Shared accountability between providers and care settings is a critical element of quality in behavioral health care.
Overcoming a fragmented system is the key to effectively measuring the efficacy of behavioral health care, a healthcare quality expert says.
Eric Schneider, MD, MSc, is executive vice president of the Quality Measurement and Research Group at the National Committee for Quality Assurance (NCQA). Before joining the NCQA staff in January, he worked at The Commonwealth Fund as senior vice president for policy and research focusing on quality measurement. Prior to his tenure at The Commonwealth Fund, he was principal researcher at the RAND Corporation. As a professor at the T.H. Chan Harvard School of Public Health and Harvard Medical School in Boston, Schneider taught health policy. He began his career as a primary care physician and practiced primary care internal medicine for 25 years.
HealthLeaders recently talked with Schneider about a range of issues related to achieving quality in behavioral health care, including the role of quality data in promoting health equity and behavioral health care, the importance of achieving shared accountability in behavioral health, and the value of using standard quality measures in behavioral health. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of measuring the efficacy of behavioral health care?
Eric Schneider: The biggest challenge is the fragmentation of behavioral health care across the United States. Primary care does a large amount of behavioral health care, but primary care physicians do not have the capability to manage all behavioral health problems. The behavioral health professional sector has been chronically underfunded, so the availability of practitioners is also a challenge. When it comes to the measuring of efficacy, in a fragmented system it is difficult to have the data systems in place that enable the collection of data on performance—particularly measures that can be reported by all of the settings and providers that contribute to behavioral health care.
Data availability is a primary challenge, but it is driven by the fragmentation of the existing system. The fragmentation means there is not a consistent set of data systems across the providers and settings to report on services for behavioral health.
HL: Why is quality data vital to promoting health equity and behavioral health care?
Schneider: One of the things we know about behavioral health—and it is true of primary care services for other chronic diseases as well—is that care is paid for by three major payers: commercial payers, Medicare, and Medicaid. Those payers are not equally generous in paying for behavioral health services. The inequities that result from that situation include lack of access to meet the demand, especially for people living in poor communities and people of color. Without sufficient funding, there is even more fragmentation of the data.
The way we can understand the lack of access and understand how needs are not being met is to do quality measurement at the payer level. So, Medicaid, Medicare, and commercial health plans all have something to contribute in terms of understanding whether people have access to behavioral health services and whether provider networks are adequate to provide services. Without shining light on where access is better or worse, it is difficult to figure out how to intervene to improve health equity.
HL: Why is shared accountability a problem in behavioral health care?
Schneider: The shared accountability model is important because without the sense of shared accountability, providers tend to just operate in their silos and manage their piece of the puzzle without being able to support the other providers in their recommendations and treatment plans.
HL: Define shared accountability in behavioral health.
Schneider: In behavioral health, it can be voluntary shared accountability to optimize the treatment plan of the patient, but that is difficult to do without either a management infrastructure or direct financing of that shared accountability. So, value-based contracting is a mechanism for trying to create shared accountability—if each of the providers who are participating are getting paid based on whether they are participating in shared accountability, that tends to be a strong incentive.
Shared accountability can also be accomplished by creating management systems such as business process management systems that specify how providers in one part of a system communicate with providers in another part of the system. It is a set of expectations or protocols. If a patient is seen in an emergency room, the primary care provider is notified and the behavioral health professional responsible for that patient is notified. If a person is in crisis and appears in a community health center, other providers will be notified. That's the kind of shared accountability that can be created by management systems that groups such as accountable care organizations or payers or care managers can provide.
HL: Why is it important to have consistent use of standard quality measures in behavioral health care to increase shared accountability and promote quality improvement efforts?
Schneider: Without a shared understanding of what represents a good outcome, it is difficult for the providers to navigate to a good outcome or help the patient navigate to a good outcome. There are several standard quality measures, and they are a mechanism for helping providers to share accountability—they can all see the metrics, preferably on a dashboard. Then they can adjust their approach over time for the populations they are seeing—they can adjust their approach to improve quality.
We think about standard measures in two categories. First, there are measures on the outcome side such as symptom reduction and functional improvement, whether patients can attain their goals, social outcomes in terms of school and employment, and family outcomes. Second, there are several measures on the process side such as whether behavioral health is being well integrated, whether goals are being set effectively, and whether there is an evidence-based care plan.
HL: How can you establish and use health information systems to capture patient-reported behavioral health outcomes?
Schneider: This is a game changer. This type of data collection for patient-reported outcomes has traditionally been done through paper-based surveys, but we are moving to a digital world. People are used to receiving surveys on their smartphones. That technology is enabling us to do much better real-time collection of data from people who are experiencing behavioral health problems. You can capture their current symptomatic state, then share and analyze the data to understand whether a patient is improving or getting worse.
After surgery for hip replacement, we would want to measure how many steps a patient can go day-by-day. If someone has a behavioral health crisis, we want to measure or understand through a standardized tool how they are doing at the time of the crisis and how they are doing after treatment is initiated. Health information systems enable much more efficient capture and analysis of that data.
There is a huge opportunity here. We still do not have digital standardization, but that is something NCQA is working on. There are also several companies that are creating electronic health records or other platforms that can enable the collection, storage, and analysis of patient-reported outcome data. Once we have the protocols in place to share that data and we have behavioral health quality frameworks to align clinical treatment settings, payers, and state and federal regulators, then we will have a much better chance of understanding a patient's journey with their behavioral health issues.
Nurse training has been a critical element of an ongoing initiative to improve the screening of new mothers for mood disorders.
A postpartum depression screening, education, and referral program at Cedars-Sinai Medical Center has generated positive results.
Perinatal mood and anxiety disorders are relatively common, and they can complicate pregnancy, delivery, and the postpartum period. Despite these risks, many hospitals have difficulty identifying and supporting patients with perinatal mood and anxiety disorders.
Cedars-Sinai launched its postpartum depression screening, education, and referral program in 2017. The initiative featured four interventions, Eynav Accortt, director of the hospital's Reproductive Psychology Program, told HealthLeaders.
1. Nurse champions: The hospital identified about 20 nurses who showed an interest in mental health. These nurse champions received a full day of training, including instruction in conducting mental health screening.
2. Mental health screening: The hospital shifted from only querying mothers on the first two items of the Patient Health Questionnaire-9 (PHQ-9) to covering all nine items. More importantly, the hospital moved PHQ-9 screening out of the admission phase of a new mother's care, Accortt said.
"For our population, it is inappropriate to do the questionnaire in triage. Women are coming in in pain, with contractions, with water breaking, and they are overwhelmed. So, one of the main elements of our quality improvement initiative was to stop asking the PHQ-9 questions upon admission. We decided to get them in, get them the medical care they needed, let them have their baby, then ask all nine items on the PHQ-9 in the postpartum unit rather than asking when they were in labor and delivery," she said.
3. Nurse training: Hundreds of Cedars-Sinai nurses received hour-long, in-service, in-person training on how to conduct mental health screening of new mothers. The training sessions featured role playing, with Accortt or a social worker playing the role of a nurse conducting the PHQ-9 and a nurse playing the role of a depressed mother.
"That role playing allowed the nurses to feel more comfortable with some of the PHQ-9 items because some of the questions can be quite jarring the first time you say them out loud. For example, one of the items asks, 'Over the past two weeks, how often have you had thoughts that you would be better off dead or thoughts of hurting yourself?' The first time a nurse says that out loud, it can be uncomfortable, and they brace themselves for an answer," Accortt said.
4. Video training: Based on nurse feedback that there were traveling nurses and night nurses who could not be present for the in-service training, the hospital developed a 10-minute training video with a key partner organization, Maternal Mental Health Now.
The four interventions improved nurse screening, nurse comfort with screening, and nurse knowledge about depression, Accortt said. "The interventions also improved our screening rates. When we were screening in labor and delivery upon admission, we were only screening about 10% of our patients because for the others it was just inappropriate to ask questions. We went from a 10% screening rate to a 99% screening rate. In addition, our screen positive rates went from nearly negligible up to 2.9% of patients in the first year. Finally, and probably most importantly, the four interventions increased our rate of social work consultation from 1.7% of patients to 8.4%."
The initiative is the subject of a research article published by the American Journal of Obstetrics & Gynecology.
Social worker consultation
If a new mother screens positive for a mood disorder or anxiety, she is connected to a social worker, Accortt said.
"The social worker begins by being caring, nonjudgmental, and a listening ear. The social worker provides support, asks questions, and provides resources after a thorough assessment of the patient's needs. Sometimes, the social worker might need to consult psychiatry if a woman seems unstable and in need of a full psychiatric evaluation. Otherwise, the social worker might provide a referral to our Reproductive Psychology Program. We have an outpatient reproductive psychology program. We have an outpatient social worker—that way, the patient has a seamless connection to care from the inpatient setting to the outpatient setting," she said.
The inpatient social worker always reviews the mental health screening data and looks for red flags, Accortt said. "For example, if a woman answers with anything other than 'not at all' to the question whether there are thoughts of harm, that is something the social worker needs to inquire more about. Under those circumstances, the social worker will likely consult with an inpatient psychiatrist. It's important. Maternal suicide is one of the leading causes of death for women in the postpartum period. We do not take that lightly. We want to make sure we provide support for anyone in distress."
Recent protocol changes
In February, the hospital dropped using the PHQ-9 for new mothers and replaced it with the Edinburgh Postnatal Depression Scale. At the same time the PHQ-9 was replaced, the hospital introduced iPads to complete the screening process.
"Our nurses still do an excellent job of introducing the concept of family wellness and the importance of the need for screening, but now they just hand the patient an iPad and the more commonly used Edinburgh Postnatal Depression Scale (EPDS) is what we use now instead of the PHQ-9. This is wonderful news because the EPDS also asks about anxiety, which is more common than depression at this time of life, and the iPad allows for more privacy," Accortt said.
The National Steering Committee for Patient Safety sees several worrisome developments, including rise in hospital-acquired conditions and decline of workforce well-being.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
Last week at the Institute for Healthcare Improvement Patient Safety Congress in Dallas, the 27 members of the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety. The NSC features healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies such as the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention.
The Declaration to Advance Patient Safety calls on healthcare leaders to embrace three resources developed by the NSC:
Identify a senior sponsor and team to use the National Action Plan's Self-Assessment Tool, which helps healthcare organizations determine where to start in improving patient safety
Use the National Action Plan's Implementation Resource Guide to bolster and sustain efforts to enact the four foundational areas identified in the National Action Plan
NSC members felt compelled to issue the Declaration to Advance Patient Safety, Patricia McGaffigan, RN, vice president of the Institute for Healthcare Improvement and IHI senior sponsor for the NSC, told HealthLeaders.
"We focused on issuing a declaration to call attention to the important work that we felt was necessary because we were concerned that the coronavirus pandemic had been diverting attention away from safety. We also wanted to focus on the ongoing foundational work that is necessary for strong safety performance in healthcare organizations," she said.
Several specific factors spurred the declaration, McGaffigan said. "Some examples of what prompted the concerns that we had was that family members were often excluded from care settings because of pandemic-related limitations on visitation or accompanying patients to their visits—family members play a key role in supporting safety. Access to care was hampered during the pandemic and there were delays in care. There have been worrisome signals from the workforce around growing fatigue and frustration as well as decline of workforce well-being. In early September, a seminal publication confirmed some of the setbacks in hospital-acquired conditions such as catheter-associated infections and ventilator-associated events. We had begun to accumulate more data on how safety culture scores were declining in many organizations."
The National Action Plan's 17 recommendations are organized into four foundational areas. McGaffigan summarized why each of the foundational areas are critical to improving patient safety.
1. Culture, leadership, and governance
The NSC determined that safety is critically dependent on healthcare leaders and governance bodies as well as the positions they take on establishing safety for patients, families, and the healthcare workforce, McGaffigan said. "Safety is a system property, and it is important for us to keep in mind that even if we are focusing on specific projects such as reducing infections, there are many factors that influence whether that work will be successful. Those factors are grounded in the culture and the tone that leaders set in their organization."
The National Action Plan was built on the premise that focusing on culture, leadership, and governance had to come first because they are essential to attain and maintain safety, she said. "Ultimately, this work is preconditional for getting to safety. We know that leaders who are committed to safety are focused on building the conditions, experiences, and workplace considerations such as culture that encourage trust and transparency, as well as ensuring the physical and psychological safety for everyone who is a part of the organization."
2. Patient and family engagement
Engaging patients and family members is a vital component of safe care, McGaffigan said. "It is not only safer when individual consumers are more meaningfully engaged in their care, but it is safer in a broad sense when we are able to integrate patients and family members into codesigning our systems and processes for care. They should also be engaged in improvement initiatives overall."
For example, patient and family engagement can improve diagnosis, she said. "Over the past two years, IHI worked with leaders and experts including patient and family advisors to develop the Safer Dx Checklist. Organizations can use this tool to advance diagnostic excellence. There are 10 recommendations in the checklist and those recommendations reflect the foundational areas in the National Action Plan. One of the items on that checklist that relates to patient and family engagement is whether the healthcare organization is seeking patient and family feedback so they can identify and understand diagnostic safety concerns and address those concerns with patients being actively involved in the codesign."
3. Workforce safety
Patient and workforce safety are inextricably linked, McGaffigan said. "If we do not have a workforce that is physically and psychologically safe, the workforce will be unable to bring the best effort to their job on any given day. Long before the pandemic and long before the National Action Plan, we had ample data confirming that the incidence of illness and injury in healthcare exceeded that in other industries we would typically consider to be dangerous such as construction and manufacturing."
In recent years, many healthcare organizations have realized they need to place more emphasis on healthcare workforce safety and well-being, she said. "This has certainly been illuminated during the pandemic, particularly in areas such as workplace violence, burnout, and increases in depression and anxiety among providers and care team members."
4. Learning systems
Healthcare organizations cannot improve unless they are constantly learning, McGaffigan said. "Because safety is a dynamic property of the system, we cannot say we have reached safety if we sit on our laurels. This is the constant daily work of everyone in healthcare. The work is fostered when we have intentional design and implementation of learning systems that can systematically integrate internal data and experiences with external evidence that we know about any topic we are pursuing."
Learning systems generate key benefits, she said. "In organizations where we have well-established learning systems, we have patients who get higher quality, safer, and more efficient care. These organizations are better able to deliver on their mission to patients and families, and they are better places to work."
The negative consequences of unnecessary surgeries include avoidable complications, increased costs of care, and opportunity costs.
Unnecessary surgeries, which have plagued U.S. healthcare for years, persisted during the first year of the coronavirus pandemic, according to a new analysis by the Lown Institute.
Last year, the Lown Institute, a nonprofit healthcare think tank based in Needham, Massachusetts, reported that hospitals performed more than 1 million unnecessary tests and procedures on Medicare patients from 2016 to 2018. Unnecessary tests and procedures can put patients at risk of complications and drive up the cost of care.
The new analysis found that hospitals performed more than 100,000 low-value procedures on Medicare patients from March to December 2020.
Stents for stable coronary disease: 45,176
Vertebroplasty for osteoporosis: 16,553
Hysterectomy for benign disease: 14,455
Spinal fusion for back pain: 13,541
Inferior vena cava filter: 9,595
Carotid endarterectomy: 3,667
Renal stent: 1,891
Knee arthroscopy: 1,596
"The Lown Institute is the first to measure rates of hospital overuse during the COVID-19 pandemic. Overuse, or low-value care, refers to medical services that offer little to no clinical benefit or are more likely to harm patients than help them. … From June to December 2020, with no vaccines available to vulnerable older adults, hospitals delivered low-value services to Medicare patients at rates similar to 2019," the new analysis says.
These are the Top 5 hospitals for avoiding overuse of eight low-value procedures and four low-value tests in the 2022 Lown Hospitals Index for Social Responsibility (the ranking is based on Medicare claims data from 2018 to 2020).
1. Highland Hospital, Rochester, New York
2. Natividad Medical Center, Salinas, California
3. Kalispell Regional Medical Center, Kalispell, Montana
4. Beth Israel Deaconess Medical Center, Boston
5. Lahey Hospital & Medical Center, Burlington, Massachusetts
These are the Top 5 states ranked by average performance on avoiding overuse of eight low-value procedures and four low-value tests in the 2022 Lown Hospitals Index for Social Responsibility (the ranking is based on Medicare claims data from 2018 to 2020).
1. Oregon
2. Maine
3. Vermont
4. Minnesota
5. South Dakota
Dimensions of unnecessary care
There are three primary negative consequences of unnecessary surgeries, Vikas Saini, MD, president of the Lown Institute, told HealthLeaders.
"First and foremost, procedures of any kind carry risk, and this is particularly true for procedures that are unlikely to benefit the patient. The risk of complications, side effects, and harms is one of the consequences of unnecessary surgeries. Fortunately, most surgeries and procedures have complication rates in the single digits. So, most of the time you are going to be fine, but the fact is if you start multiplying unnecessary surgeries by large numbers of people there will be unnecessary harms."
"Second, there is the cost. Quite often, people with insurance do not face costs for unnecessary surgeries, but sometimes they do. There can be copayments, costs for complications, costs for new medications, and costs associated with follow-up care. Mostly, the costs are felt at the systemic level. In that sense, we all are paying for unnecessary surgeries."
"Third is the classic question of opportunity costs. If you can free up capacity to do other procedures that have more value, you can generate a bigger bang for the buck. Those procedures are being crowded out by low-value procedures. If you imagine a world where we are trying to be efficient and have a healthcare system that does not cost too much, then you want to be using doctors' time, nurses' time, and all staff time for its highest purpose."
In the first year of the pandemic, the rate of unnecessary surgeries initially fell then returned to pre-pandemic proportions, Saini said.
"When the pandemic first hit, many people speculated that it would cause a drop in unnecessary care because the pandemic caused a drop in all care. When we looked at this, what we found was that the factor that caused a drop in unnecessary care was the shutdown. In April and May 2020, rates of medical care in general plummeted, and the rates of unnecessary care also plummeted. After the shutdown as business returned to normal, the rates of unnecessary care came back, and eventually they returned to 2019 levels," he said.
The pandemic trends for unnecessary surgeries show that several change factors are needed to address the problem, Saini said. "The experience of the pandemic tells us it is going to take something stronger than exhortation or pointing to a study that shows a surgery is unnecessary to reduce unnecessary care. As with all change in a complex system such as healthcare, it is going to take multiple things all at once to reduce unnecessary surgeries."
For now, unnecessary surgeries are widely embedded in U.S. healthcare, he said. "Unnecessary surgeries are entrenched because they are part of the fabric of modern medical practice. … Among the Top 20 U.S. News & World Report recognized hospitals, some do well, and some do not do well. The fact that some of the top hospitals do unnecessary surgeries shows that it is entrenched."
The hospital's chief strategic integration and health equity officer says the coronavirus pandemic has opened eyes and made health equity a national priority.
To eliminate health disparities, it is essential to address "upstream" inequities, an experienced hospital health equity officer says.
Chris Pernell, MD, MPH, is the chief strategic integration and health equity officer at University Hospital in Newark, New Jersey. Additionally, she is a clinical assistant professor in the Department of Medicine at Rutgers New Jersey Medical School and a former adjunct associate professor at New York University College of Global Public Health.
HealthLeaders recently talked with Pernell about a range of topics, including how to address health disparities, health equity and health disparity initiatives at University Hospital, and the country's journey in tackling health equity and health disparities.
The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary ways to address health disparities?
Chris Pernell: It is important to back up and go upstream before we talk about health disparities. We need to talk about health inequities—the structural conditions or determinants that are unfair and unjust, which lead to differences in health outcomes. Those structural determinants are issues around where people were born, where people work, and where people age. We need to talk about access to affordable housing, access to quality education, access to safe and equitable healthcare, and access to green spaces. We know that place-based factors drive health outcomes and the disparities that we see.
If we start with the COVID-19 pandemic, which in recent data is the third leading cause of death in America after heart disease and cancer, and we look at how COVID-19 disproportionately impacted the African-American community in particular, that shines a light on disparities. For example, if you go to the Centers for Disease Control and Prevention website, the CDC has been tracking the differences in COVID-19 infections, hospitalization, and death across different populations. There are differences across Black, Latino, Native American, and Asian populations that are distinct. In particular, there are differences in hospitalizations. In data from March, Black people were 2.4 times more likely to be hospitalized with COVID compared to White people. Native American people were 3.1 times more likely to be hospitalized. Latino people were 2.3 times more likely to be hospitalized.
If you start to talk about death from COVID-19, it is roughly 2 times more likely in the Black, Latino, and indigenous populations compared to White Americans. This is not because of biological reasons, rather the reasons are related to risk of exposure, access to care, quality of care received, and pre-existing chronic morbidities.
Health disparities are formed because there is differential access to care, there is differential access to the quality of care received, and there are unjust and unfair differences in access to life opportunities such as housing and education. At those three fundamental levels, we see disparities that are amplified and highlighted in the COVID-19 pandemic.
If we think about the Newark community, like in all of New Jersey, heart disease is the leading cause of death in the Newark community. Like in all of New Jersey, cancer is the second leading cause of death in Newark. But something that is unique in Newark is the prevalence of asthma. Approximately 32% of people living in Newark have asthma. If you look at Newark's county, which is Essex County, only about 6% of the people in the county have asthma. It begs the question—why are people in Newark having higher rates of asthma? You have to look at environmental injustice issues.
HL: What are other examples of health disparities in Newark?
Pernell: Newark has primarily a Black and Brown population. The Newark population hovers around 50% Black and 36% Latino. Asthma is only one example of unique health condition prevalence in Newark. With chronic obstructive pulmonary disease (COPD), 16% of Newark residents have COPD but only 5.1% of people in Essex County have COPD.
In Newark, 16.4% of residents have diabetes, but if you look at the prevalence in the state it is 9.6% of the population. Another disparity is in obesity. About 36% of Newark residents have obesity compared to 27% of New Jersey residents.
HL: What are some of the health equity and health disparity initiatives that have been launched at University Hospital?
Pernell: Through our population health department, we have focused a lot on clinical prevention and bringing care to people where they are situated in the community. That involves partnering with community assets to deliver health screenings, such as screenings for high blood pressure and diabetes. We do screenings in a consistent and regular fashion to emphasize the power of prevention.
We are ensuring that our ambulatory practices are accessible to the community—accessible with time and availability of appointments. Our community members can be serviced for primary care, which is fundamental to solving health equity. We have a robust network of primary care and people have access to longitudinal care; we offer primary care services as well as specialty and subspecialty services through our outpatient practices.
We are making sure our care is being delivered in a community-integrated fashion, so we can reach health inequities that cause health disparities. We are ensuring that care is situated in the community where people reside.
For example, we are undertaking a project with the state housing and mortgage financing agency, as well as a local developer, to develop affordable housing close to the hospital. There will be about 16 housing units specifically geared toward patients who have multiple medical and social complexities that drive poor health or poor management of chronic health conditions. People will be identified by eligibility criteria, and they will be able to screen into these supportive housing units. They will have access to wrap-around services that address social needs and social determinants of health that are driving their health outcomes. As part of this project, we will be building a primary care health center, which will be open for not only the residents of the development, but also all residents of the city to have access to primary care and some specialty care.
Another initiative we have is the use of community health workers or community healthcare chaplains. These are credible messengers who have lived experiences that are socially and culturally fluent with the patient populations that we serve. They help navigate patients with social and medical complexities. They help people to connect with appropriate care. They help ensure that people have their social needs met. They work with chronic high utilizers of the emergency department. They work with patients who have a particular payer such as Horizon Blue Cross Blue Shield of New Jersey and have identified social needs.
HL: As a nation, where are we in addressing health inequity and health disparities. How far have we come?
Pernell: I am a public health and preventive medicine physician by training, and as someone who has been working in this space for many years, I can say that prior to the pandemic the conversation about health equity and health disparities was conceptual. Since the beginning of the pandemic, we have been having a more honest, more robust, and more comprehensive dialogue and solution-generating process around tackling health inequities.
The pandemic has been the collision of multiple pandemics, such as the collision of systemic racism with the pandemic. With the coronavirus, we have been able to describe in compelling ways what disparities look like. Black, Latino, and Native American populations are dying of COVID-19 at two times the rate of White Americans. We all have to pause and ask, "Why is this happening?"
The pandemic has afforded a richer dialogue, and that has afforded more complex solutions, and that has afforded an imperative in priorities around health equity. Not only do you see healthcare leaders having a conversation around health equity, but also you see the American public having a more honest conversation about what is driving health inequities. People are looking for solutions in a collaborative, cross-sector matrix approach.
If you think about the summer of 2020, as we were coming out of one of the first waves of the COVID-19 pandemic, and the public saw the murder of George Floyd. We saw protests on the streets, and that allowed us to have a more transparent and authentic conversation around systemic racism.
We are poised to do something about health equity. These next few years and decades will determine how sustained the efforts will be. I believe that we cannot turn back. Racism wastes human resources and wastes our potential. We cannot be as prosperous, we cannot be as great, and we cannot solve the dilemmas that we need to solve in the 21st century if we are not taking care of all of our communities. We will never achieve our full greatness it we do not make health equity front and center of our priorities.
In a survey conducted in 2020, 23.4% of physicians reported that they had experienced mistreatment in the prior year.
A survey of physicians found that a significant proportion of the clinicians had experienced mistreatment in the prior year, with patients and visitors the most common source of abuse, a new research article says.
Mistreatment of healthcare staff including workplace violence has become a pressing national issue. In March, American Hospital Association President and CEO Richard Pollack wrote a letter to Merrick Garland urging the U.S. attorney general to back legislation to protect healthcare workers from assault and intimidation. "For medical professionals, being assaulted or intimidated can no longer be tolerated as 'part of the job.' This unacceptable situation demands a federal response," Pollack wrote.
The new research article, which was published by JAMA Network Open, reports the results of a survey of nearly 1,400 physicians conducted from September to October 2020. The study features several key data points.
23.4% of physicians reported that they had experienced mistreatment in the prior year
Patients and visitors were the most common perpetrators of mistreatment, with 16.6% of physicians reporting mistreatment by patients and visitors
Other physicians were the second most common perpetrators of mistreatment, with 7.1% of survey respondents reporting mistreatment by physicians
Female physicians were more than twice as likely to report mistreatment than male physicians (31% versus 15%)
The most common forms of mistreatment were verbal abuse (reported by 21.5% of physicians), sexual harassment (5.4%), and physical intimidation or abuse (5.2%)
On a scale of 1 to 10, experiencing any type of workplace mistreatment was linked to a 1.13-point increase in burnout
On a scale of 1 to 10, experiencing any type of mistreatment was linked to a 0.99-point drop in professional fulfillment
Lower perception that protective workplace systems were in place was linked to higher levels of burnout and lower levels of professional fulfillment
Workplace mistreatment was linked to 129% higher odds of moderate or greater intent to leave employment within two years
"This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that healthcare organizations should prioritize reducing workplace mistreatment," the study's co-authors wrote.
Interpreting the data
The lead author of the research article told HealthLeaders that it was unsurprising that patients and visitors were the most common source of mistreatment.
"Mistreatment of healthcare workers has been described for decades, but it appears to be growing much more widespread and more severe. On one level it makes sense—we are all experiencing an extraordinary confluence of stressors: the pandemic, of course, but also accelerating epidemics of mental illness and opioid use disorders; financial insecurity; erosion of public trust and politicization of science and healthcare; and race- and gender-based trauma, to name a few recent stressors," said Susannah Rowe, MD, MPH, an ophthalmologist at Boston Medical Center, and chair of the Wellness and Professional Vitality Council at Boston University Medical Group.
New tools are required to address healthcare worker mistreatment by patients and visitors, she said. "Organizations have traditionally relied on Human Resources to address employee mistreatment by other employees, a strategy that is both appropriate and essential given the incidence of mistreatment by coworkers and supervisors. Addressing mistreatment by patients and visitors requires a different approach and would most likely succeed through broad collaboration among those working in patient experience, patient advocacy, health equity, public safety, and workforce well-being. Local and federal policy level interventions could also be needed as healthcare institutions may not be able to do this without additional support."
The study highlighted the importance of perceiving that there are systems in place to ensure healthcare workers are treated with dignity and respect, Rowe said. "Supporting a culture of bystanders represents one promising strategy, especially when managers know how to respond effectively to bystander action. Ensuring that workers can discuss and report mistreatment without repercussions (for example via anonymous reporting systems and confidential resources) will, at the very least, help organizations diagnose where problems lie."
Another emerging strategy relies on promoting positive actions—initiatives that actively affirm people's dignity may be even more powerful than preventing mistreatment alone, she said. "Some examples include fostering inclusive language in the workplace, equitable hiring and promotion practices, education about counteracting unconscious biases, and upstander training. Providing ways for feedback, input, and ideas may also help, allowing for consistent assessments and changes to institutional policies and practices that truly prevent harm and keep workers safe."
The findings of the inspector general study are similar to Medicare data reported in 2010.
Medicare patients experience harm in hospitals at a relatively high rate and the harm costs the federal program hundreds of millions of dollars per month, according to a new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG).
In 2010, OIG published the first report on Medicare patient harm in hospitals, finding that 27% of patients experienced harm in October 2008. These harm events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of the harm events were deemed preventable.
The new report is based on a review of medical records for a random sample of 770 Medicare patients who were discharged from hospitals in October 2018. Patients experience two kinds of harm. "Adverse events" resulted in longer hospital stays, permanent harm, life-saving intervention, or death. "Temporary harm events" resulted in interventions, but they did not cause lasting harm, prolong hospital stays, or require life-sustaining measures.
The report features several key findings.
In October 2018, 25% of Medicare patients experienced adverse events (12% of patients) or temporary harm events (13% of patients).
Reviews by physicians found that 43% of the harm events could have been avoided with better care.
The most common harm events were linked to medication (43%), followed by patient care such as pressure injuries (23%), procedures and surgeries (22%), and infections (11%).
Among patients who experienced a harm event, 23% required treatment that resulted in additional Medicare costs. These costs were variable and there was a small sample of patients, so OIG was not able to estimate the costs with precision. The costs of patient harm events in October 2018 range from $347 million to $1.2 billion.
The Centers for Medicare & Medicaid Services (CMS) have two programs that reduce reimbursement to hospitals for some hospital-acquired conditions (HACs): the HAC Reduction Program and the Deficit Reduction Act HAC list. For the harm events that the OIG found, only 5% were on the HAC Reduction Program list and only 2% were on the Deficit Reduction Act HAC list.
In comparing the first OIG report in 2010 with the new report, there has been little change in harm events for hospitalized Medicare patients, the new report says. "Our findings suggest that patient harm events continue to be widespread among Medicare patients in hospitals since the publication of our 2010 report, with an estimated 27% of Medicare patients experiencing harm in 2008 and an estimated 25% of Medicare patients experiencing harm in 2018. … When comparing the results, we did not detect a statistically significant difference in the rates of patient harm, severity of harm events, or preventability of harm events over time."
Recommendations to improve safety
The new report issues seven recommendations to improve safety for hospitalized patients.
Three recommendations are made to CMS: "(1) update and broaden its lists of [hospital-acquired conditions] to capture common, preventable, and high-cost harm events; (2) explore expanding the use of patient safety metrics in pilots and demonstrations for healthcare payment and service delivery, as appropriate; and (3) develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm."
Four recommendations are made to the Agency for Healthcare Research and Quality: "(1) with support from HHS leadership, coordinate agency efforts to update agency-specific Quality Strategic Plans; (2) optimize use of the Quality and Safety Review System, including assessing the feasibility of automating data capture for national measurement and to facilitate local use; (3) develop an effective model to disseminate information on national clinical practice guidelines or best practices to improve patient safety; and (4) continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals."
Researchers surveyed patients about their experiences with care transitions from hospitals and skilled nursing facilities to home.
A survey of more than 1,000 patients found inconsistencies in care transition processes from hospitals and skilled nursing facilities to home, including social determinants of health challenges and racial disparities, a new research article shows.
Boosting the quality and value of care can be achieved by improving patient experiences and outcomes while limiting costs. One strategy for achieving this goal at hospitals and skilled nursing facilities is to improve the care transition process, which includes education, medication reconciliation, follow-up appointments and telephone calls, and supportive care in the home.
The new research article, which was published by JAMA Network Open, is based on survey data collected from 1,257 patients discharged from hospitals or skilled nursing facilities (SNFs). Seventeen hospitals and six SNFs in Michigan participated in the study.
The study features several key findings.
11.4% of patients said they did not receive a telephone number to call for care-related questions after hospital or SNF discharge
Compared to White patients and patients of other races, more Black patients did not receive a telephone number to call with care-related questions
21.4% of patients said they did not receive a follow-up phone call
Among patients who did receive at least one follow-up phone call, 89.9% said the calls were helpful or very helpful
1.9% of patients said they did not receive prescribed medical equipment in the home
Compared to White patients and patients of other races, more Black patients did not receive prescribed medical equipment in the home
20.8% of patients said they had at least one social determinants of health (SDOH) challenge
The four most common patient SDOH challenges were inability to afford aspects of care such as prescriptions and physical therapy (7.6% of patients), lack of transportation for health-related activities such as physician appointments and grocery shopping (6.0%), inability to afford medical visits and copayments (5.6%), and lacking help at home to care for themselves
Lack of transportation decreased the odds of completing a follow-up appointment by nearly 70%
Patients who said they had at least one SDOH challenge were more likely to have no follow-up appointment than patients who said they did not have SDOH challenges
63.3% of patients said they had seen a physician for follow-up and another 28.1% said they had an appointment scheduled
Compared to White patients and patients of other races, Black patients were less likely to see a physician for follow-up or have an appointment scheduled
"These findings suggest that health systems should recognize that care transition processes are variable, patients experience substantial social determinants of health issues, and potential racial disparities exist in postdischarge follow-up with physicians," the study's co-authors wrote.
Interpreting the data
The data shows inconsistency in follow-up phone calls, the study's co-authors wrote. "Overall, these findings show that most patients receive postdischarge follow-up telephone calls and find them valuable, but 21% of patients do not receive a telephone call, indicating inconsistencies in care transition processes."
The data shows there are disparities impacting Black patients, the study's co-authors wrote. "We also found that 1 in 10 patients reported not receiving a telephone number to call regarding their care after discharge, with a higher proportion of Black patients not receiving a telephone number to call. In addition, Black patients reported not receiving prescribed equipment more often than White patients, and these gaps persisted even after adjustment for demographic variables. … Black patients reported fewer scheduled or completed follow-ups with physicians compared with White patients and patients of other races."
SDOH play a significant role in care transitions, the study's co-authors wrote. "One in 5 patients surveyed … reported SDOH concerns, such as the inability to afford prescriptions, medical care, doctor appointments, and basic needs; transportation issues; and having adequate assistance at home. Although the healthcare industry is aware of the important role SDOH plays in patient health, awareness has not translated into improvement. In a 2019 survey of Michigan seniors, 34.7% noted their reason for not seeing a physician for follow-up was because they could not afford to, another 18.1% did not because of lack of insurance coverage, and 22.1% did not because of lack of transportation."
The data points to several areas for enhancement, the study's co-authors wrote. "There are still multiple opportunities for improvement, including (1) providing reliable, systematic care transition processes for all (follow-up telephone calls, numbers for patients to call, and delivered home medical equipment); (2) addressing patient SDOH, such as transportation; (3) scheduling and helping patients attend follow-up appointments; and (4) recognizing and reducing racial disparities in care. This information on patient challenges during the transition of care process could help hospitals and physicians tailor future care transition interventions to be specific to their patients' needs."
An orthopedic ambulatory surgery center executive says an easing in the upward trajectory of ASC growth is unlikely.
The coronavirus pandemic has accelerated the growth of ambulatory surgery centers (ASCs) and growth is likely to continue for the foreseeable future, an ASC expert says.
The first ASC in the United States opened in 1970 and explosive growth happened through the late 1980s and into the 1990s, according to the Ambulatory Surgery Center Association (ASCA). ASC growth as been steady over the past two decades, with more than 5,800 ASCs performing an estimated 30 million procedures in 2020, the ASCA says.
"ASC growth has continued in the United States, and particularly for orthopedics, the number of ASCs is growing, and the number of cases shifting from main hospitals to ASCs continues to grow. We have seen this trend in recent years; but with the coronavirus pandemic, we have seen ASC growth accelerate over the past two years," says Alexander Sah, MD, co-director of the Institute for Joint Restoration and Research in Fremont, California.
Several factors are driving ASC growth, he says. "We see that there is an increasing movement of cases from the main hospitals into ASCs, mainly for increased safety for patients, profitability, removing costs from the health system, and better patient outcomes. Many surgeries that used to be thought to only be done in a main hospital can be done safely in a surgery center, which can be beneficial for physicians, health systems, and patients."
Sah says ASC growth is strong in his field. "Particularly in orthopedics such as elective hip and knee replacements, there has been a major shift, where it has been projected that by 2030 more than 50% of joint replacements would be performed in ASCs. That trend has likely been accelerated by the pandemic."
ASC growth is likely to continue for years, he says. "ASC growth will continue. I do not know when it will plateau—one would assume that at some point it will plateau because the number of ASCs would saturate the market, or the number of patients appropriate for ASCs would plateau. But we are not near that point yet."
ASC benefits
ASCs benefit healthcare providers, patients, and payers, Sah says.
"For healthcare providers, ASCs are an opportunity to have more control over how things are done. In a main hospital, you have many resources at your disposal, but you also have the challenges of emergency cases as well as operating rooms that have a wide scope of procedures that they perform. In an ASC, there is an opportunity to fine-tune skills and develop very specific programs. For example, you can develop an orthopedic-specific ASC or another facility that has a narrow focus of care. In that way, you can have areas of excellence. You can have centers that focus only on hip and knee replacement. Those centers can fine-tune their protocols and processes so that patients can have more efficient and predictable surgeries and outcomes."
For patients, there are benefits in avoiding main hospitals, he says. "For elective surgeries, such as joint replacement, many patients do not want to go to a main hospital. They do not want to be in a building where there are ill people—they want to avoid infection risk or other complications. By avoiding exposures to potential risks in the main hospitals, patients can achieve better outcomes."
An example of superior care for patients in ASCs is MicroPort Orthopedics' comprehensive pathway for patients, which looks at the entire episode of care for patients having elective joint replacement so that they can have the best preoperative experience and preparation, the best surgical experience, and the best recovery over the first 90 days after a procedure, Sah says.
"This program has virtual joint classes, engagement with patients throughout their episode of care, and good communication with surgeons. These surgeries are done in an ambulatory surgery setting with rapid discharges, where patients get to go home the same day, they do not have to sleep in a hospital, they can recover in the comfort of their own home, and there are ways to have patients tightly connected with their surgeons, thereby having better outcomes, quicker recoveries, and a more satisfactory experience," he says.
Compared to procedures done in main hospitals, ASCs have reduced costs, which benefits payers, Sah says.
"With the growth of ASCs, the amount of dollars that are saved by the healthcare system are in the realm of billions. When cases and surgeries move to ASCs, billions of dollars are saved by the healthcare system because procedures can be done more efficiently outside of the main hospitals. For payers, ASCs save money. There is less waste and less cost because ASCs can be more efficient in how they deliver their care. Both Medicare and commercial payers can save money by having cases shifted from the main hospitals to ASCs," he says.
Best practices for operating an ASC
There are two primary considerations when a health system or hospital operates an ASC, Sah says.
"The most important thing in opening an ASC is looking at what procedures are done and what the surgeons are capable of. A lot of the confusion for surgeons about ASCs is they think just because you do the same surgery under a different roof called an ASC, you will automatically have better outcomes and save money. You must have surgeons who are able to do surgery in an efficient way. They must be able to do surgery in a predictable fashion," he says.
The only way to make an ASC profitable is to be efficient, Sah says. "For example, if an elective joint replacement should only take an hour, if some cases it takes two hours and others take 40 minutes. The variability can make it challenging for the ASC to produce a consistent product. So, surgeons need to be capable, and they need to have the proper protocols in place. That means there needs to be buy-in from the anesthesia team, the recovery nurse team, and the physical therapy team. A successful ASC is more than just what happens in the operating room—it's everything that is involved surrounding a surgery."
The watchdog group also released a report that shows patient experience in the inpatient setting has declined significantly during the coronavirus pandemic.
The Leapfrog Group conducted an analysis of 2,844 U.S. hospitals, and one-third of the facilities earned an "A" grade for patient safety.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
Today, The Leapfrog Group released its latest grades for hospital patient safety. The analysis utilizes more than 30 measures, including the PSI 90 Patient Safety and Adverse Events composite, which features 10 component measures.
The Leapfrog Group was founded in 2000 by large employers and other purchasers of healthcare. The nonprofit group publishes reports on hospital patient safety in the fall and the spring.
The distribution of letter grades for the hospitals in the spring report is as follows:
A…33%
B…24%
C…36%
D…7%
F…Less than 1%
The Top 10 states by percentage of "A" grade hospitals are as follows:
1. North Carolina (59.8% of hospitals with an "A" grade)
2. Virginia (59.2%)
3. Utah (55.6%)
4. Colorado (55.3%)
5. Michigan (50.6%)
6. Idaho (tied at 50.0% of hospitals with an "A" grade)
6. Massachusetts (tied at 50.0% of hospitals with an "A" grade)
6. Hawaii (tied at 50.0% of hospitals with an "A" grade)
9. Oregon (47.1%)
10. Pennsylvania (45.9%)
Four states and the District of Columbia had no hospitals with an "A" grade: North Dakota, West Virginia, and Wyoming.
Seventeen hospitals received an "F" grade:
Shoals Hospital, Muscle Shoals, Alabama
Barstow Community Hospital, Barstow, California
Henry Mayo Newhall Hospital, Valencia, California
Pacifica Hospital of the Valley, Sun Valley, California
Pioneers Memorial Hospital, Brawley, California
San Joaquin General Hospital, French Camp, California
Howard University Hospital, Washington, District of Columbia
Halifax Health Medical Center - Port Orange, Port Orange, Florida
Vista Medical Center East, Waukegan, Illinois
Southwest Medical Center, Liberal, Kansas
Byrd Regional Hospital, Leesville, Louisiana
Jennings American Legion Hospital, Jennings, Louisiana
Granville Medical Center, Oxford, North Carolina
Great Plains Regional Medical Center, Elk City, Oklahoma
Baylor Scott & White Medical Center—McKinney, McKinney, Texas
CAMC General Hospital, Charleston, West Virginia
CAMC Teays Valley Hospital, Hurricane, West Virginia
Effects of the coronavirus pandemic
The pandemic has had a grave impact on hospital safety, for both patients and health workers, Leah Binder, MA, MGA, president and CEO of The Leapfrog Group, told HealthLeaders.
"As a recent New England Journal of Medicinearticle authored by Centers for Disease Control and Prevention as well as Centers for Medicare & Medicaid Services leadership found, the stress of the pandemic—from burnout to shortages—has reversed years of patient safety progress, most notably regards to healthcare-acquired infections and patient experience. Comparing the fall 2021 and spring 2022 rounds, we saw that three infection measures—central line-associated bloodstream infection, catheter-associated urinary tract infection, and methicillin-resistant Staphylococcus aureus—worsened by a statistically significant amount. The pandemic has revealed that we must build a more resilient culture of safety," she said.
Hospitals need to take action to get patient safety back on track, Binder said. "Hospital leadership and boards must make patient safety a top priority. They need to be transparent and hold themselves accountable for progress. That means hospitals need to recommit to the patient safety basics—proper hand washing, infection prevention, communication, and medication safety to name a few—and fortify safety culture from the top down. An aggressive approach to patient safety can help reduce burnout, which is directly associated with staffing shortages."
State of patient experience
In addition to the hospital safety grades report, The Leapfrog Group also released today a report on adult patient experience in the inpatient setting. The watchdog group analyzed data collected in the Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) survey.
The patient experience report includes three key findings:
During the pandemic, patient experience in the inpatient setting has declined significantly in nearly all measures
Patient experience in the care transitions metric remains the least favorable measure and declined significantly during the pandemic
Declining metrics of patient experience are associated with patient safety indicators, which indicates the pandemic has had a negative effect on hospital patient safety
Patient experience in the inpatient setting has declined across the board during the pandemic, Binder said. "This is deeply disturbing. Research has shown that hospitals that score higher on these patient experience measures tend to have better safety outcomes. For example, effective patient communication with nurses and doctors can prevent errors like medication mix-ups or misdiagnoses. Hospitals with better staff communication ratings have been shown to also have lower rates of hospital-acquired conditions. Additionally, if a patient is in pain, experiencing new symptoms, or cannot reach the bathroom, it is critical that staff respond quickly."
The largest difference comparing adult patient experience in hospitals pre-pandemic and mid-pandemic is in "responsiveness of hospital staff," which experienced a 3.7-point HCAHPS score decrease. Hospitals and patients can act to address this problem, she said.
"There are several ways hospitals can improve, but the first step they need to take is ensuring appropriate staffing levels. When hospitals don't have enough nurses, for example, patients might face greater risk of harm. Additionally, patient safety is a team sport—patients and hospitals will need to work together on this. While hospitals work to ensure appropriate staffing and care, patients, families, caregivers, and loved ones also play an important role. Patients should be encouraged to bring a caregiver along to act as a second set of eyes and ears. Hospitals should engage patients in every aspect of care, and the Agency for Healthcare Research and Quality, among others, offer extensive resources that hospital staff can utilize."
