The American Hospital Association's new Health Equity Roadmap provides a model for transformation and resources to make progress.
The American Hospital Association (AHA) has released a Health Equity Roadmap to help the organization's members make advancements in equity and inclusion.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
"The Health Equity Roadmap is a framework to support our member hospitals and health systems in their efforts to become more inclusive and more equitable organizations as we work toward dismantling the structural barriers that exist for some of our patient populations," says Joy Lewis, MPH, MSW, senior vice president of health equity strategies at AHA.
The AHA's Health Equity Roadmap has five components and resources, she says.
1. Transformation model: "There are six levers of transformation in the model. If our members focus on these six areas, they will be well-positioned to mobilize and make positive change toward becoming more equitable. The six levers of transformation are community collaboration for solutions, equitable and inclusive organizational policies, culturally appropriate patient care, collection and use of data to drive action, diverse representation in leadership and governance, and systemic and shared accountability," Lewis says.
2. Transformation assessment: "The transformation assessment serves as both a diagnostic of a hospital's current state and a baseline of where they are to help create a structure and process for continuous improvement toward transforming to more equitable and inclusive environments for both their workforce and the patients and communities they serve. The assessment calls out key performance indicators across each of the six levers of transformation," she says.
3. Transformation profile: "When a hospital conducts the assessment, they get the results in the form of a transformation profile. The profile says, 'Here is where you are. Here is your placement on the equity continuum.' There are five placements on the equity continuum—exploring, which is an embryonic stage of development; committing; affirming; immersing; and transforming, which is the most advanced stage. The profile provides data around where you are in each of the six levers of transformation. For example, a hospital could be transforming in their data collection and how they use data to improve care, but they could be exploring when it comes to addressing the issue of diverse representation in leadership and governance," Lewis says.
4. Action planners: "Once a member has the profile, they are then able to access the action planners, which are like a workbook. You gather a team of leaders from across the hospital who would be making contributions in each of the levers of transformation. This team thinks through and crafts actions that need to be taken to move from exploring to committing, for example," she says.
There 30 different action planners in total given the six levers in the transformation model and five placement levels of the equity continuum. Each action planner includes reflective questions that hospitals should ask of themselves and best practices.
For example, there is an action planner for the affirming placement level of the equity continuum for community collaboration for solutions. Reflective questions that hospitals should ask of themselves for this action planner include: What are the obstacles related to community collaboration for solutions at your organization? What are the impacts of these obstacles? Who is most impacted by these obstacles? Best practices for this action planner include: Conduct an audit to determine what barriers exist for individuals and marginalized communities in their ability to achieve good health and access healthcare services. Assess how well your existing services are reaching marginalized communities. Gather information on patient experience and disaggregate by race to determine common barriers for communities.
5. Health Equity Action Library: "When our members get their profile and they receive their placements on the equity continuum, they are also given a link to the resources in the Health Equity Action Library that can help them to mobilize and take actions to move from one placement to another on the equity continuum," Lewis says.
The Health Equity Action Library is accessible to all hospitals and health systems. Access to the rest of the Health Equity Roadmap is limited to AHA members.
Benefits of addressing health inequities
Addressing health inequities benefits patients, she says. "Given that the goal of the healthcare system is promoting health, it is clear that eliminating disparities is the right thing to do for patients. We want each patient to have the opportunity to achieve their optimal health status, and the same goes for communities. For example, if you look at racial health inequities, studies have shown that racial health inequities can cost billions of dollars in lost productivity and can result in premature death."
Addressing health inequities also improve the performance of hospitals and health systems, Lewis says. "For hospitals and health systems, eliminating inequities improves patient engagement, decreases readmissions, and improves health outcomes. Eliminating inequities also improves performance and reduces healthcare costs. Addressing health disparities allows hospitals and health systems to perform better in value-based payment arrangements. So, there is a business case for addressing health inequities."
Racial, ethnic, and linguistic concordance between healthcare providers and patients is low for people of color, a new report says.
Lack of diversity in the healthcare workforce risks undermining trust and patient health, according to a new report published by the Urban Institute.
Past medical mistreatment of people of color such as ignoring patients’ health concerns has resulted in mistrust of healthcare providers in these populations. “Perceptions of a shared identity between patients and their healthcare providers could be one way to improve the patient-provider relationship and foster trust and better communication,” the new report says.
Earlier research has shown benefits of having healthcare providers of the same race as patients or who speak the same language as patients. These kinds of concordances have “been associated with a greater likelihood of patients agreeing to and receiving preventive care, better patient experience ratings, and higher ratings on patient-reported measures of care quality,” the report says.
The report, which received funding from the Robert Wood Johnson Foundation, includes two key findings.
Only 22.2% of Black adults reported being of the same race as their healthcare providers compared to 73.8% of White adults.
Only 23.1% of Hispanic/Latinx adults reported racial, ethnic, and language concordance with their usual healthcare provider.
“Trust is part of the foundation of good patient-provider relationships and is especially important for communities of color, who have long been discriminated against in healthcare. Having a provider who looks like you and shares your experiences builds trust. Diversifying the healthcare workforce and increasing access to culturally competent care are significant opportunities to promote health equity and reduce disparities,” Jacquelynn Orr, DrPH, Robert Wood Johnson Foundation program officer, said in a prepared statement.
Addressing healthcare workforce diversity
Medical education should be a focal point in efforts to increase diversity in the physician workforce, the report says. “Because Black medical institutions play a key role in training Black providers and other providers of color, creating and supporting medical schools at historically Black colleges and universities and other minority-serving institutions could help increase the diversity of the healthcare workforce,” the report says.
Barriers for people of color who apply to medical school include the high cost of medical education programs, inadequate guidance in navigating admissions, and insufficient support systems to make sure people of color have the resources necessary to pursue a medical education, the report says.
“Cost barriers are particularly salient, given that the median cost of attending an in-state four-year medical school is about $260,000 for public institutions and more than $350,000 for private ones. … Tuition-free programs, debt-free medical education programs for students qualifying for financial aid, and scholarships and grants for underrepresented students are promising strategies for lowering the price of medical education and increasing the representation of Black students and other students of color,” the report says.
Importance of language
Earlier research has shown that patients for whom English is not the primary language have worse health outcomes than patients with English proficiency.
There are two primary strategies to address language gaps, the report says.
First, healthcare providers can offer interpretation services. “Most Medicaid programs reimburse for professional medical interpretation, but reimbursement ranges from $30 to $50 per visit, and interpretation for an encounter could cost up to $200; private insurers seldom reimburse for interpretation services. Stronger enforcement of language access regulations and higher reimbursement for medical interpretation services by health insurance payers could improve language access in healthcare,” the report says.
Second, healthcare providers can be encouraged to be multilingual. “Although some medical schools recommend students be fluent in a language other than English, making this a requirement or a heavily positively weighted factor for medical school admissions could also help diversify the languages spoken in the healthcare workforce. Offering bonuses and higher pay for healthcare workers who speak multiple languages could also incentivize providers to add staff who speak languages other than English,” the report says.
A chief medical officer for physician experience is tasked with boosting physician well-being and experience.
To address physician burnout and physician well-being, Altamonte Springs, Florida-based AdventHealth is focusing on the broader concept of physician experience.
Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency. Prior to the pandemic, burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
At AdventHealth’s Central Florida Division, Omayra Mansfield, MD, MHA, has been charged with boosting physician experience. She is an emergency medicine physician, chief medical officer for AdventHealth Apopka hospital, and chief medical officer for physician experience at the Central Florida Division.
HealthLeaders held a recent discussion with Mansfield about AdventHealth’s approach to physician burnout and physician well-being. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How is your role different from a chief wellness officer?
Omayra Mansfield: I have two project managers that I work with. I have one manager for experience projects such as physician recognition, scribes, and leadership development. Those are experiential projects that we are moving forward with our physicians.
I have a second project manager who focuses specifically on the well-being and wellness of the medical staff. The well-being project manager focuses on the core elements of physical health, emotional health, spiritual health, and psychological health. For example, the well-being project manager can pursue opportunities for connections with families and other opportunities, like going to a kitchen to learn how to cook healthy meals.
The key is the three of us work collaboratively. Each of the project managers feeds into the other. Traditionally, chief wellness officers have focused more on the wellness space. What we have added is the experience project space. But there is overlap, and that is the beauty of having two project managers.
HL: What are the primary elements of physician experience at AdventHealth?
Mansfield: I define physician experience as what it is to be a physician at AdventHealth. What is your experience from day one? From the minute that you decide you want to join AdventHealth, what is your experience? How is it to navigate the system? How easy is it to be credentialled? Then once you are a medical staff member, what is your experience day-to-day? What is it like to be on call? How do people communicate with you?
All of those elements will ultimately contribute to or detract from a physician’s personal well-being.
The experience is how the physician interfaces with AdventHealth and all of the parts of the health system, our patients, the rest of the staff, and nurses. The primary elements of physician experience are understanding that concept, then what we have done is broken it out to say, “How would you define each of those components?”
Well-being is probably by far the most important component of physician experience because well-being is not just your well-being at work—it starts at home. We want to look at physicians as whole individuals and attend to their well-being at home. Is your work distracting you too much? What are we contributing to in your personal life? How are we enhancing your personal life? How are we engaging your family in your experience at work?
The way we break up the rest of physician experience is related to the vision we have as a company and what we aspire to be by 2030. We want to be known as the company that looks at patients as whole individuals and healthcare as one facet of being a whole individual. I’m looking at my physicians in the same way.
HL: Are there guiding concepts for physician experience at AdventHealth?
Mansfield: We have four service standards—love me, own it, keep me safe, and make it easy. These service standards apply to physician experience.
One of my elements of experience for physicians is what am I doing every day to show them that we love them. For example, what are we doing to make them feel like they are part of the campus and not siloed as a medical staff member? What are we doing to show them that we love them and their families? What are we doing at the campuses to organize family events?
From the "own it" piece, we want to know, what are the rocks in their shoes? There are a lot of big things that I can do to enhance physician experience—I can help their transition to our new electronic medical record. But in the end, there are little rocks in the shoes that each doctor has that we need to identify, because we can do big things, but if those little rocks are still there, the big things don’t matter as much as they should. It can be little things such as not being greeted when you walk onto a medical unit. It can be helpful to have someone say, "Good morning, Dr. Jones. How are you doing?"
"Keeping me safe" includes if doctors are facing hostile situations in the work environment, we are supporting them. If they are faced with a challenging patient, we are supporting them. We want to make sure doctors have the tools and the resources that they need to provide safe patient care.
An example of "making it easy" is one of the things that we identified to love our physicians—recognizing physicians for exceptional care. We had a once-a-year opportunity to recognize physicians for extraordinary service at the end of the year during our medical staff banquet. But the question arose, why are we just doing this once a year? Our medical staff do extraordinary things every day.
So, we created a physician recognition program, where physicians can be nominated by anybody. There is a service excellence pin, and physicians can be recognized for meeting one of the four service standards—how they demonstrated "love me" or how they demonstrated "make it easy," for example. When a physician gets recognized, they get two pins—one that they can keep for themselves, and a second pin the physician is tasked with finding a colleague to award that pin to. It’s a pay-it-forward mentality.
The physician recognition program is crafted in the "make it easy" spirit. To date, we have had more than 700 physicians recognized in nine months.
HL: What is the primary benefit of a positive physician experience?
Mansfield: If we take better care of our physicians and make sure they are having a positive experience, by default they take better care of our patients. We know that burnout has a direct correlation to adverse clinical outcomes. For example, we know that medical errors increase if a physician is burned out compared to a physician who is not burned out. That is regardless of your tenure—you can be a resident or an attending physician.
HL: How do you measure physician burnout at AdventHealth?
Mansfield: There are two relevant things that we trend and track over time. One is our SCOR survey, which is a safety survey that we take as an organization that allows us to benchmark against other organizations. Part of the SCOR survey looks to the questions of reflections of your own burnout, reflections of team members’ burnout, and questions about your personal resilience. For the most recent SCOR survey, physicians had higher levels of reported self and team member burnout. But what gives me hope is that there were high reported levels of resilience.
The other marker that we use is physician engagement surveys. Looking through those and the comments, we have an opportunity to address the burnout of our physicians.
We use the SCOR and physician engagement surveys because they give us historical data, and they also give us something that we can look at objectively. But I also take the surveys with a grain of salt because there is also the reality of people with boots on the ground. We have a well-connected group of chief medical officers across the Central Florida Division. I rely on this group to give me their feelings about levels of burnout. There are the numbers in the surveys, but there is also the sense that you get from your campus.
Although home health aides play a key role in keeping homebound older adults in their homes, there is a looming shortage of these workers.
Home health aides play a vital role in the care of homebound older adults and there is an alarming shortage of these key caregivers, according to researchers and a recent Alzheimer’s Association report.
Home health aides are critically important to keeping many older adults in their homes, a trio of researchers wrote in a recent Journal of General Internal Medicineeditorial. “Without a strong community support system, we can expect inadequately supported older adults to continue to cycle through illness, repeated unnecessary hospitalizations, and potentially unwanted nursing home admissions,” they wrote.
There is a looming shortage of home health and personal care aides nationwide, according to the recent Alzheimer’s Associationreport. There were 3,083,310 home health and personal care aides in 2018, and 4,146,220 of them will be needed by 2028, representing a 34.5% increase, the report says.
A co-author of the Journal of General Internal Medicine editorial recently discussed the importance of home health aides with HealthLeaders. “There is a significant group of older adults who, over time, lose the ability to perform activities of daily living. Home health aides help to fill in some of those gaps. So, things like bathing and meal preparation can become just too difficult for some older adults. Without the support of home health aides, these older adults will lose the ability to remain at home,” said Jennifer Carnahan, MD, MPH, a practicing physician, Regenstrief Institute research scientist, and assistant professor at Indiana University School of Medicine.
Home health aides can reduce healthcare costs, she said. “In terms of lowering healthcare costs, we know that nursing homes, which are where many older adults often end up, can be highly expensive. Home health aides are usually less than 24/7 service, but they can provide the support that often prevents the high-cost investment of living at a nursing home.”
Home health aides also improve health outcomes, Carnahan said. “Everybody wants to define what a better healthcare outcome would be. The most important person to ask is the older adult themselves and their loved ones. They would say that staying at home is a better outcome. Home health aides help them maintain community living. Home health aides can also help identify medical concerns before other people realize what is going on. At lot of times, home health aides see these older adults every day or every other day, and they will notice if there is a change in mentation or their ability to function.”
Home health aides undervalued
Home health aides do not get the credit they deserve in the U.S. healthcare system, Carnahan said.
“They are often labeled as unskilled laborers. We don’t learn about them in medical school, even though they provide support for many older adult patients. We need to understand better how they fit into the entire picture. They are an afterthought—I learned about home health aides when I was acquiring additional geriatric training. We should think of home health aides as a vital part of the healthcare team even though they are not prescribing medicine or doing some of the things we think of as traditional medical care. They are contributing to care,” she said.
Carnahan and her editorial co-authors found that home health aides are not adequately compensated. “We looked at Bureau of Labor statistics and found that the median salary for a home health aide is $13.02 per hour. So, if you think about the recent discussions about elevating wages in other sectors of the workforce to $15 per hour, you can see how it might be more attractive to look at other types of employment. Home health aides are definitely undervalued in terms of compensation,” she said.
Including home health aides in care teams
Integrating home health aides into care teams can be beneficial, Carnahan said.
“This is a potential solution for making the pathways for communication easier. It is always easier to communicate with colleagues who are part of your company or the institution you are working for. If we can integrate home health aides into care teams, it can make things a lot smoother and easier. I have witnessed this problem in other arenas in healthcare, such as struggling to communicate with other health systems to try to get more information about a patient. When everyone is in the same health system, it is just easier to figure out what is going on with a patient,” she said. “Integrating home health aides with care teams also makes it easier to raise red flags. If a patient seems to be declining, everyone, including home health aides, can be on the lookout for decline. That way, you can nip problems in the bud.”
There are options to integrate home health aides into care teams, Carnahan said.
“A lot of this requires thinking outside of the box. Health systems could hire home health aides or contract with them. The way it is now is fractured. I work for the Indiana University Health Physicians, and any of the home health aides who are working with my patients are working for different companies. So, it is hard for me to find the home health aide who is working with Mr. Smith. Integration of home health aides could come through bringing them into the fold of a health system or partnerships between health systems and home health companies, where we have huddles once per week.”
Impact of coronavirus pandemic accelerated national health spending growth to 9.7% in 2020.
National health expenditures are expected to be influenced significantly by the coronavirus pandemic from 2021 to 2024, then typical factors that drive changes in health spending such as demographics are expected influence spending trends from 2025 to 2030, a new analysis indicates.
The new analysis was conducted by the Centers for Medicare & Medicaid Services’ Office of the Actuary. The analysis features expected annual health expenditures and projected hospital spending growth.
The analysis includes chronological healthcare expenditure projections.
In 2020, unprecedented financial stimulus from the federal government and insurance market upheaval drove national health expenditure growth to a nearly two-decade high of 9.7%. In 2020, the health spending share of the gross domestic product (GDP) increased 2.1 percentage points from 2019, to 19.7%.
In 2021, national health expenditure growth is expected to decline sharply to 4.2%, largely due to reductions in federal coronavirus relief funding. The slower growth rate in healthcare spending combined with growth in GDP, which rebounded to 9.6%, is expected to result in a 0.9-percentage point drop in the healthcare spending share of GDP to 18.8%. Healthcare spending is expected to total $4.3 trillion.
In 2022, national health expenditures are expected to increase at 4.6%, driven in part by higher healthcare prices linked to inflation in the economy. Healthcare spending is expected to total $4.5 trillion.
National health expenditures are expected to increase 5.0% and 5.1% in 2023 and 2024, respectively. These growth rates are tied to an expectation that patient care patterns will return to prepandemic levels. From 2022 to 2024, healthcare spending’s share of GDP is expected to be just over 18%.
The healthcare spending impact of the pandemic is expected to wane progressively from 2021 to 2024.
From 2025 to 2030, traditional drivers of healthcare system trends such as economic, demographic, and health-specific factors are expected to return to prominence. During this period, healthcare spending is expected to increase at an average rate of 5.3% annually, reaching a total annual spending level of $6.8 trillion by 2030. Healthcare spending’s share of GDP is expected to be 19.6% in 2030.
The analysis also includes projections for hospital spending growth.
In 2021, hospital spending growth is expected to decline 0.7 percentage points to 5.7%. The primary reason for this drop in spending growth is a decrease in federal coronavirus relief funding. In 2021, total hospital expenditures are expected to reach $1.3 trillion.
In 2022, rebounding demand for care and hospital price growth linked to inflation are expected to drive hospital spending growth upward sharply to 6.9%.
In 2023 and 2024, hospital spending growth is projected to decrease to 5.6%, with a normalization of pandemic-related effects such as utilization, federal stimulus funding, and insurance market disruptions.
From 2025 to 2030, hospital spending growth is expected to decrease slightly to an average of 5.5% annually. Influencing factors are expected to include reduced Medicare and private health insurance spending for hospitals.
Projections dependent on pandemic
The projections presented in the analysis are based on the assumption that the effects of the pandemic will wane through 2024, the co-authors of the analysis wrote. “As the severity of the COVID-19 pandemic and its related health and economic impacts are projected to lessen during the next few years, it is anticipated that the health spending and enrollment trends observed in 2020 will unwind as well.”
Traditional factors are expected to influence healthcare spending trends from 2025 to 2030, but there is considerable uncertainty associated with the pandemic, the co-authors wrote.
“Economic and demographic factors are anticipated to reemerge as the most influential drivers of health-sector trends, resulting in more stable health spending trends and a slowly increasing share of the economy devoted to healthcare. However, this outlook is contingent on a virus that has evolved and surprised at every turn—and could do so again. So although a normalization of health spending and the economy underlie this projection, only time will tell how normal the next decade is,” they wrote.
Despite willingness to address social drivers of health, two-thirds of physicians report inadequate time or ability to act, according to a new survey.
Physicians view social drivers of health (SDOH) as critically important in the health of their patients and they want to do more to help address SDOH, a new survey report has found.
SDOH such as food insecurity, housing instability, and transportation problems can have a pivotal impact on health outcomes, with a far greater effect than clinical care alone. “Physicians know that reducing total cost of care and achieving health equity are only achievable by addressing SDOH. Despite the well-documented impact of SDOH on health outcomes and costs of care, our current healthcare system does not operate in a way that includes addressing them,” the new survey report says.
The survey was conducted by The Physician Foundation from Feb. 2 to Feb. 11. Data was collected from more than 1,500 physicians. One-third of the physicians who responded to the survey practice primary care, which was defined as family medicine, general practice, internal medicine, or pediatrics. The remaining survey respondents practice in one of two dozen specialties.
The survey report includes several key data points.
99% of physicians reported that at least one SDOH affected the health outcomes of all or some their patients
Financial instability (34% of patients) and transportation problems (24% of patients) were the top two SDOH experienced by physicians’ patients
61% of physicians reported having insufficient time and ability to affect the SDOH of their patients
87% of physicians reported wanting more time and ability to affect the SDOH of their patients
Physicians reported that the top three reported obstacles to addressing their patients’ SDOH were limited time during patient visits (89% of physicians), inadequate staff to connect patients with community resources (84%), and the lack of community resources or difficulty of accessing community resources (77%)
83% of physicians reported that addressing the SDOH of patients contributes to physician burnout
68% of physicians reported that addressing the SDOH of patients has a major effect on physician mental health and well-being
80% of physicians reported that addressing SDOH is essential to improve health outcomes and decrease healthcare costs
Interpreting the data
Physicians are willing to do more to address the SDOH of their patients, Gary Price, MD, president of The Physicians Foundation, told HealthLeaders. “It’s clear physicians recognize how critical it is for our patients and our country’s healthcare system to address SDOH—and they are very much eager to play a more proactive role in this work. In fact, our survey found that nearly nine in 10 physicians (87%) indicated that they would like greater time and ability to effectively address their patients’ SDOH in the future.”
Physicians have a key role to play but they need partners to address the SDOH of their patients, he said.
“We physicians know that reducing total cost of care and achieving health equity are only achievable by addressing the SDOH. We must remain central to this discourse and decision-making as we’re closest to these issues and our perspectives are critical to improving patient outcomes. But we cannot do it alone. Addressing SDOH requires a holistic approach, including comprehensive coordination among individual physicians, medical societies, health systems, social service systems, and policymakers. A Physicians Foundation grant partner, Health Leads, is a great example of cross-sector community collaboration to enact systemic change in integrating SDOH in healthcare delivery,” Price said.
The link between physicians working on SDOH and physician burnout is concerning and should be addressed, he said.
“Physician burnout is a complex challenge and according to physicians surveyed, multiple factors contribute to physician burnout rates—from administrative burdens to prior authorization requirements. However, eight in 10 physicians (83%) reported challenges in addressing patients’ SDOH contribute to physician burnout rates. Additionally, six in 10 physicians (68%) believe managing patients’ SDOH has a major impact on physician mental health and well-being. Much of this is due to lack of resources. More than half of physicians reported experiencing stress or frustration on a daily or weekly basis because of limited time during patient visits to discuss SDOH, insufficient workforce to navigate patients to community resources to address SDOH, existing payer reporting requirements taking time away from being able to address patients’ SDOH, lack of reimbursement for screening for or addressing SDOH, and community resources unavailable, inadequate or difficult to access,” Price said.
There are several changes that can be made to support physicians in their efforts to address the SDOH of their patients, he said. “In our survey, multiple SDOH policy steps were identified by physicians as important to improve health outcomes and ensure high-quality, cost-efficient care for all. These steps included reimbursing physician-directed efforts to address SDOH, incentivizing payers to invest in availability and quality of community resources to address patients’ SDOH, providing greater flexibility for Medicare Advantage to reimburse for addressing SDOH, and integrating SDOH into payment policy.”
Promoting joy is a powerful approach to addressing healthcare worker burnout.
Fostering meaning and purpose in staff members is the key to promoting joy in healthcare workplaces, a healthcare well-being expert says.
Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency. Burnout continues to play a leading role in the widespread healthcare workforce shortages.
Elizabeth Goelz, MD, is an internal medicine physician and associate director of the Hennepin Healthcare Institute for Professional Worklife in Minneapolis.
HealthLeaders recently interviewed Goelz to discuss the intricacies of promoting joy in healthcare workplaces. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary elements of joy in healthcare workplaces?
Elizabeth Goelz: Joy can have different meanings for different people. Creating joy directly is not a goal that I would try to pursue. It is really about cultivating a workplace where meaning and purpose thrive—that creates the space for joy to exist.
HL: What are the primary elements of meaning and purpose?
Goelz: When you think about what brings you meaning in your work or what brings you purpose in your work, is it providing quality care, is it connecting with people, is it easing the burden of suffering for others? Those are the kind of large, overarching things that are often meaningful and purposeful to healthcare personnel. Then the question is, what does that look like? Does that look like having adequate time to see patients? Does that look like having access to the right resources when taking care of patients? Does that mean having adequate support staff? Does that mean having an electronic medical record that is not obstructing the work that needs to be done?
What meaning and purpose are and what they look like to cultivate meaning and purpose are separate but related questions. It’s more about finding examples than having a dictionary definition.
HL: How can healthcare organizations make healthcare workers feel valued?
Goelz: For some people, it simply takes acknowledging their hard work. For other people, it is making time for things such as eating healthy food, or showing you value their work-life balance by not contacting them after hours, or respecting their time by not having unnecessary meetings or unnecessary emails.
There are a lot of different things that can make people feel valued. But it all comes back to creating space for meaning and purpose to thrive, and saying "thank you."
HL: Conversations about what matters most to staff can help determine projects with the best potential for creating space where joy can exist. What kind of process can promote these conversations, then translate the conversations into actions and programs?
Goelz: You need to commit to asking what matters to staff members. That is the most important step. Then you need to log the answers and reflect on the information received. It is a commitment to a culture of curiosity and change. It can take the form of asking what matters during daily or weekly team huddles, and a monthly time to reflect on the information collected, plan ideas for modifications, and reconvene to assess the progress from previous months. It can take the form of a survey. Most certainly, it includes having a point person to lead this type of work. If nobody is in charge of something like this, it simply won't get continued. Having a point person for this work says something about an organization’s commitment to a healthy workplace.
The Institute for Healthcare Improvement has a spectacular white paper on "what matters to you?" conversations. The white paper gets at the practical tools and the importance of having these conversations.
HL: Who are good candidates to be a point person in conversations about what matters most to staff?
Goelz: A chief wellness officer is the best person to do this work. A chief wellness officer can keep tabs on the work, report back to the C-Suite, and be the person who is coordinating the work. If an organization does not have a chief wellness officer, there are other people who can serve as a point person. In any organization, there are undoubtedly people who are interested in what matters to staff. Simply listening can identify who those people are. Having a point person can involve carving out a small amount of FTE for somebody to be the go-to person not only for the healthcare team but also the go-to person for the C-Suite.
In addition, there are many organizations that have wellness champions—someone from each department who stays on top of wellness work who can report back to the point person.
HL: How can healthcare organizations identify what brings meaning and purpose to healthcare professionals?
Goelz: You simply need to ask. The "what matters to you?" conversation illustrated in the IHI white paper can be a great way to go about it. Ask, log the answers, and commit to a culture of asking, recording, reflecting, changing, and repeating. Without asking, there is no other way to identify what brings meaning and purpose. We can assume that meaning and purpose is related to providing quality care. We can assume, but you must ask.
For people who are stressed or are already burning out, it is easy for them to assume that if they are not asked about meaning and purpose, then the organization does not care about it. There are a lot of things that an organization asks about, and if meaning and purpose are not being asked about, that sends a message.
HL: How can healthcare organizations create the space for joy during disruptions such as leadership changes and staffing shortages?
Goelz: First, leadership changes should always include consideration of commitment to joy and wellness prior to hiring a leader because the right leadership team is essential for prioritizing this kind of culture.
Beyond that, joy is about meaning and purpose. So, learning what creates meaning and purpose for your healthcare workers can show organizations what to prioritize during inevitable disruptions. For example, if having the appropriate amount of time to see patients is something that allows meaning and purpose to thrive, then it should be prioritized.
If having the right support staff is important, which is different for different types of organizations, then it should be prioritized. A safety net organization is going to have different staffing resource needs than a non-safety net organization, particularly when it comes to community health workers and social workers. So, prioritizing staffing around the needs of the community that the organization serves shows commitment to the meaning and purpose of the healthcare workers.
Racial disparities that existed prior to the pandemic remained problematic in the first year of the public health emergency, according to a new study.
Breast cancer screening disparities persisted in the first year of the coronavirus pandemic, and screening of some minority groups did not bounce back as well as it did for White women, according to a new study.
Breast cancer screening has the potential to detect disease at its earliest stages, when it can be treated most effectively. Racial disparities in breast cancer screening rates have been shown in earlier research. For example, data published before the passage of the Affordable Care Act showed that Black and Hispanic women without insurance were less likely to have access to mammography.
The new study, which was published online by the journal Evidence-Based Oncology, analyzes breast cancer screening rates for two periods: March 1 to Sept. 30, 2019, and March 1 to Sept. 30, 2020. The research features data from more than 14 million patient records in a multipayer database that included Medicare fee-for-service, managed Medicaid, and commercial insurance beneficiaries. The study was conducted for the nonprofit Community Oncology Alliance (COA).
The researchers examined data for five racial groups: White, Black/African American, Hispanic/Latino, Asian/Native Hawaiian/Pacific Islander, and American Indian/Alaskan Native.
The study includes several key data points.
In 2019, mammogram utilization among Asian, Hispanic, and American Indian/Alaskan Native beneficiaries was lower than utilization among White beneficiaries.
At the peak of the first COVID-19 wave in April 2020, mean monthly screening rates for White Medicare fee-for-service patients plummeted to 0.6% of eligible beneficiaries. The screening rate recovered to 6.5% of eligible beneficiaries by June 2020, which was above the pre-pandemic level of about 6.1%.
Asian, Hispanic, and American Indian/Alaskan Native women did not experience a rebound in screening rates until September 2020.
American Indian/Alaska Native women experienced the most striking screening disparities. In June 2020, screening rates for American Indian/Alaska Native women were less than half of White women. At the peak of the first COVID-19 wave in April 2020, screening rates for American Indian/Alaska Native women fell to 0.5% of eligible beneficiaries and only recovered to 3.1% in June 2020.
Pre-pandemic mammogram utilization disparities remained in September 2020 among Black (6.2%), Hispanic (4.3%), and Asian (4.5%) women.
The lead author of the study said the research is troubling for breast cancer care in general and minority women in particular. “What’s worrisome is that the combined two-year lag in screenings we are reporting will translate into not only more and more severe breast cancer cases, but that the cancer health disparities we already knew existed have remained stubbornly unmoved,” Debra Patt, MD, PhD, MBA, executive vice president at Texas Oncology and secretary of COA, said in a prepared statement.
Healthcare providers should be encouraging their patients to get routine cancer screenings, Kashyap Patel, MD, a practicing oncologist who is a co-author of the study and president of COA told HealthLeaders.
“We can have multiple interventions. At Community Oncology Alliance, we have a program called Time to Screen. Every Community Oncology Alliance practice is trying to do their best to make their patients aware of cancer screening when they come to the office. We ask about their spouses and other family members to see whether they need cancer screening,” he says.
Linguistic barriers are an issue, Patel says. “For patients for whom English is not the main language, they need explanations about cancer screening in their own language. Community Oncology Alliance has started multi-linguistic approaches, including through social media. We are trying to use a multi-pronged approach to educate patients as much as we can to make them aware about the need for screening and consequences of not getting screened.”
The Lown Institute has ranked city hospital markets and individual hospitals by racial inclusivity.
A new report uses a racial inclusivity metric to examine how well 2,800 hospitals serve people of color in their surrounding communities.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The new report from the Lown Institute uses Medicare claims and U.S. Census Bureau data in a racial inclusivity metric. Vikas Saini, MD, president of The Lown Institute, described how the racial inclusivity metric works during a webcast yesterday.
"For every hospital, we used Medicare claims data to determine the Zip codes where that hospital's patients came from. We then used that data to define the perimeter around the hospital that represents the entire area from which patients could have come. We call this the hospital community area. Once we have a hospital community area, we then use the Census data to compare the demographics of the Zip codes of where patients actually come from for a hospital to the demographics of the whole hospital community area. This let's us see which communities are being over- or under-represented for any given hospital," he said.
Using this racial inclusivity metric, the Lown Institute was able to rank hospital markets and hospitals based on racial segregation.
The following 10 cities had the most racially segregated hospital markets, with at least 50% of their hospitals falling in the most or least racially inclusive categories:
1. Detroit, when considering service to all patients, it is 90% segregated
2. St. Louis, 77% segregated
3. Kansas City, Missouri, 75% segregated
4. Atlanta, 68% segregated
5. Philadelphia, 68% segregated
6. Washington, DC, 63% segregated
7. East Long Island, New York, 61% segregated
8. Houston, 58% segregated
9. Baltimore, 56% segregated
10. Manhattan, New York, 55% segregated
The 10 most racially inclusive hospitals in the report were as follows:
1. Lakeside Medical Center, Belle Glade, Florida
2. St. Charles Madras, Madras, Oregon
3. Metropolitan Medical Center, New York
4. Boston Medical Center, Boston
5. John H. Stroger Jr. Hospital, Chicago
6. The University of Chicago Medical Center, Chicago
7. Harlem Hospital Center, New York
8. Truman Medical Center Hospital Hill, Kansas City, Missouri
9. Methodist Dallas Medical Center, Dallas
10. Grady Memorial Hospital, Atlanta
The 10 least racially inclusive hospitals in the report by rank were as follows:
2769 Palos Community Hospital, Palos Heights, Illinois
2770 St. Elizabeth Dearborn Hospital, Lawrenceburg, Indiana
2771 St. Elizabeth Fort Thomas, Fort Thomas, Kentucky
2772 Mercy Hospital South, St. Louis
2773 Peterson Regional Medical Center, Kerrville, Texas
2774 Cass Regional Medical Center, Harrisonville, Missouri
Reflections on racial inclusivity
The analysis is a reflection of structural racism in healthcare, Saini said during yesterday's webcast. "I view the data and the method as a measure of structural racism. For me, the 'structuralness' of it means that it is deeply embedded in history, patterns of residential segregation, bifurcation of the labor market, and bifurcation of the insurance market. Then you get these patterns of segregation."
Race plays a role in elective surgery, he said. "With elective surgery, although it declined in 2020 because of the pandemic, we saw a pattern. What we saw was that elective patients were drawn from whiter and wealthier areas in a hospital's surrounding community. That is not a surprise—70% of hospitals were less inclusive for elective patients than for their population as a whole. Elective surgeries are part of a selective, biased process."
Financial incentives drive racial inclusivity in healthcare, Anthony Iton, MD, JD, MPH, senior vice president of healthy communities at The California Endowment, said during yesterday's webcast. "We have constructed a market-justice-oriented healthcare system that does not respond to the needs of people—it responds to the privilege of people and their ability to pay."
Segregation in hospital markets and at individual hospitals is not the result of malicious healthcare leadership, Iton said. "When you see this over and over again, you are looking at a pattern—you are not looking at a bunch of bad actors. You are looking at a normal reaction to a set of incentives. The problem is the incentives. There are not bad people running hospitals—they are doing exactly what anybody would do under the constraints."
Thomas Sequist has been promoted from chief patient experience and equity officer to serve as the health system's top physician executive.
Boston-based Mass General Brigham has appointed the health system's first chief medical officer.
Thomas Sequist, MD, MPH, was announced as the health system's CMO last month. He has been with the health system since 1999, when he started his residency at Brigham and Women's Hospital. He still practices as a primary care physician at the hospital, and before taking on the CMO role, Sequist served as chief patient experience and equity officer at Mass General Brigham.
Sequist recently spoke with HealthLeaders about a range of issues, including leadership at Mass General Brigham, patient experience, health equity, and patient safety. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: You are the first CMO at Mass General Brigham. What are your top goals in pioneering this new position?
Thomas Sequist: At a high level, the top goal that we have is to bring together the great minds that we have across our system to address some of the most pressing patient care concerns that we have in a way that we have not done in previous iterations of our organization. We want to all be driving toward a single purpose and a single set of strategies.
Diving down one layer deeper, our passion and our commitment across Mass General Brigham is going to be in the spaces of equity, patient experience, and maintaining our foundation of quality and safety. I hope that we are going to be able to substantially move the needle in the areas of equity and patient experience.
HL: What are your top goals in promoting patient safety?
Sequist: We want to maintain the ongoing excellence that we have in the hospital space, whether it is related to hospital-acquired infections or excellent outcomes related to acute myocardial infarction or congestive heart failure. We want to pioneer patient safety in spaces that are increasingly important; in particular, the ambulatory safety space.
As we move care more and more out of quaternary hospitals and into community hospitals, ambulatory centers, such as ambulatory surgical centers and medical offices, and home-based care programs, we need to parallel that movement with the development of important patient safety programs.
Ambulatory safety is a space where there is a ton of potential for us to make care even safer. It has different characteristics to it than the hospital space—it is much more episodic. A typical hospital stay is three or four days in a contained environment. Ambulatory care happens over time—it can happen over the course of months or even a year. It has many more providers and care team members involved, and much more degrees of freedom, which means it presents more challenges to patient safety. We are gearing up to address all of those challenges.
HL: What are your top goals in promoting community health equity?
Sequist: On community health equity, I separate that out between what we call health equity, which is related to the clinical delivery of care at our hospitals and offices, versus community health, which is related to a much broader concept of all of the neighborhoods we serve and how we improve their health status.
On the community health side, our top goal is to promote precision community health, which is using a data-driven approach to identifying the most pressing health concerns of a community and targeting our resources and interventions in partnership with community leaders to address those concerns. We are initially going to be focused on prevention of excess morbidity and mortality from substance use disorder and cardiovascular disease. Of course, we will not lose our attention to many of the other community health concerns, but we do want to have a targeted impact on those two areas.
On the health equity side, we have a platform called United Against Racism. This year and into the next year, our most pressing priority in the health equity space is continuing our journey of becoming an anti-racist organization. That journey takes many steps to accomplish from how we collect demographic information about our patients such as race, ethnicity, and language, to how we build out digital tools, to how we train our staff to deal with racism across our organization, to how we build care teams in primary care and staffing community health workers and social workers. We are taking a multifaceted approach to health equity, with the goal of achieving anti-racism across our organization.
HL: You have played a leadership role in the United Against Racism initiative. What have been the primary learnings from this program?
Sequist: We are about 15 months into the United Against Racism platform. Racism in healthcare is a large problem, so we are on a multi-year journey to try to have an impact.
So far, we have had an important impact in a few areas. For example, during the coronavirus pandemic, we and many others across the country noticed very early on that there was a digital access divide as telehealth stood up and people started doing video visits more regularly. We quickly noticed that many people in our Black and Latino populations were not able to access that technology and maintain their continuity of care.
We set aggressive goals to increase the enrollment rates of our Black and Latino patients into our electronic patient portal, which is the venue through which you do telehealth visits. Over the course of the past 18 months, we have seen aggressive increases in the rates of enrollment of our Black and Latino populations—more than 10 percentage point increases, which is a substantial increase in the number of patients who are now able to access the digital tools that we offer.
HL: What are your top goals in promoting patient experience?
Sequist: One of the things that we want to emphasize is that when our patients interact with our health system that they understand that they are not only going to be cared for but also cared about. It is the notion that we can provide excellent clinical delivery of care and at the same time we recognize there is much more to the patient experience. There is the care coordination. There is the empathy that we show to our patients. There is making sure that our patients have a comprehensive understanding of their care plans, so they can engage in their care in a meaningful way. We are dedicated to doing all of those things.
Another primary goal in our patient experience is going to be making sure that patients can both achieve the benefits of the scale of our health system and also not be overwhelmed by the scale of our system. That is a difficult balance to achieve. The benefit of the scale of our system is that we can treat every clinical problem of a patient—whether it is an advanced problem or a specialized problem. The diversity of the doctors, nurses, pharmacists, and staff that we have can treat a patient across the entire life span. However, with such a large and diverse system, we want patients to feel comfortable in navigating our system.
HL: How do you characterize your leadership style?
Sequist: There are a couple of things that drive me. The first is that I tend to lead through passion. I have been passionate about the things that I have been blessed to lead such as equity, community health, and quality.
The second thing about my leadership style is that I am impact-driven. The thing that matters to me the most is whether we are demonstrating that we are improving the lives of our patients and community members.
I also am someone who tends to thrive more as a leader in times of change.
