In 2020, the primary feelings healthcare professionals reported about the coronavirus pandemic shifted from fear to fatigue.
A new research article shows healthcare professionals (HPs) on the frontlines of the coronavirus pandemic in 2020 experienced significant levels of moral injury.
"Moral injury is emotional distress resulting from events or transgressive acts that create dissonance within one's very being due to a disruption or violation of their existential orientation and values system," the co-authors of the research article wrote. Moral injury has been associated with clinician burnout, medical errors, and suicidal thoughts.
The research article, which was published by JAMA Network Open, is based on survey data collected from more than 1,300 healthcare professionals in 2020 before vaccinations for COVID-19 were available. The surveys were conducted in two phases from April 24 to May 30, 2020, and Oct. 24 to Nov. 30, 2020. The surveys included a half-dozen open-ended questions such as, "What has been your greatest source of fear during the pandemic?" Survey respondents included nurses, physicians, advanced practice practitioners, and chaplains.
The research article features several key findings.
Stressors during the first year of the pandemic included fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment
Fear was the primary emotion experienced in phase 1 of the study
Fatigue was the primary emotion experienced in phase 2 of the study
Survey respondents reported feeling isolated from non-healthcare professionals
Survey respondents reported feeling alienated from patients
Survey respondents reported feeling betrayed by coworkers, administrators, and the public
"These findings suggest that HPs experienced moral injury during the COVID-19 pandemic. Moral injury was not only experienced after a single moral dilemma but also from working in morally injurious environments. These experiences can serve as potential starting points for organizations to engender and enhance organizational and individual recovery, team building, and trust. System-level solutions that address shortages in staffing and personal protective equipment are needed to promote HP well-being," the research article's co-authors wrote.
Shifting from fear to fatigue
The primary emotions that HPs experienced shifted from phase 1 to phase 2 of the study.
"In phase 1, most participants expressed fear and uncertainty about the virus itself and its societal consequences. Fears were predominantly associated with 'catching the virus' and becoming ill and/or 'spreading it' to friends, family, and patients. Some referenced fear of COVID-19 transmission to higher risk people, such as pregnant people, older people, and/or those with other medical comorbidities," the co-authors wrote.
The availability and effectiveness of personal protective equipment (PPE) was another source of fear during phase 1 of the study. "We just all assume that we will get sick or have asymptomatic COVID at some point," one survey respondent wrote.
Fatigue supplanted fear in phase 2 of the study.
"In phase 2, most participants stated that as there was more knowledge about COVID-19, there was a decrease in fear: they were 'over it' and experiencing 'COVID fatigue.' There was also resignation around adapting to 'the new normal,'" the co-authors wrote.
By phase 2 of the study, fear associated with PPE dissipated, the co-authors wrote. "In phase 2, many respondents stated that as their PPE became more available with better protocols in place, their fear is gone and replaced with exhaustion."
Isolation and alienation
In both phases of the study, survey respondents reported feeling distrustful and afraid of others such as patients and coworkers. "I don't know that others are taking it as seriously as I am," one survey respondent wrote.
Some survey respondents wrote that family, friends, and community members had become afraid of healthcare workers, with one survey respondent writing that conducting errands while wearing scrubs had to be avoided because of the stigma associated with being a healthcare worker.
Isolation and withdrawal were reported by several survey respondents. "Some people isolated and withdrew physically from others 'for fear of infecting them or exposing them to this as every day I feel that I am a carrier' (respondent 8). They also withdrew emotionally, often assuming other people did not know what they were going through. People felt isolated from their community due to politicized discourses circulating on social media on social distancing protocols, such as wearing masks, especially after having 'dealt with death or even just the difficulty of caring for these patients' (respondent 9)," the co-authors wrote.
Survey respondents reported feeling isolated from patients. "The use of PPE and social distancing measures in patient care contributed to isolation from patients, with HPs feeling as if they were providing suboptimal care. As essentialized by one respondent, 'We can't build a connection with our patients because we can't spend the time to really care for them the way they deserve to be cared for' at the bedside (respondent 14). Many lamented the use of telehealth in clinics and loss of 'the true connection,' finding telehealth to be 'dehumanizing and disjointed' (respondent 15)," the co-authors wrote.
Feelings of betrayal
In phase 1 of the study, the lack of PPE fed a sense of betrayal among some survey respondents. "I felt like our lives were more disposable than our PPE was," one survey respondent wrote.
Some survey respondents still felt betrayed over PPE in phase 2 of the study. "We've just gotten better at protecting ourselves. Our hospital doesn't do a lot for us," one survey respondent wrote.
The feeling of betrayal came from several sources, the co-authors wrote. "HPs felt betrayed and unsupported by management, administrators, institutions, the healthcare system more broadly, and the government. Many pointed to a disconnect between leadership and 'those of us in there doing the hard work.'"
The combination of fentanyl and the coronavirus pandemic have become primary drivers of overdose deaths in the United States.
With overdose deaths reaching a historic level, the co-founder and CEO of a substance abuse treatment organization says medical interventions must be the top priority.
Earlier this month, the Centers for Disease Control and Prevention reported that provisional data show 100,306 overdose deaths occurred in the country in the 12-month period ending in April, representing a 28.5% increase over the overdose deaths that occurred during the same period the year before. The data show opioid overdose deaths increased by nearly 20,000.
Under the circumstances, medical interventions to reverse overdoses are crucial, says Nicholas Mathews, co-founder and CEO of Agoura Hills, California-based Stillwater Behavioral Health.
"This might get into a taboo conversation, but we are at a place, with the deaths of more than 100,000 people in 12 months, where I'm not too concerned about hurting people's feelings. The harm reduction conversation is one that we need to have as a society. What that means is making sure that when, not if, people overdose by using narcotics, we as a society are prepared to help them," he says.
Medications are available to reverse opioid overdoses, and individuals should be prepared to administer them, Mathews says. "Treatment is a long-term proposition. When someone is overdosing, that is a medical emergency, and there are life-saving drugs on the market. There are nasal sprays that can reverse an opioid overdose immediately and save someone's life. I constantly encourage people, if you are in a community where overdoses are happening more and more frequently, get certified on the administration of Narcan—have Narcan readily accessible and available."
Hospitals have a key role to play in the overdose crisis, he says. "Case management departments in hospitals can have resources available for somebody post-overdose if they make it to the emergency room. Hospitals can make sure that all emergency room staff and emergency medical technicians are trained on the administration of Narcan. They can make sure that Narcan is available at all times in the ambulance and at the hospital, so that they can bring somebody back from an overdose."
After patients have been medically stabilized following an overdose, hospitals should be prepared to refer them for follow-up services, Mathews says. "There should be referrals to an addictionologist, to methadone clinics, to intensive outpatient programs, to residential detox programs, and to something as basic as an Alcoholics Anonymous meeting. An AA meeting can show these people that there is light at the end of the tunnel and there are resources to get help."
Why overdose deaths are soaring
Although the cause of the spike in overdose deaths is multifactorial, Mathews says two primary factors stand out.
1. Increased abuse of fentanyl: "The first and most obvious factor is we have a meteoric rise of the new opioid fentanyl, which is 100 times more powerful than morphine. There are many instances of accidental overdose—even by people who did not know they were taking fentanyl. They think that they are taking something else, but it is fentanyl disguised. It is insidious," he says.
The increased abuse of fentanyl is the result of a "logical progression" in the human body's ability to build tolerance to opioids, Mathews says.
"For individuals who have a physical addiction to opioids, tolerance starts with taking more and more of the drugs. Then it moves to taking opioids in a different way such as crushing pills and snorting them. There is always a point where that particular substance stops giving the addict the desired effect. So, people find the next best thing. For a long time, that process ended with intravenous heroin abuse—that was the most powerful opioid that was readily available. Now, there is fentanyl, which makes traditional heroin seem safe," he says.
2. Strain of the coronavirus pandemic: "The pandemic has been very depressing and anxiety inducing. For many people, their livelihood has been at risk, and they did not know what their future was going to look like. People had anxiety just going to the grocery store—they feared catching COVID-19 and giving it to their family," Mathews says.
For many people, the temptation to self-medicate during the pandemic has been overwhelming, he says.
"Anxiety is a powerful motivator when it comes to a desire to escape, whether that is a beer, or a pill, or smoking a drug. Whatever it is, these drugs will do exactly what they are supposed to do and alleviate anxiety. With the coronavirus pandemic, I have never seen such a clear-cut example of society-induced anxiety. All at once, everybody walked into a new environment. We did not have the tools to cope. We did not know what was safe. There has been misinformation and the lack of information. On top of those factors, everything was closed down. So, you take people who are riddled with fear, and they are stuck in their homes. They could not even get out and see family. They could not engage in healthy coping skills that could alleviate anxiety such as physical exercise. Once positive coping skills were stripped away, anxiety reached levels higher than we have ever seen before," Mathews says.
Coupling fentanyl with the pandemic has had cataclysmic consequences, he says. "You take people, you stick them at home, you remove their jobs, you increase their anxiety, and you give them the most powerful drug we have ever had. You have a recipe for disaster."
Dartmouth-Hitchcock Health's cancer center has scored at or above the 95th percentile for patient experience by Press Ganey.
For the second year in a row, Dartmouth and Dartmouth-Hitchcock's Norris Cotton Cancer Center has received a national award for exceptional patient experience.
Patient experience is a crucial element in patient-centered care. Key components of patient experience include timely appointments, easy access to information, and good communication with healthcare providers, according to the Agency for Healthcare Research and Quality.
Norris Cotton Cancer Center, which has its main campus in Lebanon, New Hampshire, and five satellite facilities in New Hampshire and Vermont, has earned the Press Ganey Pinnacle of Excellence Award for patient experience for the second year in a row. "To earn that recognition, we had to compete with healthcare institutions nationally—not just cancer centers. Winning the Press Ganey Pinnacle of Excellence Award means that over a three-year period our cancer center scored at or above the 95th percentile in patient experience," says Steven Leach, director of the cancer center.
Norris Cotton Cancer Center excels in several facets of patient experience, he says. "One of the big things we stress is responsiveness—responding to patients as quickly as we can. We let them know that we have their information, that we have them in our electronic health record system, and that we are in the process of scheduling their appointment. Access is important. We have a target to see patients as quickly as possible after diagnosis."
Effective communication with patients is a top priority at the cancer center, Leach says.
"It is important to give our patients an opportunity to communicate. We have several tools that we provide to our patients to help them tell us what matters most to them. For example, we are in the process of rolling out a new digital app called Patient Wisdom, where our patients can pre-populate information about them before a visit. They can share who they are, who their loved ones are, what they do for a living, and what they do for fun. They can share what matters most to them and what they want their visit to focus on. With Patient Wisdom, our physicians and nurses have access to this information, when they walk into the exam room, on a tablet. They literally have in their hands what the patient wants them to know," he says.
The cancer center provides patients with easy access to care, Leach says.
"Another way that we generate a good patient experience at the Norris Cotton Cancer Center is we provide care close to where patients live at one of our six cancer center sites in New Hampshire and Vermont. For many patients, the patient experience also involves having convenient access to multidisciplinary teams. They don't have to drive to one office to see a medical oncologist then drive to another office to see a surgical oncologist. We offer one-stop shopping under one roof," he says.
The cancer center offers many support services, Leach says.
"We also provide extensive patient and family support services that range from disease-specific support groups, to art therapy, to music therapy, to massage therapy, to a whole host of classes, including meditation and cooking. We offer classes in creative writing to help our patients express their ideas and help find their own meaning in what they are going through. In the disease-specific support groups, patients can tap into the collective experience of both fellow patients currently being treated and cancer survivors," he says.
Patients are deeply involved in their care at the Norris Cotton Cancer Center, Leach says.
"We pride ourselves in co-producing a patient's care with the patient and their family. This idea of co-production is that an optimal clinical experience does not involve a unidirectional transfer of information from a physician or a nurse to a patient. Rather, the transfer of information is bidirectional. The real expert in the room regarding the patient's needs and best interest is the patient. So, we listen to our patients," he says.
Measuring patient experience
The cancer center monitors patient experience, Leach says. "We track several metrics for patient experience. Some of them are just simple questions. 'How satisfied are you with your care?' 'Would you recommend our cancer center to a friend or family member?' 'Were you treated as an individual?' Those are the kind of questions that populate our patient experience questionnaires."
Patient experience at the cancer center is also reflected in demand for services and assessments by national organizations, he says. "Part of patient experience is measured in ongoing demand for our services. Reputationally, we rank very high in measures such as the US News & World Report survey. We recently were accredited by the American College of Surgeons Commission on Cancer. Those national surveys and accreditations are based on objective metrics that include patient outcomes and delivery of safe care."
Impact of coronavirus pandemic on patient experience
The pandemic has had significant impacts on patient experience at the cancer center, Leach says.
"There have been periods when we have not been able to invite family members to be in the room with their loved one during visits with the oncologists. Sometimes, that was just heartbreaking, but it was the right thing to do to keep our patients, their family members, and our clinical teams safe. We still have a limited number of visitors, which can be challenging. We also had to switch our entire program of patient and family support services to a virtual format. For more than a year, all of our offerings such as yoga classes, meditation classes, and sessions for music therapy and art therapy were converted to a virtual, Zoom format."
Workforce shortages linked to the pandemic have also affected patient experience at the cancer center, he says. "COVID has led to upheaval in the clinical workforce in healthcare. We are struggling with staffing issues. If not managed appropriately, that can have a negative impact on the patient experience."
Approach to psychotherapy encourages patients to be observant of their thought processes and to focus on values.
Acceptance and Commitment Therapy can help coronavirus "long haulers" cope with the chronic illness, a psychology professor and practicing psychologist says.
One of the more mysterious characteristics of COVID-19 is that a significant number of patients who are long haulers experience symptoms for weeks or months after recovering from the acute phase of the illness. Coronavirus long haulers have a range of physical symptoms, including cough, shortness of breath, constitutional symptoms such as numbness and tingling, cardiac issues, hair loss, and deconditioning.
Coronavirus long haulers can also experience several behavioral health conditions, says Joseph Trunzo, PhD, a professor in the Department of Psychology at Bryant University in Smithfield, Rhode Island, and a practicing psychologist at Providence Psychology Services in Providence, Rhode Island. Trunzo is also co-author of a book on coronavirus long haulers—Long Haul COVID: A Survivor's Guide.
"At the top of the list, in no particular order, are depression, anxiety, significant and overwhelming fatigue, and cognitive dysfunction, which is commonly referred to as brain fog. There are rare instances where the behavioral health issues become more significant and problematic, including hallucinations and psychosis, but those are relatively rare," he says.
Brain fog is one of the most common long haul COVID symptoms, Trunzo says. "People do not seem to be processing information as quickly or as easily or, sometimes, at all. They may have short-term memory problems. They are not encoding information in the way that they would normally do. Prior to their COVID infection, they might have been able to read a magazine article and remember and digest it well. After their COVID infection, that kind of comprehension becomes very hard."
Acceptance and Commitment Therapy for coronavirus long haulers
Acceptance and Commitment Therapy (ACT) can ease the burden of long haul COVID, Trunzo says. "ACT is a form of psychotherapy grounded in behavioral science that has a lot of empirical evidence in helping people with chronic illnesses to live as rich and full a life as possible, even though they may be experiencing significant symptoms."
Defusion is one of the primary skills taught to patients in ACT, he says.
"The idea is to separate yourself and be more observant of your thought processes. As human beings, we tend to take whatever we think as gospel truth. So, when the thought pops into your head, 'I'm never going to get better,' defusion is the process of rather than having that thought and accepting it as true, you take a step back and say, 'I just had a thought that I might not get better.' Putting yourself in a more observant stance as to what your thought process is then gives you an ability to make better decisions around how functional the thought really is," Trunzo says.
ACT sets aside the truthfulness of thoughts and focuses on their utility, he says.
"For example, with the thought, 'I'm never going to get better,' ACT is not interested in arguing whether that is true. The only thing that ACT cares about is whether there is any functional value or usefulness to that thought. When you can observe your own thought processes, you can ask yourself whether a thought has functional value or usefulness and decide whether it is worth engaging in those thoughts," Trunzo says.
ACT also focuses on values, he says.
"Values are the things that we find inherently meaningful and important to us. ACT encourages values to be the guideposts for all decision-making. For example, someone could have a value of being close to family and friends. But brain fog makes it hard for them to go to trivia night with friends. Their mind is just not sharp enough. The behavior—going to trivia night—is driven by the value of connecting with friends. Even though someone may not be able to engage with the specific behavior of going to trivia night, there are other ways that they can connect with that value. They can have friends come over to watch a movie or have friends over for dinner," Trunzo says.
ACT can help coronavirus long haulers deal with the loss of control from the chronic illness, he says.
"ACT is an approach to psychotherapy that helps people to deal with situations over which they do not have a lot of control. For people who have long haul COVID, they do not have a lot of control over their symptoms. We do not have a lot of treatments. ACT is a way to help people deal with this kind of a situation. ACT can help people engage in their lives in a way that is still meaningful and can provide enrichment. It can help people move forward rather than having them trapped in the thought, 'I cannot do anything in my life until I get physically better.' ACT can help people break out of that cycle."
A report from The Commonwealth Fund finds disparities in health outcomes, healthcare access, and quality and use of healthcare services.
A new report from The Commonwealth Fund finds that racial and ethnic health disparities exist in every state of the country.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
The new report is based on data collected for 24 indicators of health system performance, and the data was stratified by state and by race and ethnicity. The indicators were grouped in three areas: health outcomes, healthcare access, and quality and use of healthcare services. The report examines data for five ethnic and racial groups: Asian American, Native Hawaiian, and Pacific Islander (AANHPI); American Indian/Alaska Native (AIAN); Black; Latinx/Hispanic; and white.
In a teleconference yesterday, the report's lead author, David Radley, PhD, senior scientist at The Commonwealth Fund, summarized the state scorecard data.
"Six states stand out for having higher-than-average performance for all ethnic and racial groups that we measured. These states include Massachusetts, Connecticut, Rhode Island, New York, Hawaii, and Oregon. They also tended to have some of the smallest—albeit still evident—within-state disparities between the groups with the best and the worst performance. In other states such as Minnesota, Michigan, and Wisconsin, health system performance was particularly strong for white residents but lacking among Black, Latino, and Native Americans. These states had some of the largest within-state disparities. Finally, there were a number of states including Oklahoma and Mississippi where performance was weak overall for all racial and ethnic groups. In these states, despite low scores for even the highest performing groups, there were still sizeable inequities in each state," he said.
Health system performance scores by state and race/ethnicity show a stark health inequity between Black and white Americans. Health system performance for Black Americans was above the all-group median in only five states: Rhode Island, Massachusetts, Maryland, Connecticut, and New York. Health system performance for white Americans was below the all-group median in only three states: West Virginia, Oklahoma, and Mississippi.
Health outcomes findings
Even states that have scored high on overall healthcare performance can have significant racial and ethnic disparities, the report's co-authors wrote. "For example, Minnesota, which ranked third in The Commonwealth Fund’s most recent State Scorecard on Health System Performance, has some of the largest disparities between white and Black, Latinx/Hispanic, AANHPI, and AIAN communities."
Health outcomes, which were measured mainly by mortality rates and the incidence of health-related problems, vary significantly by race and ethnicity, the report's co-authors wrote. "In most states, Black and AIAN populations tend to fare worse than white, Latinx/Hispanic, and AANHPI populations. While enduring lower life expectancies for Black and AIAN individuals in the U.S. can be attributed in large part to generations of structural racism, oppression, and other factors beyond healthcare delivery, the healthcare system nevertheless has a crucial and often unfulfilled role in mitigating disparities."
Racial and ethnic disparities exist for treatable conditions, the report's co-authors wrote.
"Diabetes is an example of a disease that can often be effectively managed—for example, with consistent blood glucose monitoring and proven medications—but is nonetheless associated with profound racial and ethnic disparities in outcomes. Black and AIAN individuals are much more likely to die from diabetes-related complications than people of other races and ethnicities. Health systems striving for equity should bolster disease management resources among these communities to achieve better outcomes," they wrote.
Healthcare access findings
There are significant disparities in access to care between white and most nonwhite populations, according to the report.
Health insurance plays a crucial role in access to care, the report's co-authors wrote. "A key contributor to these access inequities is lack of comprehensive insurance coverage, or any coverage at all. Insurance alone cannot guarantee access, but it is necessary for getting needed healthcare without incurring substantial or even catastrophic financial risk."
In 2014, expansion of insurance coverage under the Affordable Care Act through the creation of an individual marketplace and the expansion of Medicaid in many states improved the uninsured rate for all ethnic and racial groups, but insurance coverage disparities persist, the report's co-authors wrote. "In nearly all states, uninsured rates continue to be higher for Black, Latinx/Hispanic, and AIAN people than they are for whites."
The lack of Medicaid expansion in 12 states negatively impacts two racial and ethnic groups, the report's co-authors wrote. "Black and Latinx/Hispanic communities are disproportionally represented in states that have not expanded Medicaid: 43% of Black and 36% of Latinx people live in the 12 nonexpansion states."
Insurance disparities have profound care access implications for people of color, the report's co-authors wrote.
"When people are uninsured, experience gaps in coverage, or are in private plans that do not provide comprehensive coverage, they often avoid getting care when they need it or pay high out-of-pocket costs when they do seek care. This is particularly burdensome for individuals with lower income and little wealth—disproportionately people of color. Because of these costs, Black, Latinx/Hispanic, and AIAN people are more likely to avoid getting care when they need it, more often have higher out-of-pocket costs, and are more prone to incur medical debt at all income levels," they wrote.
Quality and use of healthcare services findings
Disparities in the quality and use of healthcare services are widespread, the report's co-authors wrote. "Across and within most states, white populations overall receive better care than Black, Latinx/Hispanic, American Indian/Alaska Native (AIAN), and, often, Asian American, Pacific Islander, and Native Hawaiian (AANHPI) individuals."
Primary care disparities have a significant impact on the quality and use of healthcare services, the report's co-authors wrote.
"Primary care clinicians play an especially critical role in providing people with high-value services, including preventive care like cancer screenings and vaccines, as well as chronic disease management. … Expanded access to primary care improves health outcomes. And given the relatively lower use of primary care by Black, Latinx/Hispanic, and AIAN people, these groups in particular are likely to see a greater health impact from improved access and quality," they wrote.
New regional CMO at Dignity Health shares perspectives on leadership, patient safety, quality initiatives, malpractice, physician oversight, and graduate medical education.
A key component for chief medical officer success is impartiality, a new regional CMO at Dignity Health says.
Victor Waters, MD, JD, was recently named CMO of Dignity Health's Arizona Central and West Valley Market. He will provide strategic leadership for patient care, safety and quality, and physician oversight at Dignity Health St. Joseph's Hospital and Medical Center, St. Joseph's Westgate Medical Center, the Dignity Health Cancer Institute at St. Joseph's, and two freestanding emergency departments.
Waters' previous administrative roles include serving as CMO of Dignity Health St. Bernardine Medical Center in San Bernardino, California, and serving as interim president and CEO of Nexus Fort Washington Medical Center in Fort Washington, Maryland. He has experience in graduate medical education, including serving as a faculty member and Dignity Health physician liaison at University of California Riverside Medical School.
HealthLeaders recently talked with Waters about a range of issues, including hospital quality initiatives, patient safety, and graduate medical education. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the keys to success for a CMO?
Victor Waters: Being neutral is important. It is like being a parent. If you have two children, you show neutrality and that you care for both. Favoritism in a climate as a leader is never helpful. You need to be impartial and fair to everyone. You need to be seen as objective to lead a medical staff and different departments. You need to be objective with private doctors, surgeons, intensivists, and long-term care facilities, for example. Whatever branch of service that you oversee, you should appear to be fair. That is a cornerstone of success for a CMO.
Second is to be able to use the toolkit of communication effectively. Those are things that physician leaders do not learn in medical school and residency training. They often learn through trial and error. I learned my communication toolkit through my law degree—how to communicate more effectively, how to address certain parties, and how to address contentious issues. That toolkit has benefited me as a leader.
Lastly, you need to be able to acknowledge when you are wrong. I am not fault free. In administrative roles, sometimes we miscommunicate. We misunderstand or just make a wrong decision based on whatever facts that we knew at the time. It is important to show humility for physicians, staff, nurses, and other leaders to respect you as a leader.
HL: What is a primary element of promoting patient safety at hospitals?
Waters: One of the basic keys is establishing safety huddles—they are a portal for all hospital staff including physicians to share any safety concerns. When you have a group that can be onsite or remotely, as we have done during COVID-19, you have a venue to share any safety concerns from almost every department. That is the landmark model for safety.
It raises administration support to hear safety issues.
It allows communication from anyone to share safety concerns.
You have broad stakeholders from every department—from nutrition, to clinical, to ICUs, to nursing, to others—to hear those safety concerns.
HL: What are the primary elements of successful quality initiatives at hospitals?
Waters: What I have found as a CMO, and being successful in quality initiatives, is recruiting the right team, and the key ingredient in having the right team is having a physician champion. You need a physician champion who is truly passionate about the measure you are seeking to improve. It may not be just one physician champion for a quality measure—it may be more than that depending on the complexity of the initiative.
For example, you may want to address sepsis and deaths related to sepsis. You can have many different types of team members on a sepsis initiative. The goal would be to have nursing, a key physician leader, and a key ICU physician because severely ill sepsis patients end up in the ICU.
Another primary element is having frequent meetings and looking at data in real time. Sometimes, if you do not keep ahead of what is going on with a particular quality metric, then you cannot intervene soon enough to make corrections. What flows from having the right team is their ability to analyze the data, look at opportunities, then develop a proactive action plan instead of looking to the past. Looking at data in real time is crucial to managing and leading a quality initiative.
HL: Give an example of a way to mitigate malpractice claims against physicians.
Waters: We have a program at Dignity Health that I have been proactively involved with and has shown success called Communication and Optimal Resolution (CANDOR).
If there is a bad event or an event that is at risk for liability, because there has been harm to a patient, and there is a certain amount of information that the patient does not know, in general, the culture has been to not say anything. That fuels the fire of the family members and often leads to litigation. Anger is what triggers malpractice claims.
The CANDOR program brings together the family members with the doctors, nurses, and anyone else who has been involved in a meeting where people can speak freely. The CANDOR meetings bring about closure because the doctors can share what happened and the family can ask questions. It is an opportunity for the doctors to say they are sorry for what happened. Saying you are sorry does not mean you are taking blame. It shows empathy for what the patient and the family have gone through, and it brings about closure.
HL: When there has been an adverse event involving a physician, how can a hospital conduct physician oversight?
Waters: When there has been a mistake or a misstep, physician oversight involves medical staff, leadership, and my role. What we have is a process. The first thing I practice as a physician leader is not to rush to judgment. I do not want to assume that I have a bad doctor. I look at an adverse event, and we have a process involving peer review where the doctor's peers look at the event and why it happened.
Many adverse events may not be tied to a physician. They may be tied to a process that failed, and the physician may be caught up in the process.
The physician should have an opportunity to speak about an adverse event and learn from it. If there is a pattern that is concerning, it rises to another level that we address. It may be something that we need to stop the surgeon or physician from doing. But overall, when adverse events happen, the mission is to treat the physician with dignity and respect, to look at the event objectively, to look at the facts, and to have an action plan that benefits everyone including the physician.
HL: What are the primary elements of good graduate medical education programs at hospitals?
Waters: Good graduate medical education requires physician leaders who are truly engaged and truly passionate about teaching. That is the starting point. If you do not have that, you cannot have a successful program; otherwise, the residents will feel they are just worker bees. They do not just want to be people doing a job. They want to learn. They want feedback. They want mentorship. So, you need physician leaders who are engaged in graduate medical education.
Second, the attending physicians that rotate with residents must be engaged in teaching, must not be overly critical, and must be patient because working with residents does slow down their normal process, whether it is in the operating room, on a hospital floor, or in a clinic. There is a real benefit if attending physicians are committed to teaching—they can share their experience.
In a joint venture, Geisinger is building two 96-bed inpatient behavioral health facilities.
Geisinger has entered a joint venture to build two behavioral health facilities and boost access to rural behavioral health services.
Providing adequate patient access is one of the primary challenges for behavioral health programs at health systems across the country. The challenge is particularly acute in rural areas such as those served by Geisinger in Pennsylvania. About 60% of rural Americans live in mental health professional shortage areas.
"Access to high-quality behavioral health services is a national issue. It is a challenge that is even greater here in rural America, and the COVID-19 pandemic has exacerbated those challenges," says M. Justin Coffey, MD, chair of the Department of Psychiatry and Behavioral Health at Geisinger.
Geisinger is facing high demand for behavioral health services, he says. "The good news is that safe and effective treatment exists. The challenge is that access to that treatment can be difficult. It certainly is not easy. Today, at Geisinger, we have 16,000 referrals to our behavioral health department. We are doing everything we can to manage that demand to take care of the incredible need that is in our communities."
To address access to inpatient behavioral health services, Geisinger has entered a joint venture with Acadia Healthcare to build two 96-bed inpatient behavioral health facilities in Moosic and Danville, Pennsylvania. Together, Geisinger and Acadia will be investing about $80 million into the new facilities, Coffey says. Geisinger will be a minority owner in the joint venture.
Meeting demand for care
The new facilities will address demand for inpatient care at Geisinger, he says. "Each of these facilities is going to serve adult and pediatric patients. Upon completion, the two facilities will address both the current and what we project will be future demand for both adult and adolescent patients who struggle with all kinds of psychiatric conditions."
The new facilities will offer a broad range of services, Coffey says.
"We will provide acute psychiatric care for adult and pediatric patients, especially those struggling with acute symptoms of psychiatric conditions such as anxiety, depression, bipolar disorder, schizophrenia and other forms of psychosis, post-traumatic stress disorder, and certain forms of substance use disorder. In addition, these facilities will offer transitional levels of care. For example, they will offer partial hospital programs and intensive outpatient programs. These are outpatient levels of care, where patients step up to them from outpatient services or step down to them from hospital-based services," he says.
The new facilities will also offer contemporary modalities of brain stimulation therapy, Coffey says. These are nonpharmacologic interventions such as electroconvulsive therapythat can treat some of the most severe forms of psychiatric illness.
The goal of the joint venture is to focus on the acute care side of the care continuum, he says. "In this region, we know that our communities are 'under-bedded' from an inpatient psychiatry perspective both in central Pennsylvania and northeast Pennsylvania. Through this joint venture, we will be constructing and operating two freestanding, state-of-the-art behavioral health facilities. These facilities are going to bring accessible, high-quality inpatient behavioral health services to our communities."
The Moosic facility is expected to open in the fall of 2022, and the Danville facility is expected to open in 2023.
For nine common maternal morbidities in 2019, medical costs were estimated at more than $18 billion and nonmedical costs were estimated at more than $13 billion.
In 2019, the estimated costs associated with maternal morbidity for U.S. births from conception through the child's firth birthday were $32.3 billion, a new study found.
The United States is experiencing a maternal health crisis. In 2019, the United States lagged other developed countries in maternal mortality ratio, with 20 maternal deaths per 100,000 live births.
The new study, which was published today by The Commonwealth Fund, examined the medical and nonmedical costs associated with nine maternal morbidities: amniotic fluid embolism, cardiac arrest, gestational diabetes mellitus, hemorrhage, hypertensive disorders, maternal mental health conditions, renal disease, sepsis, and venous thromboembolism.
Medical costs include treatment and hospitalization of mothers and their infants. Nonmedical costs include productivity loss and use of social services, such as the Supplemental Nutrition Assistance Program; Special Supplemental Nutrition Program for Women, Infants, and Children; Medicaid; and Temporary Assistance for Needy Families.
The research features several key data points for 2019 from conception to the child's fifth birthday.
Medical costs for the nine maternal morbidities were estimated at $18.723 billion
Nonmedical costs for the nine maternal morbidities were estimated at $13.576 billion.
Total costs for the nine maternal morbidities were estimated at $32.3 billion.
The costs associated with child outcomes were estimated at $24.0 billion.
The costs associated with maternal outcomes were estimated at $8.3 billion.
The healthcare system accounted for 58% of maternal morbidity costs.
Employers, public social services programs, and other nonmedical entities accounted for 42% of maternal morbidity costs, including losses in productivity ($6.6 billion) and costs linked to behavioral and developmental disorders in children ($6.5 billion).
In a prepared statement, the lead study author said maternal morbidity has a widespread impact on society.
"We show that the costs of maternal morbidity affect not only birthing people and their families but also all of us. Our findings highlight the need for more societal investments in maternal health, an area where the United States performs poorly in comparison to other developed nations, despite having the resources to prevent morbidity and mortality," said So O'Neil, a senior researcher and director at Mathematica.
Interpreting the data
The study's co-authors say that the costs associated with maternal morbidity are likely much higher than they have estimated.
"Our model estimated that nine common maternal morbidity conditions associated with births in a given year (2019) cost society $32.3 billion from the beginning of pregnancy through five years postpartum. The lack of comprehensive data for other conditions suggests that maternal morbidity has the potential to exact a much higher toll on society than what we have found, rivaling that of expensive chronic conditions like diabetes, whose costs run into the hundreds of billions of dollars," they wrote.
In addition, the availability of data also likely underestimates the costs associated with maternal morbidity in the study, the co-authors wrote.
"Of the costs documented, medical costs made up the majority (58%). This preponderance of medical costs is likely driven by the relative availability of hospital discharge data compared with other cost information. The focus of these costs on the delivery period also implies our estimates might further miss costs associated with later and longer-term physical and mental health consequences of maternal morbidity for birthing people and their children, including consequences for subsequent pregnancies," they wrote.
Nonmedical costs are also likely underestimated, the co-authors wrote.
"Nonmedical costs accounted for the other 42 percent of total costs, which mainly stemmed from maternal mental health conditions—the maternal morbidity for which we had the most complete information on outcomes and costs. While the literature contained fewer documented nonmedical costs for the eight remaining maternal conditions in this model, studies of other health conditions have found that nonmedical costs attributable to lost earnings, productivity loss, and other indirect costs can account for more than half of overall costs. Additional information on nonmedical costs related to maternal morbidity could raise our estimate of nonmedical and total costs," they wrote.
The co-authors conclude that addressing maternal morbidity must be a healthcare system priority. "The cost of maternal morbidity has significant implications for delivery system leaders and policymakers. System failures that result in today's severe maternal morbidity can result in tomorrow's maternal death, which makes preventing morbidity even more critical to addressing the U.S. maternal health crisis," they wrote.
The Mountain View, California-based health system helped develop one of the first electronic medical record systems.
As El Camino Health marks the health system's 60th year of operating in the Bay Area of California, the health system is celebrating its history of innovation.
Innovation has been a hallmark of the healthcare sector for more than a century. Innovation has driven advancements in a range of medical areas, including medical technology, surgical techniques, and patient experience.
It is critical for health systems and hospitals to be innovative, says Deb Muro, chief information officer at El Camino Health, which features two acute care hospitals.
"You are not going to be able to survive, thrive, and grow if you are not innovating. We all know that healthcare does not provide the best experience for patients—we know that we must innovate to get better. We have opportunities to do things better, and the only way to do that is to do things differently. Innovation is the way that we can make that happen," she says.
El Camino has a lengthy innovation track record:
In the late 1960s, El Camino Health collaborated with Lockheed Martin to develop a computerized physician order entry system. The system was implemented in the early 1970s and became the precursor to one of the first electronic health records.
El Camino Health participated in the development of MitraClip, a medical device that uses a catheter-based approach to repair the mitral valve in a beating heart. MitraClip has revolutionized therapy for mitral regurgitation and received Food and Drug Administration approval in 2013.
In 2014, El Camino Health was one of first hospitals in California to perform a new, minimally invasive aortic valve procedure using the Medtronic CoreValve System.
In 2019, El Camino Health's interventional pulmonology program was the first in the world to perform a robotic lung nodule biopsy commercially. Since then, El Camino's Ganesh Krishna, MD, has published findings showing that the use of robotic-assisted technology leads to more accurate diagnoses and more successful removal of hard-to-reach lung nodules.
In 2019, El Camino Health became the first hospital in California to perform bronchoscopic lung volume reduction, a minimally invasive procedure for severe chronic obstructive pulmonary disease.
One of El Camino Health's newest innovations gives patients the ability to communicate with the health system that they are on their way to the emergency department, Muro says.
"First of all, the patient can go on our website to see how long it will take for them to be seen in the ED. Then the patient, at that moment, can communicate that they are coming, along with a brief description of what is happening with them so we can be prepared when they arrive. We are in our infancy with this initiative, but there is so much that we can do with being able to be predictive. In other words, we do not only want to know what is going to be happening in this moment, we want to know what is going to happen in an hour, four hours, or 24 for hours in the future," she says.
'We have innovation in our DNA'
El Camino Health is committed to innovation as an organization, says CEO Dan Woods. "It is part of the culture of being in Silicon Valley. The people who live in this area have a mindset of new ideas and being innovative. So, innovation is fostered and nurtured within the community and the people who work at El Camino."
Innovation is deeply rooted at El Camino Health, Muro says. "We have innovation in our DNA. We love innovation. We take care of Google patients. We take care of Apple patients. We take care of high-tech industry patients. Innovation helps us to deliver great care and to differentiate us in the community."
There are several factors involved in promoting an innovative culture at health systems and hospitals, Woods and Muro say.
"You cannot be afraid to lead. Sometimes, hospital folks have a tendency to follow. You also need to heed the perspective of the consumer. We as healthcare leaders have a tendency to look at our problems through our own lens and through our own operations, as opposed to looking at our problems from the consumer perspective. You should not try to boil the ocean. Sometimes, hospitals and inventors feel they have to solve moon shots. You need to just try to move the dial one notch. That movement of one notch can start additional waves of innovation, like a pebble into a pond. In promoting innovation, you need to identify a problem or a friction," Woods says.
Fostering an innovative culture at a health system or hospital requires linking innovation to the goals of the organization and having a keen awareness of the market, Muro says.
"You need to place those goals front and center, then you need to determine how you can move the dial to achieve your goals. You need to think about doing things in different ways. Some of it is educating ourselves and going out into the market to see what opportunities are out there. We partner with startups. We partner with our technology vendors to see where they are going," she says.
Achieving innovation at a small health system or standalone hospital
When it comes to innovation, El Camino Health has several characteristics that have enabled the organization to succeed despite its relatively small size, Woods says.
"There is a high willingness to embrace change, which is related to accepting new ideas. There is a willingness to accept failure and to learn from failure. Finally, part of the reason I came to El Camino is because it is a smaller organization that is nimble. I wanted to use that nimbleness to our advantage. We can get things done much faster than larger organizations. We have tech companies that have come to us because we respond with a 'yes' or 'no' much faster than any of the large academic medical centers in California," he says.
Muro offered advice for other small health systems or standalone hospitals that want to aggressively pursue innovations.
"In a small organization, it is critical that you run the business well. Sometimes, the margins are tight, so you want to make sure that innovation helps financially, helps to drive growth, helps with quality, or helps improve the patient experience. If you can achieve those goals, it is an easier road," Muro says.
The study found that if all hospitals operated as efficiently as the most cost-efficient hospitals, the Medicare program would save $8 billion annually.
A new analysis by the Lown Institute lists the 10 most cost-efficient hospitals in the country.
Healthcare accounts for a significant share of the U.S. economy, according to statistics published by the Centers for Medicare & Medicaid Services. In 2019, national health expenditure grew 4.6% to $3.8 trillion, or $11,582 per American. In 2019, national health expenditure accounted for 17.7% of the country's gross domestic product.
The Lown Institute analyzed data from more than 3,000 hospitals. The study examined how much Medicare was billed and compared that figure to 30- and 90-day mortality rates.
For hospitals with average 30-day mortality rates, per-patient Medicare costs ranged from $9,000 to $27,000. The study found that if all hospitals operated as efficiently as the most cost-efficient hospitals, the Medicare program would save $8 billion annually.
The 10 most cost-efficient health systems and hospitals were as follows:
1. Pinnacle Hospital, Crown Point, Indiana
2. Saint Mary’s Regional Medical Center, Reno, Nevada
3. Mercy Medical Center Dubuque, Dubuque, Iowa
4. Encino Hospital Medical Center, Encino, California
5. Park Ridge Health, Hendersonville, North Carolina
6. Oroville Hospital, Oroville, California
7. Saint Michael’s Medical Center, Newark, New Jersey
8. UnityPoint Health-Meriter, Madison, Wisconsin
9. East Liverpool City Hospital, East Liverpool, Ohio
10. Maple Grove Hospital, Maple Grove, Minnesota
The study proves that hospitals can provide cost-efficient care with good outcomes, Vikas Saini, MD, president of the Lown Institute, said in a prepared statement. "If we want to keep costs low for the Medicare program and provide quality care for the 60 million Americans who depend on it, hospitals must be as efficient as possible. The best hospitals prove that you can save Medicare dollars and deliver great patient outcomes at the same time."
The study analyzed Medicare claims data for patients hospitalized from 2016 to 2018. Mortality rate and cost data was adjusted based on patient risk. Hospitals with the lowest mortality rates and lowest costs generated the best cost-efficiency scores.
