Zero-tolerance policies and the promotion of reporting incidents of mistreatment such as sexual harassment are essential, CMO says.
A recent JAMA Network Openarticlefound sexual harassment and other forms of mistreatment are common in the obstetrics-gynecology field. CMOs and other healthcare leaders need to address the problem, a CMO says.
The recently published research article conducted a systematic review of 10 studies on harassment and 12 studies on interventions. One study that examined harassment rates in several medical specialties found that OB-GYN was second only to general surgery in specialties linked to the highest rates of sexual harassment.
"This systematic review found that 28% to 71% of participants reported sexual harassment, sexual coercion, or unwanted sexual advances within the field of OB-GYN in surveys," the research article's co-authors wrote. "These events were often not reported to institutional leadership, however, given that individuals experiencing these forms of mistreatment feared retaliation and did not feel that their experiences would be taken seriously. There were also high rates of bullying, gender bias, and microaggressions among trainees and practicing physicians."
The research article has several key findings:
Workplace discrimination among female gynecologic oncologists ranged from 57.0% to 67.2%
Bullying was reported by 52.8% of female gynecologic oncologists
Sexual harassment such as gender harassment, unwanted sexual attention, and sexual coercion was reported by 69.1% of OB-GYN trainees
The primary perpetrators of harassment were identified as physicians (30.1%), trainees (13.1%), and operating room staff (7.7%)
In a survey of 250 female gynecologic oncologists, 83.2% reported experiencing microaggressions such as being told to smile more, dress in certain ways, and to act more female or motherly
In gynecologic surgery, gender discrimination was the most common form of discrimination for male clinicians (72.3%) and female clinicians (90.1%)
"These findings suggest that there is high prevalence of harassment in OB-GYN," the research article's co-authors wrote.
CMO perspective
The data in the research article reflects the problem of workplace mistreatment and sexual harassment in American society, says Mark Simon, MD, MMM, CMO of Ob Hospitalist Group.
"Unfortunately, gender harassment and sexual harassment is too common in American society in general," Simon says. "The field of medicine is made up of people from society, so you see a continuation in what you see in society at large inside medicine in general and OB-GYN in particular."
OB-GYN has the highest percentage of female clinicians such as physicians and midwives, which underlies the data in the research article, Simon says. "With a large percentage of female clinicians and as is the case in society at large, women are on the receiving end of sexual harassment, which makes OB-GYN prone to sexual harassment."
The finding that nearly three-quarters of OB-GYN trainees experience sexual harassment is disturbing but not surprising, Simon says. "Especially when you are talking about OB-GYN trainees, there is a power dynamic between people who are teachers or other individuals who are responsible for the trainees. This power imbalance can set up a dynamic for a harassment situation. In addition, the data shows that vast majority of trainees and young OB-GYN clinicians are women, which is a component of this problem."
When perpetrators are senior staff members, CMOs need to hold them to the same standards as other staff members, Simon says. "Even if the alleged perpetrator is a powerful individual within an organization, staff members need to see that the alleged perpetrator will be subject to an investigation the same as anybody else and will be held accountable the same as anybody else."
CMOs and other healthcare organization leaders can take actions to reduce mistreatment such as sexual harassment, Simon says.
"It is important for CMOs and other healthcare leaders to take the opportunity to set expectations and have zero tolerance for sexual harassment and other mistreatment," Simon says. "That requires codes of conduct, education, an internal recognition that harassment is occurring, a willingness to hear and be open to any complaints that are lodged, and a commitment to investigate complaints thoroughly and fairly. Then healthcare leaders must hold perpetrators accountable to the expectations."
CMOs must be intentional to alleviate fear of retaliation when mistreatment is reported and to address the concern that complaints will not be taken seriously, Simon says. "The best thing CMOs can do is have an open and transparent process for the lodging of complaints. CMOs should have zero tolerance for harassment when it is identified. CMOs should have clear and transparent policies for retaliation, which is illegal."
The CMO of Northwell Health is developing a specific care strategy for the fastest growing segment of the nation's population.
With seniors comprising the fastest growing segment of the American population, Northwell Health is developing an "age-friendly" strategy aimed at improving clinical outcomes.
According to thePopulation Reference Bureau, the number of Americans who are 65 or older is expected to rise 47% over the next three decades, increasingfrom 58 million in 2022 to 82 million by 2050. During this period, the share of the total population of Americans who are 65 or older is expected to increase from 17% to 23%.
Healthcare providers need to step up efforts to serve that population, says Jill Kalman, MD, CMO, deputy physician-in-chief and executive vice president at Northwell Health.
"They are complex with multiple chronic conditions," Kalman says. "We need to take care of this growing part of our population. Both the 65-and-older and 80-and-older patient populations are growing."
Northwell has joined 29 other health systems in launching the Institute for Healthcare Improvement's Age-Friendly System-Wide Spread Collaborative. The collaborative is designed to accelerate and spread evidence-based care for older adults. A primary goal of the collaborative is to push adoption of four evidence-based elements of high-quality care, known as the 4Ms: medication, mobility, mentation, and what matters most to older patients and their families.
Kalman says Northwell has embraced the 4Ms at the health system's 21 hospitals and 900 ambulatory practices:
For medication, Northwell is focused on how an older adult metabolizes certain medications, which can be significantly different with younger patients, especially if there is kidney disease, liver disease, or heart disease. Clinicians take great care with medications that can be harmful for older adults such as benzodiazepines and opioids. Those medications are used when necessary, but doses are adjusted and clinicians are intentional about the medications they choose.
Mobility is of the utmost importance in the inpatient and outpatient setting. For example, clinicians need to be aware of a patient's mobility for risk of falls. In the outpatient setting, Northwell is encouraging physical therapy and mobility activities that can be specifically tailored to an older patient's co-morbidities.
Mentation and cognition may decline naturally over time, and there are diseases that impact mentation such as Alzheimer's. Northwell is focusing on how patients can improve their mentation with specific activities such as games or social interactions.
Northwell is focusing intently on what matters most to the health system's older adult patients and their families. For example, patients are asked about what matters to them as they advance in an illness and about their goals in care.
Age-friendly care delivery and CMOs
Kalman says CMOs have an obligation to address quality of care, and the delivery of age-friendly care is part of that mission.
"It is important to deliver on quality metrics for older patients," she says. "I am focused on making sure evidence-based forms of care are used and making sure we are minimizing harm in everything that we do. I understand that older adults often have multiple chronic conditions that need to come into play when we are looking at the complexity of care for these patients."
The primary quality metrics in the care of older adults include the 4Ms, length of stay, and hospital readmissions, Kalman says.
"I monitor dashboards for our age-friendly health system that look at multiple metrics across our hospitals and ambulatory practices, so we can continue to understand how well we are doing in the evidence-based delivery of care," she says.
A CMO must recognize that older adult patients also have different needs and risks when it comes to surgery, Kalman says.
"Someone coming into a hospital for an appendectomy at the age of 80 is going to have different needs than someone coming in for an appendectomy at the age of 25," Kalman says. "It can be extremely different. Even the least complex surgery can be complex in an older adult, particularly in the recovery phase."
CMOs who are committed to age-friendly care delivery should make sure their health systems pay attention to medication management, delirium screening, and the goals of care, Kalman says.
"These factors need to be put together to drive the best outcomes," she says. "If we can drive the best outcomes in the outpatient and inpatient settings, we also work toward preventing some of the frailty in the older adult [and supporting] a better health span. We can also reduce length of stay and reduce hospital readmissions."
Value of age-friendly care delivery
The benefits of age-friendly care delivery are considerable, Kalman says.
"It is all about the quality of life and quantity of life, if that is what the older patient desires," she says. "The combination of health span and life span is extremely important. The benefits of age-friendly care include driving good clinical outcomes."
"The drawbacks of not providing age-friendly care delivery are poorer outcomes," Kalman says. "For health systems, there are financial drawbacks from not providing age-friendly care delivery. If you provide the best care and achieve the best outcomes, it will drive the financial health of your organization as well."
MaineGeneral Medical Center's CMO also says the noncompete ban will make healthcare organizations face higher physician recruitment costs.
A Federal Trade Commission (FTC) ruling last week that bans noncompete agreements will likely raise healthcare costs, the CMO of MaineGeneral Medical Center says.
The FTC estimates that about 18% of the nation's workforce—roughly 30 million people—are subjected to noncompete clauses. The American Hospital Association and other healthcare stakeholders claim the FTC overstepped its authority to approve what the AHA calls "a bad law, bad policy, and a clear sign of an agency run amok."
The noncompete agreement ban, which will take effect 120 days after it is published in the Federal Registry, will be challenging for healthcare organizations that employ physicians, says Dana "Dan" Vick, CMO of MaineGeneral Medical Center.
Vick does not agree with the FTC's assessment that the noncompete agreement ban will reduce healthcare costs by $194 billion over the next decade.
"I can see an increase in worker earnings," Vick says. "Without a noncompete agreement, a physician can easily move from one practice to another depending on who is the higher bidder, so I do not see how the ban will reduce healthcare costs. Banning noncompete clauses is going to force healthcare organizations to compete on price point for physicians. It also costs thousands of dollars to recruit physicians."
The noncompete agreement ban will spur bidding wars for physicians, Vick says. "If a physician who is employed gets a better offer across the street and decides to take that offer, then the initial employing organization may make a counter offer to keep that physician. If the counter offer is successful, the initial employing organization will have a higher cost for keeping that physician."
Dana "Dan" Vick is CMO of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.
Vick, who has been a physician in private practice subject to a noncompete agreement and works at an organization where noncompete clauses are part of employment agreements, sees both sides of the issue.
"From the employee standpoint, if a job does not work out, the employee may want to move to another position and noncompete clauses can prevent them from doing so in a certain geographic area, which is typically how noncompete clauses are set up," Vick says. "These clauses can have a time limit that forces employees to wait to work in another part of the designated geographic area."
"From an organizational standpoint, noncompete agreements are a way to protect a business by reducing the risk of business loss," Vick says. "These agreements prevent clinicians from taking patients, staff, and organizational information with them if they go somewhere else. These agreements increase employers' incentives to provide training to healthcare workers that could be costly versus opting not to provide training if employers think workers are going to jump ship and go somewhere else. These agreements also help to decrease labor turnover."
About 40% of physicians are bound by noncompete agreements, according to the American Medical Association. That level of noncompete agreements among physicians is probably reasonable in terms of where the noncompete agreements are in effect, Vick says.
"In large metropolitan areas, where you have competitors overlapping with each other, you would tend to see noncompete agreements more prevalent than in rural areas where competitors are not located close to each other," Vick says.
Vick says the noncompete agreement ban will likely have a negative impact on MaineGeneral Health, which uses noncompete clauses in employment contracts with physicians. "It is going to increase the cost of employing physicians as well as increase the cost of recruiting physicians if people do leave."
It remains to be seen whether the noncompete agreement ban will be upheld in the courts, Vick says. "There are going to be some significant legal challenges to the ban. The U.S. Chamber of Commerce has already said that it plans to file suit to block the ban. We'll have to see exactly what happens."
WellSpan Health is set to open three small-format hospitals by the end of 2025.
WellSpan Health is opening small-format hospitals to increase access to emergency care and inpatient care in three communities.
The small-format hospitals, which are being sited in New Freedom, Carlisle, and Newberry Township, Penn., feature emergency rooms with 10 beds and 10 inpatient rooms. The hospitals, which do not have operating rooms, will offer X-ray, CT scanners, and ultrasound as well as diagnostic laboratory studies. The hospitals will be open 24/7 year-round.
The three hospitals are expected to open by the end of 2025.
"We are locating the hospitals in convenient areas for our patients, particularly in areas that are underserved in relation to inpatient care," says David Vega, MD, MBA, senior vice president and CMO at WellSpan.
One of the big benefits of the small-format hospital model is that they tend to have short wait times compared to traditional hospitals and emergency departments, Vega says. "Typically, the wait time in the emergency department is 10 minutes to care, and for patients who are discharged from the emergency department, it takes about 90 minutes from the time patients check in to the time when patients go home."
The small-format hospitals are based on a streamlined model of care that allows caregivers to see patients faster and to expedite services without any reduction in the patient experience, Vega says. "In fact, it is a better patient experience than what most hospitals in the country can achieve."
The streamlined model of care includes use of standardized protocols and standardized ways of seeing patients that will help the small-format hospitals to gain efficiency, Vega says, adding the scope of care is more narrowly focused than at WellSpan's traditional hospitals.
"The scope of what is going to happen in the emergency departments at the small-format hospitals is not the same as we experience at York Hospital, which is a Level 1 trauma center," Vega says. "At York Hospital, there can be several trauma patients and stroke patients in the emergency department. At the small-format hospitals, the scope of care and the volume of patients is going to be lower than what you see at traditional hospitals, which will make us more efficient in the care that we provide."
The small-format hospitals will also be designed to provide efficient access to specialists through virtual connections, Vega says.
"This is a different model than traditional hospitals," Vega says. "Instead of having to wait for a specialist to become available and come physically to a location, a lot of our specialists will be available immediately at the bedside through a virtual connection. For example, if you need a cardiologist, they will work with the nursing team at the small-format hospital to be able to examine the patient remotely such as hearing the heartbeat."
From a CMO perspective, the small-format hospitals will allow WellSpan to have a more focused and efficient approach to care within the scope of services that will be offered, Vega says.
"The services that are offered are a little different than traditional hospitals," Vega says. "For example, there are no operating rooms or surgical procedures performed at small-format hospitals. However, the emergency department is fully licensed by the state and available 24/7. The inpatient side of the hospitals is also available to our patients."
As WellSpan's CMO, it also is important to have the small-format hospitals integrated into the health system's electronic medical record, Vega says. "If a patient needs a higher level of care than what the small-format hospital can offer, we will make it smooth and easy for patients to be transferred to a higher level of care at one of our traditional hospitals."
Providence is expanding the health system's Co-Caring Model at inpatient units and working to improve patient care progression in the inpatient setting.
The chief clinical officer of the Providence health system is shepherding a pair of inpatient care initiatives aimed at improving the patient's journey.
Hoda Asmar, MD, MBA, is supporting a quality improvement initiative called the Co-Caring Model. Under the Co-Caring Model, bedside teams in the inpatient setting are supported by a team of nurses, social workers, case managers, and other staff members who work in a virtual role 24/7.
The Co-Caring Model was launched as a pilot last year on one acute-care unit. By the end of 2024, Providence will have 33 acute-care units using the Co-Caring Model.
Staff satisfaction with the Co-Caring Model has been high and it has the potential to help address workforce shortages, Asmar says. In the first seven months of the pilot for the Co-Caring Model, there was 100% retention of staff on the inpatient unit that adopted the model.
Patients have also been receptive to the Co-Caring Model, says Asmar, who has been executive vice president and chief clinical officer of Providence since October 2021. Previously, she served as executive vice president and chief clinical officer of Adventist Health and chief medical officer of system clinical improvement at Baptist Memorial Health Care.
"We tell the patient there will be a virtual team supporting the bedside team that they interact with in-person," she says. "None of our patients have opted out of the Co-Caring Model. When we looked at patient satisfaction and experience scores for patients and their families who were engaged in the Co-Caring Model, there were great results."
The Co-Caring Model gives the patients and staff more choices, which supports growth, Asmar says.
"In healthcare right now, there is a challenge in having enough caregivers joining the workforce," she says. "By creating choices, efficiency, and a positive culture, the Co-Caring Model is helping us to recruit and retain staff members, which is helping us to serve more patients."
Providence considers the Co-Caring Model to be a learning opportunity, Asmar says.
"As we are implementing the model at acute-care units, we customize elements for the local context, and we keep refining the model as we go based on the results and what we are learning," she says.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer of Providence. Photo courtesy of Providence.
Improving patient care progression
Asmar is also involved in efforts to improve patient care progression. Patient care progression is measured by operational efficiencies in the acute-care space and hospital length of stay, she says.
Providence started working on patient care progression about three years ago to address some of the challenges that occurred during the pandemic—long lengths of stay, difficulty in discharging patients, and lack of access to enough post-acute care.The work began with the goal that every patient deserves a safe and timely discharge from acute care, Asmar says.
"We created a multidisciplinary team from across the organization and implemented a back-to-basics approach," she says. "We adopted more than a dozen basics that hardwired and established critical processes and workflows. We also worked on the connection to post-acute care such as home care and skilled nursing facilities in addition to access to primary care after discharge."
The work is paying off. In the first quarter of 2024, the health system is seeing a trend in the right direction for length of stay in acute care.
What happens before and after an acute-care stay is part of the patient care progression work, Asmar says.
"We are looking at hard-wiring standardized workflows, promoting automation, having safe and timely discharge from an acute-care stay, and addressing some of the chronic and repetitive issues with access to primary care as well as access to post-acute care," she says.
As is the case with the Co-Caring Model, patient care progression work is supporting growth at the health system, Asmar says.
"The ability to create operational efficiencies, reduce length of stay, and improve access in primary care gives us more capacity to serve patients in our emergency departments and have the beds ready for patients who need acute care," she says.
The South Carolina-based health system's ACO is working in collaboration with CVS Accountable Care.
Prisma Health has established a collaboration between its accountable care organization, InVio Health Network, and CVS Accountable Care to participate in the ACO REACH model.
ACO Realizing Equity, Access, and Community Health (REACH) is an accountable care model developed by the Centers for Medicare & Medicaid Services that features upside and downside risk for healthcare providers serving traditional Medicare beneficiaries. Clinicians participating in ACO REACH include primary care physicians and specialists. ACO REACH participants must have a plan to meet the needs of people in underserved communities and to address health disparities.
The ACO REACH collaboration between InVio Health Network and CVS Accountable Care will have both organizations capitalizing on their strengths, says Drew Albano, DO, MBA, chief medical officer of population health management at Prisma Health.
"They can look at ways to provide additional clinical programs or expand on existing programs," he says. "They can also work together to harness data—there are increasing volumes of data in the healthcare space, and these partners will be able to manage data and use it in a meaningful way. This collaboration also will supplement InVio Health Network's population health programs."
InVio Health Network's strengths include robust connections locally with Prisma Health's employed physician practices and the health system's medical group, Albano says, adding InVio Health Network has strong relationships with independent physician practices in Prisma Health's geographic footprint in South Carolina. That local presence will be complemented by CVS Accountable Care's national presence and CVS Health's MinuteClinics in South Carolina, he says.
InVio Health Network also has staff tackling population health and value-based care initiatives from different angles, Albano says.
"Some of those angles include addressing care gaps such as cancer screening, scheduling of wellness visits, and getting patients in for chronic disease management for conditions such as diabetes and hypertension," he says.
CVS Accountable Care also has extensive experience with longitudinal care and care coordination, Albano says. "This will help us do well in managing populations of patients as they transition from acute care such as hospitalizations back into their communities."
Navigating upside and downside risk
Prisma Health has been serving Medicare beneficiaries since 2015, including downside risk arrangements such as Medicare Advantage health plans. Prisma Health is confident that InVio Health Network can achieve shared savings in the ACO REACH model, Albano says.
"We feel it is important to equip our clinicians with resources that are going to help them better address the holistic aspects of a patient's care," he says. "We think about not only medical management but also helping the patient to align with their optimal health trajectory and care pathways. So, we think about how we get patients in for preventative visits, chronic care management, and medication adherence."
Providing access
To be successful in ACO REACH, InVio Health Network is thinking beyond traditional methods of providing access such as getting patients into ambulatory settings for evaluation, Albano says.
"What we have seen since the coronavirus pandemic is that there are novel models for access that we can start to leverage," he says. "Virtual visits are certainly an opportunity, particularly in behavioral health. CVS Accountable Care has sought to provide access through their MinuteClinics. We are thinking about chronic disease management using remote patient monitoring for conditions such as hypertension and heart failure."
InVio Health Network and CVS Accountable Care want to provide access through the traditional model of providing in-person office visits for patients, but they also want to decentralize that model by taking care of patients in their homes, Albano says.
"So, there are many avenues to provide access," he says. "Partnerships such as this one help us to showcase which avenue is best to pursue with each patient. We know that the one-size-fits-all model is not going to work. We must take a tailored approach knowing that we are going to meet the patient where they are at and address the needs that they have using the right access pathway."
Promoting health equity
InVio Health Network's plan to boost health equity in ACO REACH includes addressing social determinants of health, Albano says.
"We have implemented a process to screen patients for social determinants risk factors," he says. "We have a tool that not only helps identify social determinants of health but also connects patients to community resources. We close the loop—it is not just providing an available resource for an identified social determinant but also making sure the patient is able to have their social determinant addressed."
CVS Accountable Care has a robust care management capability, which will also promote health equity, Albano says.
"We are going to be able to scale up what we have done historically from a care management standpoint," he says. "For example, we are looking at how the CVS Accountable Care transitional care management team can do more acute-care transitions such as patients who have a hospitalization for surgery then are transitioned back into the community."
David Battinelli says the health system must offer a range of approaches to boost the well-being of employees.
The top priority for the physician-in-chief of Northwell Health is the well-being of physicians and other staff members.
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell. He is also dean and Betsey Whitney Cushing Professor of Medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Prior to taking on his current roles, Battinelli served as senior vice president and chief medical officer at Northwell.
1. Physician and staff member well-being
"I need my providers and staff members to be as well as possible," Battinelli says.
Addressing the well-being of a clinical staff requires "an entire menu of approaches," he says. "The concept of well-being is not a one-size-fits-all. We are going to have to engage a variety of different strategies for a variety of different people."
For some people, the adoption of a hybrid work environment at Northwell has been a big improvement, but for others, it does not work, Battinelli says. "You can't just say a hybrid work environment is going to solve well-being problems."
A crucial element of addressing workforce well-being is engaging staff members, he says. "If you are not aware of the things that people are struggling with regarding maintaining their well-being, then you are going to offer programs that have nothing to do with their real problems."
For clinicians, Northwell wants to work on reconstituting relationships that were formed in the past, Battinelli says.
"Years ago, ambulatory providers would round at the hospitals. They would congregate in a doctor's office or lounge, and they helped each other maintain their balance," he says. "Doctors used to support each other quite a bit, which helped them maintain balance. Now, ambulatory doctors don't go to the hospitals anymore."
The health system has two programs to foster physician get-together events. "The Doctors Lounge" is a regional dinner program initiated by practice leadership. "Connect the Docs" is a smaller local program initiated by individual physicians.
"These programs are a way for physicians to get together and relax," Battinelli says. "These programs have been remarkably successful—it is a way to ensure that doctors can support each other when they are feeling unbalanced."
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell Health. Photo courtesy of Northwell Health.
2. Patient access
Battinelli is also focused on an organizational goal to improve access for patients.
"There are many ways that our people are working at providing access," he says. "Getting in to see a provider for an appointment is important, but it is not the primary issue when people talk about access. The primary issue is that the only way to speak to a provider is with an appointment. Often, a provider cannot see a patient for two months."
Battinelli says Northwell has learned a lesson from the banking industry, which expanded access with online banking rather than hiring more tellers or expanding hours.
"We need to embrace 'connected care,' which is what they use in Great Britain, or embrace virtual care," he says. "Patients want to be connected first, then achieve access through an appointment later. They do not want to feel like they are being left 'out there' on their own."
To promote access, Northwell has two primary initiatives: offering a nurse navigation program and launching a virtual patient engagement program.
"Our nurse navigation program is centered on cancer services because of the emotional context of cancer and making sure that patients are connected immediately with anybody that they need," Battinelli says. "Our nurses can connect with patients 24/7 and make sure they understand everything that is going on with their care."
"The virtual patient engagement program is triggered the moment a patient calls in," he says. "The patient gets a virtual connection with a member of our staff, even if it is not the doctor with whom they get an appointment. This virtual connection assures the patient that waiting for an appointment for two weeks or two months is the best time if that is appropriate. The virtual connection also assures the patient that they are going to meet with the right doctor."
3. Technological transformation
Battinelli is also involved in efforts to establish the mindset at Northwell that artificial intelligence and other new technologies will help the staff to do work in the future.
"Many of these technologies are not mature yet, but it is clearly a good idea to be thinking about adopting these technologies," he says. "The number of things that can be done with AI is mindboggling."
For example, the patient-provider interface of the future will not involve a mouse and a keyboard, Battinelli says. At Northwell, the right interface is going to be new digital technology such as AI. The health system is looking at technology that will record the entire patient-physician interaction, then AI will generate the clinical note and documentation for the encounter.
"This will free up the physician, who can interact better with the patient," he says.
4. Becoming an age-friendly organization
Battinelli says he wants to be at the forefront of efforts at Northwell to better serve the health system's aging patient population.
"The healthcare industry has delayed addressing the aging population for as long as theoretically possible," he says. "If we do not start thinking about how to engage our aging population, the Silver Tsunami is going to hit us, and we are going to be overwhelmed."
Leaders and care teams at Northwell must think about all the things the health system should do beyond just giving expert medical care to be perceived as age friendly, Battinelli says.
"We must be able to provide things that aging patients might need," he says. "This does not necessarily commit us to something specific, but as things come along, we are thinking about how we can position ourselves to be age-friendly because we want our aging population to understand that we want to partner with them to learn how to take care of them."
Northwell is challenging care providers and other employees to identify potential programs that are going to be age friendly, Battinelli says. "For example, as an organization, we have more than 85,000 employees. We are considering creating a program that will allow employees to take time off to care for aging family members. We want to provide an employee environment that is age friendly."
The health system is also reaching out to older patients to find out about their needs, he says. "We are not going to solve the aging problem. But we can engage the aging population to find out what it is that they want from us."
Through automation, Ardent Health has increased inpatient vital sign collection from four times per day to 1,440 times per day.
Automating the collection of inpatient vital signs has improved the ability to identify patients who are deteriorating at Ardent Health.
Vital signs are critical indicators of a patient's condition in the inpatient setting. Manual collection of vital signs is conducted about four times per day, which is often insufficient to determine whether a patient is decompensating, says F.J. Campbell, MD, chief medical officer of Ardent Health.
The health system has adopted HealthCast, a technological solution that has increased the collection of vital signs to 1,440 times per day, Campbell says.
"We looked for technology that could automate the collection of vital signs. We felt that if we could improve the collection of vital signs, we would be in a better position to identify patients who were deteriorating," he says. "We were looking to improve workflow, take away workflow from the staff who were already overburdened with tasks, and identify the deteriorating patients better."
The data collected by HealthCast has been incorporated into the health system's deterioration index software, which has revolutionized the accuracy and efficacy of Ardent's deterioration index tools, Campbell says.
"We have deterioration index algorithms that look for rapid changes in vital signs, either up or down," he says. "These changes in vital signs can indicate whether a patient is going into respiratory failure, cardiac arrest, hypotension, or some other life-threatening condition."
Prior to adopting HealthCast, Ardent was using the deterioration index in the health system's electronic health record, Epic, to help identify patients who were deteriorating, Campbell says.
"We leaned in on the deterioration indexes that we had in Epic, which helped. But what we were not appreciative of was how limited that system could be without significantly increasing the amount of vital signs that we were collecting," he says. "The deterioration indexes in Epic helped, but there was not enough specificity. The sensitivity and specificity for all of our deterioration indexes went up with more vital signs coming in."
With essentially continuous collection of vital signs at inpatient units, Ardent has improved three key outcomes, Campbell says. The health system has reduced mortality, decreased length of stay, and increased transfers of patients to ICUs. The increase in patient transfers to ICUs shows that the health system is catching deteriorating patients before it is too late to provide them with critical care.
"It is a far better thing to capture someone who needs to go to the ICU than to not capture them in time," he says. "Patient satisfaction has increased because patients feel safer."
Reducing burnout
Automating the collection of vital signs and improving identification of deteriorating patients has reduced burnout among physicians, nurses, and technicians, Campbell says.
"We became aware of the untenable amount of work that we were asking bedside nurses and technicians to do," he says. "Their ability to identify deteriorating patients was their No. 1 source of stress. By extension, if nurses were not in a position to identify patients who could be deteriorating, that made the hospitalists and specialists working in the hospital uncomfortable."
A major source of burnout for anyone in the hospital working at the bedside is fear, Campbell says. "There is the fear that there could be a patient who is deteriorating that we can't identify. So, we tried to figure out what we could do tangibly to reduce this fear."
The emotional burden on clinicians seeing patients deteriorate that they were not expecting to deteriorate usually involves clinicians feeling that they made a mistake, he says. "The absence of identifying the patient who is deteriorating creates a situation that we call the second victim, which is specifically the clinicians. If a patient deteriorates on a clinician's watch, it has a tremendous impact on them. It is a catalyst for clinicians to leave the industry."
Advice for other health systems
Health systems and hospitals should not accept burnout as an inevitable consequence of the work that they perform, Campbell says.
"You do not want burnout to become a form of capitulation," he says. "We need to identify the elements that drive burnout. One example is patients declining on a clinician's watch, which makes the clinician feel they have failed the patient and they have failed themselves in their ability to execute care safely. Deterioration of patients cannot be viewed as, 'That's just the way it is.'"
Another example of a driver of burnout is the sheer number of tasks and burdensome workflows such as vital sign collection and interpretation that clinicians and nurses face, Campbell says.
"The best way to improve workflows is to take them away through automation," he says. "At Ardent, we are militant about workflow, which has gained the appreciation of our staff. Improving our workflows has an impact on our turnover and our recruitment, particularly for nurses and clinicians."
Anil Keswani is focused on organizational goals including promoting operational excellence and patient engagement.
Supporting efforts to bolster Scripps Health's financial standing is the top priority for the health system's chief medical and operations officer for ambulatory care.
Anil Keswani, MD, has been corporate senior vice president and chief medical and operations officer for ambulatory care at Scripps since February 2020. He was previously corporate vice president of population health and president of Scripps Executive Health.
1. Financial health of Scripps
The top priority for Keswani this year is promoting the financial standing of Scripps. After the coronavirus pandemic public emergency, many not-for-profit health systems have been struggling financially, he says.
"We are looking at making sure we are fiscally responsible and financially strong to keep providing care," Keswani says. "This is a big issue in California because of the state Office of Healthcare Affordability. To meet this state agency's targets, we are going to have to manage our costs appropriately."
One area where Scripps is seeking to contain costs is the purchase of new equipment. For example, surgeons requested the purchase of new robots for operating rooms, but the health system conducted a robot utilization review and found that a surgery robot was not being used to its full potential at one of Scripps' hospitals, he says.
"With some operational changes and some clinician changes with how we schedule procedures, we were able to improve our robotic utilization across our health system to the point where we were optimizing that asset," Keswani says. "Had we not done that, we would be buying more robots and underutilizing them. Optimizing the use of our assets contains costs."
Scripps has also enlisted physician leaders in cost management efforts, he says. The health system has formed the Medical Equipment Capital Advisory Group, which includes physician leaders and operational leaders, to look at the purchase of capital equipment on both the ambulatory and acute-care sides of the organization.
"These experts are prioritizing our capital expenditures, which bubbles up to our C suite, and we make sure we are utilizing our assets appropriately," Keswani says. "It involves a lot of education and communication so our leadership can understand how to invest in the right equipment."
Anil Keswani, MD, corporate senior vice president and chief medical and operations officer for ambulatory care at Scripps Health. Photo courtesy of Scripps Health.
2. Operational excellence
Keswani's second priority for 2024 is promoting operational excellence.
"When you talk about operational excellence, people typically think about staffing appropriately and using resources appropriately," he says. "What we need to figure out now is how artificial intelligence plays into operational excellence."
One of the things Scripps is doing this year to foster operational excellence is using ambient technology to produce AI-generated notes of clinical encounters that clinicians can review.
"Gone are the days when doctors were typing on the keyboard throughout a patient encounter," Keswani says. "We are moving to the next stage, where clinicians are able to talk face-to-face with patients, then generate a clinical note with AI."
Scripps is also using AI to help clinicians manage in-basket messages from patients, he says. Clinicians receive thousands of messages from patients, and the health system is using AI to help construct return messages.
"We have started to use AI to construct a first draft of a message back to the patient," Keswani says. "If a patient emails a doctor with a question, we are using AI to create a first draft of a message that tees it up for the doctor or nurse to review and edit, then they can send the message to the patient."
3. Care access and patient engagement
Keswani's third priority for this year is supporting a care access and patient engagement program that Scripps calls "Getting to Yes."
During the pandemic, barriers were erected in the interaction between healthcare providers and patients, Keswani says.
"There were literal barriers such as Plexiglas walls between us and the patients," he says. "Over the past few years, we have pulled back from the patient. When we had a patient surge during the pandemic, patients had to see us through telehealth."
Getting to Yes is a philosophical change and a change in care teams' attitudes so they embrace patients, Keswani says.
"Getting to Yes encompasses access and experience, but it is also creating personal accountability to connect with our patients the way we wanted to prior to the pandemic," he says. "This is more than a tag line. We want to make sure that we stay true to our organization's brand, which includes being a high-quality experience provider for our patients."
One Getting to Yes initiative has been replacing the health system's call center for patient phone calls with a hybrid contact center model, Keswani says. In some cases, patient phone calls are directed to clinical care offices, but in most cases, patient phone calls are directed to the health system's contact center.
"We have an on-site contact center, where we monitor metrics and how the staff is operating," he says. "At the contact center, we have highly skilled customer service representatives who check each other's work."
Health systems and hospitals have high turnover among customer service representatives, which affects the quality of patient engagement, Keswani says. Scripps has addressed this challenge by letting most customer service representatives work from home part-time.
"We have taken a percentage of the people in the contact center and let them work from home," he says. "Then they rotate into the contact center one week per month. We have found that the staff is excited to come into the contact center for one week, and they have an engaged attitude."
4. Engaging and developing staff
Keswani's fourth priority for this year is staff engagement and development.
Scripps has been named to Fortune magazine's 100 Best Companies to Work For list 16 times.
"The award is nice, but it reflects that we have a good relationship with our frontline people," he says.
The healthcare sector is going through a challenging time, and Keswani wants to make sure he is engaging staff members, he says.
"With an inordinate amount of change, we need to keep our clinicians with us," Keswani says. "We want to make sure they are part of the changes and understand the changes. We make sure that we keep our staff educated and informed as well as aware of the decisions that we are making."
One of the ways Keswani engages his staff is sending out a weekly "highlights" email to hundreds of people in his leadership structure.
"The email talks about what is happening locally, what is happening nationally, and what is on my mind," he says. "It is important to be connected with your staff."
A pair of chief physician executives talk trends with HealthLeaders at the recent AMGA Annual Conference.
The AMGA Annual Conference that concluded last week showed medical groups and health systems are rising to challenges and seizing opportunities, says John Kennedy, MD, AMGA chief medical officer and president of the AMGA Foundation.
Medical groups and health systems are facing a range of challenges, including workforce shortages, improving patient access, addressing health disparities, and adopting artificial intelligence solutions. All of these issues were front of mind during the AMGA Annual Conference.
Kennedy told HealthLeaders that he was impressed by the embrace of innovation shown at the annual conference.
"Medical groups are addressing key challenges such as physician engagement and physician resilience," he said. "I spend a lot of time with chief medical officers, and they have their workforces front-and-center. They are investing in new technology to help offload work from physicians. Chief medical officers are working to allow their physicians to spend more face-to-face time with their patients and less time in the electronic health record."
To address workforce shortages, medical groups and health systems are striving to improve the efficiency of clinicians and other healthcare workers, Kennedy said.
"There is a recognition that you cannot just continuously throw more people at the problem," he said. "Medical groups have physicians, advanced practice providers, case managers, pharmacists, dieticians, and other healthcare workers. There just are not enough healthcare workers to fill the entire need for staffing."
Kennedy said technology is at the heart of efficiency-gaining efforts at medical groups and health systems, and he gave two examples.
First, medical groups and health systems are adopting ambient transcription services in clinics to reduce clinician administrative burden and improve patient experience.
"The doctor can use their smartphone to capture all the elements of a clinic visit and immediately produce a medical note that requires only a short review for the physician," he said. "Ambient transcription services allow the clinician to engage the patient without working on a computer at the same time. The doctor is happier, and the patient has had a better experience."
Second, medical groups and health systems are adopting solutions to reduce the burden of in-box messages. "Doctors get all sorts of messages in their in-basket," Kennedy said. "It can come from a patient portal. It can come from phone messages. It can come from lab results or imaging. Those messages have gone up about 29% year-over-year since the coronavirus pandemic."
In-box solutions include artificial intelligence bots to help triage messages to the appropriate level of care and telehealth physicians who can provide remote care, he said. "What you are seeing is that messages are getting answered faster. Patients are more satisfied. And the huge volume of in-basket messages is starting to get under control."
Health equity is both a challenge and an opportunity, Kennedy said.
"The medical groups are all enabling their data systems to collect health equity data that is being required in accountable care programs," he said. "They must report on demographic information, race, gender, ethnicity, and insurance status. Medical groups' data systems are being set up to collect this data, and they are identifying underserved communities and developing programs to address underserved communities."
There are two primary areas related to patient access challenges, Kennedy said.
"One area is related to workforce. Medical groups need to strive to have fully staffed clinics—not just physicians but also nurses and the support staff. Medical groups are catching up on staffing after some difficult years during the coronavirus pandemic," he said. "Another area is related to technology. What we are finding is that patients are now able to self-schedule appointments from home. So, there can be openings in a doctor's schedule that have occurred in the previous 24 hours. Patients can fill those openings themselves, which improves access because there are fewer open visits in a doctor's schedule. In this way, clinics are getting more patients in sooner."
Chief physician executive perspectives
A pair of chief physician executives shared their views in separate interviews with HealthLeaders at the AMGA Annual Conference.
There are three keys to success in relationships between health systems and physician groups, said Bedri Yusuf, MD, MBA, chief physician executive of Northeast Georgia Physicians Group.
"The No. 1 key to success is trust," he said. "The second key to success is identifying the major challenges for the health system, then the medical group needs to consistently deliver on addressing those challenges. Third, physicians must buy-in to the health system's goals and what the health system is trying to achieve such as value-based care. When physicians are committed, you have accountability."
It can be a challenge to maximize the value of the interaction between a health system and a physician group, Yusuf said.
"There is a perception that medical groups lose money. But if you establish that a medical group is an investment in healthcare and the community, there are downstream benefits such as care efficiency, clinical outcomes, and meeting your mission," he said. "In our health system, we have pillars including safety, quality, healthcare stewardship, and healthcare delivery. If our medical group addresses those pillars point-by-point, we can generate revenue, achieve cost avoidance, make referrals to the hospitals, and attain improvements in service. By bringing new patients to the hospitals, we are adding to the bottomline and advancing the health system."
Matthew Mulder, MD, executive vice president and chief physician executive of UW Medicine's Valley Medical Center in Seattle, shared the keys to success for chief physician executives.
"First off, you must build your clinical credibility prior to taking the role," he said. "You also need to have a good relationship with the clinicians that you work with—you need to be a good listener and truly understand the needs of your clinicians. Likewise, you need to understand the needs of the administrative leaders you work with, who may not necessarily have a clinical background."
A chief physician executive must be intentional in bridging any gaps with administrative leaders, Mulder said. "Having common goals and common objectives helps," he said. "You need to understand their challenges, and they need to understand your challenges—very often, they are similar."
Dana "Dan" Vick is CMO of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer of Providence. Photo courtesy of Providence.
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell Health. Photo courtesy of Northwell Health.
Anil Keswani, MD, corporate senior vice president and chief medical and operations officer for ambulatory care at Scripps Health. Photo courtesy of Scripps Health.