The president of the American Medical Association calls for "urgent action" to improve physician well-being.
The physician burnout level and other measures of physician distress have increased dramatically during the coronavirus pandemic, a new research article has found.
The researchers led by Tait Shanafelt, MD, chief wellness officer at Stanford Medicine, have measured physician burnout every three years since 2011. After measuring physician burnout in 2020, the researchers decided to measure the impact of the ongoing pandemic, conducting a survey from Dec. 9, 2021, to Jan. 24, 2022.
The findings of 2021 survey are troubling, with 62.8% of physicians reporting at least one symptom of burnout compared with 38.2% in 2020.
Yesterday, Jack Resneck Jr., MD, president of the American Medical Association, said the new findings are alarming.
"While the worst days of the COVID-19 pandemic are hopefully behind us, there is an urgent need to attend to physicians who put everything into our nation's response to COVID-19, too often at the expense of their own well-being. The sober findings from the new research demand urgent action as outlined in the AMA's Recovery Plan for America's Physicians, which focuses on supporting physicians, removing obstacles and burdens that interfere with patient care, and prioritizing physician well-being as essential requirements to achieving national health goals," he said in a prepared statement.
The new research article, which was published this week by Mayo Clinic Proceedings, features information collected from more than 2,400 physicians. In addition to the finding on increased physician burnout, the study includes several key data points.
Mean emotional exhaustion scores among physicians increased 38.6% from 2020 to 2021
Mean depersonalization scores increased 60.7% from 2020 to 2021
Satisfaction with work-life integration decreased from 46.1% in 2020 to 30.2% in 2021
The proportion of physicians with a favorable professional fulfillment score decreased from 40.0% in 2020 to 22.4% in 2021
The proportion of physicians who reported they would choose to become a physician again if they could reconsider their career choice decreased from 72.2% in 2020 to 57.1% in 2021
In a multivariable analysis of the 2021 data, being a woman (odds ratio 2.02), long work hours per week (odds ratio 1.02 for each additional hour), and practicing emergency medicine (odds ratio 4.59), family medicine (odds ratio 1.57), and general pediatrics (odds ratio 2.44) were linked to higher levels of burnout
In a multivariable analysis of the 2021 data for work-life integration factors, being a woman (odds ratio 0.59) and long work hours per week (odds ratio 0.94 for each additional hour) were linked to lower odds of satisfaction with work-life balance
The data indicates a significant increase in physician distress between the 2020 and 2021 surveys, the research article's co-authors wrote. "The results show a large increase in mean emotional exhaustion and mean depersonalization scores, as well as the proportion of physicians with symptoms of burnout compared to both fall of 2020 and all prior assessment timepoints over the last decade. Mean scores for emotional exhaustion were 39% higher relative to the 2020 survey while mean depersonalization [scores] were 61% higher. The prevalence of burnout increased roughly 25% over the 12-month interval between the end of 2020 and the end of 2021. Satisfaction with [work-life integration] also declined over this interval."
Interpreting the data
The pandemic has had a disproportionately negative impact on female physicians, the study found. In a multivariable analysis that adjusted for personal characteristics such as age and professional characteristics such as practice setting, the odds ratio for burnout among female physicians compared to male physicians was 2.02 in 2021 compared to 1.27 in 2020. "These data suggests the long-documented increased risk for burnout and work-life conflict in women physicians has been exacerbated by the COVID-19 pandemic," the study's co-authors wrote.
The impact of the pandemic on physicians has broader ramifications for the entire healthcare system, the study's co-authors wrote. "The collective effect on the US physician workforce appears to be profound. Given the association of physician burnout with quality of care, medical errors, reductions in clinical work effort, turnover, departure from practice, and healthcare costs, these findings also have potentially critical implications for the US healthcare delivery system."
Rising to the challenge
Although the pandemic has prompted many healthcare organizations to acknowledge the essential role that their workforce has in providing high-quality and safe care, efforts to promote physician well-being are often inadequate, the study's co-authors wrote.
"While sincere, many of these organizations have focused on providing resources for individuals in distress, such as psychological first aid, peer support, mental health care, and counseling. These organizations will benefit from embracing a more expansive and holistic approach to prevent occupational distress rather than simply perpetually reacting to it by providing support to distressed clinicians. Such approaches require organizational commitment as well as dedicated leadership and include comprehensive and sustained approaches to reduce administrative burden, enhance team-based care, address inefficiency in the practice environment, and establish staffing models consistent with new models of care delivery."
Joshua Lenchus' leadership style is to seek consensus and to try to ensure that everyone's voice is heard.
Broward Health has elevated Joshua Lenchus, DO, from interim chief medical officer to chief medical officer.
In September 2018, Lenchus joined the Fort Lauderdale, Florida-based health system as chief medical officer of Broward Health Medical Center. He was named as the health system's interim chief medical officer in July 2021.
Before joining Broward Health, he served as chief of staff and as an internal medicine/hospitalist at Jackson Memorial Hospital in Miami. He was also associate program director for the University of Miami Jackson Internal Medicine Residency Program.
HealthLeaders recently spoke with Lenchus about becoming the permanent chief medical officer at Broward Health and a range of issues, including physician engagement, patient safety, and quality improvement. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary elements of physician engagement?
Joshua Lenchus: Physician engagement is predicated on credibility, networking, and relationships. To engage folks as a fellow physician, you need to build those foundational elements to be successful. This helps us in problem solving, appropriate communication, and timely responses.
The office of chief medical officer is responsible chiefly for problem solving. So, on a day-to-day basis, we have people who bring up issues and we must understand the mindset of the individuals that bring up the issues. That level of understanding is predicated on networking and relationship building.
HL: What are your goals for patient safety at Broward Health?
Lenchus: Our patient safety goals at Broward Health are similar to other healthcare organizations across the nation. We are trying to create the safest environment in which patient care can be provided. There are always opportunities for improvement through identifying issues that preclude us from achieving a 100% patient-safe environment. Once those issues are identified, we put them through a root cause analysis to try to identify system-based solutions to mitigating future events from happening. We are always looking at providing the safest care that we can to our patients, who entrust us to do so.
HL: Are there particular safety issues that you are personally interested in?
Lenchus: I have a predilection for the more clinical patient safety goals such as prevention of infections. I have a background as a pharmacist, so medication safety is a personal and professional interest of mine. Of course, all patient safety issues are equally important, and we focus on all of them.
HL: What are your goals for quality improvement at Broward Health?
Lenchus: Similarly to patient safety, we obviously want to provide the best quality to the patients that we care for. We are doing a good job on that path. We have a graduate medical education program at two of our four hospitals. Involving residents in education necessitates keeping up on the transformation of medical practice throughout the health system, which only emboldens us to continue to take steps in a positive direction by providing high-quality care.
We recognize that standardization has its limits—each patient is an individual—but to the extent that we can standardize the care that we provide in an evidence-based manner is a primary goal in quality improvement.
HL: What is your vision for the role of the CMO at Broward Health?
Lenchus: My goal is to collate best practices, not just across our institution but also among other institutions with whom I have relationships, in an effort to apply best practices at Broward Health. I realize that not everything that works at another site may work at Broward; but to the extent that we can bring transformation here, my job is to navigate and spearhead transformation along with the medical staff, nursing leaders, and administrators to move the health system forward.
As the highest-ranking clinician in the organization, it also is my job to ensure that clinical practice is front-and-center in everything that we do. That means that the care of the patient takes precedence over everything else. The health system has been a part of the community for nearly a century, and the patient has always been at the heart of what we do. I see my job as furthering that mission to provide the high-quality care that our community should expect when they come to see a Broward Health physician or when they come to seek care at a Broward Health facility.
HL: How do you view the CMO as a member of the C-suite team?
Lenchus: At finance meetings, operational meetings, and strategic meetings, it is my job to keep the clinician within that conversation. So, when we have conversations of a nonclinical nature, it is important to have a clinical voice in the room because, sometimes, we may want to make a move financially or operationally that discounts the role that the clinical workforce has in the organization. Frankly, the workforce that we have at Broward Health is largely clinical, so it would be a grave omission for the CMO's voice not to be heard. I carry the torch for the clinical folks—doctors, nurses, therapists, and support staff who work in the health system.
HL: How do you see your role as CMO as the coronavirus pandemic continues?
Lenchus: I work with a host of specialists and representatives of diverse departments. From the outset of the pandemic, we have developed several task forces for different aspects of our preparedness and interventions. With medications, there are specialists in infectious disease, pharmacy, nursing, and the emergency room that we work with to gain experience and insight. If we are talking about masking, testing, vaccines, and the host of other facets in our response to the coronavirus pandemic, we have created task forces to leverage talent so that you can hear a multitude of perspectives and interests to come to a palatable solution in trying to move the institution in the right direction. My role is to work closely with these specialists and task forces.
HL: How would you characterize your leadership style?
Lenchus: I have had the pleasure over my years in medicine of working with incredibly talented and knowledgeable people. My leadership style has always been to try to recognize the talent in the room and leverage folks for their strengths. When I must manage a situation, I try to engage the people who are going to be affected downstream. Even if I create a solution in draft form, I want to give people something to build upon. I try to engage people, so they have ownership over whatever solution we are going to implement.
I do not rule by executive fiat—I operate more on a consensus method. In management, as any leader will tell you, you cannot appease everyone at all times. However, the objective is to ensure that everyone's voice is heard, and everyone is at the table to provide their unique perspective. It would be incredibly presumptuous of me to think that I have all of the answers. That is why I try to include as many people as possible in change management.
Concordance between telehealth diagnoses and in-person visit diagnoses was lowest when in-person visit diagnoses involved physical examination, neurological testing, or pathology.
There is a significant level of agreement between telemedicine diagnoses and in-person outpatient visit diagnoses, a recent research article found.
In the early phase of the coronavirus pandemic, telehealth utilization increased exponentially—one published estimate pegged the increase in utilization in April 2020 at 20-fold. A concern associated with this increase in telehealth utilization is the accuracy of telemedicine diagnoses compared to in-person visits.
The recent research article, which was published by JAMA Network Open, examines data collected from more than 2,000 Mayo Clinic patients who had telehealth diagnoses followed by an in-person visit diagnosis for the same clinical concern in the same specialty within 90 days.
The study generated several key data points:
Overall, the telehealth diagnosis matched the in-person visit diagnosis in 86.9% of cases.
For ICD-10 conditions, diagnostic agreement between telehealth visits and in-person visits ranged from 64.7% for diseases of the ear and mastoid process to 96.8% for neoplasms.
In non-primary care specialties, diagnostic agreement between telehealth visits and in-person visits ranged from 77.3% for otorhinolaryngology to 96.0% for psychiatry.
Diagnostic agreement between telehealth visits and in-person visits was significantly higher for specialty care compared to primary care (88.4% versus 81.3%).
When an in-person visit diagnosis could be established through clinician opinion only, there was a high level of agreement with diagnoses made in telehealth visits.
When an in-person visit diagnosis required confirmatory pathology, a physical examination, or neurological testing, there was a lower level of agreement with diagnoses made in telehealth visits.
Among the 313 (13.1% of the total) cases where there was not agreement between the telehealth diagnosis and the in-person visit diagnosis, 166 cases had the potential for morbidity and 36 of those cases had actual morbidity.
Among the 313 cases where there was not agreement between the telehealth diagnosis and the in-person visit diagnosis, 30 had the potential for mortality and 3 of those cases had actual mortality.
Telehealth diagnoses often should be paired with in-person visit diagnoses, the study's co-authors wrote. "These findings suggest that video telemedicine visits to home may be good adjuncts to in-person care. Primary care video telemedicine programs designed to accommodate new patients or new presenting clinical problems may benefit from a lowered threshold for timely in-person direct follow-up in patients suspected to have diseases typically confirmed by physical examination, neurological testing, or pathology."
Interpreting the data
The level of agreement between telehealth diagnoses and in-person visit diagnoses appears to be dependent on how the diagnoses are confirmed, the study's co-authors wrote.
"In diagnoses confirmed through clinician opinion, such as many psychiatric diagnoses, there was a significantly greater concordance between video telemedicine diagnosis and in-person diagnosis. In diagnoses necessitating confirmation through traditional physical examination, neurological testing, and pathology—such as many otological and dermatological diagnoses—there was a significantly decreased concordance between video telemedicine and in-person diagnoses," they wrote.
A primary result of the study was the difference in diagnosis agreement between specialty care versus primary care, the researchers wrote.
"One of the most salient findings in our study was the discrepancy between video telemedicine diagnostic concordance with in-person visits in specialty care (higher concordance) and primary care (lower concordance) clinical settings. This finding was further emphasized by our individual analyses of cases that resulted in morbidity and mortality. There were some cases identified in our primary-care telemedicine program that resulted in morbidity and mortality that might have been mitigated by an initial in-person visit, an observation that was not mirrored in specialty practices," they wrote.
Longer wait times for physician appointments in metropolitan areas indicate that demand for physicians is exceeding supply.
The time it takes for patients to schedule a new physician appointment in 15 metropolitan areas has increased significantly, according to a recent survey report.
Physician appointment wait times reflect the supply and demand for physician services. The survey's reported increase in physician appointment wait times in four out of five specialties suggests that there is a shortage of physicians.
The survey was conducted by AMN Healthcare and the company's physician search division, Merritt Hawkins. The survey features data collected from more than 1,000 physician practices in 15 metropolitan areas: Atlanta, Boston, Dallas, Denver, Detroit, Houston, Los Angeles, Miami, Minneapolis, New York, Philadelphia, Portland, Oregon, San Diego, Seattle, and Washington, D.C. The survey was conducted from March to May 2022.
The survey sought to simulate someone new to a community trying to schedule a nonemergent appointment over the phone or online. The survey focused on five specialties: cardiology, dermatology, family medicine, obstetrics-gynecology, and orthopedic surgery.
The survey has several key findings:
Since the survey was conducted in 2017 and 2004, average physician appointment wait times have increase substantially. In 2022, the average wait time for a physician appointment across the five specialties is 26.0 days, an 8% increase compared to the 2017 survey and 24% increase compared to the 2004 survey.
In 2022, the average wait time to see a cardiologist is 26.6 days, which is a 26% increase compared to 2017. Average wait times to see a cardiologist range from 49 days in Portland to 13 days in Dallas.
In 2022, the average wait time to see a dermatologist is 34.5 days, which is a 7% increase compared to 2017. The average wait times to see a dermatologist range from 72 days in Minneapolis to nine days in Philadelphia.
In 2022, the average wait time to see a family medicine physician is 20.6 days, which is a decrease of 30% compared to 2017. The average wait times to see a family medicine physician range from 44 days in Portland to eight days in Washington, D.C.
In 2022, the average wait time to see an obstetrician-gynecologist is 31.4 days, which is a 19% increase compared to 2017. The average wait times to see an obstetrician-gynecologist range from 59 days in Philadelphia to 19 days in New York.
In 2022, the average wait time to see an orthopedic surgeon is 16.9 days, which is a 48% increase compared to 2017. The average wait times to see an orthopedic surgeon range from 55 days in San Diego to five days in Washington, D.C.
Portland (45.6 days) has the highest average physician appointment wait time across all five of the specialties.
New York (17.4 days) has the lowest average physician appointment wait time across all five of the specialties.
Interpreting the data
The data indicate that there is an ongoing physician shortage, Merritt Hawkins President Tom Florence told HealthLeaders.
"Simply stated, demand for physicians continues to exceed supply. Even though at its height COVID-19 temporarily suppressed demand for physicians, the underlying factors driving the physician shortage never went away. These include an aging population, widespread ill-health, an aging physician workforce, and a limited supply of newly trained physicians. The pandemic actually added accelerant to the physician access problem by creating patient backlogs and by exacerbating physician burnout and attrition. We are emerging from COVID-19 with the same key challenge we faced prior to the pandemic—a chronic shortage of physicians. The practical effect for patients is longer wait times to see a doctor," he says.
Average physician appointment wait times are even higher in rural areas of the country, Florence says. "The top metro areas we surveyed have some of the highest ratios of physicians per population in the country, yet physician appointment wait times even here can be extended and are growing. In smaller communities, wait times can be 50% or more longer. That is provided patients can find the type of specialist they need, which often is not the case. Long physician appointment wait times in major cities clearly are a troubling sign for rural communities."
Change in the healthcare provider market are linked to the decrease in wait times to see a family medicine physician, he says. "Over the last several years a new front door has opened up in healthcare. More patients are accessing primary care through urgent care centers, retail clinics, and telehealth, all venues that often are staffed with a growing number of nurse practitioners and physician assistants. That makes it less challenging to see a family physician, though it can still be difficult."
The variation in physician appointment wait times between metropolitan areas is not surprising, Florence says. "The number and type of physicians per specialty can vary in large metro areas, as can disease incidence, patient demographics, physician practice patterns, and rates of insurance coverage. These are complex medical service areas and some variation within them is to be expected."
A landmark study examines the economic burden and lives lost due to mental health inequities.
Mental health inequities cost billions of dollars and thousands of lives annually, according to a new report.
Indigenous populations such as Native Americans and minority groups such as African Americans experience mental health inequities that limit access to care. These inequities result in poor clinical outcomes such as suicide.
The new report was produced by the Satcher Health Leadership Institute at the Atlanta-based Morehouse School of Medicine, with support from Otsuka America Pharmaceutical Inc. The researchers examined data from 2016 to 2020.
The report features two key data points:
From 2016 to 2020, 116,722 members of indigenous populations and racial and ethic minority groups experienced premature mental and behavioral health-related deaths.
From 2016 to 2020, the costs associated with premature mental and behavioral health-related deaths among indigenous populations and racial and ethnic groups linked to mental illness, substance abuse, and suicide were $278 billion.
The new report is unique, according to the study's executive summary. "Previous studies have attempted to highlight how health disparities affect economic and lifespan outcomes for indigenous populations and racial and ethnic minoritized groups, but none have specifically analyzed the economic burden of mental and behavioral health inequities. This first-of-its-kind report is designed to inform all stakeholders on the ramifications of a chronically underfunded and siloed system of mental health care, with a particular focus on underserved and under-represented communities."
The full report, which has not been published yet, calls for actions and solutions on three fronts:
Long-term investments in mental and behavioral health, including solutions that advance mental health equity
Development of socio-culturally crafted approaches to mental and behavioral health services
Tackling the social and political determinants of health inequities
Interpreting the data
The report represents a call-to-action, Daniel Dawes, JD, director of the Satcher Health Leadership Institute, told HealthLeaders. "We must do something about mental health inequities. This is a first step in helping our policymakers and our political influencers to have a better understanding of this issue that has eluded us for decades in America. It took me 15 years to finally get an organization that was aligned with our vision and our research agenda to say, 'Yes, this is worthy of studying and reporting out.' We appreciate the efforts that Otsuka America Pharmaceutical have helped us to finally get this work done."
Payers have a key role to play in addressing mental health inequities, he says. "Insurance coverage is a major systemic issue that we have been trying to address, and the lack of health insurance is often flagged as one of the most statistically significant determinants of depression, low educational attainment, and poor self-rated health."
Several factors drive mental health inequities among indigenous populations and minority groups, Dawes says. "The fact that we have not addressed stigma and cultural beliefs about psychiatric issues as we should has posed significant barriers to mental health care among communities of color. Then you tie that to the rural geographic variations that we have seen, and these communities report that more than two-thirds of their communities have no psychiatrists, no psychologists, and no behavioral health professionals. These disparities are even worse when you break them out by race and ethnicity."
The economic cost of mental health inequities is deeply rooted, he says.
"The economic burden of behavioral health conditions is even greater for mentally unwell persons who are representative of indigenous populations or racial and ethnic minority groups. This is due to a hindered ability to participate in economic activities such as employment, workforce training, and educational opportunities. They are exacerbated by having historically disadvantaged socio-economic status because of their indigenous, racial, or ethnic status. From an economic standpoint, the structural barriers in accessing care, the cultural differences to pursuing behavioral health care, the biased delivery of behavioral health care, as well as the social and political determinants of health including insurance status all perpetuate systemic inequities."
Addressing mental health inequities would result in significant cost savings, Dawes says. "We could save billions of dollars in this country if access to behavioral health services was more equitable. Health equity will not be achieved unless there is adequate coverage and payment for behavioral health services among all public and private insurance programs. Whether it is Medicaid, Medicare, or commercial payers, there needs to be enforcement of mental health parity. We need better enforcement of the parity law to cover mental health services in line with physical health services."
Thousands of live could be saved if mental health inequities were mitigated, he says. "We found during the period from 2016 to 2020 that nearly 117,000 people of color lost their lives prematurely due to behavioral health conditions, and the inability to access the treatments, interventions, and the services that they needed. We could save lives if we could rectify and repair the structures of behavioral health and if we were to do a better job building and repairing the behavioral health infrastructure."
At Bon Secours Mercy Health, a peer support program is a key component of healthcare worker well-being efforts.
A program that features peer support is helping healthcare workers at Bon Secours Mercy Health address behavioral health issues.
Healthcare worker burnout has reached alarming proportions during the coronavirus pandemic, a healthcare worker well-being expert has told HealthLeaders. Prior to the coronavirus pandemic, healthcare worker burnout rates on average ranged from 30% to 50%, says Bernadette Melnyk, PhD, APRN-CNP, chief wellness officer of The Ohio State University and dean of the university's College of Nursing. Now, burnout rates range from 40% to 70%, she said.
In 2021, 71% of Bon Secours Mercy Health providers reported experiencing COVID-19 distress.
In May 2020, the Cincinnati-based health system launched Caring4Colleagues in response to the pandemic and the toll it was taking on healthcare providers and their families. The program features peer support, which in the beginning focused on clinicians, says W. Carson Felkel II, MD, system medical director for behavioral health.
"It started out with flyers in the physician lounges. It was a grassroots initiation effort. The beauty of the early version of the program was the simplicity. The flyer had many cellphone numbers on it. When people are in crisis, they reach out and often feel shame and guilt. They want a person to talk to and they want to feel heard. So, they would call one of our cellphones, and we would begin to have a conversation and continue to follow up with them over time," he said.
The peer support effort has grown to include all of the health system's associates, Felkel says. "To date, we have done 430 of these peer support pairings among physicians, advanced practice clinicians, nurses, and other associates."
Peer support volunteers not only engage struggling healthcare workers in a deep conversation but also help connect them with behavioral health services, he says. "What we have been finding from COVID and the workplace in general is associates need to have easy access to a colleague—a peer—who can navigate the complex mental health world and get them to the right resource at the right time."
The peer support volunteers receive training from health system professionals, Felkel says.
"We have a robust team of psychiatrists, psychologists, therapists, nurses, chaplains, and other specialists who train volunteers to have conversations with their colleagues. The volunteers are in the trenches alongside our associates, and that is why peer support works. It's not like just having a behavioral health team applying mental health. We are colleagues talking with colleagues. Within the training, we train individuals to have deep conversations using a trauma-informed approach and motivational interviewing," he says.
The engagement of top health system leaders has boosted the Caring4Colleagues program, Felkel says.
"One of the successes of this program has been our extraordinary leadership within Bon Secours Mercy Health supporting the effort. Whenever you do associate well-being efforts, it is usually top-down, meaning that it comes from upper leadership, and that is exactly what has happened with the Caring4Colleagues program. Leaders have talked about the program in many meetings, and they have utilized the program—it is not just physicians, advanced practice providers, and nurses who have been struggling, it's all of us, including leaders. So, leaders have modeled the use of the program themselves and talk about the success and share it with others. That creates trust in these conversations," he says.
Caring4Colleagues serves as a bridge to the health system's employee assistance program (EAP), Felkel says. "The beauty of Caring4Colleagues is that we provide the transition from a crucial conversation to the therapists within the EAP program. We grew EAP services within our ministry for physicians from 6.8% to 9.7%. With Caring4Colleagues, we were able to get almost 1 in 10 physicians into an EAP therapist, and that is not common in healthcare."
Reaching out to healthcare workers
The Caring4Colleagues program also includes "empathy rounding."
"Rounding is essential to our ministry because it creates visibility, trust, and relationships. We have many types of rounding that go on daily. We have leaders rounding, but more recently, we have started empathy rounding with chaplains and therapists rounding on units to provide visibility and immediate care when necessary. The beauty of our Caring4Colleagues program is that we can support empathy rounding when there is a crisis or the identification of someone who is struggling. We can immediately surround them with multidisciplinary care," Felkel says.
Empathy rounding is a way to be proactive with healthcare workers, he says. "In empathy rounding, we are visible and present. We must be intentional about being present with our colleagues. Several times a month, the chaplains and therapists are available on the units just to check in."
Getting help
At Bon Secours Mercy Health, healthcare workers in crisis have a support system in place to navigate behavioral health services, Felkel says. "It is as easy as calling one of our Caring4Colleagues cellphones, so we can have a conversation and walk alongside them. We can listen to what they are going through."
The health system is helping healthcare workers with a multidisciplinary approach, he says. "To address mental health needs, it takes a coordinated health system effort, and we have great leader engagement around this effort. For example, we have a great provider network within our benefit plan, we have excellent EAP benefits such as six free counseling sessions, we have leader rounding, we have well-being committees, we have chaplains and therapists rounding, and all of this must be tied together through a trusted peer program."
Two federal payment programs that give financial support to rural hospitals are set to expire on Oct. 1.
The Federation of American Hospitals (FAH) is urging Congress to reauthorize two federal programs that provide financial assistance to rural hospitals.
Rural hospitals face multiple financial challenges, including low patient volumes and relatively high numbers of Medicare, Medicaid, and uninsured individuals in their patient populations. Over the past decade, more than 130 rural hospitals have closed and more than 30% of rural hospitals are at risk of closing, according to the Center for Healthcare Quality and Payment Reform.
Two Medicare payment programs that provide financial support to rural hospitals—the Medicare-Dependent Hospital (MDH) program and the Low-Volume Hospital (LVH) program—are set to expire on Oct. 1. Last week, FAH President and CEO Charles N. Kahn III sent a letter to Congressional leaders imploring them to reauthorize the MDH and LVH programs.
"Rural hospitals traditionally serve patient populations that are older, lower income, uninsured and more likely to rely on Medicare and Medicaid when compared to the national average and to their urban counterparts. This challenging patient demographic means rural hospitals have a high volume of Medicare-dependent patients, and a lower volume of total patients overall. The MDH and LVH Medicare payment programs provide eligible rural hospitals with the financial stability and support they need to prevent closures and ensure continued access to care in rural communities," Kahn wrote.
Citing rising inflation and supply chain challenges, he wrote that rural hospitals are facing "unprecedented times" and financial pressure. "The nation's healthcare workforce shortage, in particular, is having a devastating, disproportionate impact on rural hospitals. Long-documented recruitment challenges have been exacerbated by an aging healthcare workforce, burnout, price gouging by traveling nurse staffing agencies, competing higher wages in larger cities, and a slowing of visas granted to foreign healthcare workers—all factors that are contributing to higher average payrolls and strained resources."
Dire consequences
Many rural hospitals are desperate for federal assistance, Jonathan Jagoda, MPP, senior vice president of legislative affairs at FAH, told HealthLeaders. "When you look at the role that rural hospitals play in their communities, you are often talking about the sole comprehensive provider for patients within many miles—sometimes hundreds of miles. It is critical that those facilities remain open and that services remain available to their patients. Even before the coronavirus pandemic, we saw the struggles that rural hospitals faced across the nation. They were cutting services lines, and many were being forced into closure. It is the community that suffers when service lines are cut or hospitals close."
If the MDH and LVH programs are not reauthorized, the consequences for rural hospital would be severe, he said. "If these programs are not reauthorized, the risk of rural hospitals closing is significant. Obviously, it depends on the hospital and the extent to which they utilize these programs to offset costs. Every rural hospital would not close, but you would see difficult decisions having to be made, whether that is eliminating services or hospital closures in the worst-case scenario. These programs help keep the doors open at rural hospitals. I would be very worried if the MDH and LVH programs were not renewed."
Congressional support
The MDH and LVH programs have bipartisan support in Congress. Last month, U.S. Rep. Terri Sewell (D-Alabama) and U.S. Rep. Carol Miller (R-West Virginia) introduced H.R. 8747, the Assistance for Rural Community Hospitals (ARCH) Act. The bill would reauthorize the MDH and LVH programs for five years.
The FAH, which represents more than 1,000 for-profit health systems and hospitals across the country, supports the ARCH Act.
Federal lawmakers know the stakes for reauthorization are high, Jagoda said. "They know they have to do it on a bipartisan basis. Leadership and the committees of jurisdiction have indicated support for these programs. They want to ensure that rural hospitals have the resources they need. So, we are fighting tooth and nail to ensure reauthorization comes by October 1 to make sure there is no gap in funding for rural hospitals."
Hospital patients experience hundreds of thousands of falls annually, with increased length of stay and care costs, according to The Joint Commission.
A smart sock system significantly reduced patient falls at The Ohio State University Wexner Medical Center's Neurological Institute, according to a recent research article.
Hospital patients experience hundreds of thousands of falls annually, according to The Joint Commission. About one-third of those falls result in an injury, which lead to an average increase in length of stay of 6.3 days and an average care cost of $14,000.
The recent research article, which was published by the Journal of Nursing Care Quality, features data collected from 569 patients over a 13-month period. The patients were equipped with Palarum's PUP (patient is up) smart socks, which alert nurses when a patient attempts to stand up in their hospital room.
The study includes two key data points:
For patients enrolled in the study, there were no falls over 2,211.6 patient days
There were 5,010 alarms generated by the PUP socks, with only 11 false alarms (99.8% of alarms were generated by patient stands)
The smart socks system includes socks with pressure sensors that can detect when a patient tries to stand up. The system also includes a tablet for patient rooms, a local server, a monitoring device at the nurse station, and notification badges that are worn by nurses.
When the system detects that a patient is trying to stand up, an alert is sent to the notification badges of the three closest nurses. When one of the nurses enters the room, the alert is deactivated. If none of the three closest nurses responds within 60 seconds, an alert is sent to the next closest three nurses. If none of the nurses respond within 90 seconds, an alert is sent to all of the nurses wearing the notification badges.
Patients were enrolled in the study after a fall risk assessment, Tammy Moore, PhD, RN, associate chief nurse at the Neurological Institute, told HealthLeaders. "We base our fall risk assessment tool on known evidence of what creates a potential fall risk in hospitalized patients. We look at history of falling, altered mobility and/or gait, altered mental status, secondary diagnoses, medications, attachment to any equipment, and altered sensory or communication deficits. This assessment is done on admission and every eight hours or as needed."
Over time, nurses shed any hesitation they had over wearing the notification badges, she said. "While I am sure there may be staff that found the wearable badge a 'nuisance' in the beginning, I believe they began to realize the worth of wearing them and the ability to react sooner to their patient with this wearable device. Response times to respond to an alarm from a patient with the socks was an amazing feature of the product."
The cost of the PUP system is about $10 per day per licensed hospital bed, Chris Baker, co-founder and vice president of business development and marketing at Palarum, told HealthLeaders. The bed license is an all-inclusive price that covers all components of the system, including hardware, software, installation, training, and 24/7 support, he said.
"Our goal is to reduce hospital falls by a minimum of 20% to 25%, which would offset the cost of our system. Additional fall rate reductions would save the hospital significant costs as well improve the patient's hospital experience and outcomes," he said.
McKinsey & Company experts say health systems should focus on three areas to boost the performance of their supply chains.
A recent article produced by McKinsey & Company provides advice on how health systems can improve their supply chains.
The coronavirus pandemic has heightened interest among healthcare executives in revamping their supply chains. For many health systems and hospitals, the pandemic served as a reminder of the key role of supply chains, with many organizations struggling to secure personal protective equipment such as respirators in the early months of the crisis.
The McKinsey article identifies three areas where health systems can bolster their supply chains.
1. Clinician engagement
Including clinicians in formal and informal supply chain roles is essential, the McKinsey article says. "In high-performing organizations, clinicians play an integral role in supply chain initiatives: They provide input on supplier selection and contracting strategies, including their financial impact; they support compliance with contract terms (for example, by committing to give a supplier a negotiated share of business); they manage the use of supplies; and they otherwise contribute to achieving financial, quality, or other goals," the article says.
The McKinsey article says health systems can take three approaches to maximizing clinician engagement in the supply chain.
Involvement of senior clinical leaders: The chief medical officer, chief clinical officer, chief nursing officer, and service line leaders should be fully engaged in the supply chain. "Leaders can accelerate progress and enable best-in-class performance by offering clinical guidance, building clinician confidence in supply chain efforts, making tough decisions, and holding other clinicians accountable for changes in behavior," the article says.
Formal teams assessing category strategies: Formal teams drawn from clinicians and supply chain leaders should play pivotal roles in contracting and utilization. "Optimally, one accountable and influential physician—for example, a service line chair or high-volume surgeon—will chair each committee. The absence of such leadership can result in extended delays, fewer savings, or stalled initiatives," the article says.
Establish a frontline supply chain team: Top executives cannot lead supply chain initiatives on their own—pairing supply chain managers with clinicians can guide supply chain functions such as product choices and compliance with contracts. " Supply organizations may consider filling this role with supply chain professionals who have clinical backgrounds and a threefold mission: support supply chain initiative implementation, identify local opportunities for improvement, and develop relationships with physician and facility leadership to better understand and meet their needs over time," the article says.
2. Establish goals across facilities and functions
Supply chains should set annual goals in conjunction with other clinical and non-clinical departments, a process that is often not achieved, the article says. "This lack of goal sharing can lead to misaligned incentives between the supply chain function and other stakeholders, siloed decision making, resistance to supply chain initiatives, and the perception that the supply chain function is focused solely on cost savings rather than broader organizational goals."
Three approaches can be taken to attain effective goal setting, the article says.
Establish mutual savings targets: "Shared savings targets between the supply chain function and its partners—specific functions, service lines, and facilities—help ensure that the organization is unified in its mission to find and implement savings opportunities. Such targets also reinforce the notion that all stakeholders are accountable," the article says.
Goal incentives: Supply chain actions are often associated with change for some clinicians such as dropping a preferred supplier, so enticements can be useful tools. "To assist this change, systems may consider providing incentives for reaching targets. These incentives can be financial or nonfinancial and may include a commitment to reinvest a percentage of savings in things prioritized by physicians, such as equipment, conference attendance, or publications," the article says.
Report goal progress: "Once targets are established, tracking performance and ensuring that stakeholders have access to up-to-date information on their progress is critical to fostering a sense of accountability. Ensure that dashboards display the high-level metrics that matter most (for example, savings and contract compliance for medical implants)," the article says.
3. Data and analytics
While data and analytics can play a pivotal role in supply chain performance, many health systems struggle to develop accurate and actionable information, the article says. "Organizations outside the hospital's walls—such as those that supply medical devices, pharmaceuticals, and services—often have better visibility into a health system's spending and utilization than the system itself does. As a result, the health system may be unable to effectively negotiate or identify savings."
Health systems should consider four kinds of investment to improve data and analytics, the article says.
Data management: "Having clean, categorized supplies data enables proactive identification of opportunities through granular product comparisons. This is especially important for systems that have gone through M&A activity because systems and data nomenclature must be reconciled across the system before savings opportunities can be identified," the article says.
Practical and applicable tools: "Analytical tools are only useful if they provide relevant insights to their users, which may require individual customization and, for convenience, accessibility on multiple devices. For example, a supplies cost-per-case tool, which shows the cost of all supplies for a given operating-room procedure, should provide the relevant views for physicians so that they can see the supplies they used; the cost compared to supplies used by peers; alternative supply options; and, where possible, quality outcomes," the article says.
Effective dashboards: "Organizations need to ensure that supply chain tools and reports are being used not only to review results but also to enable decisions. Organizations should ensure ample visibility into key supply chain metrics across all levels of the organization and ensure that conversations focus not just on what has happened but also on what actions can be taken to influence future performance," the article says.
Staffing: "Building a robust analytics engine requires an integrated team comprising analysts, data translators, visualization experts, and data engineers, among other roles. Recruitment that focuses on these skills, regardless of previous industry experience, can expand the talent pool and ensure that leading practices are brought into the organization, including from industries such as tech that have invested substantially in developing data and analytics as part of their core businesses," the article says.
HealthLeaders talked with Winters recently in a conversation that included how healthcare leaders should work with colleagues during a crisis, delegating decision-making during a crisis, and being realistic during a crisis. The following transcript of the conversation has been edited for brevity and clarity.
HealthLeaders: How can a leader liberate colleagues' time for deliberate focus so that they can adapt to a crisis and triage what is most important to address?
Richard Winters: First of all, it means that there is an understanding that it takes time to process and think through complex problems. As you are meeting with groups of colleagues, it starts out with whether people are just making decisions or are they thinking about the decisions that they are making. Even as we are structuring meetings and group decision-making, are we allotting time for individuals to process what is occurring, to understand different perspectives, then to make decisions? Generally, that tends not to be the case. Generally in a crisis, a few people who are opinionated speak up and a decision is made, with those who did not speak up not being able to reflect or not feeling safe to evolve their thinking.
Leaders need to role model taking the time to consider complex, thorny issues.
Leaders can also block out time. They need to understand that they are there to act but also to gain perspective. I use the metaphor of the balcony and the dance floor. Leaders need to get off the dance floor and get up to the balcony, then gain perspectives on what they might do about a situation before they react, so they can act with deliberate intent. That means as leaders are scheduling meetings and putting things on their schedule, they are leaving some space to take time for deep thinking. That can be role modeled by senior leaders so others can feel free to move deliberately.
HL: How can you use your leadership team to clarify perspectives as well as align thinking and actions?
Winters: The thing that is great about Mayo Clinic is triad leadership. You have a physician leader, a nursing leader, and an administrative leader who work together to run the departments and divisions. With triad leadership, each individual has a perspective that the others may not have. The nurse has a different perspective than the administrator and the physician. If you just have a physician alone looking at a difficult issue, they proceed forward with their own perspective, which includes their blind spots.
With triad leadership, you have multiple perspectives that help address blind spots. You can see different ways to move forward and different possibilities. You can benefit from multiple perspectives.
HL: What about aligning thinking and actions?
Winters: Aligning thinking and actions means understanding the thinking at play. You are not aligning individuals with your thinking and blind spots. You are aligning thinking by understanding the perspectives that are within the environment in which you are making decisions. To align thinking, we must first understand the perspectives of others and bring them together. Within those perspectives, you will find disagreements, but those thoughts represent a range of understanding. By understanding the disagreements and agreements and what individuals see as the opportunities and the threats, then you can start to think about the options.
First, you develop a shared reality and shared perspectives, then you develop options for what you might do given the shared reality and perspectives. From there, you can move forward. So, first you are understanding perspectives and aligning perspectives, then you are choosing the options for how you can move forward.
HL: How can a leader delegate decision-making to experts in a crisis?
Winters: As leaders step up—as a cardiologist becomes a leader or an emergency physician becomes a leader—we have our expertise but there are things that we do not know. Leadership requires other individuals who have a broader knowledge or understanding to make sense of specific areas. So, it makes sense to delegate decisions to individuals who have the necessary areas of expertise.
For example, when the coronavirus pandemic started, we did not know anything about the virus. We did not know what was going to happen. We did not know the morbidity and mortality associated with the virus. But the CEOs needed to make decisions, and they did not have the benefit of bringing together task forces and having committees over several months. They had to make difficult decisions. So, some decisions were delegated to the infectious disease specialists, who certainly knew more about virus transmission.
HL: Why is it important for a leader to be open, humble, and realistic during a crisis?
Winters: During a crisis, there are many unknowns. You are in a world of unknowns. If a leader is operating without an openness to the unknown, they are at a disadvantage.
During a crisis, there may be a sense that we make decisions and if a decision works out, then it was a good decision. If it doesn't work out, then it was a bad decision. However, that is not the correct way to make decisions in times of crisis. The best way to make decisions in times of crisis is to acknowledge that the leader has some expertise, the leader sees the situation, the leader senses what is occurring, then the leader simulates in their mind what might happen if different options are pursued. The leader makes decisions to poke at the crisis and see how the situation responds. It is not about failing in a decision. The leader makes decisions of discovery.
So, being open and humble about what might occur is essential. You need to be open to how the situation responds and the new data that arises. You need to be open about what information the leadership team can come together around to make better decisions as we move forward and continue to understand the situation. A leader needs to be humble because they may make a decision that does not generate the desired effect.
HL: Why is being realistic important?
Winters: There are constraints that we all face. There are limitations. We do not have infinite budgets. We have groups of individuals who have different perspectives. There are politics. There are regulations. Within these sorts of constraints, we need to be understanding and realistic about them. We need to face them head-on. We need to make decisions based on realistic constraints about where we do have efficacy and where we can affect change.
