Private equity-backed management services organizations provide independent physician practices with business-savvy talent and access to capital, according to one practice leader who has taken that route.
Private equity-backed management services organizations (MSOs) are helping independent physician practices to remain independent.
Independent physician practices are declining, according to the American Medical Association (AMA). From 2012 to 2022, the proportion of physicians working in private practices fell from 60.1% to 46.7%, the AMA says. Over the same period, the proportion of physicians working in hospitals as employees or contractors rose from 5.6% to 9.6%.
"In 2017, we saw that there were other independent physician practices across the country that were joining these MSOs and we wondered whether we should, too," he says. "As we got further into the weeds, what became apparent to us as a physician-led organization is that joining an MSO would provide us with several abilities."
"We were thinking: How do we stay independent?” he adds. "How do we deliver quality care? How do we keep costs to the system low? And how do we make sure access to our services is expanding? That is what led us to join the GI Alliance."
An MSO serves as the business office of a medical practice, providing such business functions as billing, compliance, information technology, and accounting.
Private equity-backed MSOs provide two primary advantages for independent physician practices, Berggreen says.
Access to higher levels of business talent. "Back in the day, we all had office managers, and they were good at managing an office of five to 10 doctors," he says. "But to run the business functions of an MSO, you need to have people who have a lot of business skills. Even at Arizona Digestive Health, which has 50 doctors, we could not afford that type of talent. Joining the MSO gave us access to that type of talent."
Access to capital. For example, Berggreen says, a large oncology practice in Tennessee recognizes that many patients in rural counties have significant access issues getting to appointments. The oncologists joined an MSO with a private equity backer and used their new access to capital to open clinics in rural areas so their patients can access oncologists without having to make a one- or two-hour drive. The oncologists were able to identify where their rural patients are located, where it makes most sense to put a rural clinic, and how they’re going to staff the clinics with help from the MSO.
With access to business talent and capital that private equity-backed MSOs provide, independent practices can remain independent with few strings attached, Berggreen says.
"At AIMPA, we look at private equity-backed MSOs as part of independent physician practices remaining independent," he says. "But we look at that as a neutral financing mechanism. In this case, private equity firms do not own medical practices. So the clinical decision-making stays separate from the business functions of a practice. The whole concept of these kinds of MSOs is that the business functions remain separate from the clinical operations, and any clinical decision-making remains with the physicians."
Arizona Digestive Health is physician-owned and -led. The CEO, chief medical officer, and chief development officer are all gastroenterologists. The practice's physicians have oversight and direction on every decision that is made without interference from the MSO, Berggreen says.
"With these private equity-backed MSOs, there is no ability for a private equity firm to make decisions or force physicians to do anything from a clinical standpoint," he says.
Prospects for private equity-backed MSOs
Berggreen says the private equity-backed MSO model for independent physician practices is a national trend.
"In 2010, you saw very few of these arrangements," he says. "In recent years, you have been seeing more and more of these arrangements because independent practices love autonomy."
"If there are concerns about getting involved with a private equity firm, the solution is for physicians to stay involved," he adds. "You need to make sure that physicians have an active role in the everyday management of the practice. You need to make sure that physicians are insisting that quality, cost, and access remain the three most important things that inform your business decisions."
Several studies have recently reported that private equity has a negative impact in the healthcare sector. For example, a December 2023 article published by JAMA found that private equity acquisition of hospitals was associated with a 25.4% increase in hospital-acquired conditions, such as falls and central line–associated bloodstream infections.
Private equity-backed MSOs that work with independent practices are an example of how private equity can have a positive impact on healthcare, Berggreen counters.
"There are many examples, such as the Tennessee oncologists, that show private equity-backed MSOs can have a positive impact when physician practices remain independent but have the operational and financial firepower of a well-tuned MSO," he says. "You are going to see more stories and research that show what private equity-backed MSOs can accomplish."
"This model is not that old," he adds. "Most independent practices have joined these MSOs in the past five years. I expect that we are going to see positive data on what we can accomplish with these MSOs."
Patient experience is linked to reimbursement, patient safety, and clinical outcomes.
Executives at a pair of healthcare organizations that earned Pressy Ganey patient experience awards say that following best practices has allowed their institutions to excel in patient experience.
Patient experience is a key performance indicator for health systems and hospitals. It's tied to reimbursement from the Centers for Medicare & Medicaid Services, and it is linked to patient safety and clinical outcomes.
Press Ganey recently announced the winners of their 2023 Pinnacle of Excellence Award for patient experience. The award recognizes health systems, hospitals, and other healthcare providers that demonstrate top performance in patient experience for three years. Nearly 100 organizations earned the honor in 2023.
Executives at two of the award winners, Hoag Orthopedic Institute in California and Dartmouth Health in New Hampshire, recently shared the primary elements of their patient experience success with HealthLeaders.
Steven Barnett, MD, chief medical officer of Hoag Orthopedic Institute, says patient experience needs to be a top concern for CMOs, other top executives, and physicians at hospitals.
"Patient experience reflects on all of us in our practice at the hospital," he says. "All of the doctors at the hospital work in private practice, and the experience our patients have in episodes of care, whether it is a joint replacement surgery, knee ligament reconstruction, or a spinal decompression, directly reflects on us and our practice. As CMO, patient experience is critical to my career."
Brant Oliver, PhD, MS, MPH, system vice president for care experience at The Value Institute at Dartmouth Health and associate professor at Dartmouth College's Geisel School Medicine, says there are three reasons why CMOs should be concerned about patient experience.
"First is the bottom line," he says. "About 12.5% of CMS reimbursement is predicated on patient experience performance. The better we do on patient experience, the better the bottom line will be."
“Secondly," he says, "the better we do on patient experience, the better workforce engagement will be. Working on patient experience can make working as a healthcare professional better. Thirdly, patient experience is connected to quality and safety outcomes. Evidence shows that as safety improves, so does quality and patient experience."
Patient experience best practices
At Hoag Orthopedic Institute, Barnett says, there are seven key components of patient experience at the hospital and the organization's ambulatory surgery centers.
Ensuring that patient navigation through the episode of care, from pre-surgery to surgery to post-op to discharge, is easy and seamless.
Educating patients before surgery to set realistic expectations about care and outcomes. Patients should not be surprised by anything during the episode of care.
Whether it is phone calls or office visits, follow-up is part of the episode of care, and care teams want to make sure patients are achieving what they are expected to achieve.
Staffing with dedicated and competent clinical care professionals is critical. The institute has been successful in maintaining high nurse-to-patient ratios, which promotes responsiveness in care settings.
Offering patient engagement tools and applications that patients can use throughout their care. These resources are easy to access, so any questions that patients have that can't be answered by someone on the phone can be addressed through the tools and applications.
Ensuring the hospital is clean and well-maintained.
Scheduling monthly meetings of the patient experience committee to discuss opportunities for improvement at the hospital and ambulatory surgery centers.
Oliver says there are several important facets of patient experience at Dartmouth Health.
"Effective communication between patients, families, and healthcare professionals is critical," he says. "Another critical area is access. Patients need to able to get access to what they need when they need it in a way that works well for them. Access can mean not just getting in to see a provider but also being able to get a response back when you call in."
"Another part is recognizing feelings and preferences," he adds. "Oftentimes in healthcare, we focus on the right service, the right medication, or the right diagnostic work, and those things are important. But if we do not know the patient's preferences and what they value most, we will miss the target in trying to help them. There also must be a respect for diversity, culture, and different backgrounds. Different people from different cultures have different expectations and different healthcare needs."
"They are frontline-oriented, meaning that if there are issues or concerns about care experience, the frontline people work to address those issues or concerns rapidly," he says. "There is also a high degree of senior leadership empowerment and engagement for patient experience activities. For example, at New London Hospital, the CEO goes on rounding with the patient relations and patient experience manager to speak with patients directly. This may seem like a small thing, but it empowers care experience actions at that site."
Avoid patient experience pitfalls
Barnett and Oliver say there are ways to avoid detracting from patient experience.
"It is important to hire the right people," Barnett says. "People who are not engaged in patient experience do not get hired at Hoag Orthopedic Institute. Patients tell us that our staff is the most caring and friendly staff they have ever experienced at a hospital. You also should never tell patients that you are too busy to do something."
Patient experience should not be approached as a matter of only amenities, Oliver says.
"Like many other fields, patient experience has evolved over time and in some health systems it is positioned as part of a communications department, HR department, or marketing department," he says. "In these health systems, patient experience efforts may be focused on improving the food in the cafeteria or having better televisions in patient rooms. Those things are helpful, but they do not target the main drivers of experience such as trust, confidence, communication, and responsiveness. So, one pitfall is to go after 'shiny things' rather than the practices that we need to focus on to optimize the care experience."
Another main patient experience pitfall is the belief that focusing just on doing the right technical things will provide a good experience, Oliver says.
"Technical prowess is necessary but not sufficient," he says. "It is critical to communicate well with people in addition to doing the right technical things in clinical encounters. It is also critical to focus on the things that are important to patients and families as opposed to the things in guidelines that we have to do."
Team-based care has many benefits for patients and healthcare providers.
Health systems and hospitals should be doubling down on team-based care, a pair of chief medical officers say.
In a recent position paper, the American College of Physicians stressed the importance of physician-led care teams. Team-based care models have been linked to good patient health outcomes and better healthcare-professional collaboration.
Healthcare has reached a level of complexity that calls for a team-based approach to care, says Brad Archer, MD, CMO of Monument Health.
"The complexity of navigating an increasingly technologically advanced medical system requires more than an individual physician or traditional doctor-nurse team can provide," he says.
Team-based care takes the doctor-nurse dyad to the next level, effectively engaging a variety of healthcare professionals, including advanced practice providers, social workers, clinical pharmacists, therapists, and back-office staff, says William Agel, MD, MPH, CMO of Cape Cod Hospital and Cape Cod Healthcare.
"Healthcare is the ultimate team sport," he says. "There are many benefits of team-based care. For the patient, they get the broad and deep talents of a group of professionals working together to get them well and keep them well. For providers, team-based care allows for the distribution of tasks and complementary skillsets that reduces administrative burdens, lowers burnout rates, and improves job satisfaction as everyone works at the top of their licenses."
CMOs need to be focused on team-based care, Archer says.
"Ultimately, CMOs are charged with allocating increasingly scarce resources for patients over increasingly more complex technological offerings," Archer says. "We have talked for years about providing the right care to the right patient at the right time. In most cases, there is no individual who has the capacity and the breadth of knowledge to focus holistically on patients. So the CMO must rely on teams to provide care."
Care team leadership
In most cases, care teams should be physician-led, Archer and Agel say.
That's the case at Monument Health. The health system participates in a Medicare accountable care organization and other value-based care arrangements, which use attribution to physicians for looking at data, so physician-led care teams make sense, Archer says.
Physician-led care teams also fit well with patients' perceptions of who is in charge of their healthcare, he says.
"Ultimately, we want a captain of the ship in place to help guide care, and physicians are well-suited to that role," Archer says. "The coordination of care needs prioritization. Physicians are the best trained healthcare professionals to be able to know how to prioritize care coordination needs."
Care teams should be led by the individual most qualified to attain a positive outcome for the patient, Agel says.
"In most cases, that is going to be a physician, who is the person with the most training and the most authority to diagnose and treat a problem," he says.
There are circumstances where a nurse or an advanced practice provider, such as a nurse practitioner or physician assistant, can take on the responsibility of leading a care team, Archer and Agel say.
"For nurse practitioners or physician assistants to lead care teams, there needs to be clear and concise guidelines," Archer says. "You should also have a patient population that has been pre-selected. The goal should be to gain adherence to the guidelines for the betterment of the patient's health. Those situations lend themselves well to having advanced practice providers leading teams. However, when there is diagnostic uncertainty or multiple problems that are contributing to a patient's overall health, it is best to have a physician leading the care team."
An advanced practice provider or nurse may have a particular area of expertise, such as coordinating the care of a patient or navigating a patient's experience through diagnosis, that makes them good candidates to lead a care team, Agel says.
"An advanced practice provider may know the patient perfectly well in the primary care setting and know the patient better than the physician does," he says. "In that case, the advanced practice provider is probably better able to guide the care of the patient, with the help of every member of the team including the physician."
Team-based care at Monument Health and Cape Cod Healthcare
The approach to team-based care at Monument Health is focused on three principles, Archer says.
The health system has embraced a culture of team-based care that is supported by participation in a Medicare accountable care organization as well as the need to manage the health system's own self-insured employee population.
Monument Health care teams define roles based on team members functioning at the top of their licenses.
Care teams address workflows and the needs of the patient outside of the care team. For example, care teams play a key role in addressing the social needs of patients and have a master list of resources that they can make available to patients.
Cape Cod Healthcare also deploys teams across the continuum of care, Agel says.
On the outpatient side, the health system's patients have a medical home in the primary care physician space that features a team-based approach to care. In another example, there is multidisciplinary care for cancer patients.
"On the inpatient side, our obstetricians and nurse midwives work side-by-side with our pediatricians, nurses, and social workers to provide wrap-around care and support for families," Agel says. "Our general cardiologists work with our interventional cardiologists, nurses, and advanced practice providers in a heart-team approach to optimize the care of our cardiac patients. Our surgeons, surgical subspecialists, emergency department staff, hospitalists, physical therapists, and nurses provide care for our trauma patients."
Deviating from physician credentialing best practices puts healthcare organizations at risk for claims of negligence.
Although physician credentialing may seem like a tedious administrative task, poor executions can result in serious consequences such as fines, delays in claim reimbursement, exclusion from federal programs, and harm to patients.
Credentialing lapses can expose healthcare organizations to malpractice suits and accreditation problems. Deviating from physician credentialing best practices—obtaining, assessing, and verifying a clinician's credentials—puts healthcare organizations at risk for claims of negligence.
Verisys, a SaaS platform specializing in provider data management, provider credentialing, and compliance, has identified eight common physician credentialing weaknesses.
1. Relying on limited staff and administration: Credentialing includes verifying a clinician's education, medical training, residency, licenses, and certifications issued by a board in the physician's area of specialty. Health systems or hospitals may not allocate adequate resources or staff to complete the medical credentialing process, which can result in lost revenue and overworked staff who are more likely to make mistakes.
2. Incomplete physician enrollment applications: The average physician enrollment application requires a vast amount of information and data. Failing to accurately fill out the application in its entirety causes delays in reimbursement and denial of claims.
3. Allowing physicians to treat patients before credentialing is completed: Courts have ruled that hospitals can be held liable when a physician falsifies credentials or begins practicing before credentialing has been completed.
4. Not updating and verifying information: Physicians need to renew their licenses and credentials on a regular basis, according to the laws of the state in which they practice. Initial credentialing and recredentialing ensures that physicians are up to date with their board certifications and licenses. When hospitals fail to stay on top of recredentialing, it could lead to physicians and facilities performing services they are not certified or licensed to perform, which can lead to malpractice lawsuits.
5. Covering up prior adverse action: Failing to disclose an adverse action is a serious oversight by any physician, but it is also the responsibility of a healthcare organization to conduct screenings for prior disciplinary actions with a thorough background check. Healthcare organizations should verify credentials against an array of databases such as the Office of Inspector General exclusion list.
6. Failing to report adverse actions: Physicians are required to report adverse actions such as license revocation; exclusion from third-party programs; and suspension or voluntary relinquishment of medical staff membership or clinical privileges. Healthcare organizations can be held accountable for a physician's omission.
7. Failing to report adverse actions to the National Practitioners Data Bank (NPDB): Physicians and healthcare organizations that fail to report adverse actions to the NPDB withhold critical information needed to complete medical credentialing. The NPDB requires reporting of the following actions: medical malpractice payments, federal and state licensure and certification actions, adverse clinical privileges actions, adverse professional society membership actions, negative actions or findings by private accreditation organizations and peer review organizations, healthcare-related criminal convictions and civil judgments, and exclusions from participation in a federal or state healthcare program such as Medicare and Medicaid exclusions.
8. Failing to take peer review activity seriously: Information provided in a peer review or investigation should be taken seriously and be evaluated as part of the credentialing process. Peer references can inform the capabilities and competencies of a physician that cannot be determined from simply checking education, training, or license status.
Chief medical officer perspective
Physician credentialing is an essential function at health systems and hospitals, and CMOs should be engaged in the process, says Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer at RWJBarnabas Health.
"Having a rigorous process and procedure around physician credentialing ensures the highest levels of quality, safety, and service in the healthcare environment," he says. "The credentialing process is essentially a crosscheck on training and past work experience to support the granting of privileges to practice in specific areas in the healthcare setting. A CMO has to be someone who monitors, shepherds, and supports that process to ensure that the highest level of quality, safety, and service is attained."
RWJBarnabas ensures that the health system has adequate resources and staffing for physician credentialing, Anderson says.
"We maintain a staffing model that ensures the work gets done at the highest levels of service and quality," he says. "We monitor areas such as turnaround time, and we also get feedback directly from our physicians on the credentialing experience. We have a talented group of subject matter experts in our medical staff office who oversee the credentialing process. We make sure they are fully supported."
RWJBarnabas ensures that physician enrollment applications are complete and that credentialing information is updated and verified, Anderson says.
The health system has a software system that makes sure every element of the process is completed and all requirements are met, he says. Additionally, RWJBarnabas has a quality control process for physician credentialing that goes back and audits and crosschecks to make sure that everything is completed and accurate. The medical staff leadership reviews and approves applications once they are complete and accurate.
At RWJBarnabas, it is nearly impossible for physicians to treat patients before credentialing is complete, Anderson says. Physicians are not activated in the electronic health record to be able to practice until the credentialing process is completed and approved by the leadership of the medical staff, he says.
The health system takes great care in handling adverse actions such as license revocation as part of the credentialing process, Anderson says.
"Any issues such as a history of license revocation are taken into full consideration as part of the assessment of an application to our medical staff," he says. "For physicians who are already on the medical staff, we follow all state laws and regulations, and we report all adverse actions to the New Jersey licensing boards. We take these issues seriously. We also want to be fair with the physicians; but in the end, we must protect our patients and the public."
Peer review as part of the physician credentialing process is also taken seriously. Anderson says.
If there is an issue that has been raised about a patient care case, typically a hospital CMO will conduct fact-finding and determine whether a peer review is necessary, he says. An independent peer is brought in to look at the patient care case and provide unbiased input, so the health system can understand why the physician chose to behave in a certain way. If a patient care case raises serious issues, it can adversely affect a physician's credentialing, he says.
Physicians play many administrative leadership roles at Tampa General Hospital and Yale New Haven Health.
Physician leaders at health systems and hospitals drive better quality, improve efficiency, and influence clinical practice, a pair of top physician executives say.
Physician leaders guide medical staffs and play key hospital leadership roles. They augment the work of nonphysician administrative leaders and bring a clinical perspective to administrative issues.
"For the hospital, we cannot solve problems well if we do not have the physicians' perspective," says Peggy Duggan, MD, executive vice president, chief physician executive, and chief medical officer at Tampa General Hospital. "Having physician leaders helps us understand how doctors work and what is going to work well for them. If we are going to drive better quality, improve efficiency, or optimize utilization of resources, we need physician voices. We need our physician leaders."
Tampa General is one of the largest hospitals in Florida, with more than 1,000 licensed beds and more than 8,000 team members.
Physicians play key administrative leadership roles for Tampa General's medical staff and the hospital as a whole, Duggan says.
For the medical staff, every clinical department at the hospital has physician leaders such as the chief of medicine and the chief of surgery who are elected by their peers. There is also a leadership team of physicians for the medical staff, which includes chief of staff, vice chief of staff, treasurer, and secretary. The medical staff leadership positions are a great way to grow as a physician leader because there are graduated leadership opportunities, Duggan says.
"Most of these leaders start as an ad hoc member of the medical staff officers, then people can move into formal leadership roles. These leaders learn every year, so it is a great way for physicians to gain leadership skills," she says.
In hospital administration, Tampa General has physician leaders in several areas such as hospital operations and care quality. Hospital departments also have physician leaders, Duggan says. "For example, in the neuroscience service line, we have a physician leader for stroke, a physician leader for spine surgery, and a physician leader for neuro critical care," she says. "We take clinically active physicians and part of their schedule includes administrative work such as making their portion of the service line more efficient, improving quality, and opening new programs."
Physician leaders are a crucial component of the administrative leadership at Yale New Haven Health, says Thomas Balcezak, MD, executive vice president and chief clinical officer at YNHH, which is an academic health system that features five hospitals.
Balcezak is the top physician executive for the health system. Each one of YNHH's five hospitals has a chief medical officer, who is the employed physician leader of the organized medical staff. There are elected medical staff leaders in each one of the medical executive committees at the hospitals. There are physician chiefs of each of clinical department who run the clinical operations and academic work for each of the departments.
The health system has many other physician leaders in key posts, he says. There is a vice president for clinical documentation and utilization review who reports to Balcezak. There is a health system chief quality officer who reports jointly to Balcezak and the chief physician executive, who is a Yale School of Medicine employee. There are several physicians who work in leadership roles in the information technology space. There is a clinical operations executive director who reports to Balcezak and works on clinical operations functions such as patient flow and length of stay.
At YNHH's hospital level, there are many physicians who serve as medical directors for inpatient and outpatient services. The medical directors report to the hospital CMOs.
Essential qualities of physician leaders
Physician leaders need to see beyond their own patients and their own practice, Duggan says.
"They should want to drive improvements in areas beyond their day-to-day clinical responsibilities," she says. "There are many phenomenal physicians who want to do clinical care and just that. That's what gets them up every day. Physician leaders must see the bigger picture beyond individual patient care. Obviously, physicians are focused on quality, safety, and patient experience, but physician leaders must be willing to understand the financial side of care. At Tampa General, they need to understand the financial challenges of running a hospital."
Communication skills are important in being a physician leader, Duggan says.
"You need to be able to make sense of the 'why' behind something we are doing and be able to communicate that to a broad audience," she says. "Temperament matters. We have an independent medical staff, so physician leaders must be able to understand the positions of our team members and be able to be patient when we are working on projects."
To influence clinical practice and how physicians work, it is crucial for a physician leader to have credibility as a clinician, Balcezak says.
"Physicians who did not do a residency or did not practice medicine shortly after residency really need a background in clinical practice and the respect of the practicing clinicians in order to influence them," he says. "They must have a background in clinical practice. A good physician leader must have a good grounding in whatever clinical discipline they have trained in. I prefer a physician leader who is a respected clinician."
Physician leaders must be equipped with emotional intelligence and values that align with the organization's values, Balcezak says.
"Physician leaders need to have emotional intelligence and need to be able to influence people because much of what we need to do to move the dial on quality, safety, and operations is not by fiat but by influence. In order to manage by influence, you must have emotional intelligence," he says. "Physician leaders need a moral compass that points in the right direction—meaning I want them to live the values of the organization."
Physician leadership development
In addition to grooming physician leaders in the medical staff's governance structure, Tampa General has a formal physician leadership program in a partnership with the Muma College of Business at the University of South Florida, Duggan says.
"Physicians learn leadership skills, leadership requirements, financial training, operational training, data analytics, and utilizing data," she says. "It is a broad educational platform, and the training lasts for about 18 months. There is also a capstone project—participants work on a project that is important to the operations of the hospital or one of our clinics that aligns with our strategic goals. We have broadened the program to include some of our advanced practice providers and administrative leaders, but it is primarily designed for physician leaders."
Tampa General also has less formal leadership development opportunities for physicians, Duggan says. There is a process improvement training program open to physicians, where doctors are selected for project work and develop their skills individually. And there are special projects with physician leaders that are led by Duggan, the chief quality officer, and the vice president of medical affairs.
The YNHH Institute for Excellence (IFE) provides leadership development programming for physicians and nonphysician administrators, Balcezak says.
"The IFE is our learning and teaching organization within the health system," he says. "The IFE helps our senior leadership team and the cascading levels of leadership below in succession planning and leadership development. The IFE has several programs. For example, seven years ago we committed to being a high-reliability organization, and the IFE provides high-reliability training. With regard to our patient experience, there are several IFE courses that we have about enhancing communication with patients."
Having a CMO involved in physician contracting can be an advantage, particularly in a dyad environment that includes the CMO and the CEO or the CFO.
Chief medical officers should be involved in physician contracting to help guide physicians and set expectations for physicians relative to a health system's or hospital's culture, the CMO of Davis Health System says.
With most physicians now employed by healthcare organizations rather than practicing independently, physician contracting has become a key area of interest for CMOs and other healthcare leaders. Physician contracts are structured to reward doctors for productivity, incentivize quality and safety measures, or combinations of these approaches.
Familiarity with physician contracting is crucial for CMOs, says Catherine "Mindy" Chua, DO, CMO of Elkins, West Virginia-based Davis Health System.
"Part of my job is to talk with physicians about culture and what we expect of them relative to our culture. So, knowing what is in the contracts and what the expectations are can be helpful to guide physicians," she says. "For example, if a physician says they want to work part-time to achieve a better work-life balance, I know how that would affect them financially, how that would affect the health system financially, and how that would affect their patients."
Having a CMO involved in physician contracting can be an advantage, particularly in a dyad environment that includes the CMO and the CEO or the CFO, Chua says.
"The CMO can guide the quality metrics that would enhance the performance of the entire health system and the way that doctors interact with patients. Whereas, the CEO or CFO drives the financial piece of physician contracts," she says. "Together, the dyad players can make a physician contract that is useful for the organization and helpful for the doctors in attaining a favorable work-life balance. Physician contracts also need to be designed to benefit the people you are serving, which are the patients."
At Davis Health System, physician contracts are designed 100% with work RVUs, which is a metric used to measure the work physicians do.
The primary elements of the health system's physician contracts include relatively standard legal terminology as well as how physicians enter into the contract and can exit the contract, Chua says. "From my perspective, the core elements are hours expected to work, call schedule, expectations for productivity, number of hours face-to-face with patients, and salary."
She says one of her goals is to introduce quality and safety metrics into physician contracting at Davis Health System. "Work RVUs do not take into account quality, safety, service, operating cost, and operating margin. If you can build those elements into the physician contract so that you have a situation where the physician is not just being paid for productivity, you can have a contract that is beneficial all the way around."
There are payment models that can guide healthcare organizations to include quality and safety metrics in physician contracts, Chua says.
"For example, you can look at the Merit-based Incentive Payment System (MIPS) requirements for different services such as surgery, ophthalmology, or family practice to see what the Centers for Medicare & Medicaid Services is rating us on in terms of quality and safety," she says. "If you can capture that information, you can give a physician a base salary then increase compensation based on their ability to meet the quality and safety metrics of their specialty."
The MIPS requirements can form the basis for structuring physician contracts to account for quality and safety, Chua says.
"You can take information from MIPS, then go to the chief of a service line and tell them, 'These are the quality metrics that are meaningful to CMS, which of these metrics are meaningful to you and your patients?' Based on that conversation, you can build an incentive package," she says.
There are several pitfalls to avoid in physician contracting, Chua says.
Make sure there is an exit clause in the contract that does not have to be for cause.
Many states are moving away from noncompete clauses in physician contracts.
If you are using 100% work RVU contracting, you want to be very specific in that language.
There are instances where you should not be too specific in contract language. For example, if a physician is contracted to work four 10-hour days per week, but they decide they want to work five 8-hour days per week, you would have to go back and amend the contract.
You should be careful with start dates because there can be delays such as licensing that can affect a start date. Being flexible on start dates can avoid more paperwork.
The physician perspective
For doctors, there are several best practices for entering into physician contracts, says Steven Furr, MD, president of the American Academy of Family Physicians and a practicing family physician in Jackson, Alabama.
"The No. 1 best practice is doing a contract far enough ahead of time. Residents often wait too late in the process because there are many steps that you need to go through," he says. "You should have advisors to help you with physician contracting. It is helpful to have a healthcare attorney who can review a contract and see whether there are issues that you need to address that you may not be aware of. It is also helpful to have a tax accountant to look at contracts to see whether there are any tax considerations."
When they look at a contract, most doctors look at the salary, but a contract is much more than compensation, Furr says. "There are many nuances such as malpractice insurance, getting paid for membership dues, and continuing medical education reimbursement."
Doctors should be wary of restrictive covenants such as noncompete clauses, he says. "Doctors need to address exclusive covenants upfront. They must decide whether working at an organization is so attractive that they are willing to live with a restrictive covenant. Otherwise, they must consider walking away from the opportunity. Some contracts say a doctor cannot practice within a certain area if they choose to leave an organization. Those arrangements can be restrictive, and sometimes the designated geographical areas can be extremely large, which means a doctor would have to leave the area to continue practicing medicine."
There is a shortage of primary care physicians, and with restrictive covenants, if a doctor wants to leave a practice, they are also leaving their patients behind, Furr says. "You are disrupting patient care. For us as family medicine doctors, it is all about the physician-patient relationship, and restrictive covenants by their nature can disrupt those relationships."
Nonphysician healthcare providers such as nurse practitioners should not be allowed to practice medicine independently, they say.
In a new position paper, the American College of Physicians (ACP) stresses the importance of physician-led care teams and makes several recommendations on team-based care.
Team-based care models have been linked to good patient health outcomes and better healthcare-professional collaboration. While physician associations such as the ACP promote physician-led, team-based care, groups including the American Association of Nurse Practitioners say that advanced practice providers such as nurse practitioners can function successfully in an independent and autonomous manner.
"Some healthcare professionals have sought to practice independent of the physician-led healthcare team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care," the ACP position paper says.
Although physician-led care teams generate positive results, the ACP position paper says these teams face barriers "including high implementation costs, insufficient financial incentives, and scope-of-practice changes that permit nonphysician healthcare professionals to practice outside of the physician-led team-based model."
To address these barriers, the ACP position paper makes several recommendations, including the following:
Physicians should lead healthcare professionals functioning in a multidisciplinary team-based care model such as the Patient-Centered Medical Home (PCMH).
Nurse practitioners, physician assistants, and other nonphysician healthcare professionals should not be allowed to practice medicine independently.
Team-based care should be based on the best interests of the patient. Physicians should have sufficient time and financial resources to lead a healthcare team.
Team-based care including physicians, advanced practice registered nurses, physician assistants, clinical pharmacists, and medical assistants is needed to address physician shortages.
Licensing organizations should not consider the skills, training, clinical experience, and competencies of physicians, nurses, physician assistants, and other healthcare professionals as equivalent. State lawmakers should review their licensure laws to make sure they are consistent with this principle.
Healthcare delivery and payment should be redesigned to promote physician-led, team-based care models such as the PCMH. Payment models should be designed to address healthcare disparities and meet the needs of individuals who are affected by social drivers of health.
Physician-in-Chief's perspective
Nonphysician healthcare providers such as nurse practitioners and physician assistants should not be allowed to practice medicine independently, says David Battinelli, MD, executive vice president and physician-in-chief of Northwell Health and dean of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
"Nonphysician healthcare professionals do not have the education, training, and experience that physicians have—it is not even close," he says. "Nonphysician healthcare professionals can do particular things particularly well, but that does not give someone the privilege to practice medicine independently."
Team-based care models such as the PCMH should be physician led, Battinelli says.
"The physician should be the ultimate leader of team-based care models," he says. "The physician possesses the education, training, experience, and specialty expertise to be the leader of a team. What people get concerned about is whether the physician has too much control. As with any good team, when team members can have specific roles that are in their wheelhouse in terms of their education, training, and experience as well as the top of their competency, then a team functions well. But it is ultimately the physician who should lead the team."
Care teams including advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, medical assistants, and other healthcare professionals can help ease physician shortages, Battinelli says.
"There are physician shortages and part of the problem is that physicians are asked to do a number of things that do not require their level of expertise and training," he says. "They could be doing other things and seeing more patients if they had other team members to help them carry out care. That can help address physician shortages."
Even if there were no physician shortages, there would still be a need to have team-based care, Battinelli says.
"Together, a team can provide the best care for patients," he says. "These teams should be physician led, but that does not mean that other team members do not have a particularly important competency-based skill set. Patients often need more than one doctor involved in their care. They need a team of providers led by a physician to take care of them. Depending on the care that is being provided, it may require nurse practitioners, physician assistants, pharmacologists, social workers, psychologists, psychiatrists, or other professionals. Everybody has a role to play."
Licensing bodies should recognize that the skills, training, clinical experience, and demonstrated competencies of physicians, nurse practitioners, physician assistants, and other healthcare professionals are not equivalent or interchangeable, Battinelli says.
"Some parts of what professionals do are the same and interchangeable but not to the point of practicing medicine independently," he says. "You might have an endocrinologist who specializes in diabetes care, but that doctor can look at the entire patient. You may have a nurse practitioner or a physician assistant who has expertise in managing a patient's blood sugar. But these professionals are not interchangeable with the endocrinologist, who has four years of medical school training, three years of residency training, and three years of training in endocrinology. The nurse practitioner or the physician assistant cannot take care of the entire patient."
There needs to be a restructuring of reimbursement and how team-based care is valued, Battinelli says.
"For example, reimbursement for care such as general internal medicine, primary care, and family medicine is not sufficient; and as a result, you do not have professionals going into those areas," he says. "That has opened the door for people to say we have an access problem and a shortage of physicians, with a need for other allied health professions to fill some of that void. But that is not the proper fill. The proper fill is team-based care, where the patient is at the center of the effort and there is a multidisciplinary team led by a physician. … I would love to see somebody figure out how to pay for the program that is taking care of patients, so that there is enough resources and reimbursement spread out through the program to pay all the team members, including the physician who is leading the team."
Physician leaders will need to respond quickly to opportunities and challenges this year.
In 2024, healthcare will be buffeted by a wave of change, a pair of chief medical officers says.
Healthcare organizations are facing a slew of challenges. Those challenges include workforce shortages that are straining the ranks of physicians and nurses and economic woes that threaten the operations of health systems, hospitals, and physician practices.
1. Recovery and restructuring
For healthcare in general, 2024 will be a year of recovery and rapid restructuring, says Donald Yealy, MD, chief medical officer, senior vice president of the health services division, and chair of emergency medicine at University of Pittsburgh Medical Center (UPMC).
"We have a need to refill and restructure the workforce," he says. "We have a constellation of factors that is making the delivery of healthcare a bigger challenge in the middle of a terrible financial environment. It's not like change never had to happen before, but the timing of change in 2024 needs to be much quicker."
The need for recovery and restructuring is related to the recent threats linked to the coronavirus pandemic, workforce issues, and financial stressors, Yealy says.
"Recovery and restructuring are necessary because continuing to deliver care the same way we have over the past three decades is not the solution to our problems," he says. "The healthcare providers who figure out how to give patients what they need in the manner that they need it as efficiently and effectively as possible will be the ones who dominate healthcare moving forward. We don't have a decade to figure this out. That is why 2024 is a key year for recovery and restructuring efforts."
Restructuring is needed at all levels of healthcare, Yealy says.
"At the individual level, it is a matter of who delivers particular kinds of care and how they deliver it," he says. "The traditional model has had highly trained people doing most of the tasks, such as physicians and nurses. We still need to have a workforce that depends on the primacy of physicians, nurses, pharmacists, and other experts, but we cannot depend solely on them. We need to involve more people and different tools. Artificial intelligence is not going to replace the interaction between a patient who needs care and a physician and a nurse, but it can augment that interaction."
"At the institutional level, whether you are talking about a single hospital or a collection of hospitals in a health system, we are going to have to exist differently to make sure we can respond to patient needs as they change," Yealy says. "A hospital or clinic cannot provide everything to everybody, so we are going to have to restructure the way healthcare is delivered. Over the past 100 years, restructuring in healthcare has occurred at a gradual pace. Now, it is going to happen much more quickly."
Highly trained professionals will remain the backbone of healthcare delivery, but other healthcare workers, including professionals with new titles that have not been utilized in the past, will come to the forefront in 2024, he says. There will be a redeployment of highly skilled healthcare workers as well as a reliance on healthcare workers who can help conduct tasks that do not require highly skilled individuals.
"For example, when a patient comes back for a repeat visit after a care episode or a procedure, an advanced practice provider or a patient care technician could initially assess the patient and gather all the basic information," Yealy says. "Then a physician could focus on the follow-up or the new needs of the patient."
In 2024, healthcare organizations will face a "rocky path," he says.
"Many healthcare providers are not going to be able to adapt quickly enough," Yealy says. "There is going to be an inability to execute on ideas. For many years, you could have a leisurely pace of change in healthcare and do quite well. In 2024, we are going to need to be quicker in responding to opportunities. Some individual providers, hospitals, and health systems are likely to fail."
2. Increased reliance on technology
In 2024, healthcare providers will move more aggressively to adopt and expand technology, says Nathaen Weitzel, MD, associate chief medical officer at University of Colorado Health (UC Health).
"In the perioperative space, there will be a reliance on an improved use of technology such as predictive analytics and AI to refine how we approach the operating room schedule," he says. "We need to optimize our schedules so that we are maximizing the time we have for nursing and anesthesia providers. Technology offers the opportunity to help us balance our resources as appropriately and ideally as we possibly can."
Over the past few years there has been a move toward increased use of robotics in surgery, and that trend will accelerate this year, Weitzel says.
"As we are getting more experience with robotics, we are seeing that patient outcomes are improving and patient length of stay is decreasing," he says. "So, in 2024, we will see more health systems and hospitals increasing the appropriate use of robotics in surgery."
3. More surgeries with patients going home the same day
UC Health is focusing on patient care pathways to select patients who are appropriate for same-day surgery, an option that the organization might not have considered before, Weitzel says.
"We are doing a lot of same-day joint replacements and same-day bariatric surgery," he says. "In 2024, we will be practicing a balancing act, where we will be looking for patients who can safely be taken care of with good outcomes and going home the same day as surgery. They can recover in the comfort of their own home, which frees up bed space for patients who are sicker and having more complex surgeries."
4. Seizing on opportunities to increase efficiency
Driven by workforce shortages, healthcare organizations will be seeking ways to increase efficiency this year, Weitzel says.
"In 2024, we should see an improvement in efficiency to help address the workforce challenge," he says. "In the perioperative space, we have been seeing 10-hour days being stretched into 12-hour days. That extra two hours per day adds up over time, and people start to get exhausted when they are asked to work extra hours. In 2024, we will be looking at the way cases are scheduled, and the way patients are handled. AI has the potential to improve efficiency in the scheduling of surgery and making it work with our level of staffing."
Improving efficiency is the short-term solution to the workforce challenges, Weitzel says, adding healthcare providers cannot significantly increase the number of physicians and nurses in one year.
"There are opportunities to improve efficiency from top to bottom in the patient stay," he says. "You must combine your operating room schedule with your bed capacity. You need to optimize where patients are going after surgery. You need to improve how the post-operative stay is choreographed."
"You need to analyze what type of floor patients are on after surgery and what type of expertise you need on those floors," Weitzel continues. "For example, you do not want to have a hip replacement patient on the same floor as oncology patients who have had complex surgeries for cancer. Those recoveries are different."
Efficiency can be improved throughout surgical episodes of care, Weitzel says.
"You need to streamline patient care, so that patients from the pre-operative phase to the operative phase to the post-operative phase are scheduled appropriately at each stage," he says. "You can cut out inefficiencies, look at the milestones for each day of care, and eliminate gaps in care."
A health system's new AI tool is helping clinicians target the right specialist for a referral, prompt appropriate workups before a referral, and eliminate unnecessary referrals.
Providence health system has developed an artificial intelligence tool to help physicians manage patient referrals more effectively and efficiently.
AI technology is becoming increasingly prevalent in the healthcare sector. For clinicians, AI is being used in a range of applications, including clinical decision support, documentation, and radiology imaging.
Providence identified patient referral management as an AI opportunity and developed MedPearl as an AI product within the health system, says Eve Cunningham, MD, MBA, MedPearl founder and chief of virtual care and digital health at Providence. "MedPearl is a product that lives within Providence. It will probably become its own entity eventually. It has been built and incubated within Providence," she says.
MedPearl is designed to address three common scenarios in patient referrals, Cunningham says.
First, the patient can be sent to the wrong specialist. For example, if the patient has a chronic cough and they see a primary care physician, there are several specialists that the patient could be sent to such as a pulmonary doctor; an ear, nose, and throat doctor; and an allergy doctor. All of those specialists could potentially be appropriate for that condition, and sometimes the patient gets bounced around from specialist to specialist because they don't get to the right specialist at the beginning.
Second, the patient gets sent to a specialist and the specialist says they have to conduct lab tests and workups, then they will ask the patient to come back a second time. A lot of that work could be done on the front-end with the referral. It is common for primary care physicians not to know what workup the specialist would want. If the primary care physician could be given good information to optimize that workup before the patient sees the specialist, access to care could be improved because it can take months to see a specialist.
Third, about 20% to 30% of the time when patients see specialists, they do not need to see a specialist at all. There isn't anything for the specialist to do. If those patients could be kept with their primary care physicians, then the patients who really need to see specialists could see the specialists quicker.
All three of these scenarios are knowledge-sharing challenges in the clinician community, Cunningham says. "The reason why we have these missed opportunities is because we do not do a very good job of sharing knowledge with each other. We are not efficient at it. We do not have a great technology capability to share knowledge with each other in an impactful way that fits into clinician workflows and is easy to use."
Over the past three years, Providence has curated a knowledge bank of referral guides and algorithms to create MedPearl. The referral guides and algorithms have been validated with the clinicians who are using the information. MedPearl features information that is needed at the point of care.
"This information fits into clinicians' workflows, helps get through a patient visit, and helps identify all of the rules of engagement for the next best action for a patient you might need to refer to a specialist," she says. "We have about 600 guides and algorithms in this library. It constitutes about 95% of what a primary care physician does, so when they go into the knowledge base, they are getting what they need."
Generating results
Data shows MedPearl is having a positive impact on patient referrals at Providence.
"We have captured thousands of data points. We have captured search terms. We crowdsource new topics based on when providers are searching for the same thing over and over again," Cunningham says.
Providence conducted a pilot of MedPearl last year. More than 200 clinicians were involved in the pilot, and there were about 14,000 searches in the pilot period. The clinicians reported how the application helped them in their decision-making for referrals.
Twenty percent of the time, clinicians said they did not need to refer a patient to a specialist at all because they got the information they needed from MedPearl and they were able to manage the patient on their own. Seventy-two percent of the time, clinicians said that MedPearl reminded them to order a lab or MedPearl reminded them to start a patient on a first-line therapy before a patient was referred to a specialist. And 20% percent of the time, a clinician changed the specialty or level of urgency for the referral, which seized on the opportunity to make sure a patient did not bounce from one specialist to another.
MedPearl launched at scale in January 2023, and there are now 7,000 users of the AI tool at Providence. Search volume surpassed 150,000 searches this year, and the tool has achieved a 95% search success rate. Early data from 2023 indicates that clinicians have improved their productivity and there is a reduction in unnecessary referrals.
"The way I interpret the data is clinicians feel more confident now that they are using MedPearl that they can refer the patient more appropriately and work them up more appropriately," Cunningham says.
AI and chief medical officers
In adopting AI technology, the primary consideration for CMOs is their workforce, she says. "Their biggest concerns about doctors and clinicians are that they are burned out, there is a shortage of them, or it is difficult to recruit them. CMOs want to make sure that they have a supportive environment for clinicians. CMOs want to be innovative and forward-thinking when they are thinking about different ways of bringing in tools and applications that are going to help assist and augment clinician workflows. CMOs want to be strategic about the types of technology they bring in."
CMOs are the frontline advocates for their clinicians, and they often see problems and prioritize problems that executives in the information systems teams are not prioritizing or are not understanding, Cunningham says.
"When we started building MedPearl, I was the chief medical officer of one of the medical groups when we started identifying the referral problems and started building out the application," she says. "I had many conversations with the information systems team, and they did not understand why we were trying to solve referral problems and why it was such a priority for us. It was because we were living in different worlds to some extent, and we had to translate that for each other and come together with a common understanding."
As members of hospital administration, CMOs must consider the effort required to implement an AI solution, Cunningham says. They need to ask, is it going to scale and is it going to be adopted?
"One of the benefits of MedPearl in this respect is there is not a massive lift for the quality department or the information systems team. We have solved a real clinician pain point, with very little burden on a halo of other teams that must help implement the solution," she says. "In addition, there has been organic adoption. Doctors have talked to each other about the tool and it has caught fire. There was not a need for an internal marketing campaign or a push to get adoption. The tool works in existing workflows. It does not create new workflows. These are all things that CMOs must tick off a list that makes it worth engaging in change management."
UVA Health offers more than a dozen workplace violence resources on the health system's Situational Awareness Violent Event website.
A workplace violence initiative at UVA Health has increased reporting of workplace violence incidents and decreased care team member injuries related to workplace violence.
A recent survey found that 40% of healthcare workers had experienced workplace violence in the past two years. Workplace violence in healthcare settings has several negative consequences such as care team members suffering physical and psychological trauma, according to the survey report. Acts of violence can also disrupt patient care when care team members fear for their personal safety or are distracted by disruptive patients or family members, the survey report says.
UVA Health launched its Situational Awareness Violent Event (SAVE) initiative in 2016. "We have developed comprehensive resources that are available to all care team members through a desktop icon that can be found on any shared health system computer. That desktop icon brings team members to our SAVE website," says Ava Speciale, nursing governance clinical leader at UVA Health.
The staff members working on the SAVE initiative feature an interdisciplinary team. The team includes direct-care clinicians from inpatient and ambulatory settings, an employee health injury coordinator, the Behavioral Emergency Response Team (BERT) leadership, the behavioral medicine consult service, members of the UVA Health security and university police department, Office of Patient Safety and Risk Management staff, and emergency management leaders.
The SAVE website at UVA Health has a range of online resources:
A link that goes directly to UVA Health's workplace violence policy
Links to de-escalation training and other educational resources on workplace violence
A resource for complex behavioral challenges, which usually apply to inpatients, and the resource lists the different teams that can be involved in a complex care meeting
A de-escalation tip sheet
Standard work for the use of "stop signs," which are signs that are hung up outside patient rooms as a visual indicator for the potential for workplace violence
A standard operating procedure for setting flags in the electronic health record that can alert care team members to the potential for workplace violence by patients
A template document that goes with the EHR flags for ambulatory settings, so ambulatory setting staff know ahead of time that a patient is coming who has a flag for the potential for workplace violence, and the document walks team members through how to prepare for those patients
A visitor algorithm that gives care teams tools on how to manage challenging visitor behaviors
Standard work for obtaining a security assessment, which is conducted by UVA Health security staff for ongoing threats of violence
Tools on how to obtain a private security resource, with a description of the private security role and how to escalate performance concerns related to security
A link to the UVA Health Red Book, which is the health system's emergency management manual that has a section on workplace violence
A recovery process for team members, so if a workplace violence incident occurs, the process makes sure that leaders are offering team members resources for recovery
A link directly to the health system's quality reporting system, so a care team member can report a workplace violence event that has occurred
The SAVE leadership team meets monthly, Speciale says. "We have a lot of ongoing work, which includes producing resources and keeping resources updated. We assist with education, training, and presentations to care team members. We report up through our Safety and Security Subcommittee. We are always available on an ad hoc basis," she says.
The robust and comprehensive resources offered on the SAVE website allow team members to problem-solve on their own, but they have support, Speciale says. "When they hit barriers, the SAVE team leadership is available to assist."
Involving clinicians in SAVE
Physicians can avail themselves of SAVE resources, and they have played an active role in launching and maintaining the SAVE initiative, Speciale says.
"We collaborate with physicians. We have gone to some of their groups such as their quality conferences and clinical chairs meeting to present SAVE to our physician leaders, so they can make sure their teams are aware of our resources," she says. "One of our neurology physicians was a great partner in the efforts that started SAVE, including securing many of the resources that we have today."
Recently, the SAVE leadership team has had a graduate medical education resident participate in their meetings and workgroup. "She has helped bring back information she learned about SAVE to her colleagues to educate new interns and residents," Speciale says.
Including residents and interns in the SAVE initiative is important, says Lauren Mathes, a UVA Health clinic manager and co-chair of the SAVE committee. "As an academic medical center, especially with the residency program, we are excited to have the participation of residents because our residents are on multiple units. Because they cross several specialties and clinics, having their participation is great for our team," she says.
Workplace violence efforts beyond SAVE
UVA Health offers workplace violence prevention efforts outside of the SAVE initiative, Speciale says.
For example, in certain departments at the health system, care team members are required to take training that teaches them how to respond to a physical attack. This effort is focused on high-risk areas such as the emergency department.
The physical attack training features Crisis Prevention Institute training, which is common across many organizations, Speciale says. "Team members are trained on how to safely defend themselves if they are attacked. They are trained on physical restraint maneuvers if they need to administer a medication or respond to a situation where someone is physically violent."
As another example, BERT staff respond to workplace violence calls if there is an episode with a patient on a unit or at a practice environment that includes a behavioral health element, Mathes says. "In those cases, the whole BERT staff responds, including behavioral health emergency staff, security personnel, nursing supervisors, and local leadership from the unit or practice. They can help problem-solve those events in the moment. We also have a behavioral medicine team that works closely with the BERT," she says.
Generating results
At UVA Health, the SAVE initiative and other workplace violence efforts have generated positive results at a low cost, Speciale says.
"If you talk to anybody about workplace violence data, there is a challenge of under-reporting. Since we started having our data represented on our internal data portal, we have put a lot of effort into encouraging more reporting and reporting has increased. I have seen statistics from across the country that 80% of workplace violence incidents are unreported," she says.
There has also been a decrease in the number of workplace violence events that result in injury to care team members, Speciale says.
These results have been achieved at a modest cost, she says. "We have incorporated this work as part of our daily jobs. We have pulled together teams where the workplace violence work is part of their jobs, and we have extended that to our leaders, with an expectation to put the resources in place to prevent and respond to workplace violence. Because this is incorporated into our daily work, the costs are minimal."