Researchers examined Yelp online reviews of 100 randomly selected acute care hospitals in the United States.
Based on an analysis of Yelp online reviews, acts of discrimination in the hospital setting can be categorized in six recurring patterns, including acts of commission, stereotyping, and intimidation, a recently published research article found.
Earlier research has shown that discrimination based on minority patients' race, sex, gender, sexual orientation, age, or disability generates worse health outcomes. The co-authors of the recently published research article found that Yelp online reviews provide insight into discrimination in the hospital setting that cannot be gleaned from traditional healthcare performance measures such as Hospital Compare.
The study, which was published by JAMA Network Open, is based on Yelp online reviews made from January 2011 to December 2020 of 100 randomly selected acute care hospitals in the United States.
The reviews were filtered with 31 keywords drawn from the Everyday Discrimination Scale such as race, racist, slur, threat, hate, and bias. A total of more than 10,000 reviews were collected and nearly 3,000 reviews were determined to be potentially related to discrimination. The research team identified 182 reviews that described at least one act of discrimination.
The study features several key data points.
53 reviews (29.1%) were categorized as institutional racism
72 reviews (39.6%) cited individual actors as sources of discrimination such as security guards, nurses, and physicians
89 reviews (48.9%) described acts of discrimination that occurred in clinical settings
25 reviews (13.7%) described acts of discrimination that occurred in nonclinical spaces such as lobbies
66 reviews (36.3%) included acts of discrimination by patients directed at healthcare workers
The researchers found that the acts of discrimination could be categorized in six patterns.
1. Acts of commission: "Instances in which actors showed their biases through purposeful acts of physical or verbal harassment. In extreme examples, a few reviews mentioned instances when actors violated patients' consent in carrying out abuses."
2. Acts of omission: "Acts of omission described instances in which medical care or basic needs, such as food or assistance with activities of daily living, were neglected or delayed by hospital staff. … Acts of omission frequently manifested around discussions of pain. Consumers described how a lack of attention to pain ultimately led to a missed or delayed diagnosis of an acute medical issue that was only discovered after seeking second or third opinions."
3. Dehumanizing: "Dehumanizing manifestations portrayed the consumer feeling dehumanized or devalued compared with others because of a particular personal attribute. For example, one consumer wrote, 'Why wasn't I greeted with enthusiasm, let alone greeted at all? Was it because of the color of my skin? Am I less of a person? Or was it because of age discrimination? In all my time here in the healthcare systems in [city], I’ve never once felt this invalidated.' Most frequently, consumers reported feeling dehumanized because of being ignored in a variety of settings."
4. Stereotyping: "Consumers often reported on racial and gender stereotypes that perpetuated poor health care treatment, including dismissal of symptoms and pain severity. In these scenarios, the patient came to the practitioner seeking treatment, only for their symptoms to be overlooked because of the practitioners’ prejudices and biases. These experiences occurred often among self-identified Black people and women."
5. Intimidation: "Intimidation manifested as verbal and physical tactics used by health care workers, such as threats of using specific medical protocols as punishments or intrusions into consumers' personal space, to bully and harass consumers during health care visits. Consumers reported being frightened by individual or institutional discrimination. Frequently, acts of intimidation occurred during psychiatric visits and toward self-identified women or older adults."
6. Unprofessionalism: "Discrimination described as unprofessional manifested as disrespectful or unprofessional behaviors, often including terms such as mean, rude, and condescending. In addition, several consumers noted that unprofessional individuals shared personal thoughts and opinions that expressed bias, judgment, microaggression, and macroaggression. In such instances, respondents believed that perpetrators’ negative attitude and treatment was caused by bias and in violation of the standard of care."
Interpreting the data
Institutional discrimination was present when an entire hospital or clinic was described as discriminatory, the lead author of the study told HealthLeaders.
"The reviews typically cited the hospital as the source of discrimination in these cases. A specific example was a consumer who said, 'Worst hospital ever. I went to the emergency room with my daughter, who had a non-stop running nose. Their customer service was horrible. They treated people not nice, like they were racists. I am Asian.' In that instance, the consumer cited the entire hospital. There was not just a specific nurse, receptionist, security officer, or physician. They associated the entire institution as the source of racism," said Jason Tong, MD, general surgery resident and national clinician scholar fellow, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Categorizing discrimination into patterns is helpful in addressing discrimination, he said.
"Discrimination is known as a difficult concept to study and target. Oftentimes, discrimination is thought of as a very experiential concept. However, by helping to organize discrimination into a taxonomy of recurring patterns, we can think of more effective ways to approach it. For example, as we highlight in our article, acts of omission have been used to describe a variety of patient safety issues such as medication administration errors. Importantly, people have already developed tools and approaches to types of acts of omission. So, by now thinking of acts of discrimination as another type of act of omission, we can apply pre-existing tools to address and study discrimination."
The research team deemed discrimination to be a form of patient harm, Tong said. "It goes back to the recurring patterns that we identified. The way that we did our study is we first went through many reviews, then the patterns emerged out of the data. At first, when we thought about it, a lot of the patterns seemed very familiar, and we went into the literature and found that all six of the recurring patterns had been previously described within the context of patient harm and patient safety, which is why we made the link to patient harm."
About $260 million of annual excess healthcare expenditures from primary care physician turnover is linked to physician burnout.
Turnover of primary care physicians (PCPs) causes about $979 million in excess healthcare expenditures for public and private payers each year, a recently published research article found.
Care continuity between PCPs and their patients has been linked to better outcomes, including diagnostic accuracy, fewer emergency room visits, and lower hospital admissions, the co-authors of the research article wrote. Continuity of care has also been associated with lower costs, they wrote.
The research article, which was published by Mayo Clinic Proceedings, found that about $260 million of annual excess healthcare expenditures from PCP turnover is caused by PCP burnout. The cost of PCP turnover linked to burnout should be a powerful motivator to improve PCP well-being, the lead author of the study said in a prepared statement.
"Turnover of primary care physicians is costly to public and private payers, yet there is an opportunity to decrease unnecessary healthcare expenditures by reducing burnout-related turnover. Physician burnout is preventable and payers, healthcare organizations, and others have a vested interest in making meaningful changes to reduce physician burnout," said Christine Sinsky, MD, lead author of the study and vice president of professional satisfaction at the American Medical Association.
The methodology of the study has several essential points and conservative estimates.
The average patient panel for PCPs was set at 1,000 individuals
The average number of Medicare beneficiaries in a PCP patient panel was set at 196 and the average number of non-Medicare beneficiaries was set at 804
Data from a survey of more than 5,000 physicians was used to estimate the prevalence of burnout and intention to leave a practice within two years
Based on earlier research, it was estimated that Medicare patients generate $189 in excess healthcare expenditures in the first year after turnover of a PCP
It was estimated that non-Medicare patients generate $61 in excess healthcare expenditures in the first year after turnover of a PCP
Based on the most conservative estimate in the literature, it was estimated that 25% of physicians intending to leave their practice in the next two years would actually leave
The study generated five primary data points.
In the first year after leaving practice, the excess healthcare expenditure per PCP was estimated at $86,336
11,339 PCPs were estimated to leave practice annually
Given the excess healthcare expenditure per PCP and the estimated number of PCPs leaving practice annually, annual excess healthcare expenditure associated with PCP turnover was estimated at about $979 million
Annual PCP turnover attributable to burnout was estimated at 3,006 physicians
Given the excess healthcare expenditure per PCP and the estimated number of PCPs leaving practice annually due to burnout, annual excess healthcare expenditure associated with burnout-related PCP turnover was estimated at about $260 million
"In this analysis, we estimate that each instance of a PCP's leaving current practice results in $86,336 in excess healthcare expenditures during the following year. We estimate that PCP turnover results in $979 million in annual excess healthcare costs across Medicare and non-Medicare patients, of which $260 million (27%) is attributable to burnout. Physician burnout is therefore costly to public and private payers, who bear most of these excess healthcare costs," the study's co-authors wrote.
Brian Tiffany, MD, PhD, says ensuring physicians feel that they have a voice in a healthcare organization is the crucial element of physician engagement.
The new chief physician executive of the Dignity Health Southwest Division has developed an executive leadership style that is heavily influenced by his background in emergency medicine.
Brian Tiffany, MD, PhD, has succeeded Keith Frey, MD, in the chief physician executive role. Frey retired in January.
Tiffany has worked at Dignity Health for two decades. Prior to moving into his new role, he served as chief medical officer at Dignity Health's Arizona General Hospital Phoenix. An emergency medicine physician since 1990, Tiffany joined Dignity Health in 2003 as a member of the medical staff at Dignity Health Chandler Regional and Mercy Gilbert Medical Centers.
The Dignity Health Southwest Division includes six hospitals in the Phoenix area, three hospitals in Nevada, and 14 free-standing emergency departments.
Tiffany recently spoke with HealthLeaders about a range of topics, including his new role, promoting clinical excellence, physician engagement, and the coronavirus pandemic. The following transcript has been edited for clarity and brevity.
HealthLeaders: What are the primary elements of your leadership style?
Brian Tiffany: My leadership style grew out of being an emergency physician. That is who I am—I still think of myself as an ER doctor. I still practice, although not at the level that I used to practice.
An ER is a very close-knit team. There is no captain of the ship in the ER—there is very little of a power gap in the ER. An experienced ER nurse will save your bacon as an ER doctor many times through the course of your career. When a nurse says, 'I need you in Room 4,' you do not ask why you are needed in Room 4, you go to Room 4.
You listen to suggestions. You communicate as a team. You take care of each other as a team. I think about leadership in those terms. You know your people. You are present. You are not the boss—you are most responsible for making sure we get to where we need to go, but the whole team must be involved. No matter how small the ER, no ER physician knows everything that is happening in a given moment. But collectively, we know exactly what is going on. That applies all the way up the line to the division-level leadership. No single person can run everything—you must have a team around you.
HL: How do you envision serving as a chief physician executive?
Tiffany: The most important thing is to work effectively together as a division to deliver high-quality healthcare. We have great diversity in our division, from academic teaching facilities to community hospitals, and a significant network of urgent care clinics. What I am here to do is to help us work together as a division—particularly in the physician realm—in the delivery of care to patients at the appropriate level of service. We want to provide care to patients as close to their home as possible at the right level of care and the right site.
HL: What is the biggest challenge you foresee in your new role?
Tiffany: The diversity of facilities is part of the challenge—bringing academic physician groups, employed physician groups, and independent practices together to work as a team. It takes a lot of interpersonal relationship building. It takes team building.
HL: How do you promote clinical excellence?
Tiffany: A big component of clinical excellence is reducing variation in how we deliver care. You need to identify best practices, then adapt them to local conditions—each hospital has its own set of local challenges and its own community—to provide better care.
Over the past six years, the division has been on a journey to achieve high reliability. Some of our hospitals have already gone through that process. A major component of high reliability organizations is teamwork. It's reducing the power gap between physicians and members of the staff. It's helping everyone to work together as a team. Every member of a team should feel the freedom to speak up, ask questions, and stop the line if they perceive that there is a safety concern. That is a way of reducing errors and delivering better care.
HL: Give two examples of your division's approach to high reliability.
Tiffany: Stop the line is a good example. A housekeeper who sees something that does not look right should not feel intimidated about speaking up and saying, 'Is this OK? Should this be happening this way?' No one can penalize someone for bringing up a concern—that kind of questioning should be welcomed at all levels of the organization.
Another big component of high reliability is checks and balances. When a physician writes an order, that order just does not get executed blindly. The order is seen at several levels—the nurse sees that order, the pharmacist sees that order, and we use an electronic health record and there is error checking that occurs in the EHR. Those checks and balances make it very difficult for any error to reach a patient.
HL: How do you build strong physician engagement?
Tiffany: Physicians need to feel heard—that is the biggest component of physician engagement. We conduct physician surveys here to gauge how they feel about the organization and how they like working here. The Number One thing for physicians is to make sure they have a voice—we do a good job at that, but we want to do a better job at that.
For me, in this role, I want physicians to know that I have an open door—that I will listen to their concerns and the organization is interested in their concerns. As in any leadership role, it is crucial that you hear someone's concerns, but it does not necessarily mean that you should do what they think should happen. However, they should understand why you are doing what you are doing. Whether they agree with you or not, they should know that their voice was heard.
As an organization, another major component of physician engagement is that a physician should have absolute confidence that their patients are going to receive excellent care. That goes far beyond the physician—it is the care that is being delivered when they are not standing at the bedside. The organization must perform reliably and with excellence.
HL: What lessons did you learn from being a member of the Dignity Health Southwest Division COVID-19 Incident Command?
Tiffany: It was a lesson in the value of talking with each other. In the Phoenix area, we were six independent hospitals working together. This pandemic has drawn us together in many ways. We must share resources. We must load balance between our institutions. The pandemic got all of our leaders to be more than acquaintances—they got to know each other well and work in the trenches together well.
Another great lesson from the Incident Command is the value of cooperation and working closely with other healthcare entities. There is a CMO group that is constantly talking with Banner Health, HonorHealth, Valleywise Health, and hospitals all over the state of Arizona. We have regular phone calls, so these healthcare organizations can know what is going on in multiple areas. We move resources around as needed. We go as a unified front to the state when we need something.
The omicron coronavirus variant forces hospitals to endure lower revenue and higher expenses.
The omicron coronavirus variant wreaked havoc on U.S. hospitals in January, according to a new National Hospital Flash Report from Kaufman, Hall & Associates LLC.
The omicron variant has fueled the latest surge in the coronavirus pandemic. The omicron variant was first detected in the United States on Dec. 1, 2021, and by Jan. 15, 2022, the variant accounted for 99.5% of sequenced specimens in the country, according to the Centers for Disease Control and Prevention. The highest daily 7-day moving average of cases during the pandemic was reported during the week of Jan. 9, 2022, at 798,976 daily cases, the CDC says.
The omicron variant had a damaging impact on hospital finances in January, the new National Hospital Flash Report says. "Hospital margins declined dramatically as many providers temporarily halted nonurgent procedures, the numbers of inpatients requiring longer hospital stays rose, and expenses continued to climb due to widespread staffing and supply chain issues," the report says.
The report is based on data collected from more than 900 hospitals. The report features several key data points.
The median Kaufman Hall Operating Margin Index for hospitals in January was -3.68%, without Coronavirus Aid, Relief, and Economic Security Act funding. With CARES funding, the median operating margin index was -3.3%.
The median change in operating margin dropped 71.3% from December to January, not including CARES funding. The median change in operating margin was down 23.7% compared to January 2021.
The omicron surge decreased outpatient care volume as hospitals and patients delayed nonurgent procedures to avoid spreading the virus and COVID-19 hospital admissions spiked. From December to January, operating room minutes fell 15.7%. Compared to before the pandemic in January 2020, operating room minutes were down 20.4% in January.
In January, there was an increase in severely ill patients requiring longer hospital stays. From December to January, average length of stay rose 8.6%. Compared to January 2021, average length of stay rose 4.9%.
From December to January, outpatient revenue fell 7.5%, which drove a 4.7% month-over-month decline in gross operating revenue, without CARES funding. Gross operating revenue declined despite a 2.7% rise in inpatient revenue from December to January.
Wage pressure associated with workforce shortages as well as global supply chain problems drove hospital expenses higher. From December to January, total expense per adjusted discharge increased 11.6%, with labor expense per adjusted discharge increasing 14.6%. From December to January, non-labor expense per adjusted discharge increased 7.8%.
Expenses were up precipitously compared to pre-pandemic levels. Compared to January 2020, total expense per adjusted discharge rose 43.5%, labor expense per adjusted discharge rose 57%, and non-labor expense per adjusted discharge rose 35.5%.
"The first month of 2022 was devastating for hospitals and health systems nationwide as they were hit full force by the omicron tidal wave. COVID-19 cases and hospitalizations peaked at record levels in January due to rapid spread of the highly contagious variant," the report says.
Gerald Harmon, MD, says the United States has endured a twin pandemic—the health effects of COVID-19 and an erosion of trust in healthcare experts.
The president of the American Medical Association delivered a national address today marking the end of the second year of the coronavirus pandemic.
The pandemic has been the gravest public health emergency in generations. As of today, the pandemic has claimed 5,941,607 lives globally and 966,736 lives in the United States, according to worldometer.
"This month marks the two-year anniversary of the first known death to COVID-19 in the United States and there isn't a single person I know who isn't worn out, frustrated, or just physically exhausted. We've experienced trauma, lockdowns, economic difficulties, and at least five distinct viral surges," AMA President Gerald Harmon, MD, said today in an address delivered via livestream from the National Press Club in Washington, DC.
The pandemic will have a lasting impact on the country, he said. "It's my opinion, two years into this tragedy, that our nation is suffering a type of battle fatigue from our long fight with COVID, and the full impact of this pandemic on our national psyche may not be known until long after this difficult period ends."
Harmon said the nation has endured a twin pandemic—the ongoing struggle with the health effects of COVID-19 and an erosion in trust.
"COVID-19 will be with us for the foreseeable future, and we must understand what that means and make every effort to protect the most vulnerable among us. That means becoming fully vaccinated against the virus and receiving booster shots when eligible. And it means vaccinating our children, when they are eligible. I encourage anyone with questions to talk to their doctor or another trusted health professional about the safety and efficacy of COVID-19 vaccines," he said.
The erosion of trust in health professionals is nearly as damaging as the pandemic itself, Harmon said.
"Sadly, COVID-19 isn't the only pandemic we are fighting in America. The other pandemic is a profound loss of trust in the advice of experts, including doctors and scientists, to help us make sense of what's happening and make informed decisions about our health. This pandemic of mistrust was probably beginning before COVID-19, but the extreme polarization during this crisis has profoundly hampered our nation's ability to respond. It is a major reason why the U.S. has a far higher death rate from COVID-19 compared to other well-resourced countries," he said.
Six primary factors have contributed to the climate of mistrust, Harmon said.
Inadequate funding of pandemic preparedness and public health agencies
Unclear lines of responsibility
Uneven use of federal authority to produce masks and other personal protective equipment, as well as testing and supplies
Mixed messaging on masks, social distancing, isolation, and quarantine
Political and sometimes personal attacks on scientists and physicians
An inadequate response to the omicron variant surge and a shortage of coronavirus tests more than 18 months into the pandemic
"Playing the blame game is an exercise in futility, but we do recognize these missteps. Our focus now should be learning from those mistakes and rebuilding the trust lost as a result," he said.
One of the main ways to restore trust in healthcare experts is to address misinformation and disinformation by a small number of healthcare professionals, Harmon said.
"Surprisingly to me, some of the loudest purveyors of misinformation and junk science during this pandemic have been a very small number of doctors and health professionals. These offenses are, in my opinion, the most egregious of all because they violate the ethics of our profession and each lie and untruth spread by the click of a mouse erodes the trust that is at the very heart of the patient-physician relationship—trust that is essential in our ability to provide care. This is why the AMA has called for state medical boards to respond swiftly when physicians spread falsehoods online and through the media, particularly disinformation relating to COVID-19," he said.
Fixing healthcare system, rebuilding trust, and responding to next major health crisis
Five steps must be taken to restore the U.S. health system and trust, as well as to prepare for the next colossal public health emergency, Harmon said.
"The first is to enhance our state and federal stockpiles of medically necessary supplies and improve the system for acquiring and distributing them. The shortage of PPE and other essential supplies in the early months of this pandemic slowed our nation's response and needlessly put lives of physicians and our frontline workers at risk. Given what we have experienced in this pandemic, global demand can quickly outpace supply for even simple items, such as cotton testing swabs. This should never happen in a country as rich in resources and manufacturing as ours."
"Second, we must significantly increase funding to bolster our nation's diminished public health infrastructure. Chronic disinvestment in government public health agencies puts lives at risk and has severely limited our ability to fight COVID-19. State public health spending has dropped 16% over the last decade, resulting in the loss of nearly 40,000 jobs at state and local public health agencies. It's gaps like these at the community level that contributed to a lack of widespread testing, resulting in more-rapid virus spread in the early stages of the pandemic."
"Third, we must learn from the process that led to the rapid-scale production of several safe and highly effective vaccines. Operation Warp Speed is, quite simply, one of the greatest scientific achievements of our lifetime. We believe the public-private partnership and operational structure of this plan should be preserved in some form for future pandemics or any time vaccines and therapeutics are needed in an emergency."
"Fourth, the rapid expansion and integration of telehealth and remote patient care has been a lifeline during this pandemic—not only for patients but for struggling physician practices during periods of intense lockdowns. The AMA has long championed telehealth and has provided expert guidance, support, and resources to help physicians implement it in their practices during the pandemic. But for telehealth to succeed the way patients and physicians want it to, we need the help of Congress.
"Finally, we must pause to consider the extraordinary pressure our nation's physicians and healthcare workers have had to shoulder the last two years—men and women on the frontlines of our emergency departments and intensive care units who have gone above and beyond in their service to all of us. They have worked extremely long hours, often for days at a time—through every surge—at great personal risks to themselves and their loved ones."
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."
