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."
Coverys report shows areas at greatest need for clinical care improvement and risk management.
Surgeries and diagnoses generate the most medical malpractice claims, a recent report on a decade of malpractice data says.
Despite advances in patient safety since the publication of the landmark reportTo Err Is Human: Building a Safer Health System more than 20 years ago, medical errors continue to draw thousands of malpractice claims annually. The recent report, which was published by Coverys, says malpractice claims that the company handled over the past decade show the quest to improve patient safety is far from over.
"Change is not happening as quickly and collectively as it needs to. Our data shows improvement in select areas such as increased patient engagement, flattened hierarchies and the ability for staff at all levels to raise concerns, increased teamwork, and better sharing of information. However, many areas remain largely unchanged," the Coverys report says.
The report features data collected from more than 20,000 closed claims at Coverys from 2010 to 2019. The report includes several key data points.
Average indemnity paid in malpractice claims increased from $342,581 in 2010 to $411,053 in 2019.
The Top 5 malpractice allegations were surgery or procedure-related (29.2%), diagnosis-related (27.3%), medical treatment-related (12.5%), medication-related (8.8%), and patient environment safety (6.0%).
The Top 5 complaints related to surgery and procedure events were surgical team performance (78.2%); retained object (7.1%); unnecessary surgeries (3.5%); wrong side, site, or patient (3.4%); and delayed surgery (2.7%).
The Top 5 complaints related to diagnosis events were evaluation of patients including history and physical (32.0%), interpretation of tests (23.9%), ordering diagnostic or lab tests (23.5%), referral management (7.5%), and doctor follow-up with patients (5.0%).
Most diagnosis-related events occurred in physician offices (34.6%) or emergency departments (24.9%).
Cancer was the top medical condition for diagnosis-related events, at 28.5%.
"We were somewhat surprised and even disappointed that we did not see improvement in some of the key areas. Certainly, failure to diagnose and surgical error were areas that remained at high levels, with many of the same issues that we saw in the early days of patient safety improvement," Bob Hanscom, JD, vice president of business analysis at Coverys, told HealthLeaders.
Improving surgery and procedures
To improve surgery and procedures, healthcare organizations should focus on the top two risk management factors, technical skill and clinical judgement, Ann Lambrecht, RN, BSN, JD, a senior risk specialist at Coverys, told HealthLeaders.
"Embedded in clinical judgment are patient assessment and diagnosis of that clinical condition. Those factor very heavily in the clinical judgment. Evaluation of surgical outcomes with feedback provided to the practitioner is part of ongoing performance evaluation and that ongoing focus is critical in addressing technical skill and improving surgical outcomes. We think this is not always happening—it is not happening on a consistent basis and it is not happening periodically," she says.
Training and building experience also are important to improving surgery and procedures, she says. "Ongoing training and being able to perform a certain volume of procedures is essential to maintaining technical proficiency. In anything we do, the more we do it, the better we get at it and the less variation."
There are three primary ways to improve surgery and procedures, Hanscom says.
Although surgical safety checklists were enthusiastically received in certain parts of the country and across Europe, they need to be implemented broadly across the United States.
Technical skill has shown improvement and less variation when organizations have invested in simulation and skills labs, where surgeons can practice procedures and be safe in making mistakes.
Health systems and hospitals need to make reducing distractions in operating rooms a priority.
Improving diagnosis
Lambrecht says efforts to improve diagnosis should focus on the three top risk management categories: clinical judgment, clinical systems, and communication.
"Certainly, use of clinical decision support tools could assist in the clinical judgment arena—they help address issues of hidden bias and narrow diagnostic focus. Clear consultation policies that define when a consultation must occur and how consultants' findings are communicated add another layer to improve diagnostic accuracy. Finally, you should have a chain of command to escalate issues when differences in care arise," she says.
To improve diagnosis, healthcare organizations should address process variability and cognitive variability, Hanscom says.
"The standardization of processes that support high reliability and at least make sure that you are taking all of the steps to reach the right diagnosis is critical. It goes from the initial evaluation of the patient, all the way through to referral management and follow-up with patients. What is the process and how do we make sure things do not fall through the cracks?" he says.
Cognitive variability is significant because clinicians with less and less time on their hands succumb to their own biases, Hanscom says. "They think they know what the condition is and they are going after that—they are not necessarily doing the rule-outs that they were taught to do in medical school because they don't have time to do it."
Technology has a role to play in reducing cognitive variability in diagnosis, he says. "This is where innovation needs to step up in terms of bringing artificial intelligence to the decision-making process."
Improving the evaluation of patients—including patient history and physicals—is essential to achieving effective diagnoses, Lambrecht says.
"One key component is having an experienced provider conduct the initial evaluation that all future assessments will be compared to. This is seldomly done. Typically, it is a resident or an advanced practice provider who conducts the initial evaluation. So, when the initial assessment does not catch even a small issue, that one oversight can trigger a cascade of events that is very difficult to reverse," she says.
Patient engagement plays a crucial role in diagnosis, Hanscom says. "Patients should be participating. They should be reporting their symptoms in the most accurate way possible. They should be encouraged to ask questions. They should be talking about their family history. Patients need to be involved. That should carry through every step of the diagnostic process."
Telehealth has experienced explosive growth during the coronavirus pandemic, with telehealth claims lines increasing 3,552% from August 2019 to August 2020, according to FAIR Health.
There has been unprecedented year-over-year growth in telehealth insurance claims, and the growth was sustained from July to August, according to FAIR Health's Monthly Telehealth Regional Tracker.
In March, when the coronavirus pandemic took hold in the United States, telehealth visits increased 50%, according to Frost and Sullivan. With in-person medical visits associated with the risk of coronavirus infection, virtual visits emerged as a safe and effective way for patients to meet with their doctors in many circumstances.
FAIR Health's Monthly Telehealth Regional Tracker, which was launched as a free service in May, follows telehealth insurance claims lines for commercial payers across the country. The data accounts for about 75% of commercially insured claims.
The August data includes several key data points:
Nationally, telehealth claims lines increased 3,552% from August 2019 to August 2020, increasing from 0.17% of medical claims lines in August 2019 to 6.07% in August 2020.
From July to August 2020, telehealth claims lines were relatively stable, increasing 1.2% from 6.00% of medical claims lines in July to 6.07% in August.
All four regions of the country followed by the telehealth tracker—Midwest, Northeast, South and West—experienced large year-over-year increases in volume of telehealth claims lines from August 2019 to August 2020.
Mental health conditions—the top telehealth diagnosis since March 2020—increased as a share of all telehealth diagnoses from July to August, rising from 45.39% to 48.93%.
Respiratory diseases were the fourth most common telehealth diagnosis in August 2020 at 2.32%. In August 2019, respiratory diseases accounted for 17.63% of telehealth diagnoses, with the year-over-year decrease linked to the diversity of other diagnoses that became more common in telehealth due to the pandemic.
Interpreting the data
The telehealth tracker has documented utilization trends for telemedicine during the pandemic, FAIR Health President Robin Gelburd, JD, told HealthLeaders.
"Beginning in March, there was a great increase in telehealth claim lines as a percentage of all medical claim lines in 2020 nationally and in every region compared to the same months in 2019. April 2020 showed even more growth than March 2020. From April to July, there was a relatively small month-to-month decline. August showed signs of stabilization," she says.
Mental health conditions are a common telehealth diagnosis that has become more prevalent during the pandemic, Gelburd says.
"We can say that even before the COVID-19 pandemic, mental health was a prominent area of telehealth, but mental health conditions have continued to rise as a share of all telehealth diagnoses throughout the pandemic. The increase may be due to stress and anxiety caused by the pandemic or by the fact that, as patients begin to return to medical offices and facilities for non-emergent care, mental health diagnoses constitute a larger proportion of the telehealth diagnoses," she says.
Telehealth has been used for a wider variety of conditions throughout the pandemic, Gelburd says. "For example, hypertension became one of the top five telehealth diagnoses nationally in March 2020 whereas it was not in March 2019 or in February 2020. In the Midwest, diabetes mellitus appeared as one of the top five diagnoses in April 2020, a position it had not occupied in April 2019. In May 2020, developmental disorders ranked among the top five telehealth diagnoses in all regions and nationally; whereas, in May 2019, it was not in the top five in any region."
The new patient action plan stresses leadership, patient and family engagement, workforce safety, and learning systems.
A new "action plan" to advance patient safety addresses fundamental elements of improving safety at healthcare organizations, a leader of the initiative says.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The new initiative is detailed in an action plan published on September 14. The document was crafted by the National Steering Committee for Patient Safety, which was formed in May 2018. There were 27 organizations represented on the steering committee from the following groups: healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies.
Jeffrey Brady, MD, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality, and co-chair of the National Steering Committee for Patient Safety, recently shared his perspectives on the four focal points of the action plan with HealthLeaders.
1. Culture, leadership, and governance
The action plan calls on healthcare leaders, governance bodies, and policymakers to demonstrate a commitment to safety as a core value and to foster cultures of safety.
Healthcare organization leaders play a pivotal role in improving patient safety, Brady says. "Culture, leadership, and governance are one of the foundational areas of the action plan. Any healthcare organization leadership is integral to patient safety."
The action plan provides a patient safety improvement road map to healthcare organization leaders, he says.
"In terms of how we envision the action plan, we view it as being helpful to healthcare organization leaders who play a critical role in establishing, maintaining, and promoting a culture of safety. Over the years of our work on patient safety at AHRQ, patient safety starts at the top. The leadership establishes the culture, and they enable resources to flow to the things that set a safe environment for patients and the healthcare workforce."
2. Patient and family engagement
The action plan calls for propagation of effective patient and family engagement. Specifically, healthcare organizations should include patients, families, and care partners in the design and delivery of care.
"The research shows us that when patients are engaged in their healthcare it can lead to measurable improvements in safety and quality. If a patient or family is paying attention, they are more likely to see something that could be a problem. That is one aspect of patient and family engagement—enlisting patients to help be watchful and mindful of potential safety hazards," Brady says.
Patient and family engagement also provides healthcare organizations with an opportunity to redesign care to be more patient-centric, he says. "Another aspect of patient and family engagement begins even before care is provided. It is the idea of co-production of care with patients and families. This aspect addresses the best ways to organize care, plan care, and structure care. You talk with patients and families about the best way to set up care and how to make it easier for them."
3. Workforce safety
The action plan says patient safety and workforce safety are linked closely. To boost workforce safety, healthcare organizations should take a unified and total-systems approach, the action plan says.
Healthcare workforce safety and patient safety go hand in hand, Brady says. "It is hard to ask anyone who themselves do not feel safe to focus on making sure someone else is safe. When someone does not feel safe, they are understandably distracted by that. If you have a healthcare worker in a situation that does not feel safe to them, even if it is subtle, you want them to feel supported, you want them to feel safe, and you want them to feel someone cares about them."
Healthcare organization leaders are essential to achieving workforce safety, he says. "We state in the action plan that workforce safety is a duty of healthcare leaders. They need to engage in continuous improvement of workforce safety. Because of the potential for distraction, healthcare workforce safety is a precondition for advancing patient safety."
"When we talk in the action plan about the safety of the healthcare workforce, we include not only physical harms such as falls and back injuries from moving patients but also psychological harm, which has been magnified during the coronavirus pandemic. There are risks to everyone in healthcare associated with this new infection. Those threats are not only physical but also psychological—there is a dark cloud of risk associated with the virus."
4. Learning system
The action plan calls on healthcare organizations to foster networked and continuous learning such as promoting the sharing of information and improvement efforts.
Learning systems harness data, Brady says. "Learning systems are more than just about the data—this is where the quantitative understanding of patient safety comes alive. These are reporting systems, data systems, and analytical systems."
Building learning systems help healthcare organizations understand their patient safety challenges and boost sharing of best practices between organizations, he says.
"These systems help healthcare organizations understand what is happening in their own organization such as how many safety events they are having and what is the most common problem. Every organization needs to have a learning system that informs them about safety risks in their own organization. In addition, organizations need to look outside—across the field—to peer organizations from which they can learn."
Learning systems generate benefits beyond boosting patient safety, Brady says.
"The nice thing is we have some efficiencies to be gained through learning systems. The resources, technical requirements, and organizational competencies that are needed for learning systems can be applied to multiple problems. For example, these data systems can be adapted to new problems such as COVID-19. What we can expect is that investment in learning systems will reap additional benefits over time as they are used for more problems."
A recently published study found that female primary care physicians spend more time with patients than their male counterparts.
Female primary care physicians conduct fewer patient visits than their male counterparts but spend more time with patients, which helps to account for the physician gender pay gap, a recent research article found.
Several studies have shown that female physicians earn 8% to 29% less than male physicians. A report published last week by the physician network Doximity found that the wage gap between male and female physicians is 28% this year, with male doctors earning over $116,000 more annually than their female counterparts.
The recent research article, which was published by the New England Journal of Medicine, is based on an analysis of 24.4 million primary care office visits in 2017. The analysis of the office visits compared female and male clinicians in the same physician practices.
The study includes three key data points:
Female primary care physicians generated 10.9% less revenue from office visits compared to male PCPs
Female PCPs conducted 10.8% fewer patient visits over 2.6% fewer clinical days per year
Female PCPs spent 16% more time with patients than male PCPs
The additional time that female PCPs spend with patients relative to their male counterparts is a likely driver of the physician gender pay gap, the research article's co-authors wrote.
"We found that female PCPs generated nearly 11% less annual visit revenue than otherwise similar male PCPs in the same practices, yet they spent more time with patients per visit, per day, and per year. The revenue gap was driven entirely by differences in visit volume, which were only in small part explained by the fewer days that female PCPs saw patients. Taken together, these results suggest that the differences in time spent with patients may be a contributor to the gender pay gap, with female physicians effectively generating 87% of what male physicians generate per hour of direct patient care," they wrote.
Interpreting the data
The study has important implications for female physician work hours and compensating physicians based on patient visit volume, the research article's co-authors wrote.
"We found that female PCPs worked slightly fewer days per year and scheduled substantially fewer visits while—and possibly in part to compensate for—spending more time with patients per visit. Our finding that this additional time spent per visit translated into more time in direct patient care per day and per year challenges conventional assumptions that female physicians work fewer hours (even if they may also choose to schedule fewer visits on the basis of this aspiration). This finding also substantiates the common critique that volume-based productivity is an imperfect measure of physician work," they wrote.
The study also found significant billing differences between female and male PCPs. "Although female PCPs documented more diagnoses and placed more orders, they were more likely to miss opportunities to bill higher-paying visit codes on the basis of the time they had spent with patients, a finding that was consistent with the results of a study showing that female radiation oncologists billed fewer lucrative procedures than their male counterparts," the co-authors wrote.
In addition to providing insight into the physician gender pay gap, the study also may indicate why female physicians are more prone to burnout than male physicians, the co-authors wrote.
"Taken together, we found a nearly 11% gender gap in annual visit revenue among otherwise-similar physicians in the same practices. The gap was due primarily to male PCPs providing more visits, although female PCPs spent more time with patients per visit and overall. The disconnect between time spent and revenue generated may help to explain why female physicians (especially PCPs) face a greater risk of burnout than their male counterparts."
