Sutter Health capitalized on functioning as an integrated network and effectively increased critical care capacity by more than 200%.
Sutter Health—an integrated network of hospitals and physician practices in Northern California—has successfully navigated several challenges during the coronavirus pandemic.
The pandemic is the greatest public health crisis in the United States in more than a century. As of July 20, there had been more than 35 million reported coronavirus cases in the country, with more than 625,000 deaths, according to worldometer.
Sutter Health, which features 24 hospitals and more than 12,000 employed physicians, has posted impressive performance metrics during the pandemic.
Acquired more than 35 million pieces of critical personal protective equipment, including masks, isolation gowns, and face shields for patients and healthcare providers
Increased systemwide critical care capacity by 200%–300% to care for patients during coronavirus surges
Doubled the capacity of the health system's electronic ICU program—providing all patients access to an ICU team regardless of hospital location
Rapidly expanded telehealth—conducting 1 million video visits in 2020
Reduced hospital length of stay for COVID-19 patients by 12 days—from 20 days at the start of the pandemic to eight days by the end of 2020
Provided COVID-19 testing with the capacity to test thousands of patients per day during surges—performing 700,000 tests in 2020
Integrated network advantages
In the Sacramento, California–based health system's response to the pandemic, functioning as an integrated network generated several advantages, says William Isenberg, MD, PhD, chief quality and safety officer.
"We have had the capability through integration to move around material resources such as personal protective equipment, ventilators, and reagents as well as the capability to move around patients. If one hospital was overrun with severely sick patients and another one had available beds and ICU capability, that gave us a lot of latitude. We were able to load-balance on both the support material as well as the patients. That gave us a lot more capability than a single hospital would have," he says.
Functioning as an integrated network generated supply chain benefits, Isenberg says.
This pandemic has highlighted just how vulnerable and integral the hospital supply chain is in the healthcare industry. To cover the pain points, lessons learned, and solutions for sustaining the supply chain, HealthLeaders is launching a monthly Supply Chain eNewsletter. Get your free subscription.
"We have a supply chain that is coordinated across the enterprise. So, this enables us to benefit from bulk purchase pricing—we do not have individual purchasing managers at every hospital. It is all managed through a centralized strategic sourcing supply chain group. Through their contacts that they have established through years of relationships and preferred customer pricing, they were able to get us things that we needed well in advance," he says.
The scale of Sutter Health's integrated network was an advantage in sourcing personal protective equipment during the pandemic, Isenberg says. "When you are a big, bulk buyer, you are considered a preferred customer at places such as 3M that make masks. We had an edge on individual hospitals that might make a purchase of one or two cases of masks every three months—that is nothing like getting a truckload of masks every other week like we do."
Integration played a key role in reducing hospital length of stay for COVID-19 patients, he says.
"Imagine an individual hospital with 100 beds. If I am a doctor at this hospital and read an article that remdesivir is a good drug to use with COVID patients, I can try remdesivir on one or two patients, but I have not amassed any data to understand whether the drug is safe or effective or understand the best treatment regimen. Because we are an integrated health system, we were able to combine data from across several hospitals. So, the doctors down in Modesto who were seeing a lot of COVID patients could share their experience with a smaller facility that had not seen many patients, and they could say, 'Stay away from hydroxychloroquine. We have already tried it and got no good results from it. But dexamethasone with remdesivir lowers the length of stay.'"
Sutter Health was able to achieve a dramatic reduction in length of stay for COVID-19 patients, Isenberg says. "The first COVID patients we saw in our hospitals were with us for about 20 days. Three months into the pandemic, we had that length of stay down to about seven or eight days. We achieved that through the sharing of information as well as the constant commentary and discussion among our various sites."
Increasing critical care capacity
To prepare for potential COVID-19 patient surges, Sutter Health assessed the health system's critical care capacity early in the pandemic, Isenberg says.
"Early on, we started working with our analytics team at modeling what would happen if the New York experience came to California. They looked at our resources such as how many ICU beds we had and what it would look like if the New York experience happened here. In looking at the models they created, they realized that to be successful we would need about three or four times the capacity of critical care beds that we currently had. We had about 300 critical care beds and needed to boost that up to about 1,200," he says.
To meet the potential need for more critical care beds, Sutter Health focused on supply chain and staffing.
"We immediately contacted our supply chain and put in orders for 900 more ventilators. Fortunately, as we continually monitored what was going on, we never got to a point where we needed that many ventilators. So, we were able to back off from those orders, which is a nice thing about having established relationships with vendors. We were able to throttle our purchasing and delivery for things such as ventilators as we needed them," Isenberg says.
The health system took two primary approaches to increasing critical care staffing.
"One, we flexed nurses from various areas. The governor had suspended elective surgery, and we have many ambulatory surgery centers that have critical care–capable nurses. We uptrained them so they could function in the role of an ICU nurse. Two, my office credentialled all of our ICU doctors and other physicians who were capable of managing ICU patients. These doctors were credentialled at all of our hospitals. So, I could call Davis and have a physician go down to Modesto to work for a week as an ICU doctor," he says.
Another important aspect of increasing critical care staffing was boosting the number of electronic ICU-capable beds, Isenberg says.
"We have hubs—one in Sacramento and one in San Francisco—where we have 24/7 ICU capability with ICU doctors who monitor patients. We have cameras in the ICU rooms so they can see the patients. There are microphones so ICU doctors can talk with the nurses and the patients. That gave the doctors who were physically in the ICU the capability of having ICU-trained physicians monitoring patients 24/7," he says.
The recovery phase of the pandemic includes leadership challenges such as balancing competing priorities, maintaining staff engagement, and avoiding burnout.
Three dozen healthcare experts from 17 countries have published a consensus statement on 10 healthcare organization leadership imperatives during the recovery phase of the coronavirus pandemic.
According to a novel model for the pandemic and other global crises, there are four progressive stages in a crisis: escalation, emergency, recovery, and resolution. The co-authors of the consensus statement say the pandemic has reached the recovery phase, which includes leadership challenges such as balancing competing priorities, maintaining staff engagement, and avoiding burnout.
The consensus statement, which was published by JAMA Network Open, features 10 leadership imperatives to rise to the challenges of the recovery phase of the pandemic.
1. Acknowledging staff and celebrating success
2. Supporting staff well-being
3. Developing an understanding of local and global pandemic conditions that includes informed projections
4. Preparing for future emergencies in areas including personnel, protocols, contingency plans, coalitions, and training
5. Reassessing priorities explicitly and regularly while providing purpose, meaning, and direction
6. Maximizing team and organizational performance while discussing enhancements
7. Managing the backlog of paused medical services while avoiding burnout
8. Sustaining innovation, learning, and collaborations while imagining future possibilities
9. Providing regular communication and engendering trust
10. Providing safety information and recommendations to government, other organizations, staff, and the community in consultation with fellow leaders and public health officials to improve equitable and integrated care as well as emergency preparedness
"The unprecedented and high stakes nature of this global phenomenon highlights an urgent need for clear guidance to support leaders at all levels in navigating the course of this crisis and in preparing for those to come," the consensus statement's co-authors wrote.
Keys to success
One of the co-authors, Jaason Geerts, PhD, of the Canadian College of Health Leaders in Ottawa, Ontario, and the Bayes Business School at the University of London in the United Kingdom, told HealthLeaders that there are five essential leadership qualities required during the recovery phase of the pandemic.
Healthcare leaders need to have humility to distribute leadership by enabling and supporting others. No leader can effectively master all 10 imperatives alone—trusting others is essential.
Healthcare leaders need to be able to accept a context that is volatile, uncertain, complex, and ambiguous (VUCA) as well as have the capacity to lead and prioritize effectively in this situation. In the recovery stage of a crisis, the context changes often. Even at times when things appear to not be changing, there is constant volatility.
Healthcare leaders need to be able to make clear decisions based on the best available information even though the volume of information can be overwhelming and conflicting.
Healthcare leaders need to have the vision to be able to anticipate future developments, including preparing for resurgences, and to imagine future possibilities and to support innovation. Healthcare leaders should not only react to immediate issues as they arise or focus exclusively on what is urgent in the present.
Healthcare leaders must be able to engage in effective communication, which is fundamental to all 10 imperatives. With so much uncertainty, frustration, fear, and burnout, it is essential to maintain open lines of communication. This involves listening to frontline workers and other leaders regarding required resources and recommended improvements, listening with empathy regarding how people are faring, celebrating staff and achievements, and communicating the evolving priorities and the constants.
Focusing on the well-being and morale of staff is critically important, Geerts said.
"In any organization, our people and those we serve are our Number One priority. This pandemic has been tough on a lot of people and has lasted so long that many healthcare professionals are burned out—many were burned out before the pandemic. It is essential that we give them the rest and support they need and to factor their well-being into decisions about re-introducing procedures that were paused during the pandemic," he said.
Reassessing priorities during the recovery phase of the pandemic is particularly challenging, Geerts said.
"Reassessing priorities during a crisis is an ongoing imperative according to the rapidly and constantly changing circumstances. Some tasks or procedures that were front and center yesterday may quickly have to change based on safety directives. This requires gathering information on an ongoing basis internally and from outside the organization through environmental scanning and strategic foresight. Reassessments should be informed by the input of those closest to the work and informed by input from the community. For many people, especially those with a strong proclivity toward predictability, processes, and routine, this situation is very challenging," he said.
There are several factors involved in engendering trust inside a healthcare organization, Geerts said.
"Trust is earned by respecting staff and trusting them to do their job without unnecessary restrictions, listening to and acting on their recommendations for improvements, and instilling in them the confidence that priorities are being decided and decisions are being made with their best interests at the forefront and that they are based on the best available information. This also involves transparency—admitting mistakes including what has been learned as a result, appropriately expressing the times when the situation is uncertain, and addressing the way in which decisions are being made," he said.
A new law in the Lone Star State grants automatic approval of medical orders for clinicians who have a track record of prior authorization approvals at a payer.
The effort to reform prior authorization of clinician orders has taken a step forward in Texas.
Reining in prior authorization of clinician orders by payers is a top priority of physician groups. They argue prior authorization delays or denies evidence-based care and places an onerous administrative burden on healthcare providers.
"Our effort at the AMA and the state medical societies is about right-sizing prior authorization. We do not expect it to go away entirely, but it has gotten out of control," says Jack Resneck, Jr., MD, president-elect of the American Medical Association and a practicing dermatologist in the San Francisco Bay Area.
In June, Texas adopted a new law that features "gold carding" clinicians to make the application of prior authorization more selective. Under the new law, if a clinician orders a medical service such as medication at least five times in a six-month period and at least 90% of the orders pass prior authorization muster, then the clinician is exempt from undergoing prior authorization for the particular medical service for the next six months.
"House Bill 3459 sought to diminish some of the burdens of the prior authorization process on Texas patients and physicians. It sought to do that by creating a path to gold carding or automatic approval when there is a study or service that is ordered by a doctor and the doctor has a track record of getting most of those studies or services approved when using a particular insurer," says Debra Patt, MD, a practicing oncologist at Texas Oncology in Austin, Texas, and immediate past-chair of the Texas Medical Association Council on Legislation.
She gave a theoretical example from her practice. "If I order a CT scan for the chest and abdomen, and I have ordered that exam five times in a six-month period and my history is that they get approved, then for the next six months all of my CT scans for the chest and abdomen through that same insurer will be approved. So, my CT scans will be gold carded."
Gold carding benefits patients and clinicians, Patt says. "The natural consequence of gold carding is that my staff will not spend five hours working on a prior authorization and patients will not have delays in care of two to three weeks to get authorization for appropriate care."
Gold carding only applies to payers that fall under the state's jurisdiction and are not state funded. The law is set to go into effect on Sept. 1.
The Texas law is only a first step in the journey to prior authorization reform, she says. "The truth is that utilization management has gotten more arduous—it has become very difficult for patients to receive guideline-based care. If the purpose of utilization management is to provide high-value care, insurance companies need to step up to the plate and work more collaboratively with physician groups to make sure that we have alignment in getting patients appropriate high-value care without the inappropriate delays and administrative burdens."
National drive for prior authorization reform
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals, and health plans signed a consensus statement outlining a shared commitment to improving five key areas associated with prior authorization. That effort has not generated action, so prior authorization reformists have shifted their focus to legislative and regulatory changes at the state and national level, Resneck says.
"It is unfortunate that since that consensus statement we have not seen any significant progress at the major national health plans. That is why we have reached the point now where patients and physicians alike are looking to legislative and regulatory solutions to try to right-size prior authorization," he says.
The new efforts largely mirror the five reforms sought in the consensus statement, Resneck says.
Selective application of prior authorization: "If you are a doctor who is following evidence-based guidelines, and you are being asked to jump through hoops and fill out prior authorization paperwork, but 99% of the care you are providing with prior authorization is being approved, the health plan should not be placing an added burden on you or themselves to put you through the same process as somebody else who may be creating more challenges."
Prior authorization program review and volume adjustment: "We want to decrease the volume of prior authorizations. For example, medications that end up getting approved 99% of the time probably should not be on prior authorization lists. Generics should not be on prior authorization lists. Things where there is not alternative to treating a certain disease should not be on a prior authorization list."
Transparency and communication: "Some of the state legislation is just asking for the basics of public release of general statistics for prior authorization. For medications, how often are they approved, how often are they denied, how often are appeals filed, and how often are those appeals granted?"
Continuity of patient care: "We see a lot of patients who have a chronic disease, and you find the treatment that works well—they are stable, and their chronic disease is being held in check. Then, all of a sudden, the patient changes health plans or their health plan changes the formulary and the medication that did not require prior authorization now does require prior authorization. So, you have a patient who cannot get renewal of their medication without the prior authorization process."
Automation: "Patients are shocked to find out that when clinicians are sitting down at our electronic health record writing their prescription, we often cannot see what is on formulary and not on formulary, we cannot see what requires prior authorization, and we cannot see how much different medications cost. Physicians feel that we should have transparency about that data."
"The reform effort is requiring a piecemeal approach. The reality is, we are seeing interest at the Department of Health and Human Services, the Centers for Medicare & Medicaid Services, Congress, and state legislatures because everybody is a patient at one time or another and prior authorization has gotten to be so ubiquitous and a burden that patients are getting frustrated. Legislatures are hearing about it," Resneck says.
A practicing family medicine physician from South Carolina becomes 176th president of the American Medical Association.
The new president of the American Medical Association says physicians have a key role to play in the lives of their patients.
Gerald Harmon, MD, is a practicing family medicine physician based in South Carolina. He has been a member of the AMA board since 2013 and served as board chair from 2017 to 2018. Before his election to the AMA board, Harmon served on the AMA Council on Medical Service.
Harmon is a clinical professor at two South Carolina medical schools. He also is a member of the clinical faculty at the Tidelands Health MUSC Family Medicine residency program.
Harmon was inaugurated as the 176th president of the AMA in June, succeeding Susan Bailey, MD. He recently talked with HealthLeaders about a range of healthcare topics, including the pandemic, health equity, and physician burnout. The following is a lightly edited transcript of that conversation.
HealthLeaders: At this stage of the stage of the coronavirus pandemic, what is the primary pandemic-related challenge facing physicians?
Gerald Harmon: Physicians have always been shown to be one of the most trusted sources of information for patients. The patients get direct advice and recommendations from their physicians. Now, physicians need to encourage vaccine confidence and encourage improved access to vaccines.
Vaccine administration has slowed because it is not quite top of mind for a lot of folks. So now, it is critical for physicians to have the vaccines available to vaccinate their patients. We know physicians have been eager to vaccinate patients, and we are still trying to make sure that physician offices across the country have a vaccine supply.
So, it is important for physicians to serve as a source of vaccine information and encourage their patients to receive the vaccine, but it is also important for vaccine suppliers to get vaccines into physician offices and practices so they can give those vaccines to patients and reduce the spread of COVID.
HL: What can physicians say to their patients to increase confidence in the vaccines?
Harmon: There is some misinformation in the media and social media. I try to offer to my patients that there are proper vaccine protocols. I say these vaccines were developed rapidly but not by missing any scientific hurdles.
The messenger RNA and adenovirus technology was taken off the shelf. We did not have to go through funding hoops because the federal government applied funding upfront. The absolute rigor of the scientific process was followed, and these vaccines are among the safest and most effective ever developed. Patients should have every confidence that these vaccines are safe.
HL: How can physicians help to advance health equity?
Harmon: One of the things I get to be is the spokesperson for the AMA's health equity accelerator. Part of our mission statement is advancing the art and science of medicine and the betterment of public health. It is hard to do that without advancing health equity and addressing healthcare disparities. So, health equity is critical to our mission statement.
We released a plan in May with different actions on health equity. We want to promote equity and racial justice in the AMA itself. We want to expand the capacity to understand and implement anti-racism and equity strategies. We want to build alliances with other stakeholders. We want to look upstream to social determinants of health and root causes of inequities. We want to ensure there are equitable structures for providing healthcare such as broadband expansion into underserved and rural communities. Finally, we want to foster some pathways for truth, education, reconciliation, and transformation for AMA's past racial inequities.
It is a big deal. We have had policies established by the AMA House of Delegates establishing that race is a social determinant of health.
HL: Assess the impact of the coronavirus pandemic on physician burnout.
Physician burnout has worsened. Physicians and others absolutely stepped up during the pandemic. They had taken an oath to take care of people. They risked their lives and even the lives of their families by taking care of COVID patients.
A factor that has limited burnout during the pandemic is a renewed sense of purpose. We have done some surveys at the AMA during the pandemic that found that as many as 48% of doctors felt a renewed sense of purpose. They realized that the practice of medicine was a calling. We have had some psychological, emotional, and physical burnout, but we have had a renewed sense of purpose.
Now that the adrenaline is pulling back and we are getting into a post-pandemic steady state where we do not have the overwhelming burden of COVID disease, we still have barriers to physician satisfaction.
We have the barrier of electronic records not talking with each other. We have statistics that physicians spend many hours per year just waiting to log on to an electronic record. We also know that for every hour of direct patient care, physicians spend up to two hours documenting what they did—so it is a very inefficient system. Then we have the barrier of prior authorization, whether it is a prescription drug, a referral to a specialist, or an imaging procedure. We know that the average doctor has almost 40 prior authorizations to process every week. We consider prior authorizations to be barriers to care. We have a lot of disincentives for physician morale to stay high.
HL: What are some of the primary solutions for physician burnout?
The AMA has some prescriptions for physician burnout. If you have an energized and engaged workforce of physicians that is resilient, it is essential for achieving national health goals. We also know that burnout it is not only a physician workforce issue—a healthcare organization must become resilient itself.
For example, if I work for a large health system, I want the organization to develop a resiliency policy. The health system cannot just say that doctors need to be more resilient and work harder. Healthcare organizations can take a more systemic approach. They can focus on staffing and scheduling. They can focus on giving physicians the right tools. They can focus on getting better vendor support for electronic records. They can work with physicians to reduce the burden of credentialling. These irritators can be reduced without reducing quality of care.
HL: What advice would you offer to new physicians who are just beginning to practice medicine?
Harmon: Remember your opportunity to be a doctor. If you are a new doctor now, you have been given a gift. You can treat your fellow human with a level of trust that you have never had before.
To get to be a practicing doctor today, you have climbed a steep hill. You have gone through education in the twelve grades, then you qualified for a college-based degree, then you qualified for medical school. You have met all kinds of successful standards—you can take data, analyze it, and come up with a meaningful application to benefit humankind. You are an extraordinarily gifted person if you are a young doctor. Take that to heart without getting an artificial sense of self-importance. Apply your gift.
Whether it is me as a family medicine physician, an emergency room physician, a researcher, a pathologist, and all manner of physicians in practice, it is such an honor to be a doctor. I recommend to every doctor—take advantage of that honor and be proud of being a physician.
The new joint venture in North Carolina will help independent physician practices by easing administrative burdens and bolstering value-based care capabilities.
A new joint venture in North Carolina that pairs a payer with a management services company is designed to support independent physician practices during the shift to value-based care.
In today's market, independent physician practices face a range of challenges to maintain their operations. In particular, independent physician practices must deal with burdensome administrative functions and develop new capabilities to achieve success in value-based care contracts.
The joint venture is being formed by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) and New York, New York-based Deerfield Management Company. Von Nguyen, MD, MPH, senior vice president and CMO of Blue Cross NC says the payer entered the joint venture for two reasons.
"First, we are very much aligned upon providing options for physician practices to remain independent. The other reason we are doing this is as we look at healthcare, we fundamentally believe that value-based care is the future. When you look beyond the day-to-day administrative tasks, there is an opportunity through people, processes, and technologies to bring new opportunities and new ideas to smaller practices. It can be really challenging to run a practice and learn new capabilities, so this the joint venture is a way to support physician practices as they grow in this new value-based care environment," he says.
Nguyen says there are three broad categories where the joint venture will support independent physician practices—people, processes, and technologies.
"For people, we can help with the staffing of mainly the nonclinical staff. We want to bring in the right staff to support providers at scale. You can imagine that one provider might not need a pharmacist but having a pharmacist across multiple physician practices might make a lot of sense," he says.
"For processes, there is an opportunity to learn from each other. During the COVID pandemic, physician practices were trying to figure out new ways to see patients and keep them safe. You can imagine that through the joint venture, a provider could quickly call and inquire about keeping patients safe, maintaining social distancing, and scheduling appropriately between visits," he says.
"For technology, COVID provides another good example of the potential of the joint venture. Telehealth was all the rage during the pandemic, but there are many platforms for providing telehealth, including Zoom, Skype, WebEx, and Teams. The joint venture can help physician practices choose the right virtual solution," he says.
A primary goal of the joint venture is helping independent physician practices cope with administrative burdens, Nguyen says.
"As we think about this joint venture with Deerfield, it offers an opportunity to get providers out of a cycle where they can focus on their job of providing quality care to patients and leave administrative tasks to a different organization—an organization that is run by this joint venture. This new organization can take care of everything from scheduling, to hiring staff, to making sure rent is paid. All of those administrative tasks are handled—allowing the provider to spend time with patients," he says.
Supporting adoption of value-based care
Another top goal of the joint venture is supporting independent physician practices in the shift to value-based care, Nguyen says.
"In value-based care, you need to think about new capabilities that you need to bring to bear. You need to make sure that you have enough dollars in the bank for when you have bad years. You need to think about care coordination differently. You need to think about keeping patients healthy—you do not make money by seeing patients in the clinic, you make money by keeping patients out of the clinic. Providers need to think about the tools they need to keep patients healthy at home," he says.
The joint venture will support independent physician practices in their journey to adopting value-based care, says Adam Grossman, MBA, a partner at Deerfield. "This is a multi-year process that requires a lot of infrastructure to support practices as they adopt new tools and resources to make the transition to value-based care. So, whether it is helping practices to evaluate the right technology tools, helping practices with relationships in the provider community, or helping practices with contracting, there are several areas where support is needed."
Applying Deerfield's resources
Deerfield has two assets that will play key roles in the joint venture, Grossman says.
"One, we have the Deerfield Institute, which has been in existence for about 15 years. The institute has a lot of capabilities. For example, we can help practices understand different geographies, we can help practices understand market access, and we have an epidemiology team. There are a lot of capabilities within the Deerfield Institute that the joint venture can leverage over time."
"The second component is the Deerfield operations team. That is a group focused on building businesses. This team can help the joint venture figure out accounting and financial management, or information technology, or human resources and talent acquisition. A lot of the business building that is required for the joint venture will be supported by the operations team," he says.
A chief quality and clinical transformation officer shares insights on checklists, value-based care, high reliability, workforce safety, and telehealth.
To advance value-based care, health systems and hospitals need to eliminate "defects in achieving value," a top executive at Cleveland-based University Hospitals says.
Peter Pronovost, MD, PhD, is the chief quality and clinical transformation officer at University Hospitals. The critical care physician has a global reputation as a patient safety champion, including life-saving work developing checklists to reduce central line–associated bloodstream infections. He is a prolific researcher, with more than 800 articles published in peer-reviewed journals.
HealthLeaders interviewed Pronovost recently to discuss a range of topics, including checklists, value-based care, workforce safety, and his vision for telehealth after the coronavirus pandemic has passed. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of a good checklist for clinical care?
Peter Pronovost: The main element of a good checklist is that the checklist helps to ensure that the task that it is intended to occur actually occurs. In other words, the check list is a means to doing something.
There are a few things that guide a good checklist.
One, is that you are crystal clear about what you are trying to accomplish with the checklist. You need to be clear about the behavior you are seeking to change. Two, is that you co-create a checklist with the people who will be using it. In other words, if you impose a checklist on people, it is often wrong and not adopted. Three, is that you ruthlessly try to reduce ambiguity. If you look at one of the main reasons why checklists are not used, it is unclear who is to do what, where, when, and how. Finally, you need to have a mechanism to review and evolve a checklist because, like any tool, the initial draft of a checklist is often wrong. As you use a new checklist with patients, within a short period of time you should have a well-vetted checklist.
HL: What are the primary opportunities to improve the value of clinical care at health systems and hospitals?
Pronovost: Everybody talks about value from a theoretical perspective. Much like checklists, if we cannot get down to the defects in value, we will never be able to achieve it.
I have developed a checklist for value that has three domains: defects in helping people stay well such as not performing cancer screenings, not helping people get well such as poorly managing chronic diseases, and defects in helping people to get better such as mistreating an acute illness. Defects in helping people to get better include making sure that inpatient care is coordinated with primary care, making sure that recommended care is optimal because a significant percentage of every procedure is not needed based on objective criteria, making sure the site of care is optimal at achieving the best outcome at the lowest cost, and eliminating harm such as using checklists to eliminate infections.
At University Hospitals, we have done research that shows defects in achieving value cost the healthcare system $1.4 trillion—it is a third of the annual healthcare spend. But most of these defects are invisible to healthcare providers. At University Hospitals, we have been able to reduce the annual healthcare spend for Medicare patients by 9% in 2018 to 2019 and another 13% in 2019 to 2020. We achieved this by systematically making defects in value visible, then designing systems to eliminate them.
HL: What are the primary opportunities to achieve high reliability in clinical care?
Pronovost: Healthcare is riddled with mindless variation and has too little mindful variation.
Mindless variation is variation that exists either because we have not taken the time to create a standard for high reliability or because someone in a position of power just wants to do something their way. In healthcare, we must make enhanced efforts to reduce mindless variation because it is harmful to patients.
Mindless variation exists in all three domains of defects in value-based care. It exists in preventive care, where we are not making sure people get the right kind of preventive care. It exists in management of chronic disease—there is variation in diagnosis, there is variation in how we treat people, and there is variation in controlling chronic illnesses. And in acute illness there is variation in several areas such as having care in an emergency department that could be provided in a lower cost setting.
A lot of what I just talked about were the technical aspects of high reliability, but there are also tremendous opportunities to achieve high reliability in our teamwork. We do not have highly reliable ways of communicating with each other. For example, most hospitals have people suffering harm because a code will go off and there is an order to call anesthesia, but the code does not say who should make the call. Predictably, five minutes later, somebody says, "Where's anesthesia?" Nobody took responsibility for calling anesthesia. This is a simple example of low-reliability systems in healthcare that need to change.
HL: What are the main areas of workforce safety at health systems and hospitals?
Pronovost: Right now, with COVID, we are seeing a tremendous uptick in assaults and aggressive behavior among patients. It is quite alarming. It is likely due to the impact of COVID and the stresses on people. The issue of assault—especially in our emergency departments and behavioral health units—is troubling and an opportunity for improvement.
A second issue is burnout and the emotional safety of healthcare workers. The past year has been enormously stressful, and staff have witnessed immense suffering. We need to make sure that we heal our healers.
In addition, needlestick injuries are a big issue along with back injuries.
HL: What is your vision for telehealth after the coronavirus pandemic has passed?
Pronovost: The most exciting piece of telehealth is the idea of combining technologies to enhance value.
For example, in our health system, we are combining several individual technologies that generate enormous value. We are doing what we call triggering, which means if you are a patient and you have gone a while without being seen or not having a required test, we can automatically notify you and your provider to come in. With that outreach, we include smart chatting, so there is a chatbot that can educate the patient about diabetes or the importance of mammograms. The outreach includes self-scheduling. And the outreach includes navigating, so you can speak to a nurse or schedule a telehealth visit.
Telehealth is great, but if the people who most need in-person visits are not coming in, we will have a defect in value. By combining technologies, we are creating what I call a web of well-being, where we can identify people in need of health services and provide them with the services that best meet their needs. A chatbot might meet someone's needs, or scheduling a primary care visit might meet someone's needs, or a telehealth visit might meet someone's needs, or speaking to a nurse on a call line might meet someone's needs.
HL: How can leadership drive change at health systems and hospitals?
Pronovost: Most importantly, it is by the narratives that we tell. Stories are the most potent source for change because they define how we act. I learned this in my central line–associated bloodstream infection work.
After we saw a 90% reduction in CLABSI across the country, we interviewed clinicians to ask what was different about this CLABSI effort. We wanted to know if it was just the checklist. Our hunch was it was not the checklist—it was something deeper. When we interviewed clinicians, what we found was they all said, "We changed the narrative." They started the effort thinking that these infections were inevitable, but they got to zero when they thought these infections were preventable and they were capable of doing something about it.
Physicians may be uncomfortable discussing end-of-life issues and avoid having the conversations.
In the outpatient setting, a significant number of oncologists miss opportunities to have end-of-life (EOL) discussions with their patients, a recent research article found.
EOL treatment that does not align with patient goals is a major public health problem that can have a negative impact on patients and families. For oncology patients, EOL treatment that does not align with patient goals includes chemotherapy during the last 14 days of life, ICU care during the last 30 days of life, and late referral to hospice.
The recent research article, which was published by JAMA Network Open, is based on an analysis of more than 400 outpatient encounters at two academic medical centers. The patients had stage IV malignant neoplasm and were expected to be admitted to an ICU or to die within one year.
The study features two key data points.
In 423 outpatient encounters, only 21 (5%) included EOL discussions
In a random sample of 93 of the outpatient encounters, 35 (38%) included missed opportunities for EOL discussions
"Opportunities for EOL discussions were rarely realized, and missed opportunities for these discussions were common, a trend that seemed to mirror oncologists' treatment style," the research article's co-authors wrote.
There were three kinds of missed opportunities to hold EOL discussions, according to the research article.
1. An inadequate response to patient concerns about disease progression: "When patients or caregivers expressed concern over disease progression or dying, they were often met with partial, avoidant, or absent responses from their oncologists. When oncologists did respond, they often deflected concerns, rather than using them as openings to explore patients' goals, values, or preferences for care, according to best practice in patient-practitioner communication," the research article's co-authors wrote.
2. Engaging in optimistic future talk: "Optimistic future talk describes oncologists' responses to patients' concerns regarding disease progression or dying. Instead of addressing patients' concerns directly, oncologists often shared anecdotes of patients who exceeded average life expectancy," the co-authors wrote.
3. Concern of discontinuation of treatment: "Oncologists frequently expressed concern over treatment discontinuation, often referred to as a holiday or break. … Often, oncologists folded statements of concern about discontinuation into discussions of future treatment, leaving no room to discuss discontinuation," the co-authors wrote.
The co-authors speculated about the reasons why oncologists avoid EOL discussions. "Evidence suggests that physicians may be uncomfortable discussing EOL topics and, thus, avoid them. In addition, emotional distancing due to physician stress or burnout may decrease the likelihood that physicians pick up subtle cues from patients regarding concerns about their disease," they wrote.
"It is also possible some oncologists believed they were sparing patients from conversations they were not yet ready to have, or preserving hope—albeit, potentially to the patient's detriment—of continuing treatment. In this vein, some oncologists may have felt a sense of denial as to their patients' disease progression, particularly after developing close relationships with their patients," they wrote.
Despite decades of effort to improve oncologists' EOL discussions, more work is needed, the co-authors wrote. "Future efforts must address barriers, such as oncologists' fear of upsetting patients and discomfort engaging in EOL discussions, and challenges inherent to providing a time-sensitive prognosis, in tandem with the need to respond to patient emotions and express empathy."
A new report shows an increase in acquisitions of independent physician practices during the pandemic.
During the coronavirus pandemic, there have been upticks in independent physicians becoming employees and acquisitions of independent physician practices, a new report shows.
The trends of physicians leaving private practice for employment at corporate entities such as hospitals and acquisitions of independent physician practices by corporate entities have been going on for years. These trends have raised concerns, including a loss of autonomy in clinical practice and increased costs associated with physician practice consolidation.
The new report was prepared for the Washington, DC-based Physicians Advocacy Institute by Avalere Health. The study examined data from January 1, 2019, to January 1, 2021.
The report features several key data points:
18,600 physicians left independent practice to become employees at health systems or hospitals, with 11,400 of those physicians changing employment after the start of the coronavirus pandemic
Health systems and hospitals acquired 3,200 independent physician practices during the study period, representing an 8% increase
29,800 physicians left independent practice to become employees of other corporate entities such as health plans and venture capital firms, with 11,300 of those physicians changing employment after the start of the pandemic
The percentage of physicians employed at other corporate entities increased 31% during the study period
Other corporate entities acquired 17,700 independent physician practices during the study period, representing a 32% increase
There was a 3.1% increase in the growth rate of physicians employed at health systems and hospitals after the start of the pandemic
There was a 3.9% increase in the growth rate of physicians employed at other corporate entities after the start of the pandemic
As of January 2021, 69.3% of physicians were employed at health systems, hospitals, or other corporate entities
"These trends are part of a greater shift towards consolidation within the healthcare marketplace, which has dramatically reshaped the practice landscape for physicians. Understanding the extent and impact of these trends is important for all healthcare system stakeholders, given the implications on healthcare spending and, in many cases, the continuity of the patient-physician relationship," the report says.
Interpreting the data
Although the report does not have data for 2021, the pandemic appears to have accelerated the pace of physicians leaving independent practice and physician practice acquisitions, Kelly Kenney, JD, CEO of the Physicians Advocacy Institute, told HealthLeaders.
"You cannot dispute the fact that there was a bump up nationally. There were 48,400 additional physicians who left independent practice during the two-year study period and became employees. And 22,700 of those physicians left independent practice in the last six months of 2020. That is a significant increase during the pandemic. We saw this upward trend reflected in both the physician employment and the practice acquisitions analysis. So, it appears to be a consistent upward trend," she says.
The report provides insights into the acquisition of independent physician practices by corporate entities such as health plans and venture capital firms, Kenney says.
"The trend of health system and hospital acquisition of practices has been going on for more than a decade, but this is the first time we have been able to look at acquisitions by other corporate entities such as private equity entities and health insurers. Given the financial model of some of these corporate entities, there are some inherent concerns that we should look at. We need to pay close attention to how these other corporate entities approach key patient issues such as access to a personal physician and access to clinically indicated care. These other corporate entities have different financial incentives than independent physician practices," she says.
Transparency is a concern related to practice acquisitions by other corporate entities, Kenney says.
"We need to look at the level of transparency around other corporate entities that are purchasing independent physician practices. We need to make sure there is enough transparency and regulatory oversight to ensure that onerous or restrictive policies are not in place. There is not a lot of scrutiny for these other corporate entities, and we need to make sure there are safeguards in place. There are patients attached to these practices, and we need to make sure those patients are not in worst shape than they were pre-acquisition," she says.
The report's data reflects the difficulty of operating an independent physician practice, Kenney says.
"It is difficult to maintain an independent physician practice, and a conversation needs to occur about whether that is something we are ready to give up as a nation. Many of us feel that we want the choice of having a physician in a practice that is run independently. We need to continue to push for that and need to support physicians who choose to remain independent. Physician practices that are independent need to be viable from a financial perspective, and they should not be overloaded with regulatory and administrative burdens that make it impossible to practice independently," she says.
Easing regulatory burdens is crucial to the future of independent physician practices, Richele Taylor, JD, CEO and chief legal officer of the South Carolina Medical Association, told HealthLeaders. "The regulatory burdens are important because it is hard for a new physician to start a practice, and you want to keep independent practices viable especially in rural and underserved areas. It has got to be something they can do. They have got to be able to run a practice while practicing medicine."
New policies such as lifting the moratorium on physician-owned hospitals need to be adopted to ensure independent physician practices do not become a relic of the past, Kenney says. "We certainly hope we are not seeing the end of independent practice. We think there are commonsense policies to put into place to protect that option for physicians and patients."
It is unlikely that independent physician practices will disappear, Taylor says. "Physicians are service-oriented, and they will always look for where they can serve. So, the independent physician practice model will always be around because physicians are going to gravitate to it. But it is our job to help protect independent physician practices to make sure that when physicians look for those kinds of opportunities, they will be available."
Scout by Sutter Health combines downloadable information with human nonclinical guides to help young people with anxiety, depression, and stress.
Sutter Health has launched a digitally driven tool matched with nonclinical guides to support youth and young adults who are struggling with anxiety, depression, and stress.
Access to behavioral health services is a challenge for many people afflicted with mental illness. In 2016, about 16.5% of school-aged children had been diagnosed with a mental health disorder. During the coronavirus pandemic, a larger than average share (56%) of people between 18 and 24 have reported symptoms of anxiety and/or depressive disorder.
Scout by Sutter Health was launched as a pilot program in July 2020. The program was launched at scale in April 2021. Scout is a 12-week, nonclinical program targeted at youth and young adults aged 12 to 26.
"Scout is a nonclinical tool—it is not a substitute for treatment. Rather, Scout is a tool to build youth and caregiver resilience. It helps youth manage their symptoms and helps them in their everyday lives in managing a variety of life challenges while they are having depression, anxiety, or stress," says Larry Marx, MD, director of integrated care for the mental health and addiction team at Sutter Health.
Pediatricians or clinicians working with young people and/or their families can refer patients or caregivers to Scout if there are concerns around stress, anxiety, or depression.
Scout has four primary elements:
1. Weekly virtual screenings
After young people enroll in Scout, they are screened weekly for anxiety and depression, says Vandana Pant, MA, director of strategic initiatives for the health design and innovation team at Sutter Health. "For a young person who uses Scout, they sign up, then they receive weekly screeners. Those weekly screeners are based on evidence-based tools that measure both anxiety and depression—the GAD-7 and PHQ-9. Based on the young person's responses to the screeners every week, they receive personalized content."
The screeners rate a young person's symptoms from mild, to moderate, to severe. When a rating reaches the moderate level, the young person automatically gets outreach from a nonclinical guide. Reaching out to a clinician is recommended for additional support, she says. "We are very conscious of directing young people back into care if their scores are showing that they are at a level that may require clinical care. That provides a safety net."
2. Digital modules of educational and supportive materials
Downloadable information that Scout provides falls into two categories: young people received personalized information based on responses to the screeners, and young people and their caregivers receive standard digital information modules on a weekly basis.
The standard digital information modules can be educational about anxiety and depression or address other topics such as communication skills, Pant says.
"When a caregiver signs up for Scout, the main difference is that the young person has a highly personalized experience with the screeners. If you sign up as a caregiver such as a parent, modules are sent out on a weekly basis that parallel the modules that the young people receive. For example, if a young person receives an educational module on anxiety, their caregiver will receive the same module of content. For the caregiver, the goal is to build resilience through building knowledge," she says.
An example of personalized information is making it age-specific, Pant says.
"A lot of people in their early 20s are in the workforce, and we have tools that are valid for that age group like isolation at work, communication with peers, living successfully with roommates, managing finances, and the stress of dating. So, there is a host of content that is not necessarily clinical but addresses things that form the basis of people's everyday anxieties. On the younger end of the spectrum, we have content modules that address things like talking with friends about mental health, having a healthy diet, tips for getting to bed on time, and tips for settling the mind," she says.
3. Exercises
Scout has been designed to not be directive or prescriptive. For example, exercises linked to the information modules provide options for young people, Marx says.
"As the youth or the young adult goes through the different modules, there is a variety of different exercises that they can choose to participate in. There are no dictates or prescribing in the tool—there are just helpful suggestions. If someone decides to do one of the exercises, Scout checks on how they feel after the exercise to give some insight into whether a particular practice improves overall well-being. Because Scout is not a clinical tool, youth can pick and choose exercises or material that are going to be meaningful to them. There is no monitoring of what material or exercise has been used, so young people are completely autonomous," he says.
4. Nonclinical guides
A unique aspect of Scout is the use of nonclinical guides provided by Boston-based Docent Health to engage young people, Pant says.
"The core of the program and what really differentiates it is that we support the experience that young people go through for 12 weeks with nonclinical guides. Docent Health provides the nonclinical guides—they essentially guide the experience. For example, in addition to my weekly screener, I can text additional concerns. In that case, a Docent guide will step in and give a personalized response. That boosts the support because young people know that they can reach out if they want to," she says.
The nonclinical guides play a key role in Scout, Pant says. "Once you are enrolled in the program, you receive the screeners in an automated way, but you are welcomed into the program by a nonclinical guide. That nonclinical guide also keeps checking in with you through the course of the program. The nonclinical guide is also available via text as a source of support and engagement."
Sutter Health decided to include a human touch in Scout because of design-stage feedback from young people and the project's youth advisory group, she says. "Across the board, from age 12 to 26 and in the youth advisory group, we heard that one of the key challenges that young people face when they are feeling depressed or anxious is that they feel isolated. We responded to that need for human connection by creating a program that had an opportunity for nonclinical, human guide support."
Measuring Scout's impact
Sutter Health and Docent Health created a dashboard for Scout that has metrics on the population health and individual level.
On the population health level, week-over-week aggregate scores on the anxiety and depression screeners measure whether participants are trending in a positive or negative direction.
Engagement level is also measured week over week. Engagement is measured by how many people are completing the screeners and how many people are texting the nonclinical guides.
So far, the numbers look good, Pant says. "We have had about 510 users over the past three months: 40% of them are caregivers and 60% of them are young people. On an aggregate basis, we have seen a 1.7% improvement in anxiety scores; so, week-over-week, we are seeing improvement in anxiety at the population health level. About 95% of the users say they are finding the modules meaningful."
More faculty at a Texas academic medical center are considering quitting or scaling back to part-time employment during the pandemic.
Faculty at an urban academic medical center are more likely to quit or move to part-time employment during the coronavirus pandemic, a recent research article found.
Clinician burnout was already at high levels before the coronavirus pandemic began in spring 2020. It is widely believed that work-life integration and burnout have worsened during the pandemic.
The recent research article, which was published by JAMA Network Open, features survey data collected from more than 1,000 medical, graduate, and health professional school faculty at the University of Texas Southwestern in Dallas. The survey was conducted in September 2020.
The study includes several key data points.
After the coronavirus pandemic began, faculty were more likely to consider quitting or scaling back to part-time employment than before the pandemic (quitting 23% versus 14% and scaling back to part time 29% versus 22%)
After the coronavirus pandemic began, female faculty were more likely to consider quitting or scaling back to part-time employment compared to male faculty than before the pandemic (quitting 28% versus 15% and scaling back to part time 40% versus 13%)
After the coronavirus pandemic began, faculty with children were more likely to consider quitting or scaling back to part-time employment than before the pandemic (quitting 29% versus 17% and scaling back to part time 40% versus 24%)
After the coronavirus pandemic began, female faculty with children were more likely to consider quitting than female faculty without children than before the pandemic (quitting 35% versus 17%)
"In this survey study, the perceived stressors associated with work-life integration were higher in women than men, were highest in women with children, and have been exacerbated by the COVID-19 pandemic. The association of both gender and parenting with increased perceived work-life stress may disproportionately decrease the long-term retention and promotion of junior and midcareer women faculty," the research article's co-authors wrote.
Interpreting the data
Raising children is a major stressor for female faculty regardless of the pandemic, the research article's co-authors wrote. "In our study, faculty who were mothers were more likely to consider leaving or already had or were considering reducing their employment to part time both before and since the pandemic compared with faculty women without children, highlighting the universal stress of caregiving independent of the pandemic."
Working part time can exacerbate existing gender gaps at academic medical centers, the research article's co-authors wrote. "In our study, women were 3 times more likely than men to consider or already be employed part time both before and since the pandemic. Part-time faculty perceive that they perform more unpaid work, have fewer research opportunities, a slower career trajectory, and may be less likely to take on leadership appointments."
Academic medical centers should take actions to improve work-life integration, particularly for female faculty, the research article's co-authors wrote.
"Better support of working parents, specifically working mothers, through flexible work policies, improved childcare and parental leave programs, more equitable sharing of unpaid care hours between women and men, and active acknowledgment of the effects of work-life conflict on academic productivity and fulfillment are paramount to ensuring academic medicine does not lose talented faculty and proactively combats gender inequity and gender-based advancement regression," they wrote.
