A five-part guide for healthcare executives includes adjusting expectations, reducing low-value work, and strategies for addressing workforce shortages.
The CEO Coalition in conjunction with the National Academy of Medicine has created the 2022 Healthcare Workforce Rescue Package to help guide executives in bolstering the well-being of healthcare workers during the coronavirus pandemic.
Healthcare worker burnout was significant before the pandemic and it has reached crisis proportions, according to national healthcare worker well-being expert Bernadette Melnyk, PhD, RN, APRN-CNP, chief wellness officer of The Ohio State University and dean of the university's College of Nursing. Prior to the coronavirus pandemic, healthcare worker burnout rates ranged from 30% to 50%; now, burnout rates range from 40% to 70%, Melnyk says.
The 2022 Healthcare Workforce Rescue Package, which was announced this month, features five prescriptions for boosting healthcare worker well-being.
1. Adjust expectations during pandemic
Healthcare leaders should give clinicians more flexibility and autonomy during the pandemic, the rescue package says.
"We know from the literature that control is an important burnout lever," says Jessica Perlo, MPH, a director at the Institute for Healthcare Improvement (IHI) who helped craft the rescue package.
An important way to provide clinicians with more flexibility is through alternative scheduling, she says. "For example, Hennepin Healthcare in Minneapolis worked on eliminating mandatory early morning and late afternoon meetings, and they allowed clinicians to flexibly schedule patients during the first and last hours of their day. Clinicians were able to maintain their productivity while decreasing conflicts with commuting and picking up kids. That kind of change is good because it does not impact patient access or total patient visits, but it does improve burnout scores and turnover."
Focusing on autonomy gives staff the freedom to determine the conditions that best support their well-being, Perlo says.
"The misconception is that autonomy somehow negates the importance of collaboration, integration, and teamwork. It does not—it allows for individuals to use discretion, judgment, and the full scope of their degrees to make management decisions that best serve a patient's needs. A good question to ask is, 'Do people feel like they have some choice in how they execute their daily responsibilities or a voice in the way things are done?' This is where quality improvement can be especially helpful because it empowers people to have sufficient authority to improve how the work gets done and can be an effective lever to help work to distribute leadership in a way that promotes autonomy," she says.
2. Identify and remove low-value work
Healthcare leaders should collaborate with clinicians to limit low-value work such as reducing electronic health record clicks for common workflows and decreasing inbox notifications, the rescue package says.
Perlo says there are two helpful tools to reduce low-value work—Get Rid of Stupid Stuff and Breaking the Rules for Better Care. "With the Breaking the Rules for Better Care tool, leaders ask their staff if they could break or change any rule in the service of better care, what would it be? The IHI's Leadership Alliance members found that asking this question enabled their organizations to identify areas where they could take direct action to eliminate habits and rules that cause harm without benefit," she says.
3. Make radical changes to address workforce shortages
Healthcare leaders should get creative to make sure frontline care teams are adequately staffed such as sending executives to the bedside and initiating voluntary redeployment of non-clinical staff to care settings, the rescue package says.
One of the most immediate steps healthcare leaders should take is Gemba, Perlo says. "This is an approach we borrowed years ago from lean manufacturing to have leaders see an actual work process. They can understand the work, and they can learn and show respect to those who are experiencing workforce shortages firsthand. The objective is for leaders to understand problems, rather than viewing problems and making recommendations from their offices."
Optimizing the efforts of care team members is also critical, she says. "We also talk about allowing all staff to work at the top of their licenses and getting serious about team-based care. This can include nurses and medical assistants taking verbal orders, performing computerized order entry, doing medical reconciliation, and assisting with visit note documentation. The idea is alleviating some of the workload of clinicians."
4. Appoint a well-being executive
Healthcare organizations should designate an executive such as a chief wellness officer who has operational authority and resources to align and execute clinician well-being efforts, the rescue package says.
A chief wellness officer is a key member of any healthcare organization's executive team, Perlo says.
"A chief wellness officer does things such as regularly monitoring and reporting on outcomes, as well as supporting a culture of well-being. It is important for the chief wellness officer to report to the CEO, president, or the dean. This individual should also work closely with the chief equity officer or take up the goal of addressing inequities in the system. The odds of burnout are greater in female physicians, and we know that burnout is higher among people of color. So, a chief wellness officer needs to identify and address the gaps in experience across these demographics. For example, at Henry Ford Health System, Kimberlydawn Wisdom is the chief wellness and diversity officer. She ensures that the staff has the resources to impact workforce equity," she says.
5. Foundational programs to support mental health
Mental health counseling, a peer-support program, and psychological first aid training for leaders are helpful to maintaining well-being at healthcare organizations, the rescue package says.
"Providing quality mental health counseling, creating peer support programs, and offering psychological first aid training to healthcare organization leaders normalize distress and encourage help-seeking behaviors. Peer support programs can be effective at creating formal systems for non-mental health clinicians to offer support to their colleagues after adverse events or any professionally stressful experience," Perlo says.
Offering psychological first aid training to healthcare organization leaders helps overcome stigma and identify staff members who need help, she says. "Right now, many healthcare workers are experiencing mental health sequelae related to the pandemic. We have had multiple waves of the pandemic, and people are experiencing a lot of trauma and stress. So, making sure people are equipped to identify when their colleagues are experiencing distress is an important part of supporting our caregivers."
The health system and medical school have teamed up to increase the number of physicians who are people of color and to boost medical training in health equity, racial disparities, and healthcare access.
People of color are underrepresented in the physician ranks. For example, Black communities account for 12.4% of the population but account for only 5% of the physician workforce, according to the U.S. Census Bureau and CommonSpirit.
"Physicians who are Black make up 5% of the physician workforce. In terms of medical students who are Black, they make up 7% of medical students. There are other physicians and medical students of color such as Hispanics making up a significant group; but, in general, people of color are underrepresented in both our general provider community and in the training community in terms of medical students," says Gary Greensweig, DO, system senior vice president and chief physician executive of physician enterprise for Chicago-based CommonSpirit.
The dearth of physicians who are people of color has negative consequences for clinical care, he says. "When we look at our population, it is quite diverse and becoming more diverse. There is clear data that from a cultural standpoint, from a lived experience standpoint, and from a trust and outcomes standpoint that having people of color underrepresented in the healthcare provider space affects patients and contributes to health inequities and poor outcomes. In general, patients like to receive care from people who are similar."
CommonSpirit, which operates 140 hospitals in 21 states, and Atlanta-based Morehouse School of Medicine launched the first phase of the More in Common Alliance in November. The first phase of the initiative features three undergraduate education sites at CommonSpirit hospitals in Chattanooga, Tennessee; Lexington, Kentucky; and Seattle. Additionally, there are four graduate medical education sites in California that will feature post-graduate residencies and fellowships.
The focus of the More in Common Alliance is twofold, Greensweig says.
"Number One, if you think about where we have all journeyed in the past two years, it has been a twin pandemic. We have had COVID-19, and we have had a pandemic of racial disparities and poor outcomes for patients of color. We hope to address that second pandemic," he says. "Number Two, we want to increase the number of Black and other underrepresented healthcare providers. It is not just a matter of increasing the numbers of those persons, it is a matter of ensuring that those persons who graduate from Morehouse and the training programs that CommonSpirit is creating will have a special focus on healthcare inequities, racial disparities, and healthcare access. Not only do we want to train people of color to be good physicians, physician assistants, and advanced practice providers, we want them to have special skills."
Expanding undergraduate and graduate medical education
Education is an essential element of the More in Common Alliance, Greensweig says.
"We need more access to undergraduate medical student training sites. At several CommonSpirit facilities, we are starting to train medical students as part of their third- and fourth-year medical student rotations. To the extent that Morehouse can have more of those student slots, they can accept more students in year one and two. If after year one and two, at the end of their classroom work, they do not have a place for them to go and be clinical students—it's a problem. If we are going to have more students, we need to have more places to train them," he says.
Graduate medical education is equally important, Greensweig says. "Once these students graduate, they need places to go and learn to be primary care doctors and specialists. That is where residencies occur. We need to expand the pool of available residencies, and we need to be sure that these residencies align with the concepts of health equity, healthcare access, and racial disparities."
CommonSpirit and Morehouse will be working in concert to expand graduate medical education opportunities, he says. "CommonSpirit has created waves of programs that we will start in the next couple of years—some on the West Coast, some in the Midwest—where we are starting to build and fund new programs. Those programs will have academic sponsorship with the Morehouse School of Medicine. Morehouse already operates several residency programs, but they will be expanding their graduate medical education services to add more residency slots for students from Morehouse and students from elsewhere who have an interest and a focus on health equity and taking care of the underserved."
Committed partners
CommonSpirit and Morehouse are committed financially and philosophically to their partnership, Greensweig says. "The $100 million does not define the relationship, but those dollars do represent a significant level of commitment. The relationship is based on the goals such as ensuring appropriate healthcare access for the underserved, ensuring that we increase the number of providers who are people of color, and improving healthcare outcomes in underserved communities."
CommonSpirit and Morehouse will be funding the initiative in conjunction with philanthropy support, he says. "We have made a 10-year commitment to help fund this initiative. The money will come from two sources—one will be operations at CommonSpirit Health and the Morehouse School of Medicine, and the other will be through an active philanthropy project which is already underway to fund some of our needs. It is an operations expense and there are people from across the country who want to support this effort with philanthropic dollars."
Commitment is essential to rise to the challenges of addressing health equity, Greensweig says. "If we had this on a roadmap and asked, 'How far of the journey have we gone?' I think we have gone about 10% to 15% of the journey. There are a lot of people in the country who have woken up and concluded that we have work to do on health equity. But there is 85% to 90% of the work remaining in front of us. We have a long way to go."
Information readily available in electronic health records can identify which children hospitalized with COVID-19 could be candidates for aggressive early treatment.
Demographic characteristics, preexisting comorbidities, and vital sign and laboratory values at the time of hospitalization indicate which children with COVID-19 are at higher risk of severe illness, a recent research article shows.
In general with COVID-19, children experience milder symptoms than adults. However, COVID-19 can advance to severe illness in children, with outcomes including death and multisystem inflammatory syndrome in children (MIS-C).
The recent research article, which was published by JAMA Network Open, features data collected from more than 10,000 individuals under the age of 19 who were hospitalized with COVID-19. Findings of the study were published first in Critical Care Medicine.
The JAMA Network Open research article includes several key data points.
Data was collected from the National COVID Cohort Collaborative, with 1,068,410 children tested for COVID-19 and 167,262 (15.6%) testing positive for the virus
Male sex (odds ratio 1.37); Black race (odds ratio 1.25); obesity (odds ratio 1.19); and several pediatric complex chronic conditions including cardiovascular, oncologic, and respiratory conditions were associated with higher severity illness in hospitalized children
Male sex (odds ratio 1.59), Black race (odds ratio 1.44), age under 12 (odds ratio 1.81), obesity (odds ratio 1.76), and not having a pediatric complex condition (odds ratio 0.72) were associated with increased risk for MIS-C
Compared with children who were hospitalized without severe illness, hospitalized children with severe illness had more abnormal values for several vital signs at the beginning of their hospitalization, including systolic and diastolic blood pressure (lower), oxygen saturation as measured by pulse oximetry (lower), heart rate (higher), and respiratory rate (higher)
Compared with children who were hospitalized without severe illness, hospitalized children with severe illness had more abnormal values for many laboratory test results at the beginning of their hospitalization. In particular, children with severe illness had test results that indicated organ dysfunction such as brain-type natriuretic peptide (higher), creatinine (higher), and platelets (lower), and inflammation such as ferritin (higher), C-reactive protein (higher), and procalcitonin (higher).
"In this cohort study of U.S. children with SARS-CoV-2, there were observed differences in demographic characteristics, preexisting comorbidities, and initial vital sign and laboratory values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission," the JAMA Network Open research article's co-authors wrote.
Interpreting the data
The findings of the research should help in the clinical care of children hospitalized with COVID-19, the lead author of the JAMA Network Open research article told HealthLeaders.
"We hope that our study will assist clinicians in identifying children at higher risk of developing severe disease once hospitalized with SARS-CoV-2. Specifically, we found that children who were male, Black/African American, obese, and who have a history of prior chronic medical conditions, specifically prior cardiovascular, oncologic, respiratory, and technology dependent conditions, are at higher risk for progressing to severe disease once hospitalized," said Blake Martin, MD, pediatric critical care attending physician at Children's Hospital Colorado and a member of the Society of Critical Care Medicine.
It was surprising that not having preexisting comorbidities was associated with increased odds of a MIS-C diagnosis, he said.
"It would have been reasonable to assume that children who are more medically fragile might be more susceptible to MIS-C, but it ended up being the opposite: that children without significant prior complex medical conditions were at increased risk for receiving an MIS-C diagnosis among children presenting to care with a positive SARS-CoV-2 test. Much of the discussion around children and SARS-CoV-2 has been that otherwise healthy children do relatively well and are unlikely to have a poor outcome. While this is definitely true overall, I think it is worth noting that 'otherwise healthy kids' are still at risk for MIS-C," Martin said.
Future research should focus on developing clinical decision support tools to help clinicians identify hospitalized children with COVID-19 who could progress to severe illness, he said.
"We now know that there are many pieces of data in the electronic health record that are associated with an increased odds of severe disease once a child is hospitalized with SARS-CoV-2. The data elements identified in this study (demographics, comorbidities, and day of admission vital sign and lab values) are all readily available and could be used to design a clinical decision support tool or computer algorithm that automatically identifies high-risk children at the time of their hospital admission. Many research teams are now working on the creation of these predictive models, which we hope will allow clinicians across the country to identify high-risk children that might be candidates for more aggressive, earlier treatment and closer monitoring."
Physicians report that prior authorization delays needed care, results in adverse patient events, and poses excessive administrative burden.
Prior authorization of medical treatments and services has a negative impact on patients and physician practices, a recent physician survey conducted by the American Medical Association (AMA) found.
Payers often require prior authorization for medical treatments and services. Physician practices have been critical of the impact of prior authorizations for many years.
The recent survey featured 40 questions that were administered online in December. More than 1,000 practicing physicians participated in the survey, with 40% working as primary care physicians and 60% working as specialists.
The survey features several key data points.
93% of physicians reported that prior authorization led to delays of necessary care (14% always, 42% often, and 38% sometimes)
82% of physicians reported that the prior authorization process leads patients to abandon treatment (3% always, 24% often, 55% sometimes)
34% of physicians reported that prior authorization has ledto aserious adverse event for a patient
24% of physicians reported that prior authorization has led to a patient's hospitalization
18% of physicians reported that prior authorization has led to a life-threatening event or required intervention to prevent permanent impairment or damage
29% of physicians reported that prior authorization criteria are rarely or never evidence-based
Physicians and their staff spend an average of 13 hours per week processing prior authorizations
40% of physicians reported having staff who work exclusively on prior authorizations
88% of physicians reported that the administrative burden associated with prior authorization is high or extremely high
51% of physicians reported that prior authorization has interfered with a patient's ability to perform his or her job responsibilities
Interpreting the data
It is alarming that 93% of physicians surveyed said prior authorization is associated with care delays, AMA President-elect Jack Resneck Jr., MD, told HealthLeaders.
"An archaic prior authorization process can have alarming consequences for patients when evidence-based care is delayed or denied. As physicians face recurring paperwork requests, multiple phone calls, and hours spent on hold, patients' lives can sometimes hang in the balance until health plans decide if needed care will qualify for insurance coverage. Not only can the patient's condition decline during this waiting time, but the stress and anxiety of not knowing if they will receive the care they need exacts an emotional toll," he said.
It is also concerning that one-third of physicians reported that prior authorization resulted in instances of patient harm, Resneck said.
"Despite evidence that prior authorization can be a hazardous administrative obstacle to patient-centered care, it remains unsettling that meaningful reforms to protect patients have been deferred, disregarded, and sometimes obstructed by health insurers. The fact that over one-third of physicians report a patient has experienced a serious adverse event related to prior authorization indicates that our current system is broken: coverage requirements should not be preventing access to care and leading to negative clinical outcomes. Beyond the distressing human costs of prior authorization shown by these data, the results also call into the question if prior authorization really reduces overall medical costs. If delayed care results in a patient's hospitalization, no one—the health plan, the employer, nor the patient—is saving money," he said.
Prior authorization needs to be reformed and "right-sized," Resneck said. "There is growing agreement across the entire health system that prior authorization is overused without justification and needs to be right-sized. Requiring prior authorization for drugs or medical services with consistently high approval rates—what many would call 'low-value' prior authorizations—is wasteful for physicians, patients, and health plans. Similarly, burdening physicians with a history of following evidence-based guidelines and/or high prior authorization approval rates adds unnecessary administrative costs to our healthcare system."
Prior authorization is an excessive administrative burden on physician practices, he said. "The AMA's survey data illustrate the current excessive volume of prior authorization requirements. Practices report completing an average of 41 prior authorizations, per week per physician, and this workload for a single physician consumes nearly two business days of physician and staff time. In addition, 40% of physicians report hiring staff just to complete prior authorizations. If we are looking for ways to reduce unnecessary administrative costs in healthcare, prior authorization is a clear target."
Health equity has been added to the Quadruple Aim of improving population health, enhancing the care experience, reducing costs, and promoting workforce well-being.
Health equity should be added as the fifth element of a Quintuple Aim to guide healthcare improvement efforts, a recent Viewpoint article published by JAMA says.
In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
Healthcare improvement efforts also require a focus on health equity, a co-author of the recent Viewpoint article told HealthLeaders.
"If we look at our work on the Triple and Quadruple Aims, many people have noted that there have been challenges to achieving those. When we considered the failure points in achieving the Triple and Quadruple Aims, our view was in large part that many of the ways we have not achieved them was because of the lack of attention to the equity dimensions of healthcare. When you look at where the challenges are in health outcomes, cost of care, care experience, and where the workforce suffers the most, it is often in under-resourced communities and more marginalized and historically oppressed populations. That is why the co-authors of the JAMA Viewpoint article thought that the inclusion of a fifth aim around equity was so important," said Kedar Mate, MD, president and CEO of the Institute for Healthcare Improvement (IHI).
There are four essential steps to address health equity, the Viewpoint article's co-authors wrote. "To address the fifth aim, healthcare leaders and practitioners must identify disparities, design and implement evidence-based interventions to reduce them, invest in equity measurement, and incentivize the achievement of equity."
1. Identifying disparities
The first step in addressing health equity is identifying disparities, Mate said. "Without knowing where the challenges are, without knowing where the system is falling down, you do not know where to concentrate your energy. You cannot build a strategy without clear aims. Knowing where the disparities are and knowing where populations are not getting the kinds of care that they need most is vital to design a different system that can address those disparities."
Many health disparities have already been identified, he said. "When you look at the troubling issues in healthcare—everything from access to care to achieving high quality care—disparities are present. For example, colorectal cancer screening rates are higher in White populations than they are in Black and Hispanic populations. We know our Black maternal survival is much lower than White maternal survival—the excess morbidity and mortality is four times greater in Black women than it is in White women. We know infant mortality is higher in Black and Hispanic babies than in White babies."
Disparities extend beyond the racial factor, Mate said. "We know poorer folks face healthcare disparities. There are disparities based on gender and disparities based on sexual identification. There are many forms of disparity that are present in any given context—there are differences between rural and urban populations that are very substantial. The hypothesis that the Viewpoint article co-authors has for adding a fifth aim is that if we start paying attention to disparities and build our systems to address them, then we will be able to achieve the original goals of the Triple and Quadruple Aims."
2. Designing and implementing evidence-based interventions
Evidence-based interventions are pivotal in addressing health equity, he said. "This comes down to how committed we are to improving healthcare for our country. The thesis that we are putting out is that much of the excess morbidity and mortality in our nation is driven by disparities and inequity. That is what we have seen at IHI, not only in the United States, but also around the world. If we are serious about improving life expectancy, if we are serious about making our communities safe and the best places for our kids to grow up, then it requires us to take a proactive position about reducing the disparities that are present with evidence-based interventions."
Interventions designed to tackle health inequities do not only benefit populations who are suffering from disparities, Mate said. "What we have learned over time is that a system that helps the most marginalized, and is built to include everyone, has the effect of improving care for all parties. For example, IHI was working with a health system on perioperative pain. There was a big difference between pain scores for Black patients compared to White patients. The health system built a better system that addressed the difference in pain scores. What was interesting was not only did the disparity go away, but the pain scores for all populations got better, including for White folks."
3. Investing in equity measurement
Equity measurement is crucial to determine whether care that is being delivered is equitable or not, Mate said. "When we looked at our own data at IHI several years ago, we did not have data on self-identified demographics or economic indicators, so we could not know whether the program or project that we were conducting was benefitting everyone equivalently. We should invest in equity measurement because it allows us to understand whether everyone is having the opportunity to benefit from improvement initiatives. With that information, we can design initiatives and interventions that make sure everyone has a chance to thrive and succeed."
Mate gave two examples of equity metrics. "One way of thinking about equity metrics is taking your existing clinical metrics and stratifying them by important demographic identifiers such as race and gender. You can take data for controlled blood pressure or cancer screening rates, and you can stratify them by race, ethnicity, language, or gender identifiers. You can stratify the data based on this kind of self-identified information, and that is one category of equity measurement. A different category of equity measurement is measures of social need and whether those social needs are being met. Examples include housing stability and food security because those factors are important contributors to health outcomes."
4. Incentivizing achievement of equity
Financial incentives will be required to promote health equity work, he says. "In the long run, the ability of our systems to maintain their focus on equity and to continue to prioritize equity will require financial alignment; so that when we do things that improve equity, we are getting supported to continue that work. Organizations that are working with populations that experience more inequity should be supported to do equity work."
There will likely be a progression of incentives for health equity work, Mate says. "In the early days of equity work, the incentives are going to flow to better data collection and better measurement. That is a worthy goal because without an unambiguous understanding of where the inequities are and what is creating the most pernicious effects on a population, we are going to struggle to design good interventions. Eventually, the incentives will start to flow to organizations that are working with populations that are under-resourced and experiencing inequity. Then the next step will be having incentives flow to organizations that are taking important steps toward remediating or closing inequity gaps."
Global death toll from antibiotic resistant infections expected to accelerate through 2050.
The antibiotics pipeline has dried up and the companies that make the bulk of antibiotics are facing multiple challenges, a new report from the Biotechnology Innovation Organization (BIO) says.
There is an ongoing struggle between antibiotic resistant infections—superbugs such as Methicillin-resistant Staphylococcus aureus—and the makers of antibiotics. The global death toll is alarming, with more than 1.2 million people dying annually, and estimated mortality expected to reach 10 million people annually by 2050.
There is an urgent need to increase development of antibacterial medications, the BIO report says. "Despite the availability of 106 unique direct-acting antibacterial therapeutic entities on the market in the U.S. and 28 unique antibacterials outside the U.S., there remains a need for alternatives to currently available drugs that will circumvent bacterial resistance to current medicines. More than 82% of all antibiotic approvals occurred prior to the year 2000. The majority of the drugs remaining on the market are facing eventual loss in efficacy due to resistance developed by bacterial strains encountering these treatments in the population."
Small and start-up biotechnology companies dominate the development of new antibiotics, with 80% of potential new antibiotics in the development pipeline coming from these companies, the BIO report says. Funding for antibiotic development is insufficient, according to the report.
"Funding has been sparse for these antibacterial developers, and the ecosystem is fragile and failing. Over the last decade, antibacterial start-ups raised a total of only $2.3 billion in both venture capital and [initial public offerings], well below other areas in medicine and not enough to compensate for the need of a broad ecosystem and diverse pipeline of candidates. By comparison, over this same decade oncology companies raised $38 billion in venture capital and IPOs, more than 16-fold over the amount invested in antibacterials," the report says.
A decrease in the number of clinical trial initiations shows that small and large biotechnology companies are withdrawing from the antibiotics market, the report says. "Phase I trial initiations declined 46% when compared to the previous five-year periods (2011-2015 vs. 2016-2020). Phase II and III trial initiations declined 33%. The same percentage drop was seen when segmenting by company size, suggesting the wane in large company interest is shared by small companies and their investors. This is particularly concerning as large companies have traditionally been a critical part of the antibiotic ecosystem, with their extensive manufacturing infrastructure and global distribution capacity."
Three dynamics are driving investors away from the antibiotics market, the report says. "First, large companies have been exiting from the space for some time, with very few listed as co-sponsors of small company pipeline candidates. Without a vested interest from large biopharmaceutical companies, licensing deals and M&A dry up, souring the incentive for early-stage investors such as venture capitalists. Second, the majority of recent examples of 'successful' biotechs (those that have raised venture capital, obtained funding through public offerings, … and achieved FDA marketing approval) have been commercial failures. Investors point to these recent stories of antibacterial company bankruptcies and acquisitions at fire sale valuations as evidence to avoid investment in this segment of medicine. The third factor is the lack of effective policy and regulatory solutions to address the unique characteristics of the antimicrobial marketplace."
The economics behind the utilization of new antibiotics are driving large biotechnology companies out of the antibacterial market and financially undermining small companies, the report says. "First, new antimicrobials will primarily be used as 'last line' therapies for use in hospitals when other options are ineffective. These products are short duration therapies and will experience slow uptake since they are usually used sparingly to preserve effectiveness. Novel antimicrobials are also generally undervalued by reimbursement systems relative to the benefits they bring society. Finally, hospital bundled-payment reimbursement mechanisms can discourage use of novel antibacterials, even when they are the most appropriate treatment for a patient, contributing not only to market challenges but also patient access to novel products. Taken together, these challenges create a market with little to no return on investment for antibacterial medicines."
Health system and hospital executives say workforce challenges and financial strains are unsustainable without government support.
The delta and omicron coronavirus variant surges have pushed health systems and hospitals to a breaking point, a trio of healthcare provider executives said yesterday during a webcast hosted by the American Hospital Association.
The coronavirus pandemic is the biggest public health crisis in generations. The pandemic has strained health systems and hospitals on several fronts, including staffing, supply chain, and finances. In 2020 and 2021, health systems and hospitals received financial assistance from the federal government, but that assistance is dwindling.
Health systems and hospitals need a new infusion of federal support to avoid calamity, Craig Cordola, executive vice president and chief operating officer of St. Louis-based Ascension, said during yesterday's webcast. Ascension operates 142 hospitals in 19 states and the District of Columbia.
"The healthcare system needs additional support now to address the immediate impacts of the exponential new costs incurred because of delta and omicron, which hit hard in the second year of the pandemic. We do appreciate that Congress recognized the need early in the pandemic to provide financial support to hospitals and health systems, but most of that support was provided before the delta and omicron surges, which have placed unprecedented strain on our caregivers," he said.
Workforce challenges
The omicron surge has created severe workforce problems at health systems and hospitals, Cordola and the other healthcare provider executives said.
"We have had a record number of associates who were on paid furlough due to COVID infection and exposure. This has increased our need for contract staffing and created unprecedented spikes in our labor costs, compounding the already difficult position we have been in regarding the need for additional staff and caregivers across our health ministry. The cost impact related to the additional contract staff alone has been substantial. In a typical year, we might spend $100 million on contract labor. We are now spending that much per month," Cordola said.
The pandemic has taken a heavy toll on healthcare workers, said Lori Morgan, CEO of 619-bed Huntington Hospital in Pasadena, California.
"The care that our staff has provided has been physically, mentally, and emotionally taxing. The pandemic has been an unending marathon of illness and death that none of our caregivers had previously experienced. In addition to the burdens of their work, our staff have all of the same pressures of COVID infection, death, and family and societal responsibilities at home. Yet, they get up every day and come to work to care for those who need us, and the need has been great. Our teams are exhausted, and they are burned out. The toll that this has taken has led to many early retirements and—worse of all—those within the first few years of training have started to leave the profession. Our retirements have increased more than 20% over usual levels and those leaving healthcare in the first few years post-training has become surprisingly common," she said.
Workforce shortages are widespread, said LaRay Brown, president and CEO of One Brooklyn Health System, which features three hospitals and two large nursing homes in Brooklyn, New York. "The workforce shortage is not just nurses. It is respiratory therapists. It is lab technicians. It is phlebotomists. Many people are leaving the healthcare workforce. Many folks have accelerated their retirement plans. Even more concerning, many of our staff are deciding to work for agencies, where they can make their annual salary in three months, even if they have to travel."
Workforce shortages are reaching epic proportions, Morgan said. "The long-term availability of well-trained providers needed for future care is tenuous. Prior to 2019, there was already concern over impending staffing shortages, with the aging of baby-boomers, but there is now a looming disaster."
Financial difficulties
For health systems and hospitals, the economics of the ongoing pandemic have been devastating.
"In addition to increased labor needs as well as labor costs, we are experiencing significant increases in costs due to supply constraints and medications. During COVID, we have had to do several things that were new for us. We have provided community COVID testing, community vaccine clinics, alternate care sites, dedicated COVID units, and employee and visitor screening stations in addition to our normal standards of care. In the face of these increased costs and responsibilities, the high volumes of COVID patients necessitated that we either stop or severely curtail elective procedures and care. This means in the face of increasing expenses it was necessary to limit our revenue-generating capability," Morgan said.
The financial strains of the pandemic have worsened over time, she said. "As just one example, our inpatient surgeries were 26% and 23% below 2019 levels in 2020 and 2021, respectively. This combination of increased care costs and decreased revenue-generating capacity is not sustainable. Each surge with COVID variants has made this problem worse."
One Brooklyn Health System is staring into a financial abyss, Brown said.
"Our hospitals are safety net hospitals. More than 45% of our patients rely upon Medicaid, and another 25% rely upon Medicare. Therefore, our financial circumstances were not stable before COVID, and they are now at crisis levels. We have had to suspend elective procedures. We have had to conduct vaccination efforts—we have given more than 150,000 vaccines for individuals in our communities. We have had to put screening into place for not only our staff but also visitors and vendors. We have put in place infusion services for monoclonal antibody treatment. We have done all of those things to be responsive to our communities and to our staff," she said.
Plea for financial support
The federal government should resume direct financial assistance for health systems and hospitals as well as stop Medicare sequester cuts scheduled to begin in April, the healthcare provider executives said.
Cordola said other financial assistance is also necessary. "We do believe the government does have a role to play. They are already sizeable payers for us, but the challenges that health systems face are bigger than what we can tackle on our own. It is going to require some short-term and long-term solutions. In the longer term, we look to operational policy solutions that will bolster our existing workforce and grow their ranks. We urge policy makers to dedicate additional resources to surge capacity support from both federal and state sources. We need nursing education, including more dollars for faculty, loan repayment programs, and direct scholarships."
The coronavirus pandemic has prompted the health system to address healthcare worker resiliency and mental health.
Ochsner Health has been awarded a $2.9 million federal grant to help support the New Orleans-based health system's multifaceted workforce well-being and retention efforts.
At health systems, hospitals, and physician practices, workforce issues have become paramount during the coronavirus pandemic. Healthcare worker burnout has risen to alarming proportions during the pandemic, and healthcare workforce shortages are being reported nationwide.
Ochsner Health's workforce grant was awarded by the U.S. Department of Health and Human Services through the Health Resources and Services Administration.
"We are trying to be more nuanced in how we reach our healthcare workers. No single initiative is going to be a cure-all for the future—we are in a time when we must experiment and measure. If some things are not working, we will eliminate them. If other things are working, we will scale them. That approach is part of what the workforce grant will allow us to do. This support will afford us an opportunity to implement many initiatives," says Nigel Girgrah, MD, chief wellness officer at Ochsner Health.
The workforce grant will help support seven programs over the next three years.
Johnson & Johnson resilience training: "A company that probably has the best track record of workforce well-being is Johnson & Johnson. They have what is called a Human Performance Institute, and we have worked with them to create a four-hour virtual resilience course. We started this course last year; and over the long term, we will have to see whether the course makes a quantifiable difference in terms of promoting resilience," he said.
Personal Leadership Program: PLP will support senior leaders, physicians, and advanced practice providers in their personal and professional wellness and growth. "Senior leaders are pulled off site for four days for intense workshops to help them better manage themselves. The idea is you cannot manage or lead others until you are effectively leading yourself. With help from the workforce grant, we will be scaling this program over the next two years," Girgrah says.
Penn Resilience Program (PRP) and PERMA™ Workshops: PRP and PERMA™ Workshops are evidence-based training programs that build resilience, well-being, and optimism. "The PERMA™ Workshops are based on the positive psychology theories of Martin Seligman, and we are going to work with the University of Pennsylvania to fashion a similar workshop that we can offer to our frontline healthcare workers," he says.
Institute for Healthcare Improvement (IHI) coaching: Nurses at eight Ochsner Health hospitals will participate in a 12-month coaching program followed by six months of reflection and feedback.
Cabana by Even Health: Cabana is a virtual program that connects healthcare professionals from across the county to discuss shared issues and areas for self-care and self-improvement. "We were the first health system to pilot Cabana. It is group therapy led by a licensed healthcare professional. The unique thing about Cabana is it is anonymous. You create an avatar of yourself. You can disguise your voice," Girgrah says.
Schwartz Rounds: This program offers healthcare workers a regularly scheduled time to openly and honestly discuss the social and emotional issues they face in caring for patients and families. "Healthcare workers have an opportunity to gather and discuss a specific case that has a high degree of emotional labor. They can work through their feelings as they talk about those sorts of cases," he says.
Employee Assistance Program: Ochsner Health offers a traditional EAP that can help employees with common personal problems, such as family or marriage conflicts, job stress, financial worries, substance abuse, depression, loss of a loved one, and parenting concerns.
Other well-being initiatives
Ochsner Health intensified its efforts to address burnout and employee retention in 2017, Girgrah says.
"We formed a wellbeing taskforce in 2017 and started to measure the state of our workforce and put together some recommendations. Originally, the focus on burnout and retention was aimed at practice efficiency and developing our leaders because we felt those were the two biggest drivers of professional fulfillment, especially among our physicians and advanced practice providers. We built some momentum in those areas, then the pandemic hit, which blew things up a bit," he says.
The pandemic required a focus on resilience, Girgrah says. "As an organization and the office that I lead—the Office of Professional Well-Being—we had to move quickly to crisis support. As we emerged from the first coronavirus surge, our efforts became all about resilience. I always knew that resilience was important, but I did not want to lead with that pre-pandemic. I did not want our workforce to feel that the organization was saying, 'If you just eat better and do some yoga, everything is going to be OK.' Clearly, as we emerged from the first surge, there was an appetite for resilience offerings. So, we had to experiment with different ways to reach our workforce. We developed a virtual course on resilience and some YouTube videos, which were adopted well, with high net promoter scores."
The pandemic also prompted the health system to step up efforts to address mental health among healthcare workers, he says. "As we continued into the pandemic, it became increasingly obvious that in addition to resilience we had to think long and hard about the mental health of our workforce. Our grant submission to the Health Resources and Services Administration reflects our interest in improving the resiliency of our workforce and encouraging a culture where mental health is promoted."
Addressing the stigma of behavioral health services among healthcare workers was a top priority, and Girgrah took a personal step to tackle stigma.
"In July and August 2020, I recognized in myself that I was languishing and struggling. I eventually reached out for help, and it made a big difference. I send out a quarterly chief wellness officer message that had historically been quite sterile. It was a report out. But in the summer of 2020, I shared information about myself and my own journey. Then I talked more broadly about mental health for healthcare workers. That was easily the most open executive communication at that point of the pandemic, with high engagement rates. People replied that they were going to seek help. That message helped with de-stigmatizing mental health services," he says.
In addition to the EAP, Cabana program, and Schwartz Rounds, which all play a role in addressing healthcare worker mental health needs, Ochsner Health has worked with a company called Happy. "It is basically an army of 2,500 empathetic support givers armed with a phone number or an app to proactively reach out to our frontline healthcare workers and check in on them. They can also arrange follow-up conversations. They can help address the epidemic of loneliness. Happy is the kind of on-demand offering that our healthcare workers have been requesting," Girgrah says.
To address burnout among healthcare providers, Ochsner Health has taken several steps to ease burdens associated with the electronic health record, he says. "We have been easing the strains of the EHR. One of the areas that has been the bane of a physician's existence is the EHR in-basket, where a physician can spend 45 to 90 minutes a day returning messages and doing various tasks in the EHR. We have launched initiatives such as a pharmacy refill clinic, which can take messages related to refilling medications away from our primary care physicians to give time back to the provider."
The health system has also been trying to limit "pajama time" in the EHR, Girgrah says. "We produce reports of our physicians and advanced practice providers who are struggling the most with pajama time—going home then logging back into the EHR to complete work. We can track the areas where providers are struggling the most such as doing notes or returning messages to patients from home. Then we can give them customizable help within the EHR to decrease the pajama time."
Health systems and hospitals can boost their behavioral health programs by working with an external partner.
Having a shared vision is a key to success in behavioral health acute care joint partnerships, a pair of healthcare executives say.
Access to behavioral health services is a primary challenge for health systems and hospitals. Behavioral health acute care joint partnerships are a strategy to improve access to services.
Last year, Ochsner LSU Health Shreveport and Oceans Healthcare opened Louisiana Behavioral Health, a new 89-bed behavioral health hospital in Shreveport, as a behavioral health acute care joint partnership. In September 2021, Louisiana Behavioral Health established a 30-bed unit for behavioral health patients who also have a COVID-19 diagnosis.
A shared vision is critical for these kinds of partnerships, according to David Callecod, MBA, interim CEO of Ochsner LSU, and Stuart Archer, MBA, CEO of Oceans Healthcare.
"The most successful of these joint partnerships start with a shared vision. Behavioral health is a huge issue for many of the health systems and hospitals that we work with. With Ochsner LSU, we have a shared vision of the struggles and the necessity to address behavioral health patients and their needs at a level and in a fashion that all the other service lines have gotten, in terms of attention and resources," Archer says.
"A joint partnership starts with a shared vision of what we want to accomplish. In behavioral health, many of the patients, their families, and the communities that we serve do not have behavioral health resources. Many times, we have made it tough on patients and families to navigate behavioral health. Alignment from a goal perspective and a care perspective is the key thing that we look at when we think about these partnerships and their ability to be successful," Callecod says.
Foundation of Ochsner LSU and Oceans Healthcare joint partnership
From Ochsner LSU's perspective, Oceans Healthcare was an ideal partner to help open a standalone behavioral health hospital, Callecod says. "From a health system standpoint, the most important factor is to go through a deliberate process of looking at the companies that can meet your needs. Who are the organizations that have similar values and similar focuses on excellence and providing a great patient experience? It is also important to have a partner that is familiar with your market and the state in which you are located. Certainly, in our case, Oceans Healthcare being familiar with the unique challenges that the state of Louisiana represents was very important to us."
Plano, Texas-based Oceans Healthcare, which is one of the leading providers of behavioral health services in Louisiana, viewed Ochsner LSU as an attractive partner, Archer says. "From our perspective, the right partner is a nonprofit health system and mission-led organization with a commitment to outcomes and quality, not only in the traditional service lines, but also believing that behavioral health patients deserve the same resources, care, and attention. One of the biggest things that drew us to the Ochsner LSU organization is the commitment that they have to the communities they serve and how they view the needs of vulnerable populations."
Ochsner LSU needed a partner to boost the health system's behavioral health services, Callecod says. "At Ochsner LSU, we faced a unique challenge in that we had a 37-bed behavioral health unit that was based on the 10th floor of our Level 1 trauma center. So, our ability to grow that unit and get it to where it was state-of-the-art and best practice was impossible in the existing footprint. In doing this partnership and creating a free-standing facility, we were able to recapture those beds and use them for the acute care services that we needed to expand at the trauma center."
Opening Louisiana Behavioral Health has increased both the inpatient and outpatient capabilities of Ochsner LSU, Archer says. "These partnerships tend to focus on the inpatient beds—that is traditionally where some of our sickest patients receive their initial care after they come into an emergency room or another setting. Our partnership with Ochsner LSU has also expanded outpatient services dramatically. In the long term, expanding outpatient services is as important as anything that we do on the inpatient side. Through our partnership, we have added intensive outpatient services working to address the chronic mental health issues of our patients. Those outpatient services are only going to grow over time."
Decreasing emergency room utilization
Creating a standalone behavioral health hospital through a joint partnership will reduce emergency room utilization by behavioral health patients in Louisiana, Archer says.
"Over time, one of the biggest things that a joint partnership will do is normalize care. A family that needs behavioral health care can [now] directly access the behavioral health hospital. Law enforcement will see that they can bring a patient to another setting than the ER. Many of our patients are chronically mentally ill. Once a patient is enrolled in high quality outpatient therapy and has access to a prescriber, we have shown that we can reduce readmission to the ER even among the highest acuity patients by 50% to 75%. The inpatient care with access to outpatient therapy wrapping around the patient is a one-two punch that helps to reduce ER utilization," he says.
Shared governance
A key to success for the Louisiana Behavioral Health joint partnership between Ochsner LSU and Oceans Healthcare is shared governance, Archer says.
"One of the best practices that we have in our partnership is a shared governance strategy. We make decisions together—not just financially but also clinically. We strive to be integrated in the approach that we take. For example, we are on the same electronic medical record, so patients have a seamless experience. We can extract data and experiences from previous times they have been at Ochsner LSU facilities. With our governance structure, it is a true partnership. We have a shared governance board, with members from both partners. We make decisions jointly, whether it be leadership decisions, care decisions, or programs that we want to roll out. We have a shared budget that we work together on, including capital expenditures," he says.
To the extent that quality work has been de-emphasized during the pandemic, patient outcomes have suffered, National Association for Healthcare Quality says.
The coronavirus pandemic has illustrated the value of quality professionals and their work in healthcare, according to a recent whitepaper from the National Association for Healthcare Quality (NAHQ).
The pandemic has posed some of the greatest challenges to the healthcare sector in generations, and quality professionals have played key roles such as operating crisis command centers, activating telemedicine programs, and developing safety protocols for healthcare workers and patients.
From a quality and safety perspective, there are three primary lessons learned from the pandemic, according to the whitepaper.
1. "Routine efforts to advance quality initiatives are highly effective, and when we stop or deprioritize those initiatives, health outcomes suffer. Any healthcare leader who has ever questioned the value of routine quality and safety work should take this as the signal that this work matters. And when it is deprioritized, even for a good reason, ground is lost," the whitepaper says.
2. "Reinstating, sustaining and advancing quality and safety initiatives is the path toward progress in healthcare. A 'new normal' in healthcare appreciates that we must be dependent on sustainable systems, process and structure to ensure continuity in the face of known and unknown challenges. Performance and process improvement—and quality management—must be hardwired into the work, so that when a crisis occurs, the focus is not shifted away from quality and safety," the whitepaper says.
3. "Deploying quality professionals to solve many of the biggest challenges that healthcare leaders face will result in the biggest impact to advance healthcare leaders' priorities. Healthcare quality leaders and professionals are uniquely qualified to solve problems. Whether leading or sustaining run-the-business quality and safety initiatives or leading in a crisis, these leaders have the tools and competencies to bring order and deliver results," the whitepaper says.
It is important to maintain routine efforts to advance quality, even during a crisis such as the pandemic, Stephanie Mercado, executive director and CEO of NAHQ told HealthLeaders.
"The run-the-business efforts save lives. When we take our foot off of the gas on those efforts, we can see that patient outcomes suffer. We saw many of these efforts get sidelined during the pandemic—generally speaking, everybody's attention was shifted to focus on a single clinical condition. The result is that we lost ground—turning back the clock on five years of progress to improve quality and safety metrics. There is recent data that shows there were significant year-over-year increases from 2019 to 2020 in hospital-acquired infections," she said.
Hardwiring performance and process improvement (PPI) as well as quality management in healthcare ensures that quality and safety efforts continue when a crisis occurs, Mercado said.
"Hardwiring PPI and quality management means that we are always looking for what is going right in healthcare, and we are always looking for what is going wrong in healthcare. It also means that we are engaging stakeholders to review their work and do it better. It also means we are activating improvements through a system in ways that are constantly eliciting change management and sustainable improvement throughout the whole system. We do not do quality work because we all of a sudden have time to do quality work. We do it because quality has become the work. It is the way that we have learned to function, and it produces better quality and safety outcomes for patients at a lower cost," she said.
Quality professionals are equipped to solve many of the biggest challenges that healthcare leaders face, Mercado said.
"Quality professionals do their jobs well because they have the training, the tools, and a deep-seated commitment to improvement as a mindset. That is what makes them a valuable resource in solving challenges in healthcare. … People who pursue a career as a quality professional have improvement as a mindset—it is part of their DNA. Quality professionals have the tools and the methods to understand a problem and create a solution. Just like firefighters rushing into a burning building, quality professionals with the right training can jump into any challenge. For example, health equity and population health are solvable problems with quality tools, methods, and mindsets," she said.
System sustainability
It is essential to focus on system sustainability in healthcare, Mercado said. "It is important to focus on system sustainability because quality can't wait. Quality cannot be viewed as just another priority in a long list of efforts that need to be accomplished in healthcare. Sustainable systems are important so that we make healthcare better for the patients and make healthcare better for the workforce."
System sustainability helps keep patients safe, she said. "When it comes to patients, we have lost ground during the pandemic on healthcare-associated infections, and it is important to focus on sustainability because patients do not expect to go into a healthcare environment after the pandemic and feel less safe getting care. But, in fact, they are less safe."
System sustainability also positions the healthcare workforce for success, Mercado said. "When we think about the healthcare workforce, sustainable systems will also make healthcare better for the workforce. … If we are going to bring back purpose for the workforce and activate the calling part of their career choice and build a strong culture, then we are going to have to put healthcare workers in situations where they have the best possibility for success."
System sustainability boosts healthcare worker morale, she said. "People in healthcare are seeing the same medical errors occur over and over again. It is depressing, and it causes burnout. So, a focus on training the workforce on how to help solve these problems before they happen and avoid the harm to patients is an important step in solving the culture and workforce problems that we are facing now. Sustainable systems are designed for the best success and for the types of experiences that elicit joy rather than sadness."
