will be to address these turnover statistics."
In a new study, deaths in U.S. emergency departments were estimated to account for 11.3% of total deaths from 2010 to 2019.
Death during or shortly after an emergency department visit is relatively common, and EDs should be prepared to provide better end-of-life care, according to a new research article.
From a patient experience point of view, it is unlikely that most EDs are a good setting for an unanticipated death. Earlier research on patients with cancer who die in an ICU shows there is a lower quality experience such as physical distress than patients who die at home.
The new research article, which was published by JAMA Network Open, features information drawn from the Optum clinical electronic health record data set from 2010 to 2020. Data was also used from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and U.S. Census.
The study features several key data points:
Among more than 104 million patients with more than 96 million ED visits, 205,372 ED deaths were found in the Optum data set, with a median age of 72
Deaths in EDs were estimated to account for 11.3% of total deaths from 2010 to 2019
A third of people who died nationally visited an ED within one month of their death
The proportion of deaths occurring in the ED decreased 0.27% annually but the proportion of people who died within one month of an ED visit increased by 1.2% annually
Compared to all ED visits, patients with ED visits resulting in death were older, male, and had higher Charlson Comorbidity Index scores
Among patients older than 80 who had ED visits, nearly 1 in 12 died within one month
"This retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently," the study's co-authors wrote.
Interpreting the data
The data suggest approaches to end-of-life care in the ED setting, the study's co-authors wrote. "We found that more than 1 in 3 U.S. residents come to the ED within 1 month of their death, a proportion that has increased 42% over a decade. Moreover, nearly 300,000 U.S. residents die in the ED annually. Taken together, these findings highlight a pressing need to develop systems and resources to support end-of-life care in the ED. Unsurprisingly, we find that patients with death proximate to their final ED encounter are older and have significantly more comorbidities compared with the overall ED population. … These patients may exhibit identifiable trajectories of dying that offer an opportunity to avoid unwanted aggressive care or hospitalization at end of life."
The quality of end-of-life care in the ED is generally suboptimal, the study's co-authors wrote. "There is general consensus that delivering high-quality end-of-life care in the ED is an unmet need. Compared with dying at home or in a hospice facility, quality of dying in the hospital is worse and may lead to protracted grief and psychological distress for families. Time constraints, patient volume, and environmental factors may contribute to suboptimal patient care and family experience."
The study's co-authors offer suggestions for improving end-of-life care in EDs. "Development and implementation of policies, structural changes, and allocation of additional resources can improve delivery of care to these patients. ED programs should clearly include grief and bereavement resources. Practitioners and staff in the ED should have core primary palliative care skills, including symptom management for actively dying patients, the ability to give serious news, and focus on talking to patients and families about goals of care."
EDs should be prepared to connect patients near the end of life with palliative care and hospice care, the study's co-authors wrote. "ED practitioners and systems of care should consider developing relations with community palliative care and hospice programs to follow up with the large number of patients who, although they will survive their acute encounter, have impending or ongoing palliative care needs."
Some medical device supply chain challenges at hospitals are foundational such as determining what they own and establishing a comprehensive inventory.
Medical devices are one of the most challenging facets of supply chain management at health systems and hospitals.
Medical devices include a range of equipment from monitors, to IV pumps, to million-dollar magnetic resonance imaging machines. Hospitals not only need to acquire medical devices but also need to keep track of them and maintain them in good working condition.
This equipment is high in the supply chain hierarchy, says David Klumpe, PharmD, president of clinical asset management solutions at Indianapolis-based TRIMEDX. "Medical devices are an important part of the hospital supply chain. On the capital side, medical equipment represents 20% to 25% of what the hospital is spending every year on capital equipment. It is a major driver of organizational spending for capital on an ongoing basis."
He says there are four primary supply chain challenges related to medical devices:
"The first challenge is gaining visibility to what you own. We find that many of our clients do not fully understand everything that they own. When we help them complete an inventory, there is a pretty big difference between what they think that they own and what they actually own—they can be off as much as 30%," he says.
"The second challenge is measuring device utilization. Hospitals own thousands of devices and they need to know how many they are using on a regular basis. Nearly every hospital struggles with this challenge because it is very difficult for hospitals without technology to monitor device utilization. A typical hospital is only using 40% to 50% of the equipment that they own on any given day. So, asset utilization can be far less than what they might expect," Klumpe says.
"The third challenge is that many hospitals lack comparative benchmarks—how much equipment does a hospital own compared to similar hospitals. For example, how many ventilators does a hospital own and how many IV pumps does a hospital own? Many hospitals do not have comparative benchmarks to gauge the level of investment they have made in their equipment," he says.
"Lastly, like a lot of things in a hospital, there are many stakeholders for medical devices—many people involved in decisions about clinical equipment. There is the administrative point of view, the frontline caregiver point of view, the finance point of view, the regulatory point of view, and the infection control point of view. So, because there are many stakeholders involved, there can be complex decisions that need to be made with input from many individuals," Klumpe says.
There are strategies to rise to these challenges, he says. "The first strategy is to create and maintain an accurate single source of truth. A hospital should have a comprehensive inventory of all the equipment that it owns in one location, where they know everything about that equipment. There should not only be an inventory of equipment but also how much of it is utilized, and an accounting of how old it is and whether parts are available."
The second strategy is to establish effective governance over medical devices, Klumpe says. "There is governance over pharmaceuticals and supplies, and there should be the same level of governance over the ongoing investment in clinical assets. You should get all of the stakeholders around the table, get alignment around goals, and establish accountability for who can make decisions and how decisions are going to be made."
The third strategy involves technology, he says. "If you are going to try to do this work with manual processes, it is going to be very difficult. So, you need to seek solutions that can automate the collection and maintenance of the data. You need to automate the understanding of utilization. You need to automate infusion of benchmarks into conversations about medical devices."
Managing medical devices
Hospitals need to establish the useful life of medical devices to help maintain the equipment in good condition, Klumpe says. "Many hospitals rely on the equipment manufacturers to make recommendations about replacement intervals, but there are many pieces of equipment that have useful life far beyond what the manufacturer may suggest through a robust clinical engineering program. Often, hospitals find a partner who can help bring insight to useful life beyond what the manufacturer might suggest is the useful life, which is a way for hospitals to stretch their capital."
There are two primary strategies to extend the useful life of medical devices, he says.
"One approach is to have a quality clinical engineering program. You should have a team of highly trained, disciplined clinical engineers who are able to do repairs on the equipment in a timely way. These engineers can keep the equipment functioning past what the manufactures have suggested as the useful life of the device," Klumpe says.
The other approach, which goes hand-in-hand with a quality clinical engineering program, is an advanced supply chain, he says.
"There are parts available for clinical devices after the manufacturers have stopped manufacturing parts. There are several firms that provide 'aftermarket' parts. You need to understand that market and be thoughtful about who you are going to buy aftermarket parts from. An advanced supply chain will conduct rigorous supplier management and make sure parts are coming from qualified suppliers. This supplier management ensures that the device is safe and continues to function as it needs to for the care of the patient."
"This system has failed many patients awaiting organ transplants due to the lack of oversight and accountability," says one health system executive.
Leaders at AdventHealth are calling for improvements in the U.S. organ transplant system—the Organ Procurement and Transplantation Network (OPTN), the federal government agency that oversees organ transplants in the country, and the United Network for Organ Sharing (UNOS), the nonprofit organization that manages the organ transplant system under a contract with the OPTN.
The organ transplant system needs to be reformed, Barry Friedman, BSN, executive director of the AdventHealth Transplant Institute, recently testified before the U.S. Senate Finance Committee. "Families in need of life-saving organs have no other choice but to trust the organ transplant system that is in place. This system has failed many patients awaiting organ transplants due to the lack of oversight and accountability. Approximately 23% of kidneys procured from deceased donors are not used and discarded, resulting in preventable deaths. It is our responsibility to address this issue."
Transportation of organs also needs to be improved, he said. "Organ transportation is a process left to federally designated organ procurement organizations (OPOs). Currently, they develop their own relationships with curriers, [and] rely on airlines, charter flights, ground transportation, and federal agencies to facilitate transportation. In many cases, organs must connect from one flight to another, leaving airline personnel responsible for transfers. While anyone can track their Amazon or FedEx package, there is currently no consistent way of tracking life-saving organs. … Currently, there is no requirement for OPOs to use tracking systems. Data availability and transparency are key to improving organ procurement, and UNOS has not proven capable in providing this function."
Also, OPTN technology needs to be updated, Friedman said. "OPTN technology has significant interoperability challenges and lags behind other technology platforms. This contributes to a fractured flow of information between OPOs, donor hospitals, and transplant programs."
UNOS should be taking advantage of electronic medical records at health systems and hospitals, Bobby Nibhanupudy, MD, a transplant surgeon at AdventHealth, told HealthLeaders.
"We need to have more integration of EMRs with the database at UNOS, so we can transfer information more easily. Right now, a lot of information is entered on donors in the hospital EMRs and the database at UNOS. There is also information in EMRs and the UNOS database on outcomes. But a lot of that data is given secondhand through forms that are entered physically. UNOS needs to catch up to the capabilities of EMRs and their interfaces. They just do not have a large enough information technology department, which is probably a financial issue, but it needs to be more robust than it is now," he said.
In addition, UNOS is not effectively screening organ donors so that they can be quickly directed to transplant programs, Friedman said. "UNOS asks centers to voluntarily opt out of certain organs via a filtering process. As a result, OPOs waste valuable time making organ offers to centers that will never accept them. Time wasted equates to prolonged cold ischemic time, and organs not placed resulting in lost organ transplant opportunities. This creates a vicious cycle that disadvantages patients on the wait list."
The shortcomings of UNOS are that the complexities of the organ transplantation system have outgrown some of the abilities of the organization, Nibhanupudy said.
"UNOS has been great responding to the transplant community for many years. But over the past five years, UNOS has become more of an executive board-driven entity rather than listening to the transplant community. This has led to a couple of problems. In information technology, the needs of the transplant community have outgrown the abilities of UNOS. That has hindered the ability of UNOS to respond quickly to what the transplant community needs. Secondly, the executive board driven–approach has led to one-blanket-fits-all allocation changes; and no matter how noble the intent was, it has led to decreased transplants in the state of Florida, organs are not being utilized, and there have been increases in costs for the transportation of organs," he said.
Perspective at UNOS
Before his departure from UNOS at the end of September, former CEO Brian Shepard, told HealthLeaders that the organ transplant system is functioning effectively. "The United States has the largest and most productive organ transplant system in the world. Nobody touches our numbers—we have set records for nine consecutive years. We had 40,000 transplants for the first time last year, which is a number that no other country has come close to meeting. Some of that performance is our size—we are a big country—but if you adjust for population, we are still the largest organ transplant system in the world."
UNOS is committed to having effective technology capabilities, he said. "We have constantly updated our technology, and technology accounts for nearly half of UNOS' budget. We spend almost $30 million a year upgrading, improving, and advancing technology. We are always adding new features to help transplant hospitals do their job better such as providing predictive analytics. We provide screening tools that help them target the right organ to the right candidate faster. So, improving the system is an ongoing and continuous process."
Although UNOS is not in charge of organ transportation, the organization does provide a tracker that OPOs can use, Shepard said.
"We do provide a GPS tracker that folks can choose to use. But there are other commercial trackers that people can use—not everybody uses our tracker. We have a couple of committees—our policies always arise from experts in the field—that are looking at questions such as mandating that everyone uses a tracker or mandating that everyone uses the same tracker so it can be monitored through the same interface. These committees are also considering whether it is OK not to use a tracker when the surgeon is traveling with the organ. So, we have committees looking at how we can make the tracking of organs better."
There is not a conflict of interest in having the OPTN and UNOS share board members, he said. "We look for specific issues to see if there is a certain policy we can adopt or a certain information technology programming plan. I don't see a conflict of interest. We are a mission-based nonprofit whose goal is to increase the number of transplants performed in the United States."
