New research shows interprofessional conflicts between female surgeons and nonphysician staff can be addressed at the individual and institutional levels.
There are strategies to address workplace conflicts between female surgeons and nonphysician medical staff members, a recent research article says.
Earlier research has shown female surgeons experience less achievement, more dissatisfaction, and higher levels of burnout compared to male surgeons. Interprofessional conflict has been associated with workplace dissatisfaction and stress, and earlier research indicates women are more likely than men to experience interprofessional conflict.
The recent research article, which was published by JAMA Network Open, is based on data collected in interviews of 30 U.S. female surgeons who were selected to reflect the age range and surgical experience level of female surgeons nationwide. The data generated several key findings.
The primary causes of interprofessional conflicts involving female surgeons were communication breakdowns, performance-related disputes such as staff members failing to provide proper equipment for a surgery, and breaches of institutional policies and protocols such as wearing nail polish.
The female surgeons felt there was a double-standard in interprofessional conflicts favoring male surgeons, an expectation that they should comply with gender norms rather than professional norms, and negative impacts on their well-being and professional reputation.
The female surgeons felt there was the potential for compromised patient safety because of decreased communication following an interprofessional conflict.
Most of the interprofessional conflicts involving female surgeons were with female staff members. In the study's interviews, many female surgeons said these interprofessional conflicts were likely related to actions violating gender stereotypes such as assertive direction from another woman.
"These data support the need for systematic changes to prevent interprofessional workplace conflict and to ensure more equitable adjudication when conflicts arise," the study's coauthors wrote.
At the individual level, female surgeons reported pursuing three primary strategies to address interprofessional conflicts.
1. Relationship management: "Participants discussed aspects such as personal accountability, gauging the emotional responses of others, and recalibrating their actions based on those responses," the study's co-authors wrote. Many of the female surgeons reported that relationship management contributed to the emotional burden of interprofessional conflicts because it was viewed as additional labor.
2. Rapport building: Many of the female surgeons reported participating in events for nonphysician staff such as baby showers to forge friendships. "For some, this process was natural and in line with how they would communicate with colleagues, but for others it felt contrived and was viewed as a form of performance needed to make things run smoother," the study's co-authors wrote.
3. Social support: "In the absence of having leadership effectively manage these situations, women surgeons would find other forms of support to alleviate the burden. This support was found in both formal and informal spaces and most often involved commiserating over shared experiences," the co-authors wrote.
Institutional strategies to address interprofessional conflicts involving female surgeons include three approaches, according to the research article.
1. Behavioral standards: Bullying, hostility, incivility, and sarcasm should not be tolerated from any medical staff member, particularly in training programs.
2. Interprofessional team building and training: "Despite the critical nature of teamwork in the operating room, surgeons rarely have significant input in choosing their team members, regular opportunities for performance evaluation, or regular opportunities for team-based training. In this way, the traditional nature of physician and nursing leadership silos may create obstacles to optimal teamwork and accountability," the study's co-authors wrote.
3. Staffing consideration: "Many conflicts reported by the participants occurred early in the tenure of the women surgeons, and relationships often improved after several years, after the staff became more familiar with the women surgeons. Given that many conflicts were related to perceived performance gaps, strategies such as assigning high-performing staff members to new surgeons may reduce interprofessional conflict by reducing the performance-based gaps surgeons may encounter when in a new system," the co-authors wrote.
Difficulties include staffing shortages, lack of personal protective equipment, and an increase in patient health burdens due to delayed or inaccessible care.
Primary care practices are continuing to struggle with the impact of the COVID-19 pandemic, a new survey indicates.
Drops in patient volume and increases in costs for infection control such personal protective equipment (PPE) have hit physician practice bottom lines hard during the pandemic. In the spring, a survey conducted by the Primary Care Collaborative and The Larry A. Green Center found only 33% of primary care clinicians had enough cash on hand to function for four weeks.
The new survey, which was conducted by the Primary Care Collaborative, The Larry A. Green Center, and 3rd Conversation, features information collected from more than 580 primary care clinicians in 47 states, the District of Columbia, and Guam. The survey, which was conducted from Oct. 16 to Oct. 19, has several data points that reflect the status of primary care practices during the fall stage of the pandemic.
60% percent of survey respondents reported seeing a rise in COVID-19 illness in their communities
In a finding consistent with four other Primary Care Collaborative surveys conducted since August, about half of respondents reported the level of strain related to the pandemic as a 4 or 5 on a 5-point scale
56% of respondents reported an increase in health burdens among patients due to delayed or inaccessible care
Only 16% of respondents reported that their practice had added capacity to help patients with mental or behavioral health conditions, despite an increasing burden
Financial difficulties have eased at primary care practices, with only 6% of respondents reporting that they were unable to pay some bills
35% of respondents reported having difficulty hiring staff
27% of respondents reported permanently losing practice members, including to early retirement and illness
44% of respondents reported that it was taking more than two days to receive coronavirus test results
23% of respondents reported that inadequate supply of PPE or the necessity to reuse PPE made them feel unsafe
Interpreting the data
With many primary care practices under severe strain, their ability to play an active frontline role in distributing COVID-19 vaccines is in doubt, the survey authors wrote.
"Successful distribution of a COVID-19 vaccine will require a high functioning primary care platform, yet practices remain weakened by lost revenue, pandemic surges, and deteriorating patient health. It is urgent that public and private payers foster primary care stability by committing to prospective payments and maintenance of telehealth at parity with in-person visits until the vaccine is widely disseminated," they wrote.
Ann Grenier, president and CEO of the Primary Care Collaborative, told HealthLeaders that primary care practices are facing daunting challenges during the fall coronavirus surge. "Many of us are very concerned about how the primary care platform will weather this surge. To date, they have proved resilient and innovative in their response to patient need. But both practices and patients are in a more compromised state as the survey shows."
It is unclear how many primary care practices face existential threats, she said. "Unfortunately, we will know in the rear-view mirror. How many primary care clinicians retire or throw in the towel? How many decide to sell their practice? The primary challenges include lack of capital to weather the volume declines, a fee-for-service payment model that depends upon volume, and a tired and discouraged workforce—many of whom do not have access to basic pandemic supplies like PPE."
There are two primary ways to bolster primary care practices during the fall coronavirus patient surge, Grenier said.
"Public and private payers need to come together and vow that they will not back away from payment parity for virtual and phone patient visits. In the middle of this surge, primary care should not have to worry whether they will be renumerated for doing their job of virtually triaging, managing, and educating patients who are scared. Prospective payments to shore up practices would also be incredibly valuable."
The physician group also adopts several other new policies and calls to action, including urging a multifaceted approach to social determinants of health.
The American Medical Association has adopted new policies this week, including prevention of bullying among healthcare professionals and recognition of racism as a public health threat.
According to The Joint Commission, intimidating and disruptive behavior in healthcare settings is associated with medical errors, poor patient satisfaction, and preventable adverse outcomes. In June, the AMA Board of Trustees recognized the health consequences of violent police interactions and called racism an urgent threat to public health.
Taking stand against bullying
Bullying in healthcare settings has far-reaching impacts, AMA Board Member Willie Underwood III, MD, MSc, MPH, said in a prepared statement. "Bullying in medicine not only negatively impacts the mental and physical health of the professional being bullied, but can also have lasting adverse effects on their patients, care teams, organizations, and their families."
Healthcare organizations and other stakeholders need to take actions to prevent bullying, he said.
"Bullying has no place in the medical profession and we must do everything we can to prevent it for the sake of the wellbeing of the healthcare workforce. Putting an end to bullying in the practice of medicine will require the healthcare industry, local organizations, and individual members of the healthcare team to acknowledge the problem, accept responsibility, and take action to address it at all possible levels."
The new AMA policy, which was approved this week at the Special Meeting of the AMA House of Delegates, includes an eight-point guidance framework to establish an effective workplace policy to prevent bullying in healthcare settings.
Describe the leadership team's commitment to providing a safe and healthy workplace that does not tolerate bullying and unprofessional behavior
Define workplace violence, harassment, and bullying, including intimidation, threats, and other forms of aggressive behavior
Specify to whom the policy applies such as medical staff, students, administration, patients, employees, contractors, and vendors
Define both expected and prohibited behaviors
Outline steps for individuals to take when they feel they have been targeted in workplace bullying
Provide contact information for a confidential means for documenting and reporting workplace bullying incidents
Prohibit retaliation as well as ensure privacy and confidentiality
Document training requirements and establish expectations about the training objectives
The new policy sets a definition for workplace bullying.
"The AMA defines 'workplace bullying' as repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target," the AMA said in a prepared statement.
Racism as public health threat
Racism is linked to healthcare inequities, AMA Board Member Willarda Edwards, MD, MBA, said in a prepared statement. "The AMA recognizes that racism negatively impacts and exacerbates health inequities among historically marginalized communities. Without systemic and structural-level change, health inequities will continue to exist, and the overall health of the nation will suffer."
Physicians can play a key role in addressing racism, she said. "As physicians and leaders in medicine, we are committed to optimal health for all, and are working to ensure all people and communities reach their full health potential. Declaring racism as an urgent public health threat is a step in the right direction toward advancing equity in medicine and public health."
The new policy declaring racism as a public health threat, which was approved this week at the Special Meeting of the AMA House of Delegates, calls on the physician organization to take six steps to combat racism.
Acknowledge the harm caused by racism and unconscious bias in medical research and healthcare
Identify tactics to address racism and its health effects
Encourage medical education curricula to promote greater understanding of racism
Support external policy development and funding to research racism's health risks and negative impacts
Work to prevent the influences of racism and bias in healthcare technology innovation
Identify a set of best practices for healthcare institutions, physician practices, and academic medical centers to address and mitigate the effects of racism on patients, providers, international medical graduates, and populations
Other House of Delegates actions
The Special Meeting of the AMA House of Delegates adopted several other new policies and calls to action, including the following:
The House of Delegates called for a multifaceted approach to addressing social determinants of health. "Addressing social determinants of health requires an all-hands-on-deck approach that is not limited to stakeholders within the healthcare system. By addressing social determinants of health in their benefit designs and coverage, health plans can be part of the effort to improve patient health outcomes," David Aizuss, MD, a member of the AMA Board of Trustees, said in a prepared statement.
A new policy prescribes actions to mitigate the negative effects of high-deductible health plans. "The new policy encourages research and advocacy to promote innovative health plan designs that respect patients' unique healthcare needs. Moreover, to ensure that innovative health plans are likely to achieve their goals of enhanced access to affordable care, the new policy encourages active collaboration among organized medicine and payers during plan development," AMA Board Member Mario Motta, MD, said in a prepared statement.
A new policy targets misinformation about the efficacy and safety of COVID-19 vaccines through a public education campaign. "We will continue to monitor the scientific data regarding safety and effectiveness during and after the vaccine development process to ensure the proper safeguards are in place to deliver a safe and effective vaccine," AMA President Susan Bailey, MD, said in a prepared statement.AMA ethical guidance on physician immunization was amended. "Physicians who are not or cannot be immunized have a responsibility to voluntarily take appropriate actions to protect patients, fellow healthcare workers and others," the amended ethical guidance says. Appropriate protective actions include non-immunized physicians refraining from direct patient contact, according to the amended ethical guidance.
Sanford Health's chief operating officer shares how the health system is reacting to a surge of COVID-19 patients in the organization's sprawling service area.
Sanford Health is prepared to address the challenges of the fall coronavirus patient surge, according to the health system's chief operating officer.
Health systems, hospitals, and physician practices are under strain as the country experiences record-setting levels of new confirmed coronavirus cases and hospitalizations. The fall surge is particularly challenging to health systems such as Sanford Health, which operates resource-strapped rural healthcare facilities in four states.
Sanford Health operates 46 hospitals and 210 clinics in Iowa, Minnesota, North Dakota, and South Dakota.
To see how Sanford Health is responding to the latest wave of coronavirus infections and hospitalizations, HealthLeaders recently spoke with Matt Hocks, MBA, chief operating officer of the Sioux Falls, South Dakota–based health system. The following is a lightly edited transcript of that conversation.
HealthLeaders: For Sanford Health, what is the primary challenge in coping with the current coronavirus patient surge?
Matt Hocks: The primary challenge right now is the record number of COVID-19 cases in addition to the other cases we are seeing. We are working to balance our resources to not only care for the COVID-19 patients but also care for patients with strokes, heart attacks, traumas, and other conditions who are seeking care from Sanford.
We have an obligation to our communities to be there for them in their time of need, and it would be a challenge for any healthcare organization as we see these numbers grow literally overnight.
In the early phase of the pandemic, we were able to manage pretty well. In May, our peak COVID-19 patient census was about 100 hospitalized patients. Today, we have almost 400 hospitalized COVID-19 patients. Our total hospitalized patient census is about 1,400.
HL: What strategies has Sanford deployed to deal with the pandemic?
Hocks: We set up some simple strategies right away at the corporate level in March. One strategy was to have 120 days of personal protective equipment on hand. We never wanted our clinicians to turn around and not have a mask in the drawer or on the shelf. That was non-negotiable. Our staff's safety was a priority.
Second, we needed to have modeling. We needed to know what was going to happen in seven days, 14 days, and 28 days. We knew that as we went further out, the modeling became less reliable, but from seven to 28 days it was very reliable. We shared the modeling with our markets, so they also could prepare.
Third, we needed to make sure we had coronavirus testing capabilities. Early on, we realized that we could not rely on others for the testing of our staff or our communities. So, we stood up our own testing capabilities in March.
The last strategy was to have clinical trials, so that we would have drugs available that were coming onto the market. We wanted to make sure that anyone hospitalized with COVID-19 had the opportunity to receive treatment.
HL: Sanford Chief Medical Officer Allison Suttle, MD, has been presenting weekly "State of the Union" videos. Why did the health system launch this communications initiative?
Hocks: We wanted to make sure that there was one source of truth about the virus and how we were responding to the virus. We also wanted to make sure that all of the efforts that we were undertaking to support all of the local leadership and clinicians was communicated and they knew what our strategy was. Our primary service area footprint is about 300,000 square miles, and the only way to communicate to all of our markets was to find a way for Allison to communicate. We thought State of the Union videos was a great way to do it.
HL: What kind of content is included in State of the Union videos?
Hocks: There are three criteria for every State of the Union video.
Number one is thanking our people and asking them to stay safe. We want to show encouragement and appreciation for the personal and professional sacrifices that have been going on for almost 30 weeks. Number two is to share our strategy as an organization and how we are pivoting. Number three is some educational component to help the staff be more educated about the virus because of all the misinformation that is out there.
HL: Rural hospitals and physician practices have limited resources. How has Sanford bolstered rural hospitals and physician practices during the pandemic?
Hocks: Typically, about 10% to 15% of our COVID-19 patients are not in our four main medical centers—they are in our critical access hospitals. Those patients are part of our integrated health system; and regardless of where patients come into our organization, we want them to receive the same level of quality care that they would otherwise receive anywhere else. That may mean they need to be transferred because we do not have the same level of sub-specialization in a small town like Sheldon, Iowa. But that just means patients are a phone call away from one of our main medical centers.
At our rural facilities, staff have access to PPE. The facilities have access to testing. They have access to our modeling, so they can see what will be happening in their communities. And they have access to clinical trials—if their patients need remdesivir, we can get them that drug.
Although we are spread across a large geography, our logistics are set up in a way that small hospitals can care for patients who have COVID-19. Thankfully, most COVID-19 patients can enter our rural hospitals and leave without a huge amount of medical intervention. But there are some patients who need to be in an ICU and need to be intubated, and those are the patients that we transfer to our major medical centers so that they can get the next level of care.
HL: During this fall coronavirus surge, the country is setting records for coronavirus cases and hospitalizations. Are you concerned that Sanford could be overwhelmed?
Hocks: Based on our modeling, we are going to see an increase in COVID-19 patients, and we have surge plans to accommodate those increases. Back in March, we asked what it would mean to have 600 coronavirus patients in our hospitals or 800 coronavirus patients in our hospitals. We looked at our options for care sites. We asked how we were going to work with our state governments and our departments of health. If we did not work as a team, I would be concerned. But as we bring together the power of an integrated health system working with state and local officials, we can endure this third surge.
So, we are not in a crisis mode, but we are very serious about the challenges. We know that the number of COVID-19 patients is going to increase, but we have ways to accommodate more patients.
It is a balancing act. How do you continue to care for COVID-19 patients while also caring for everyone else who needs care, too? We are focused on our coronavirus patients and how we can keep them out of the hospital. As long as we continue to do that and leverage all of our resources and challenge all of our strategies, we believe we can handle whatever comes at us next.
In recent research, healthcare professionals with sleep disorders were nearly four times as likely to suffer burnout than staff members without sleep disorders.
Healthcare professionals with sleep disorders face a significant risk of burnout, a recent research article found.
Burnout is one of the most vexing challenges facing physicians and other healthcare workers nationwide. Research published in September 2018 indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
29% of the staff members screened positive for at least one sleep disorder
Insomnia was the most common sleep disorder, which affected 14% of staff members
The next most common sleep disorders were obstructive sleep apnea (12%), shift work disorder (11%), and restless legs syndrome (2%)
Out of the staff members who screened positive for at least one sleep disorder, 92% were previously undiagnosed and untreated
29% of staff members screened positive for burnout
Screening positive for a sleep disorder was linked to increased odds of burnout (odds ratio 3.67) and lower odds of professional fulfillment (odds ratio 0.53)
"The findings of this cross-sectional study suggest that undiagnosed sleep disorders are common among faculty and staff employed in a teaching hospital system. A positive screening result for a sleep disorder was associated with nearly 4-fold increased odds of occupational burnout. Those who had a positive screening result for a sleep disorder were half as likely to report professional fulfillment," the study's co-authors wrote.
Interpreting the data
Sleep and mood are related closely, the lead author of the study told HealthLeaders.
"Prior research has established a bidirectional relationship between sleep and a variety of mental health outcomes. Sleep deficiency—through insufficient sleep duration or a sleep disorder that reduces the quality or quantity of sleep—impacts mental health and reduces resiliency. The vulnerability to adverse mental health outcomes introduced by sleep disorders likely increases the risk of occupational burnout," said Matthew Weaver, PhD, an associate epidemiologist at Brigham and Women's Hospital as well as an instructor in medicine at Harvard Medical School in Boston.
The link between sleep disorders and decreased odds of professional fulfillment is a "novel finding" that is open to speculation, he said. "The same evidence that supports the relationship between sleep and burnout likely applies here, though other factors may be important as well. I can say that regardless of job role and specialty, an individual with a sleep disorder is only half as likely to feel fulfilled with their work."
More research is needed to evaluate the effectiveness of a sleep health and wellness program on reducing burnout symptoms, Weaver said.
"The findings indicate that randomized trials to test the effectiveness of a sleep health education and sleep disorder screening program to reduce burnout symptoms are warranted. In addition, replication of these findings at other institutions would add to the evidence in this area. Occupational burnout has proven to be resistant to many prior treatment approaches. This represents an exciting new approach."
The new COVID Recovery Heart Clinic features a multidisciplinary team of physicians, nurses, imaging experts, and physical therapists.
This month, the Cedars-Sinai health system in Los Angeles opened a dedicated clinic to assess and manage COVID-19 patients who are experiencing persistent cardiac symptoms after recovering from acute illness.
One of the more mysterious characteristics of COVID-19 is a select group of patients who are "long haulers" experiencing symptoms for weeks or months after recovering from the acute phase of the illness. Long haulers have a range of symptoms, including cough, shortness of breath, constitutional symptoms such as numbness and tingling, cardiac issues, hair loss, and deconditioning.
At Cedars-Sinai and across the country, it became clear in the early days of the pandemic that COVID-19 can have profound effects on the cardiovascular system, Siddharth Singh, MD, a staff cardiologist and assistant professor at the Smidt Heart Institute and director of the new COVID Recovery Heart Clinic, recently told HealthLeaders.
"Some of us among the cardiology faculty were closely involved in the care of the first patients in the ICU and medical floors. We got to experience first-hand some of the effects on the heart in COVID-19 patients," he said.
After the spring coronavirus surge, it became clear that COVID-19 long haulers were experiencing persistent cardiac symptoms, Singh said. "As time went along, we started getting calls from physician friends and patients who had recovered from COVID-19 but were having persistent symptoms. In the past couple of months, we started talking amongst ourselves as a group, and we came up with this idea to start a dedicated clinic for COVID-19 patients who had recovered but were actively experiencing cardiac symptoms."
How the COVID Recovery Heart Clinic works
The new clinic features a multidisciplinary team of physicians, nurses, and physical therapists, Singh said. "The COVID Recovery Heart Clinic at Cedars-Sinai is part of a wider institutional mission to better characterize multi-organ involvement in COVID-19 patients. On the cardiology side, we have a team of general cardiologists, imaging experts, and heart failure specialists."
Treatment of patients at the new clinic starts with a thorough history and physical examination, he said. "We check blood work to see whether patients have any signs of ongoing heart damage. We get electrocardiograms and echocardiograms, which is ultrasound of the heart to check the pumping function of the heart and to see whether we can identify any subtle signs that would suggest some decline in heart function."
In patients who have clinical features that would suggest arrhythmias, the clinic conducts ambulatory heart rhythm monitoring to make sure patients are not experiencing heart rhythm issues, Singh said.
Advanced imaging is conducted on some patients, he said. "Based on blood work, when we suspect ongoing heart involvement, we are performing state-of-the-art imaging with cardiac MRI to investigate whether there is any swelling or inflammation in the heart muscle."
Athletic patients receive a unique course of care, Singh said. "In selected cases where patients want to go back to rigorous athletics, we advise patients against vigorous exercise for two or three months after their recovery from COVID-19. Once they have recovered, we will perform exercise testing to ensure that they can go back to rigorous exercise safely."
Cardiovascular conditions common in COVID-19 patients
Coronavirus patients can experience a range of cardiovascular conditions, Singh said.
Myocarditis, which is inflammation of the heart muscle
Abnormal clotting linked to inflammation of the lining of blood vessels
Septic cardiomyopathy or stress cardiomyopathy, which are forms of reversible heart failure that are seen in critically ill patients with or without COVID-19
Low blood pressure or elevated heart rate linked to cytokine storm
Heart attacks
The right ventricle of the heart tends to become weaker or fail in patients who have severe pneumonia from COVID-19
Arrhythmias can affect anywhere from 30% to 50% of severely ill COVID-19 patients
COVID-19 patients recovering from the illness should be on guard for several cardiac-related symptoms, Singh said. "Symptoms that patients should be on the lookout for are persistent chest pain with exertion or without exertion, shortness of breath especially with exertion, palpitations, swelling in the legs, feeling faint or dizzy, passing out spells, and feeling very fatigued with physical activity."
The COVID-19 pandemic has reshaped healthcare on several fronts—either promoting new care models or accelerating adoption of innovations.
A prime example is telemedicine. Prior to the pandemic, telehealth visits were relatively limited, and physicians were hesitant to adopt telemedicine in their practices. Once the pandemic hit and both physicians and patients were concerned about the spread of the novel coronavirus in healthcare settings, telemedicine adoption accelerated to unprecedented levels.
A relatively unexplored frontier of telemedicine that could heat up as the pandemic continues is in the inpatient setting, says Shafeeq Ahmed, MD, MBA, vice president of medical affairs and chief medical officer at Howard County General Hospital—A Member of Johns Hopkins Medicine.
"As a community hospital within a large academic health system, we do not necessarily have every specialist. There are several specialists that may not be present, which can prohibit some types of care. Now, we can get specialists via telemedicine, and it can work across the country for all sorts of rural hospitals. And you do not have to move your patients to a higher cost of care setting," he says.
Telemedicine specialists could work in the postacute setting, too, Ahmed said. "Instead of physically embedding someone in a skilled nursing facility, you may be able to have evaluations via telehealth."
The pandemic is changing the approach and priorities related to value-based care at health systems and hospitals, says Gary Smalto, MD, MBA, a practice partner at Optum Advisory Services.
"What we are seeing across the country is an intense focus on managing cost and quality at the same time on the acute care side though care standardization to improve those costs under value, and around bundled payments. But on the ambulatory side, we need to find out how we are going to invest in digital health to expand our footprint and dive into the customer experience. One of the biggest things we are seeing is an intense focus on customer experience and how we can deliver valuable programs into the home that go beyond telemedicine or replacing an office visit with telemedicine," he says.
The coronavirus pandemic has increased cooperation between former health system rivals, says Brian Johnson, MD, chief medical officer of Allegheny Health Network's West Penn Hospital.
"In Pittsburgh, we have a competitive healthcare environment, with several providers in the area. We are not well known for collaborating because of the intense level of competition between us. But during the COVID-19 pandemic, the CMOs from every network as well as other leaders from every network came together to discuss how we were going to collectively manage the pandemic from a public health perspective. How are we going to share best practices? How are we going to do the right things for patients by working through this process under one umbrella?" he says.
Some degree of cooperation is likely to continue after the coronavirus crisis has passed, Johnson says. "It started out as sort of a trial. Within a couple of weeks, it became a weekly discussion, and we enhanced how we did things. I do not think it will remain in place to the same degree, but it has opened the door to us sharing ideas."
Integrating family caregivers into formal healthcare teams benefits patients, caregivers, and healthcare providers, RAND Corporation report says.
Healthcare providers, payers, and policymakers should work harder to integrate family caregivers into formal healthcare teams, a new report from the RAND Corporation says.
The new report says there are multiple clinical benefits from integrating home caregivers into formal healthcare teams, including improving patient access to services, reducing unmet needs of patients, boosting quality of care, and delaying patient institutionalization. Integration also benefits the caregivers such as increasing mastery of caregiving, boosting confidence, and improving quality of life, the report says.
Despite challenges, both sides want to make integration work, the lead author of the RAND report told HealthLeaders this week.
"Providers want to include family caregivers in formal healthcare teams, but they have so many responsibilities already that it is hard to add caregivers to the mix. Family caregivers need a lot of information, and they do not know who to turn to. We need to find ways to help everybody communicate with each other and coordinate better," said Esther Friedman, PhD, a behavioral and social scientist at RAND, and a professor at Pardee RAND Graduate School in Santa Monica, California.
The report says healthcare providers, payers, and policymakers should focus on six areas to promote integration of caregivers into formal healthcare teams.
1. Identifying and recording caregiver information
The first step to promoting integration is taking a three-part approach to gathering information on family caregivers, the report says.
Providers should ask patients for permission to work with family members and learn about the caregiving routine.
Caregiver assessments should be included in documentation of healthcare encounters. "The goal is to inform providers about who is participating in a patient’s care and what tasks each person is doing," the report says.
During advanced care planning with primary care physicians, patients should be asked whether family members should be included in the conversation.
"One of the fundamental barriers to integrating family caregivers into the formal healthcare team is the difficulty that they face in identifying caregivers. There are several difficulties. There are some individuals who do not self-identify as caregivers. There could be multiple caregivers. And patients may not want to identify caregivers out of worry over losing autonomy and private healthcare information," Friedman said.
2. Incentivizing provider engagement with caregivers
To boost provider engagement with caregivers, one recommendation in the report is adoption of payment models that allow providers to bill for time spent engaging caregivers.
Another recommendation to increase engagement is to promote value-based healthcare delivery systems. "Value-based healthcare systems reward providers on the quality of care, thereby incentivizing providers to coordinate care with family caregivers if doing so would improve patient health outcomes," the report says.
"We did hear from our interviewees that financial incentives do need to be aligned to promote provider engagement with caregivers. But there definitely is more work that needs to be done to determine the best ways to incentivize providers to engage family members," Friedman said.
3. Investing in supportive services for caregivers
"Increasing supports for family caregivers can reduce the burden on caregivers and give them time to coordinate with the healthcare team," the report says.
The report makes four recommendations for investing in supportive services for caregivers.
Routine assessments of caregivers to give clinicians and care coordinators information about caregiver needs and the best ways to support caregivers
Expanding programs that pay caregivers for their efforts such as Medicaid programs
Boosting caregiver supports in Medicare Advantage health plans
Expanding paid leave policies to help caregivers decrease income loss associated with taking time off to care for family members
"There can be more implementation of routine assessment of caregivers by payers. They can assess caregiver needs and provide payments to family caregivers," Friedman said.
4. Increasing utilization of care coordinators
"Having a single designated person who connects caregivers to the training and clinical resources they need can provide valuable information, improve communication, and save time for both caregivers and the care team," the report says.
One recommendation in the report is to expand payer utilization of care coordinators to connect caregivers to clinicians and healthcare information beyond high-risk patients. "Efforts in this policy area would expand access to care coordinators for all patients with care needs, provide opportunities for caregivers to connect with care coordinators separately to help meet their needs, and allow for interaction with clinicians and nurses as needed," the report says.
Increasing utilization of care coordinators can drive efficiency gains for providers and caregivers, Friedman said. "Expanding the use of care coordinators could benefit providers by alleviating some of the burden on providers as being the primary point of contact. Care coordinators also provide family caregivers and patients with their own centralized point of contact."
5. Train providers and caregivers to improve communication
Communication training for clinicians and care coordinators can help them discuss complicated clinical information with caregivers who have limited healthcare literacy, the report says.
Communication programs should also account for diversity among caregivers, the report says. "Given the diversity of caregivers' cultural backgrounds and needs, it is essential for clinical providers and care coordinators to learn how to communicate with different types of caregivers."
Friedman cited a Veterans Administration program as a possible model for communication training.
"The VA Campaign for Inclusive Care, which is one of the case studies we had in our report, provides an online training program specifically for VA healthcare providers. It teaches them how to integrate family caregivers and covers a variety of topics, including communicating with caregivers, privacy regulations, and how to understand the caregiving journey from the caregiver's perspective," she said.
6. Technologies that foster caregiver-provider integration and information-sharing
"Family caregivers need access to patient health information and mechanisms for sharing information with clinical providers and care coordinators," the report says.
Several technologies to promote caregiver-provider integration and information-sharing already exist or could be developed, the report says.
Expanding access to electronic health records and clinical notes
Shared access features on patient portals
Developing systems to record information about family caregivers
Apps and other digital technologies that connect caregivers to each other and care teams
Including caregivers in telemedicine visits and virtual clinics to share information in a secure environment
Healthcare providers are a key players in these technological solutions, Friedman said.
"As primary users of existing technological tools, providers have a critical role to play in evaluating existing technologies. Providers can give feedback on which technologies work best to foster caregiver-provider integration and which technologies are easiest for caregivers to use. Providers also are the ones who can give suggestions for new technologies or new features that could be developed for existing technologies to improve coordination with caregivers to give them access to the kind of information that they request."
RWJBarnabas Health's Connect Together initiative features more than a half-dozen well-being programs for healthcare professionals and their families.
RWJBarnabas Health has launched a sweeping initiative to boost the well-being of its healthcare workforce during the coronavirus pandemic.
Healthcare workers are in a precarious position at the frontlines of the struggle against COVID-19. Before the pandemic, physicians, nurses, and other healthcare professionals were already experiencing high levels of burnout. The pandemic has increased stress in healthcare and introduced new challenges to healthcare worker well-being.
Frank Ghinassi, PhD, senior vice president of RWJBarnabas Health's Behavioral Health and Addictions Service Line, and president and CEO of Rutgers University Behavioral Health Care, says the pandemic has strained the healthcare system and the professionals who care for patients.
"A pandemic like this is a force magnifier for demand on the healthcare system. No organizational structure is staffed for care as usual and a global pandemic. So, it overtaxes the system, and that overtaxing means it is overtaxing the human beings in the system. It is very important to keep healthcare workers functioning and to keep them healthy, both in mind and body," he says.
The pandemic is taking a heavy toll on healthcare professionals, Ghinassi says.
"A lot of what we are seeing is stress, and that can lead to distress. Stress can affect the ability to get a good night's sleep. Healthcare workers may be finding that they are less hopeful about the future. They may be questioning their career. … For those people who either are predisposed toward depression genetically or had histories of anxiety disorders or depression, they are more likely to have those symptoms recur."
To rise to the challenge, RWJBarnabas launched the Connect Together initiative this summer.
"It is a multilevel intervention that has the premise of connecting people to personalized support when, where, and how they need it. We have created a network of resources that are available in multiple contact formats. Resources are available live and in-person, by telephone through named or anonymous call center services, through online platforms such as Zoom and WebEx, and through email and Internet-based apps," he says.
Range of services
The Connect Together initiative is offering healthcare professionals and their families more than a half-dozen programs to address well-being during the pandemic, Ghinassi says.
1. Employee assistance program
"First and foremost, the resource that is probably most familiar with people is the employee assistance program. At RWJBarnabas, the employee assistance program includes six free counseling sessions, stress management seminars that can be conducted on the phone or online, and a series of calming videos that are designed to provide stress relief," he says.
2. Be Healthy program
The Be Healthy program offers resources for healthcare professionals to take care of themselves and their families both physically and emotionally. Be Healthy includes online workout videos, self-guided relaxation programs, mindfulness activities, tips on health and nutrition, and easy technology to track health habits online.
"There is an extensive wellness video library. There are things like videos for at-home yoga and fitness activities. There is an opportunity to interact with health coaching by nationally certified, on-site health coaches," Ghinassi says.
3. Schwartz Rounds
RWJBarnabas is offering Schwartz Rounds to help healthcare professionals discuss challenges in the workplace.
"These are very different than typical medical rounds, where the purpose is to discuss a case and talk about all the technical expertise that goes into delivering healthcare. The Schwartz Rounds talk about a stressful case or adverse event clinically through a brief panel discussion, then allow the healthcare professionals to interact either in person or by video with their thoughts, feelings, and experiences," he says.
Schwartz Rounds are well-suited to the adversity associated with the pandemic, Ghinassi says. "The Schwartz Rounds are an opportunity for healthcare workers to share what it is like to deliver healthcare under these trying circumstances. It allows for universality, for support, and for humanizing the challenges that go along with being a healthcare provider in these difficult times."
4. Peer-to-peer support
The Connect Together initiative includes several peer-to-peer programs for a range of people including healthcare professionals, police officers, veterans, and mothers who have children with behavioral health disorders. RWJBarnabas is offering the peer-to-peer programs in a partnership with Rutgers University Behavioral Health Care.
"We stood up a peer-to-peer line specifically for this crisis called the Doc-to-Doc Together Line, where a group of physicians from the RWJBarnabas community has volunteered to staff a hotline from 8 a.m. to 10 p.m., seven days a week. Physicians can call and speak anonymously with another doctor about what they are experiencing or use the line to connect with formal care," he says.
5. Good Grief program
Good Grief is a nationally based service that provides group opportunities to process grief when an immediate family member has been lost to COVID-19 or other circumstances, Ghinassi says.
"These resources have been made available free of charge to RWJBarnabas staff and faculty during the pandemic. The Good Grief program provides weekly support groups in addition to a variety of videos, podcasts, and webinars about the experience of grief—what to expect and how to deal with it."
6. Health plan programs
For staff members who are enrolled in the RWJBarnabas health plan, behavioral health copays are being waived during the pandemic. "There also is a health advocate program, which is one-stop shopping to access all of our programs to help navigate billing issues, and to connect staff and their loved ones to programs they are eligible for," he says.
7. App offerings
RWJBarnabas is providing staff members and their families with access to three proprietary apps that are designed to address behavioral health issues and to boost well-being, Ghinassi says.
AbleTo provides teletherapy programs and one-on-one support with licensed therapists to help manage stress, anxiety, and depression. Joyable provides online support, a personalized coach, and weekly activities to manage stress and recover from setbacks. MindRight provides an opportunity for teens and young adults to enroll in culturally responsive and trauma-informed coaching programs via text messaging.
8. Information sharing
To raise awareness about the programs offered in the Connect Together initiative, RWJBarnabas has developed a comprehensive set of interactive link grids.
"These grids are available in PDF form, so they can be emailed. In a color-coded way, the grids lay out our Connect Together programs in categories. It is a grid that has six columns and three rows. It tells staff members what a program is, what it provides, and who it serves. There is a legend at the bottom of the grid that makes it very easy to use," he says.
Assessing impact
RWJBarnabas is planning to assess the impact of the Connect Together initiative in the coming weeks and months, but it is certainly making a difference, Ghinassi says.
"The biggest outcome thus far has been service utilization. The employee assistance program tracks its utilization, and their utilization has spiked. There have been many more calls to their support lines. We track the call center lines, and we have seen spikes in those lines from people who self-identify from RWJBarnabas."
The Connect Together initiative can be implemented at other healthcare organizations, he says. "The lesson learned is how a broad array of both problems and accessible solutions can be marshaled quickly. Our efforts in Connect Together serve as a guide for how to do this quickly and effectively. There is an opportunity for this to be used by other health systems across the country."
One of New York's largest health systems marshaled a range of resources and expertise to cope with the spring coronavirus surge.
With coronavirus hospitalizations surging nationwide this fall, healthcare leaders can benefit from the lessons learned in the country's first COVID-19 epicenter in New York.
The resiliency of Manhattan, New York-based Northwell Health was tested in dire circumstances during the spring coronavirus surge. The health system, which features 23 hospitals and 800 ambulatory sites, treated about 20,000 hospitalized COVID-19 patients during the spring surge, says Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at Northwell.
"On the peak day, Northwell had 3,500 inpatients and more than 800 patients on ventilators," he says.
Ten strategies and initiatives helped Northwell cope with the epic influx of seriously ill coronavirus patients, Jarrett says.
1. Focus on the basics
Northwell approached the spring surge with a focus on "basic" strategies, he says.
"Number One is the fact that Northwell has a long history of robust emergency management processes. We have gone through everything from 9/11 to H1N1 to hurricanes. So, we have a very robust emergency management system, and a corollary to that was we immediately went into our incident command structure. We started our incident command in the end of January. That gave us great flexibility because of all the different roles such as logistics and planning were able to work together very quickly."
Another basic strategy involved capitalizing on Northwell's integrated delivery network, Jarrett says. "Throughout the spring surge, we acted as if we were a single hospital even though we have multiple sites. We acted as one. There was one single command structure at the top—emergency operations centers at each hospital reported up to the incident command leadership."
2. Centralized decision-making
Decisions were made centrally—not to exercise control but to be able to shift resources from place to place quickly, he says.
"For example, when ventilators were in short supply in late March and early April, we had meetings twice a day at the system level with the critical care team leadership, procurement, logistics, and the clinical team that looked at where the patients were and how many ventilators we needed at each site. Especially at the 4 o'clock meeting, if we saw a hospital that was down to two ventilators and had a need for about six, we would move eight or nine ventilators to that hospital. We would give them a cushion."
3. Load balance
Jarrett says load balancing, which involved shifting patients from crowded hospitals to hospitals that had more empty beds, played a crucial role in managing the spring surge.
"Long Island Jewish Forest Hills Hospital was in the epicenter of the epicenter. Queens was the worst in the New York area. They were overwhelmed. Some nights, they would have 40 patients who needed to be hospitalized. What we would do is proactively move those patients rather than try to wait for a bed. We would empty the emergency room and get patients where they could get the best care, which is not in an emergency room, it is up on a floor in an ICU. We moved patients all around."
4. Building surge capacity
Northwell created nearly 2,000 additional hospital beds by converting conference rooms, rehabilitation gyms, and other spaces into clinical care sites, he says. Staffing the new clinical care sites—particularly new ICUs—was a daunting challenge.
"As outpatient care went down dramatically and elective surgeries got cancelled, we took that staff and we put them in the hospitals so they could increase the staffing in new areas that were surging. We had to build ICU-level care on regular floors. So, we took staff such as anesthesiologists from ambulatory surgery who have some critical care training to staff the new ICUs. We would mix the new ICU staff with regular ICU staff who would supervise the new staff and serve as a resource," Jarrett says.
5. Virtual ICU
Northwell enhanced the health system's existing virtual ICU program, he says. "We have an eICU that monitors our regular ICUs, and we expanded that with telemedicine carts in the new ICUs so that the doctors there could get almost instantaneous consults if the unit was busy."
6. Clinical advisory board
Northwell created a clinical advisory board that included infectious disease specialists, nursing leaders, hospitalists, and other staff members to standardize treatment protocols, Jarrett says. The board met once a day. Pivotal initiatives launched by the board included standardizing medications and proning seriously ill patients rather than quickly placing them on ventilators, he says.
7. Personal protective equipment management
In the early days of the spring surge, Jarrett says Northwell decided to have all staff members in emergency rooms and COVID-19 units wear N95 respirator masks. Staff members in other patient care areas were required to wear surgical masks. "We believe we reduced the infection rate in our employees significantly. To keep staffing levels adequate, that was important," he says.
8. Asking for staffing help
Northwell drew on existing relationships with other health systems such as Salt Lake City, Utah-based Intermountain Healthcare to import temporary nursing staff, Jarrett says. "At that point we were lucky. Coronavirus was not surging in many places across the country."
9. Communication initiatives
Several communication initiatives were launched to keep the clinical care staff informed during the crisis, including a weekly clinician update video that focused on the latest scientific information, he says. "We tried to keep everybody up-to-date with what was going on because the greatest stress is the fear of the unknown."
10. Staff well-being
Northwell also launched initiatives to bolster the hard-pressed clinical staff's well-being, Jarrett says. For example, the health system used its employee assistance program and behavioral health resources to support staff members, established respite rooms, and provided day care so staff members could leave their children at home.
For staff members who were afraid of bringing the virus home to at-risk family members, Northwell provided hotel rooms, he says. "In the beginning when there was a lot of fear, people didn't have to worry about infecting loved ones."
