The mindfulness program at an Ohio-based medical center has been expanded to include short videos for healthcare workers during the coronavirus pandemic.
A mindfulness program for healthcare workers at The Ohio State University Wexner Medical Center has decreased burnout and significantly increased resilience and work engagement, a recent research article found.
Burnout is one of the top challenges facing clinicians and other healthcare workers nationwide. In a report published in September 2020 by The Physicians Foundation, 30% of more than 2,300 physicians surveyed cited feelings of hopelessness or having no purpose due to changes in their practices related to the coronavirus pandemic. Research published in September 2018 indicates that nearly half of physicians across the country were experiencing burnout symptoms.
The recent research article, which was published by Global Advances in Health and Medicine, highlights the impact of the Mindfulness in Motion (MIM) program at The Ohio State University Wexner Medical Center in Columbus, Ohio. "Mindfulness is described as a nonjudgmental, present-moment awareness with non-reactivity to introspective perceptions," the study's co-authors wrote.
The study includes three key data points.
As measured by the Maslach Burnout Inventory, there was a 27% reduction in MIM participants meeting burnout criteria.
As measured by the 10-item Connor-Davidson Resilience Scale, which rates resiliency on a scale from 0 to 40, there was a significant increase in resilience. After participating in MIM, mean resilience scores rose from about 29.2 to about 31.6.
As measured by the Utrecht Work Engagement Scale, which rates work engagement on a scale from 0 to 6, there was a significant increase in work engagement. After participating in MIM, mean work engagement scores rose from about 3.9 to 4.3.
MIM was launched in 2008, starting with the nursing staff in the medical center's surgical intensive care unit. The program has since been expanded to all staff members at the facility, the lead author of the recent research article told HealthLeaders.
"We have environmental workers, we have respiratory therapists, we have nurses, and we have physicians and many other job titles. So, we have the whole healthcare teams understanding the stresses of other staff members," said Maryanna Klatt, PhD, a professor in the Department of Family and Community Medicine at The Ohio State University College of Medicine in Columbus.
MIM is an eight-week program, with participants meeting for a one-hour session each week. The sessions have five primary elements:
1. Reflective writing in response to a weekly prompt
2. Video on the science of mind/body interventions
3. Voluntary sharing of reflective responses
4. Experiential video on yoga/mindfulness practice
5. Closing meditation based on a weekly theme
An example of a weekly prompt to spur reflective writing is asking MIM participants about an experience they had in the prior week with a co-worker or a patient where they felt totally present, Klatt said. "They felt they were totally there, and the experience was different than day-to-day interactions."
This weekly prompt can have a profound impact, she said. "People get totally blown away. They say, 'I did not recognize the difference. It reminds me of why I went into healthcare.' But until they are prompted to remember this kind of experience, that experience just happens, and they do not note it. Without the prompt, they do not get the boost from the experience."
Klatt said a good example of a weekly theme for the closing meditation of a MIM session is presented in Week 1 of the program.
"We ask participants to watch their habits without judging them. Participants are asked to watch their habits of how they communicate with others, habits of thought, or physical habits. The first step of mindfulness is noticing. So, the Week 1 theme for the closing meditation is to begin the meditation with seeing yourself and paying attention to how you operate in the world. In the reflection at the beginning of Week 2, people share what they realized from the Week 1 meditation on their habits," she said.
Avoiding passing judgment on habits or other MIM exercises is crucial, Klatt said. "An important aspect of mindfulness is not to judge yourself. In this case, you begin by noticing a habit. Then you can choose to either keep the habit or change it."
A pivotal part of the MIM program that makes it well-suited to the hospital setting is making the weekly sessions part of the workday, she said. "By scheduling the Mindfulness in Motion sessions during the workday, it shows healthcare workers that their hospital cares about them—it shows the hospital cares about how healthcare workers are functioning. Mindfulness in Motion is not an extra thing that healthcare workers must do—it is incorporated in the workday."
Adapting Mindfulness in Motion to the coronavirus pandemic
During the coronavirus pandemic, Klatt has expanded MIM offerings beyond the eight-week program.
"To serve the whole medical center during the pandemic, I had to shift to a more condensed format. I started with 5- to 6-minute video practices. We are up to more than 19,500 views of those videos. I was shocked at how many people used the short videos. Now, we are in a patient surge situation with COVID-19 in Ohio, and I was asked to make some 2-minute videos. These videos are designed for the healthcare providers in the medical center who are overwhelmed with work to help them ground themselves and reboot when they feel they cannot go on because they are so exhausted," she said.
Klatt also has created 30-minute PowerPoint videos to explain what mindfulness is to people and how they can apply mindfulness during the pandemic. Those videos have about 4,000 views, she said.
A recent study found an unexpectedly high level of discrimination against patients, researcher says.
More than 1 in 5 adults experience discrimination in healthcare settings, a recent research article found.
After lurking in the background for decades, health equity has emerged as a top concern in the U.S. healthcare system. In earlier research, experiences of discrimination in healthcare settings have been shown to drive negative impacts on trust, communication, and health-seeking behaviors.
The recent research article, which was published by JAMA Network Open, features survey data collected from more than 2,100 U.S. adults. The study includes several key data points.
458 (21.4%) of the survey respondents reported experiencing discrimination in healthcare settings
Among survey respondents who reported experiencing discrimination, 72.0% reported experiencing discrimination in healthcare settings more than once
Racial or ethnic discrimination was the most common type of reported discrimination (17.3%), followed by discrimination based on educational or income level (12.9%), weight (11.6%), and age (9.6%)
The odds of experiencing discrimination were high for women (odds ratio 1.88)
The odds of experiencing discrimination were low for older survey respondents (odds ratio 0.98), survey respondents earning at least $50,000 in annual household income (odds ratio 0.76), and survey respondents who reported good (odds ratio 0.59) or excellent (odds ratio 0.41) health compared to poor or fair health
Non-Hispanic white survey respondents reported significantly less racial discrimination (4.0%) compared to non-Hispanic black survey respondents (54.6%) and Hispanic survey respondents (21.9%)
"The prevalence of discrimination identified in this study points to a need to examine discrimination in the healthcare system as a risk factor for other negative effects. Future work on interpersonal discrimination in the healthcare system should examine the types of discrimination we have identified herein, with the understanding that they are harms imposed on patients rather than caused by or reflective of patient demographic characteristics," the study's co-authors wrote.
Interpreting the data
The lead author of the study told HealthLeaders that the level of discrimination found in the research was higher than expected.
"The prevalence of discrimination in the healthcare system we identified (21.4%) was higher than we anticipated. Among those who reported discrimination, 72% experienced it more than once. We know that discrimination has serious downstream impacts on people's health and engagement with the health system, and we see this as an urgent issue," said Paige Nong, BA, a doctoral candidate in the Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.
The study highlights the need to address discrimination against black patients, she said. "Because the study is national, we get a picture of the disproportionate impact of interpersonal racism on black people in the U.S. healthcare system. This adds to what we already know about the harms of racism in other domains such as housing, employment, and policing, for example. The discrimination we identify in our study is fundamentally a justice issue, reflecting both historical and contemporary racism."
The study also adds to the foundation of other research that should lead to effective interventions to address discrimination in healthcare settings, Nong said.
"We hope that our findings highlight this critical issue for healthcare systems and focus attention on the harm being done while people are seeking care. Although prior research analyzes interventions and ways to address discrimination more directly, we think that one part of addressing interpersonal discrimination effectively is more precise measurement and evidence-based responses. There is a wealth of important literature on discrimination that should necessarily inform these efforts. We think that our survey questions might be used to better understand the particular experiences of patients in healthcare systems across the country."
RWJBarnabas Health is set to launch the pilot phase of its Health Beyond the Hospital initiative in January.
RWJBarnabas Health (RWJBH) is launching an ambitious initiative that will eventually screen every patient who visits the health system's facilities for social determinants of health (SDOH) that could also serve as a blueprint for other healthcare organizations to follow.
SDOH factors such as food security and housing play a pivotal role in the health of individuals and populations. A landmark 2016 study published by the American Journal of Preventive Medicine found that socioeconomic factors, health behaviors, and the physical environment account for determining more than 80% of health outcomes, with clinical care accounting for only 16% of health outcomes.
In January, West Orange, New Jersey–based RWJBH is set to launch the health system's Health Beyond the Hospital initiative. DeAnna Minus-Vincent, MPA, senior vice president and chief social integration and health equity strategist at RWJBH, says the program will eventually be one of the country's first universal SDOH efforts.
"It is universal because once we get beyond the pilot phase, anyone who comes into an RWJBarnabas facility will be screened for social determinants of health. Some health systems have chosen to limit social determinants of health screening to either the most chronically ill or to those patients with limited income. We have chosen to take a broader view because all patients have social determinants of health and most health outcomes are affected by social determinants," she says.
Through the Health Beyond the Hospital initiative, RWJBH will be screening for several SDOH, including food and nutrition, living conditions, safety at home, isolation and socialization, and substance use.
In the pilot phase, RWJBH is launching Health Beyond the Hospital in a range of clinical settings to test the initiative, "so that we could build out the proper processes for different settings," Minus-Vincent says.
The pilot sites include the following:
An emergency department and inpatient setting in Newark
A clinic and an ICU in New Brunswick
A handful of physician practices across New Jersey
RWJBH Children's Specialized Hospital, which includes several outpatient centers across the state
The pilot phase of the initiative is expected to last about a year, she says.
SDOH assessments and connecting patients to social services
One of the ultimate goals of Health Beyond the Hospital is to make SDOH assessments as routine as assessing patients for height, weight, and blood pressure. Because the initiative is new and the COVID-19 pandemic is surging in New Jersey, RWJBH has contracted with a vendor to help clinicians conduct SDOH assessments, Minus-Vincent says.
"ConsejoSano will do assessments proactively prior to patients coming into a clinical setting. Patients respond to social determinants of health questions so that our clinicians do not have too many questionnaires to do. However, once the assessments become a routine part of our processes, assessments will occur as part of a normal piece of the clinical setting," she says.
Another vendor will play a key role in referring patients for social services, Minus-Vincent says.
"Once a patient identifies that they have a need, we are working with NowPow, which is a technology tool that has already identified services both in the community and within our RWJBarnabas Health network. NowPow will match needs to appropriate services. For example, if a patient does not know how to prepare healthy foods, needs help with nutritional education, cannot afford food and is not already on SNAP, NowPow could refer the patient to a dietitian in-house. NowPow could get the patient set up with cooking classes and could help with phone-based support to get the patent enrolled in SNAP," she says.
When NowPow makes a referral, the primary stakeholders are notified, which helps to ensure patients get connected with services, Minus-Vincent says. "The patient knows the organization providing the service, the organization providing the services knows there has been a referral, and the referral goes into the patient's electronic medical record. So, everybody knows that the patient has selected a particular organization for services."
If a patient does not connect with a social service, there will be follow-up contact via text, email, or phone calls within a week, she says. "The patient will get a text, email, or phone call noting that they have not received nutritional counseling or another service, and they will be asked questions about whether they need help, such as transportation."
Monitoring the impact
RWJBH will be following several metrics to gauge the impact that Health Beyond the Hospital has on patients and other stakeholders. Minus-Vincent says those metrics include the following:
Comparing health outcomes data prior to a patient receiving social services to health outcomes data after social services have been received
Tracking whether providers and other crucial healthcare workers are being educated about SDOH
Examining health outcomes of patients by types of providers
Conducting financial modeling for the initiative
Monitoring changes in healthcare spend at the patient level
Tracking whether patients believe they have fewer SDOH after receiving services
Following whether unnecessary emergency department visits are reduced
"There is a laundry list of metrics that we will be looking at to see how we are changing knowledge base, behaviors, and health outcomes," she says.
Laying a foundation for Health Beyond the Hospital
There will be two primary educational efforts for the RWJBH healthcare workforce, Minus-Vincent says.
"First, there is a mandatory session for all of our RWJBarnabas Health employees that will educate them about some of the technology tools and available resources. Second, we have developed a program with Rutgers University that is a five-part, guided, virtual series for physicians and intake workers and everyone in between that touches on equity, racism, bias, culturally competent care, and social determinants of health such as food and nutrition, housing, substance use, and violence."
Education for RWJBH healthcare workers is an essential component of the initiative, she says. "The education is important because we have a great deal of diversity in New Jersey. We have pockets of great wealth and pockets of poverty. Some of our physicians believe few of their patients have social determinants of health, so they are hesitant to do SDOH work."
When it is fully implemented, Health Beyond the Hospital will have a broad scope, Minus-Vincent says.
"We have created an end-to-end program that includes the relevant stakeholders, with the patient as our true North Star. We also know that if we do not build a program that is easy for our providers to use, it will not get used. And we have thought about how we create a comprehensive program that brings in our government and nonprofit partners. We want to reengineer how the health and social service sectors work together."
As has been the case in 2020, the COVID-19 pandemic will dominate the clinical care field in 2021, three experts say.
A trio of clinical care experts have shared their 2021 clinical care predictions with HealthLeaders.
As is likely expected by most healthcare observers, the coronavirus pandemic looms large in the predictions for the coming year. But the grim COVID-19 outcomes of 2020 should ease in 2021, the experts say.
1. Coronavirus vaccine and the course of the pandemic
With two COVID-19 vaccines already granted emergency use authorization in the United States and more vaccines on the horizon, the vaccination of Americans will have a major impact on clinical care in 2021, says Shafeeq Ahmed, MD, MBA, interim president of Howard County General Hospital—A Member of Johns Hopkins Medicine.
"Vaccination is going to help us in healthcare. We are going to have fewer healthcare workers out sick because of COVID-19. That is going to be important from a staffing perspective," he says.
Despite the rollout of vaccines, Ahmed predicts coronavirus will affect patient care significantly into the summer of 2021.
"In 2021, we are still going to be social distancing, wearing masks, and taking other precautions. From an outpatient perspective, there is still going to be prepping and managing of patients with the precautions that we currently are taking. On the inpatient side, we are still going to be dealing with coronavirus patients, which challenges us on many levels including not being able to have visitors. After the summer, we will still have COVID-19 patients, but we are not going to have overwhelming surges."
Patrick Godbey, MD, president of the College of American Pathologists, and laboratory director at Southeast Georgia Regional Medical Center in Brunswick, Georgia, is more optimistic about the course of the pandemic.
"I expect the number of cases to go down in the spring. As the weather gets warmer, people will be able to spend more time outside and spend less time indoors close together. The major holiday season will be over. And more people will have been vaccinated. So, for a combination of reasons, by March or April our coronavirus infections should see a significant decrease," Godbey says.
2. Return of the patient
Both Ahmed and Godbey predict deferred care linked to the pandemic will decrease significantly in 2021.
"What has been shown is that patients are still interested in coming in for routine care as opposed to delaying care for a long time. They will want to get back to seeing their doctors. So, we should see an uptick in growth in care that is not related to COVID-19. With the vaccine out, people are not going to be as afraid to seek care. They are going to feel more comfortable with healthcare organizations and they are going to come back," Ahmed says.
"We have had patients who have broken their hips and have waited much longer than they should to receive medical care because they were afraid of COVID-19. Or care has been delayed at healthcare organizations because of the need to take care of COVID-19 patients. I predict that we will be able to deliver care and patients will seek care in a more expedient fashion as we get a better handle on COVID-19," Godbey says.
3. Coronavirus testing
Demand for coronavirus testing will remain high in 2021, but the healthcare system should come closer to meeting the need in the first half of the year, Godbey predicts.
"What we would like to have happen is to have more polymerase chain reaction tests available, so that we can have everybody who needs to be tested receive tests. We are not there yet. We need to be able to provide accurate testing to every patient who needs it. The demand will continue, and we need to address that need. We have been told that in the first quarter of 2021, we will see an increase in the availability of reagents. If that is the case, we will come closer to meeting the need," he says.
4. Telehealth sustainability
After explosive growth in the early phase of the pandemic, telemedicine will continue to play a major role in clinical care next year, Ahmed predicts.
"Healthcare organizations will continue to use telemedicine as an option for care to manage patients. Telemedicine is just another version of social distancing, so it is going to be with us for the foreseeable future. People are recognizing that there is a value to not having patients come in for office visits. Patients can get their health condition management from the comfort of their own homes. It is going to be very tough for patients to want to give that up," he says.
Brian Johnson, MD, the chief medical officer at West Penn Hospital in Pittsburgh, Pennsylvania, is bullish on telemedicine in 2021.
"Telehealth has certainly ramped up. It is here to stay—the question is to what degree. If we go back to March and April of this year, telehealth was being used a lot. Then it tailed off, but it has gone back up again. Telehealth will find a sweet spot in 2021," he says.
Telemedicine will help drive the consolidation of physician practices next year, Johnson says. "We will be able to use telehealth to consolidate outpatient practices and reduce overhead, particularly in primary care. We can have less overhead but bring better care to patients by adding telehealth services to the book of services that practitioners provide."
5. Behavioral health bubble
Demand for behavioral health services will explode in 2021, Johnson predicts. "Given the stressors around the coronavirus—not just the disease process itself but also the relationship challenges, economic challenges, and healthcare challenges for the general public and healthcare workers—I foresee much more of a need for behavioral health services."
6. Addressing health equity
After decades of lurking in the healthcare background, health equity will emerge as a high-priority issue in 2021, Johnson says. "COVID-19 has brought health equity to the forefront."
Large healthcare organizations will lead the charge on addressing health equity next year, he says. "With engagement from large healthcare institutions, we can make progress on health equity. We are not going to make headway through government. We are not going to make headway through little pockets of small physician practices or small healthcare organizations. It is going to require large healthcare entities such as mine at Allegheny Health Network."
The larger healthcare entities need to make a commitment to address health equity, Johnson says. "That is where we are going to have an impact—2021 is the year when we are going to begin to see health equity rise to the forefront. We may not be able to create an impact where we see changes in mortality or changes in health outcomes, but we will make the first step to ensuring that more people have appropriate access to the care and health education that they have not had in the past."
Read some of the best clinical care stories that HealthLeaders produced about the COVID-19 pandemic.
This year, HealthLeaders produced more than 100 clinical care stories related to the coronavirus pandemic.
The greatest U.S. public health crisis since the 1918 influenza pandemic, the COVID-19 pandemic dominated the clinical care landscape in 2020. At HealthLeaders, clinical care coverage of the pandemic spanned dozens of topics, including critical care, rural medicine, medical ethics, home-based medical care, and rising to the challenges of coronavirus patient surges.
The following is a list of the Top 10 HealthLeaders clinical care coronavirus stories of the year.
1. Medical ethics: "4 Ethical Dilemmas for Healthcare Organizations During the COVID-19 Pandemic"
In March, there had already been rationing of coronavirus testing, and healthcare providers were bracing for care rationing such as mechanical ventilation. Medical ethicist James Tabery, PhD, shared his perspectives on rationing of care and vaccines as well as ethical dilemmas for healthcare workers.
2. Home healthcare: "Home-Based Medical Care in High Demand During Coronavirus Pandemic"
The coronavirus pandemic has increased demand for home-based medical care, according to the chief medical officer of Landmark Health. In July, Landmark reported a spike in demand for its in-home medical services, with the organization's 2020 revenue projected to rise 230%.
3. Care rationing: "Coronavirus Care Rationing: 'It's Not Just About Ventilators'"
In addition to ventilators, there are four primary care rationing scenarios during the coronavirus pandemic, a bioethicist told HealthLeaders in May. Particularly in hotspots such as New York, the early phase of the pandemic prompted triage and rationing of care "at almost every level," said Christine Cassel, MD, a bioethicist and adjunct professor at UCSF Medical School in San Francisco, and a former president and CEO of the National Quality Forum.
4. Rural medicine: "6 Steps for Rural Hospitals to Rise to the Coronavirus Challenge"
In May, the president and CEO of Batesville, Indiana–based Margaret Mary Health shared how the organization's 25-bed critical access hospital coped with a surge of coronavirus patients. Successful strategies to address the patient surge included formation of a response team, increasing bed capacity, and securing essential equipment.
5. Lessons learned: "Prepared in Raleigh: 8 Lessons Wakemed Learned From the Coronavirus Pandemic"
In June, a pair of physician leaders at Wakemed Health & Hospitals in North Carolina discussed how the health system had prepared for the coronavirus pandemic. WakeMed was spared from an influx of coronavirus patients during the spring surge, which gave the health system an opportunity to effectively plan for future pandemic challenges.
6. Long haulers: "Coronavirus 'Long Hauler' Care Model"
A significant number of COVID-19 patients have experienced symptoms for weeks or months after the acute phase of their illness has passed. Valhalla, New York-based Westchester Medical Center has established a comprehensive clinical program to treat these long-hauler patients.
7. Specialty care: "Coronavirus: Speech Language Pathologists Playing Key Frontline Role"
Speech language pathologists are providing essential rehabilitation services to patients recovering from serious cases of COVID-19. For example, coronavirus patients who are placed on mechanical ventilation often require help from these specialists to restore the ability to communicate and swallow.
8. Critical care: "ECMO Life Support 'Last Ditch' Intervention for Coronavirus Patients"
Extracorporeal membrane oxygenation (ECMO) provides life support for severely ill coronavirus patients suffering respiratory failure. At Michigan Medicine, more than half of coronavirus patients who undergo ECMO are expected to survive.
9. Respiratory therapists: "Coronavirus: Providing Respiratory Therapy on Frontline of the Pandemic"
A respiratory therapist who traveled to New York City during The Big Apple's coronavirus patient surge in the spring shares her story. With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
Northwell Health, which features 23 hospitals and 800 ambulatory sites in and around New York City, treated about 20,000 hospitalized COVID-19 patients during the spring surge. Prime strategies and initiatives Northwell used during the spring surge included centralized decision-making, building surge capacity, and creating a clinical advisory board.
The Patient Safety Movement Foundation is seeking to reduce preventable patient deaths to zero by 2030.
The Patient Safety Movement Foundation has changed its commitment model for hospitals and other healthcare organizations to achieve zero preventable harm and deaths.
Despite making considerable progress over the past two decades since the publication of the landmark reportTo Err Is Human: Building a Safer Health System, patient safety remains a primary concern at U.S. healthcare organizations. Estimates of annual patient deaths due to medical errors range as high as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The Irvine, California-based Patient Safety Movement Foundation has shifted its focus away from preventing specific kinds of patient harm, says Donna Prosser, DNP, RN, chief clinical officer of the nonprofit group.
"We have revised our commitment model because in the prior eight years what we were asking healthcare organizations to do was to make a commitment to improving safety and reducing incidents of medical harm through certain populations. When I say populations, I mean reducing falls, reducing healthcare-acquired infections, reducing sepsis, and so on. So, we had asked healthcare organizations to make a commitment to improve specific focus areas," she says.
Now, the Patient Safety Movement Foundation has adopted a three-part commitment model.
1. Person-centered culture of safety
Healthcare organizations should commit to ensuring the safety of every person who enters their doors, Prosser says. "For every person who comes into a healthcare organization, everybody needs to have in the front of their minds the safety of every person. It could be a patient, a family member, a physician, any staff member, or a vendor representative—it could be anybody."
The coronavirus pandemic has illustrated the need for a person-centered culture of safety at healthcare organizations, she says. "One of the things we have learned from the COVID-19 pandemic is that we did not have adequate healthcare worker safety. We did not have the personal protective equipment to keep our healthcare workers safe. If we have learned anything from the pandemic, it is that you cannot have patient safety without healthcare worker safety."
2. Holistic and continuous improvement framework
Although hospitals and other healthcare organizations have made progress in working collaboratively, siloes persist, Prosser says. "Since the publication of To Err Is Human, we have learned a lot about continuous improvement. But we have done continuous improvement the same way we have always delivered care, and that is in siloes. The Joint Commission has been telling us for 30 years to get out of our siloes in healthcare. And it has gotten better—it has gotten a lot more collaborative over the years."
A more holistic and coordinated approach to patient safety is needed, she says.
"In a hospital, there can be 10 or 100 committees that are all doing continuous improvement work. There are committees, departments, even students that are doing continuous improvement work. Everybody picks and chooses what they want to do, so we end up with a patchwork quilt of improvement where the right hand does not know what the left hand is improving. This makes it difficult for the frontline workers, who are the recipients of continuous improvement projects."
Coordination is crucial, Prosser says. "We need to look at continuous improvement holistically and figure out how we can have one department, one committee, or one person overseeing the continuous improvement work that is happening in a hospital. One entity needs to know what is going on and plot it on a calendar, so you do not have multiple committees or departments competing for the same resources, and you do not have the frontline being bombarded by change."
3. Effective model for sustainment
Sustaining patient safety initiatives is a daunting challenge, she says.
"For any healthcare leader, the most difficult aspect of performance improvement is sustainment. Healthcare is a profession made of human beings taking care of human beings. There is ambiguity in healthcare. So, if we do not give clear direction to the frontline, they are going to make up their own rules. And they are usually going to revert to rules that are comfortable that they know. It is not intentional—it is just human nature."
To achieve sustainment in continuous improvement of patient safety, healthcare organizations need to have an effective education plan, Prosser says. "You need to reinforce change. You need to build change into existing annual competency reviews, so that you make sure people stay on track and know what to do. Your education program needs to be aligned with your continuous improvement framework."
There are several primary elements of an education plan related to patient safety initiatives, she says. "To sustain continuous improvement with an education program, it is all about onboarding, orientation, annual competency validation, continuing education, and leadership development. That is the continuum of education for any healthcare organization. You need to learn how to keep people accountable."
For example, Prosser says if a hospital does an improvement project for appropriately restraining patients and rolls it out to the frontline staff, the hospital also must insert the change into orientation, insert it into competency evaluation on an annual basis, insert it into the continuing education curriculum, and insert it into leadership development, so that leaders can learn how to measure the change and hold staff accountable.
In addition to education, healthcare organizations must account for the human factor to sustain change, she says. "You must study human factors. You must understand the ways human beings react and behave. You must anticipate what is going to happen when you make a change."
Physician Orders for Life-Sustaining Treatment forms help ensure that resident and surrogate care preferences are honored.
Nursing facilities that use Physician Orders for Life-Sustaining Treatment (POLST) forms achieve a higher level of concordance between orders in the medical record and resident preferences than facilities that do not use the forms, a recent study shows.
POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with "comfort measures only" directives.
The recent study, which was published by the Journal of General Internal Medicine, is based on information collected from 40 nursing facilities in Indiana. POLST was used in 29 of the nursing facilities and was not used in 11 facilities.
The research article includes two key findings:
At nursing facilities using POLST, concordance between orders in the medical record and residents' preferences was 59.3%. At nursing facilities that did not use POLST, concordance was 34.9%.
When compared to nursing facility residents without POLST, residents with POLST were 3.05 times more likely to have orders for life-sustaining treatment match their current care preferences.
POLST basics
The lead author of the research article told HealthLeaders that POLST is a medical form that is used to document care preferences as orders, including orders about cardiopulmonary resuscitation, medical interventions, and artificial nutrition.
"The decisions that are most emergency-oriented are the orders for CPR and decisions around intubation, which is an intervention that is used when someone is having difficulty breathing and typically leads to the use of a ventilator. So, it is critical that preferences about those interventions be known in advance because there is rarely time in the moment to understand what a resident wants," said Susan Hickman, PhD, director of the Indiana University Center for Aging Research at Regenstrief Institute in Indianapolis.
POLST is a valuable care tool because it can be followed by medical personnel both within a nursing facility and outside of the facility, she said. For example, a copy of a resident's POLST form is usually included in the packet of materials that accompany a resident if he or she is taken to an acute care hospital.
"Emergency medical services play a crucial part in this process because they are a link between settings. So, if a resident starts to experience a medical emergency, EMS will be called to transport the resident to a hospital, and EMS is an important part of the process to make sure a resident's preferences are honored. When the resident arrives at a hospital, the POLST orders are relevant in terms of making decisions about what care will be given in that setting," Hickman said.
Nursing facilities use several strategies to ensure that POLST care preferences are honored, she said.
Nursing facilities that use electronic medical records typically have code status on the face page of the medical record
Code status is often communicated with a colored sticker on a resident's door or chart in their room
In addition to having a POLST form scanned into the medical record, some nursing facilities have a binder for every patient with a copy of the POLST form in it
In nursing facilities, POLST has taken on heightened importance during the coronavirus pandemic, Hickman said. "Nursing home residents and staff have been hard hit by COVID-19. For residents, this means that they are much more likely to imminently face decisions about hospitalization, ventilatory support, and cardiopulmonary resuscitation. Decisions that have been made previously may differ in the context of the pandemic."
Rising to POLST challenges
The recent research article and earlier studies have found that two of the primary challenges of working with POLST in nursing facilities are staff difficulties with understanding and explaining the form as well as lack of time to have the POLST conversation.
These difficulties reflect both training gaps as well as advanced care planning often being an afterthought rather than being defined as part of staff members' roles, Hickman said.
"Nursing home facilities and companies can address these difficulties by creating policies and procedures that support advanced care planning as well as recognizing that advanced care planning is part of staff members' jobs. This may sound obvious, but it is often not. Advanced care planning is often added on without any clear responsibility or goals. There need to be policies for how often staff members talk about advanced care planning with residents and how staff members share what they learn," she said.
Staff education and training is crucial, Hickman said. "Education needs to be provided on a regular basis—not just for the staff members holding the POLST conversations but also for everyone in the facility. Advanced care planning is a team sport—everyone has a role in honoring resident preferences."
Additionally, nursing facilities routinely engage in quality improvement activities, and advanced care planning needs to become a focus of quality improvement initiatives on a regular basis, she said.
While acknowledging nursing facilities are "incredibly busy places," Hickman said time spent managing POLST forms is time well spent.
"One of the things we here from staff is that when a facility invests the time upfront to have advanced care planning conversations, it helps save time and energy in the long run. Advanced care planning needs to be viewed as an investment, with the payout coming over time. It needs to be a priority—not just for individual staff members but also for the company or standalone facilities. There needs to be leadership engagement and buy-in," she said.
Advanced care planning conversations
In healthcare settings, there are several skills that staff members should have to hold advanced care planning conversations, Hickman said.
"One important part of the skill set is knowledge about basic decisions that we are asking residents and surrogates to make. So, staff members need to understand the risks, benefits, and alternatives, and they need to be able to explain that information. Staff members need to know where there are resources to support the conversation. Additionally, it is critical for staff to have training to ask questions in value-neutral ways that help to understand the resident's preferences rather than what the staff member's preferences may be."
Other skills include being able to ask questions that are open-ended to explore preferences and to help residents and family members to connect values to treatment, she said.
Individuals can use the online calculator to estimate their risk of dying from COVID-19 if they become infected with the coronavirus.
Researchers at Johns Hopkins Bloomberg School of Public Health have developed online tools for estimating individual and community-level risk for COVID-19 mortality.
COVID-19 has become a leading cause of death in the United States. As of Dec. 18, more than 17,600,000 Americans had become infected with the coronavirus and more than 317,000 had died, according to worldometer.
The new online tools feature an online calculator that individuals can use to estimate their risk of dying from COVID-19 as well as interactive maps for viewing numbers and proportions of individuals at various levels of mortality risk across U.S. cities, counties, and states. The online tools are based on information drawn from several U.S. databases and the United Kingdom-based OpenSAFELY study.
The online risk calculator combines individual risk factors such as age, weight, and pre-existing medical conditions with community-level pandemic dynamics. As a result, if infections spike in a community, the mortality risk estimates for individuals will increase in that community. The data underlying the online tools is updated weekly.
A detailed description of how the online tools work was published recently in a Nature Medicinearticle.
"We developed a COVID-19 mortality risk model for the general U.S. population by combining information across multiple data sources. We believe that the model is unique in that it can be used to project absolute rate of mortality for individuals with different risk profiles by combining information on individual-level risk factors, as well as on changing dynamics in the epidemic at the community-level captured through available forecasting models. We applied the model to data available from U.S. national databases to identify high-risk cities and counties and estimate the size of populations at risk within these communities," the journal article's co-authors wrote.
High-risk cities include Baltimore City, Detroit, Miami, New Orleans, and Philadelphia, according to the journal article.
Applying the online tools
The senior author of the article told HealthLeaders that the online risk calculator is a powerful tool to assess COVID-19 mortality risk and help determine who should be prioritized for vaccination.
"The current guidance provided by the Centers for Disease Control and Prevention is to vaccinate healthcare workers and older individuals living in congregated conditions using the initial supplies of vaccine doses by the end of this year. After that, one of the major questions would be how individuals in the general population would be prioritized based on age and pre-existing conditions to receive vaccines. It is also known that individuals from certain minority populations as well as neighborhoods with high social deprivation have high risk. Further, the risk can widely vary for individuals based on the intensity of the pandemic in their communities at a given time," said Nilanjan Chatterjee, PhD, a professor of biostatistics and epidemiology at the Johns Hopkins Bloomberg School of Public Health.
The online risk calculator is unique and well-suited to prioritizing individuals and communities for vaccination because it generates quantitative information, he said.
"While the CDC and National Academy of Science, Engineering and Medicine have developed broad guidelines regarding how different factors may be prioritized, a risk calculator, such as ours, brings all of these factors together and weights them to define a single score according to their overall contribution to risk of mortality. Our risk calculator can help to bring in more quantitative risk information into vaccine prioritization than has been considered before."
Quantitative information is crucial in determining vaccination prioritization, Chatterjee said.
"Without quantitative analysis of risk, it is hard to figure out how all of this information should be weighed to come up with an optimal vaccine distribution strategy that will save the most lives. In our analysis, we were able to show if vaccination is performed based on underlying risk information, large proportions of deaths—about 50%—in the population could be quickly averted by vaccinating relatively small proportions of the population—less than 5%."
High-risk cities share a combination of risk factors, he said. "Many high-risk cities have a high proportion of African Americans, who are known to be at increased risk of COVID-19 infection and mortality. Further, these cities also rank high in social deprivation due to various socioeconomic conditions, which, independent of ethnicity, can contribute to risk of infection as well as complications after infection."
Universal Health Services Inc. has picked Mark Friedlander, MD, MBA, to lead the sprawling health system's behavioral health services.
Behavioral health is a challenging field in medicine, but it is moving in the right direction, a new behavioral health leader at Universal Health Services Inc. says.
Based in King of Prussia, Pennsylvania, UHS operates about 400 acute care hospitals, behavioral health facilities, and ambulatory clinics in the United States and the United Kingdom. Mark Friedlander, MD, MBA, was recently named as the chief medical officer of UHS' Behavioral Health Division.
Friedlander is a practicing psychiatrist. Prior to joining UHS, he was CMO for a decade at Aetna's behavioral health unit, where his responsibilities included utilization management, quality, and clinical compliance. Before working at Aetna, he was corporate medical director for Penn-Friends Behavioral Health Systems in Plymouth Meeting, Pennsylvania, where he developed enterprise behavioral health strategies and implemented an emergency assessment capability to triage and manage high-risk patients.
Friedlander recently spoke with HealthLeaders on a range of behavioral health issues, including leadership, promoting evidence-based care, and achieving parity between health plan coverage of behavioral health conditions versus coverage of medical-surgical care. The following is a lightly edited transcript of that conversation.
HealthLeaders: What do you think will be the key to success in your new leadership role at UHS?
Mark Friedlander: I want to have a clear vision so that the people who work at the UHS Behavioral Health Division understand what we are dealing with. They need to understand that our commitment to patients is not just for someone who came into a hospital, got fixed up, and went about their way. For behavioral health patients, hospitalization is just one step in a journey.
The vision needs to recognize that behavioral health patients have a chronic condition that is going to keep coming back. These conditions not only affect individuals but also their families, their friends, and their jobs. These conditions do not occur in isolation. They are impacted by social determinants of health, health literacy, and access to care—those factors are aspects of the mission that UHS has for behavioral health.
When it comes to figuring out how to become a successful leader of a health system's behavioral health division, the important thing is having a clear strategic vision of where the organization is heading. At UHS, we are building a system for tomorrow that includes more than just hospitals. It includes peer counseling, it includes health coaches, and it includes secure transitions from one setting to the next one.
HL: Give examples of the biggest challenges of providing behavioral healthcare.
Friedlander: Even before the coronavirus pandemic, there was very high demand for behavioral health services, with limited resources. Stigma remains an issue. The delivery system is very fragmented, so navigation of the fragmented and confusing system of care remains a huge challenge for individuals.
Behavioral health is not like orthopedics; where if you break an arm and get an x-ray, everybody can see it is a broken arm. In behavioral health, the diagnoses are more subjective and somewhat expandable—there are blurred boundaries between what is normal behavior and what is abnormal.
HL: Standardization and evidence-based care are buzz words in medicine. How can behavioral health providers get away from subjectivity in the diagnosis and treatment of patients?
Friedlander: It is going to be an ongoing process, and there is no silver bullet. Subjectivity is present in many of the other medical specialties. There was a recent study in the Journal of the American Medical Association on the interpretations of electrocardiograms, which are used to detect heart arrhythmias and heart abnormalities. Depending on the level of training, the concordance of physicians on electrocardiograms can vary widely.
Our aspiration for standardization in behavioral healthcare does not need to be perfect. There does not need to be perfect adherence to a protocol or perfect agreement on a diagnosis, but the aspiration needs to be that standardization is the direction in which we are heading.
We know certain treatments work, and certain treatments have little evidence to support them. At UHS, we are emphasizing interventions that work. So, the quest for standardization and evidence-based care in behavioral health is a journey. It is not going to happen in one step. But psychiatry as a field has advanced tremendously. There are still some grey areas, but what works and what does not work is increasingly clear.
As I think about what UHS can accomplish, we are moving in the right direction. We are moving toward evidence-based practice. I would argue that in most of our facilities most of the time, the care that is provided is evidence-based.
HL: It has been more than a decade since the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. Is there still work to be done to achieve parity between health plan coverage of mental health care versus medical-surgical care?
Friedlander: The report card has mixed grades.
In terms of the spirit of the law rather than the letter of the law, we have a long way to go. We still see a system of care where behavioral health is in its own silo, and medical-surgical care is in its own silo.
There was a very good study released earlier this year by Milliman about the presence of a behavioral health condition driving medical costs. When we look at the overall spend of medical-surgical care versus behavioral healthcare, mental healthcare accounts for about 4% of the spend but it drives about 44% of the total cost of care. So, parity still has a long way to go.
Health plans still look at behavioral health separately from medical-surgical care. What we need to achieve real parity is to integrate behavioral healthcare into medical-surgical care. Behavioral health is undervalued. The coverage from health plans needs to manage behavioral health in terms of the total cost of care, not just the cost of behavioral healthcare.
If you look at the letter of the law, health plans can say that they are managing behavioral health benefits in a manner that is not more restrictive than medical-surgical benefits. That is probably true, but that represents the letter of the law rather than the spirit of the law.
The Providence health system is conducting about 10,000 telehealth clinic visits daily.
There are several keys to building and sustaining successful telehealth programs at health systems, hospitals and physician practices, a top executive at Providence health system says.
Largely due to concern over the spread of the coronavirus in healthcare settings, many patients have avoided in-person visits and healthcare providers have expanded telemedicine programs. A recent research article published by JAMA Internal Medicine shows explosive growth of telehealth in the first half of the year. From the weeks of Jan. 1 to June 10, the rate of telemedicine visits increased 2,013%, rising from 0.8 to 17.8 visits per 1,000 health plan enrollees, the study found.
At Providence, the Renton, Washington-based health system has made nearly a decade worth of progress in expanding telehealth services in a matter of months, says Todd Czartoski, MD, chief medical technology officer.
"We are doing about 10,000 telehealth clinic visits per day across the health system. We are doing direct-to-consumer telehealth visits in the 500-to-1,000 visits per day range across multiple states. We have monitored more than 12,000 patients in their home with COVID-19 or symptoms of COVID-19 to help keep them safe and out of our facilities. We are way down the road compared to where we were a year ago in fulfilling the vision of telehealth being used across the care continuum to improve access, improve quality, and lower overall cost of care," he says.
Building telehealth programs
Whether a telemedicine initiative is based in a hospital, clinic, physician practice, skilled nursing facility, or patient homes, Providence asks four essential questions before building a program, Czartoski says.
1. Is the telehealth program safe for patients?
2. Is the telehealth program as good or better than an in-person visit?
3. Is the telehealth program reimbursable by government or commercial payers?
4. Is the telehealth program supported by a clinician champion?
Having a clinician champion for a telehealth program is often overlooked at other health systems, he says. "Whether it is an obstetrics program, primary care program, or any other telehealth program, you need to have a clinician champion to pull their partners and colleagues along."
With 15,000 clinicians who are now telehealth-enabled, Providence has many clinician champions for telemedicine programs, Czartoski says. "We still have some naysayers. Not surprisingly, there are still people who do not believe in telehealth and do not like it. But the wholesale change we have seen with most of our providers has been toward accepting telehealth. We are seeing most of them excited about how they can use telehealth to effectively and efficiently care for their patient panels."
Sustaining telehealth programs
There are three primary factors necessary to sustain a telehealth program, he says.
1. Financial return on investment
"We need to make sure that if we are going to operate a program there is a model to get paid, whether it is Medicare fee-for-service, commercial payers, or at-risk payment models," Czartoski says.
At-risk contracts such as accountable care organizations and Medicare Advantage have significant potential to sustain a telehealth program, he says. "Where you see risk being taken by the care delivery system, you will see providers pushing the envelope of what they can do safely and effectively with virtual care."
2. Patient and provider experience
"You need to consider both the patient and the provider journey. We need to make the telehealth experience more seamless, frictionless, and efficient for our providers and the patients who are using this technology," Czartoski says.
The biggest driver for patients in terms of telehealth experience is the ease of connecting to the service such as adequate bandwidth and having the device that they need, he says. "It should not require a bunch of apps or log ins—patients should be able to touch a button and the provider pops up."
Providence has tried to use existing tools to ease the way patients connect to telehealth services such as MyChart. "We have also used some secure texting to engage with patients and folks who are not as tech savvy—they do not want to download an app and they do not want to log in. They just want something that comes to their phone when they need it in a way that is easy to manage and use. How you engage patients is critically important," Czartoski says.
Clinicians also need to put patients at ease to generate a positive telehealth patient experience, he says. "We give basic training to our providers such as eye contact with the camera and putting people at ease. If it is a new visit, providers are trained to show their ID to assure patients that you are who you say you are. Simple things may not sound that important, but they are."
The ease of use and efficiency of telehealth platforms are crucial for provider experience, he says. "Clinicians want to be able to care for their patients efficiently. If they are running late, they want to be able to let a patient know through secure text that they will be five minutes late. Providers also want to have their telehealth visits embedded in their electronic health record. They do not want to open up another app. Almost all of our telehealth visits are conducted through Epic. Providers want telehealth visits to be seamless as part of their workflow."
3. Retooling the provider setting
The third primary factor for sustaining telehealth programs can be the most challenging, Czartoski says.
"You must re-envision what a practice is going to look like. Many practice groups have been reluctant to do that, mainly because there is no certainty that the shift to telehealth to see Medicare patients is going to be permanent. Without that reassurance or confidence, completely overhauling your practice such as changing the number of nurses and front office staff as well as changing the physical footprint that you need, the technology, and the scheduling of patients is daunting."
For example, several Providence physician practices and medical groups have launched an initiative to use a centralized team of medical assistants to conduct blood pressure monitoring and to call high-risk patients to check on them. The medical assistants have taken those responsibilities off the plate of primary care doctors, he says.
"This is an example of monitoring patients at the enterprise level through calls, texts, and Bluetooth-enabled home monitoring. It improves access and adds touchpoints to the patients who we are serving."
In the initiative, a team of about 50 medical assistants is supporting nearly 1,800 clinicians, Czartoski says.
