Alan Harmatz, CMO of Medical City Dallas, says patient safety involves assessing how a care process works, determining whether the outcome was anticipated, and identifying improvements.
A strong risk management strategy is what drives chief medical officer Alan Harmatz, MD, of Medical City Dallas. It's a key component of his job for delivering high-quality care for patients.
Harmatz, who was named CMO of Medical City Dallas in August, oversees clinical care at Medical City Dallas, Medical City Children's Hospital, Medical City Women's Hospital Dallas, Medical City Heart Hospital, and Medical City Spine Hospital. The hospitals are part of HCA Healthcare and Medical City Dallas is a flagship hospital, with nearly 900 beds.
Prior to joining Medical City Dallas, Harmatz was CMO of HCA Healthcare's Florida Brandon Hospital.
Harmatz says risk management often involves examining patient safety events after they have occurred. This involves taking what is learned from patient safety events, then putting processes into place to help develop a robust safety program to prevent these events from happening in the future.
Risk management informs patient safety at health systems and hospitals, he says, adding that you must make sure that the processes you have put in place are followed and the clinical staff's focus is where it should be.
"That requires communication, support, education, coaching, and monitoring. Once this process is started, it never stops," Harmatz says.
Patient safety is not only ongoing but also requires a conversation about what care teams are doing, how care processes are going, and what care teams can do better the next time.
"You ask how a care process worked, did it work better, was the outcome what we anticipated, and what do we need to change and improve," he says. "It is a constant cycle."
Alan Harmatz, MD, is chief medical officer of Medical City Dallas. Photo courtesy of HCA Healthcare.
Rising to leadership challenges
Harmatz oversees clinical care at five hospitals that provide a huge range of services, including emergency department care, complex oncology, pediatrics, cardiovascular services, heart transplants, and solid organ transplants. As he acclimates to this CMO role, he says the main challenges are getting to know the facilities, getting to know the people, and understanding the culture.
"First, I must spend time and go to meet people where they are—I must meet the people who make the miracles happen every day," he says. "Second, I must listen—that can be a challenging thing to do but I think it is the most critical thing to do. Third, I must work hard. There's a lot to be done. There is a lot that goes on here every day, and I must commit to it.”
In establishing a working relationship with the medical staff, Harmatz says it is important to recognize they are highly intelligent and engaged professionals who have been at the organization, in many cases for several years.
"I do not lead the medical staff—I collaborate with them," he says.
Listening to the clinical staff will be essential to being a successful CMO, he says.
"Most of the great ideas do not come from me or above—they come from the people who are delivering the care," Harmatz says.
Physician leaders can be a rare commodity, but if CMOs look and listen, they can find them, he says, adding the best physician leaders are not only interested in what they do but also what the entire clinical staff does.
"They are interested in the processes that get us to the point where we can deliver excellent care," Harmatz says.
Promoting infection prevention
Before joining Medical City Dallas, Harmatz led an HCA Healthcare effort to develop a software program that reduces infections in the hospital setting.
He was part of a group that looked at how to facilitate discharges from hospitals in a timely and efficient manner. They used an effective discharge tool that was developed by some of HCA Healthcare's software developers and content experts. Harmatz suggested creating a similar tool for preventing infections.
Harmatz was paired by his division chief medical officer with another physician leader who runs HCA Healthcare's innovation center. They were given access to two programmers, and he brought in his infection prevention director, who had three decades of experience.
"Three months later, we had a product that was ready to be used in the division and eventually spread across the enterprise," he says.
At HCA Healthcare, the software program has helped to significantly reduce Clostridioides difficile infections as well as methicillin-resistant Staphylococcus aureus, he says, adding the software program is part of an overall effort to use technology to improve patient outcomes.
Clinical background suited to serving as CMO
Harmatz says his clinical experience as a plastic surgeon was good preparation for becoming a CMO.
Plastic surgeons see a lot of problems, including patients who have had attempts to fix conditions in the past that have not worked out well, he says.
"You see a lot of complex challenges," he says. "Every day, you are confronted by different challenges, and very few of them have cookie-cutter solutions."
CMOs and plastic surgeons have similar thought processes, Harmatz says. A CMO must be able to analyze what the true problem is, come up with the reasons for the problem, then look for ways to mitigate the problem, much like what a plastic surgeon does.
The CMO says clinical integration requires communication, trust, and knowing roles and expectations.
To achieve successful clinical services integration, healthcare leaders can't sit in their offices and wait for things to happen, says Philip Heavner, MD, MBA, chief medical officer of Guthrie Cortland Medical Center.
Heavner became CMO of the medical center in September, having previously served as Guthrie Clinic's system chief of pediatrics. Before joining the five-hospital health system, he was chief of pediatrics at Bassett Healthcare Network.
Heavner recently talked with HealthLeaders about a range of issues critical to the role of the CMO, including ensuring clinician engagement and establishing clinical integration.
Clinical integration success requires communication, trust, and making sure the contributors know their roles and expectations, he says.
"As the CMO of a regional hospital, when you have various clinical services such as the emergency department, inpatient services, surgical services, and a cancer center, you need to make sure that the provision of services is well understood across the organization," he says. "You need to communicate with each other to get things done clearly and safely."
CMOs also need to play an active role in clinical integration.
"You make yourself visible," he says. "You do not sit in your office and wait for things to happen. You reach out to people, and you ask them about what support they need as opposed to being passive. When you ask someone what they need, you need to address it."
When there are inadequate resources to support a clinical integration initiative, healthcare leaders need to be direct and honest, Heavner says.
"You acknowledge that any clinical initiative that makes sense deserves support, but there may be a lack of resources for the initiative," he says. "Our organization has a clear strategic process, where we consider and prioritize the resources that we have. We rely on that expertise to decide how resources are distributed. So, you explain the process for how we make decisions, and you help colleagues understand why we are not able to provide resources based on what our overarching strategy defines for us."
Philip Heavner, MD, MBA, chief medical officer of Guthrie Cortland Medical Center. Photo courtesy of Guthrie Clinic.
Rising to CMO challenges
The biggest challenge for CMOs is balancing the clinical factors that contribute to quality, safety, and patient experience, Heavner says.
"You must manage the expectations of all the stakeholders and be a reliable go-between," he says.
In the current healthcare environment, human resources are a primary consideration for CMOs and other leaders.
The coronavirus pandemic taught healthcare leaders the value of nurses, and their stock has risen as a result, Heavner says. Nurses are in high demand, and there are probably not enough experienced nurses to cover the needs of all the healthcare organizations in the country, he says. To be competitive in recruiting nurses, Guthrie Cortland Medical Center needs to be a place where nurses want to be, he says. "We need to be a destination for their careers."
Beyond nursing, there are human resources challenges in other capacities, Heavner says.
"There are other parts of our team that take care of our hospitals and do the work after hours that most people would not wish to do," he says. "Those folks are in demand, too, and this includes our clinicians—our doctors and advanced practice providers. We are constantly trying to attract and retain the very best clinicians, and that is a challenge right now."
Staff retention is critical for healthcare organizations. "Compensation must be fair," Heavner says.
You must be competitive in your market for clinicians, nurses, and support staff, he says. Healthcare leaders also must be clear about their organization's expectations and standards, he says. They also must make sure staff members feel supported in achieving goals related to patient safety, quality, and patient experience. "It is not just about patient experience—it is about clinician and caregiver experience, too. Those things go hand in hand," Heavner says.
Recruitment starts with a clear vision and a clear message about mission and values, Heavner says.
"It starts at the top with our president and CEO, who is a practicing physician. He talks the talk and walks the walk," he says. "When I sit down with someone who is considering an opportunity here, I tell them that this is a good place to work with a conscience. I tell them we take excellent care of our patients and are involved in our communities. I tell them this is a place where they can build a career."
Effective clinician engagement
Clinician engagement is similar to patient engagement, with a premium on clear communication, transparency, and honesty, Heavner says. But there are other key factors as well to take into consideration.
He says health systems and hospitals need to make sure the electronic medical record is a valuable tool rather than an obstacle to quality care. They need to make sure clinicians have time to continue their medical education, he says. And clinicians need to know that their voices are heard. "When a clinician speaks up and says they need assistance with an issue, it should be addressed," he says.
Guthrie Cortland Medical Center has several clinician engagement strategies, Heavner says.
The medical center conducts safety huddles every day, which promotes clinician engagement. The hospital also conducts multidisciplinary rounds every day, where the clinical care teams review every inpatient, their care plan, and what can be done better. In addition, there are regular medical staff meetings. "I meet with the leadership of the medical staff and departments on a regular basis. We talk about how we are taking care of our staff. If you make engagement a priority and talk about it consistently, you can establish momentum," he says.
Health systems are devoting resources to develop physicians as administrative leaders.
Health systems must be committed to developing physicians to serve in administrative leadership roles, the chief medical officers of AdventHealth and RWJBarnabas Health say.
Physicians bring a clinical perspective to administrative roles at health systems and hospitals. Once physicians take on administrative roles, they can help other administrators balance factors that drive clinical care with business priorities such as finance and operations.
"We have a strong belief that physician leadership matters, and we have a strong commitment to physician leadership all the way up to the senior roles at the health system," says Brent Box, MD, senior vice president and CMO of AdventHealth.
Physicians play leadership roles at all levels of the Altamonte Springs, Florida-based health system, he says. "It starts at the top with the chief clinical officer of the health system, who is a physician, Dr. David Moorhead," Box says. In addition, the health system's chief quality and safety officer is a physician, as is the leader of AdventHealth's hospital medicine and clinical documentation program. Several hospital CEOs are physicians, and physicians lead medical groups, service lines, and institutes, he says.
AdventHealth's market leaders make selections of physician leaders such as chief medical officers and work collaboratively with the medical staff and medical executive committees to select physician leaders at the service line level and department levels of the health system's acute care facilities, Box says.
AdventHealth looks for physician leaders who have credibility, he says. Physician leaders should possess clinical excellence, they should be respected by their peers, and they should demonstrate leadership potential at medical staff committees, the market level, or the regional level, Box says. "In addition to credibility, healthcare is team based, so we look for physicians who are oriented toward team leadership," he says.
Physician leaders are pivotal players at RWJBarnabas Health, says Andy Anderson, MD, MBA, CMO and chief quality officer of the West Orange, New Jersey-based health system. "It is important for physicians at the front lines to know there is physician leadership at the table making key decisions for hospitals, service lines, and the health system," he says.
Physicians are involved at almost every level of management at RWJBarnabas, Anderson says. They are involved at the unit level in partnership with nursing leaders. They are involved in hospital administration, including CMOs working with hospital administrators. They are involved at the health system level such as physician leaders who manage medical affairs initiatives and service line leaders.
At RWJBarnabas, physicians are generally selected for administrative roles in a process that takes time, he says. "Typically, a physician would get involved at their local level in areas including committee work or health system quality initiatives. Over time, they take on more administrative responsibilities. Ultimately, physicians become available to serve in leadership roles such as chief of a service line or CMO of a hospital."
Encouraging physician leaders
It can be a challenge to attract physicians to serve in administrative leadership roles, Box says. "We recognize the importance of physician leadership and cultivate it through several programs at the system level and the market level to generate interest in the administrative side of the health system."
Physician leaders are attracted to administrative leadership roles by having the opportunity to change healthcare in a positive way, Anderson says. "Part of that is having role models—having other physician leaders as mentors and people who have been on an administrative leadership trajectory. That helps spark interest and helps nurture physician leaders so they can take on leadership roles at the site level, the hospital level, or the health system level."
Devoting resources to physician leadership
The AdventHealth Leadership Institute, which was established several years ago, is engaged in physician leadership training, Box says. "The leaders of the AdventHealth Leadership Institute are constantly thinking about what it means to be a learning organization. The clinical team partners with our leadership institute to sponsor physician leadership training."
The health system has two other physician leadership programs, he says. In the Physician Team Leadership program, the health system sponsors a six- to seven-month leadership program specifically for physicians. The physicians are nominated for the program by their market leaders. There are 50 clinician leaders in each training cohort. In early 2024, the health will graduate its fifth cohort out of the program. The health system also has the AdventHealth Hospital Medicine Leadership Fellowship. In this program, hospital medicine leaders are trained in a partnership between the clinical team and the leadership institute. About 125 physicians have gone through this program.
RWJBarnabas has dedicated sessions with outside speakers to get physicians motivated and excited about playing leadership roles, Anderson says. The health system has also sent physicians to formal training and national meetings, where they can network and have curriculum around leadership. In addition, the health system encourages mentorship for physician leaders, he says.
RWJBarnabas has developed a manual as a resource for physician leaders, Anderson says.
Effective leadership is a fundamental driver of change and reinforces culture, the manual says. "An effective physician leader should be a role model, teacher, and coach for physician colleagues and for all members of the healthcare team. Leaders should not work in a vacuum, but rather must seek out the input of stakeholders to develop and implement the strategies, goals, and tactics to achieve exceptional outcomes for patients," the manual says.
Physician leadership training has a return on investment, Box says. "At the corporate level, we have invested the money and resources required to pay for our leadership programs because of the recognition of the value of leadership."
Congress must take action as soon as possible, Jesse Ehrenfeld says.
A slew of factors is driving the country's physician shortage, including burnout, shrinking Medicare reimbursement, an aging workforce, administrative burdens, and efforts to criminalize care, American Medical Association President Jesse Ehrenfeld, MD, MPH, said yesterday in a National Press Club address.
The country is facing an estimated shortage of 37,800 to 124,000 physicians by 2034, according to the Association of American Medical Colleges. The projected shortage of primary care physicians ranges from 17,800 to 48,000. The projected shortage of specialists ranges from 21,000 to 77,100.
"The physician shortage that we have long feared—and warned was on the horizon—is already here. It's an urgent crisis hitting every corner of this country—urban and rural—with the most direct impact hitting families with high needs and limited means," Ehrenfeld said.
The physician shortage is leading to alarming gaps in access to care across the country, he said. "It's estimated that more than 83 million people in the U.S. currently live in areas without sufficient access to a primary care physician. In large parts of Idaho and Mississippi, pregnant women can't find OBGYNs to care for them. Ninety percent of counties in the U.S. are without a pediatric ophthalmologist and 80 percent are without an infectious disease specialist. More than one-third of Black Americans live in cardiology deserts."
While the physician shortage is already limiting access to care for millions of Americans, it is going to get worse, Ehrenfeld said.
He noted several disturbing statistics. About two-thirds of doctors reported experiencing burnout during the coronavirus pandemic. About 20% of physicians surveyed during the pandemic reported that they planned to leave medicine within two years. About half of practicing physicians are more than 55 years old. The average doctor leaves medical school saddled with more than $250,000 in debt, which drives them away from primary care to more lucrative specialties.
Ehrenfeld said declining Medicare reimbursement is driving many doctors out of business or forcing them to stop serving Medicare patients. "When you adjust for inflation, the payment rate to physicians who care for Medicare patients has dropped 26% since 2001, which was my first year of medical school, with additional cuts planned next year. I don't know many businesses in any industry that could withstand a 26% drop in revenue and still survive—much less an industry like ours which is so essential to the health and well-being of our nation. Meanwhile, we've seen high inflation, rising personnel costs, and increased practice costs that exacerbate these payment cuts."
Ehrenfeld listed five steps that could help address the physician shortage:
Make significant Medicare payment reform
Reduce administrative burdens such as limiting prior authorization
Pass bipartisan legislation to expand residency training options, to provide greater student loan support, and to establish easier pathways for foreign-trained physicians to work in the United States
Stop the criminalization of healthcare
Ensure physicians are not punished for taking care of their mental health needs
The physician shortage and the factors contributing to it require immediate attention, he said. "We must take action to create a stronger and more resilient physician workforce to care for an ever-changing nation. We must ensure that you, me, and everyone else in America has a physician to care for them, or a parent, or a family member, in their time of need. Most of these solutions have bills pending in Congress with strong bipartisan support, and momentum growing in many states to put other safeguards in place."
Congress must take action as soon as possible, he said. "There isn't much that our two major political parties see eye to eye on right now, but on these issues they do. We just need the will—and the urgency—to get it done. We need leaders in Congress to step forward and make this happen. Sadly, every day we wait, the size of this public health crisis grows."
Career development is essential for job seekers. Learn how the CMO of Northeast Georgia Health System uses it as a selling point.
Key elements of healthcare worker recruitment include investing in culture and educational programs, says Vikram "Vik" Reddy, MD, chief medical officer of the Northeast Georgia Health System.
Reddy became CMO of the Gainesville, Georgia-based health system in July. His previous leadership experience includes serving as CMO of two hospitals at the Wellstar Health System in Georgia.
HealthLeaders recently talked with Reddy about the many challenges he faces, including promoting quality in the hospital setting, clinical integration, and population health. Reddy says his biggest challenge is course correcting and dealing with the "new normal" following the crisis stage of the coronavirus pandemic.
"There are challenges in recruitment for nursing," he says. "There is an increasing challenge with regard to reimbursement. There is also an issue with wage inflation. It all adds up to being more mindful with resources. While you are trying to focus on quality and safety, you must acknowledge that we are not going back to the pre-COVID times."
To address the workforce challenge, Reddy is focusing on strategies to draw nurses, physicians, and other team members to Northeast Georgia. The health system needs to recruit healthcare workers in a way that makes joining the organization attractive, he says. This involves investing in the health system's culture and offering educational programs.
"For example, we have a program where someone starts off as a medical assistant and can advance to becoming a nurse," he says. "You are not just coming to us for a job. You are coming to us for a career."
In physician recruitment, the health system is looking for candidates who are willing to make a commitment to the communities they serve and the region's medical community, Reddy says.
"We want to find people who are going to make an investment in both the broader community and the medical community in the area," he says. "We want to make sure our physicians feel they are making a difference—it is not just a job where they show up and move on."
Reddy says he also needs to be mindful that there are not unlimited resources at the health system.
"If there is already a service being provided by other health systems or other healthcare providers in the area, we do not want to duplicate services just because we can," he points out. "We want to be selective in what the community needs."
Vikram "Vik" Reddy, MD, chief medical officer of Northeast Georgia Health System. Photo courtesy of Northeast Georgia Health System.
Serving as a hospital CMO vs. a health system CMO
Having previously served as CMO of two hospitals, Reddy says overseeing five hospitals in the Northeast Georgia Health System requires him to be cognizant of the individual hospitals and their differences.
"For example, our flagship hospital, Northeast Georgia Medical Center Gainesville, has nearly 600 beds," he says. "It is a Level 1 trauma center. The hospital offers several quaternary care services. Whereas our smallest hospital, Northeast Georgia Medical Center Habersham, is much more rural and we do not have as many services there. What you want to do is ensure that the patients at Habersham and the patients at Gainesville have the same level of quality of care."
One of the biggest challenges in serving rural populations is ensuring access to primary care, Reddy says.
"One of the reasons I was attracted to Northeast Georgia Health System is that unlike several other health systems in the Georgia market, we have alignment with 70% of the primary care practices—whether it is employment or agreements—in our primary service area," he says. "With Habersham, we are going to be investing in more primary care in that area. Primary care drives quality."
He says the health system is taking a three-pronged approach to boosting primary care services in rural areas: Opening new primary care practices, opening new urgent care centers, and expanding virtual care.
Succeeding in clinical integration
The key to success in clinical integration is partnerships outside the four walls of the hospital, says Reddy, who previously served as chief clinical integration officer at Henry Ford Health's Macomb Hospital. Clinical integration requires having partnerships with other nonprofits and government agencies as well as having a tight relationship between the inpatient and outpatient settings, he says.
"For example, with hospital readmissions, our goal is to try to avoid readmissions if they can be avoided, and that requires an exchange of information with the ambulatory practices to know what changes have occurred, what medications were prescribed, and what tests occurred," he says. "There needs to be a bidirectional feed of information so that we can make sure when the patient is discharged there is a smooth transition to the outpatient setting."
Driving clinical quality
The health system uses lean management and daily huddles to drive clinical quality, Reddy says.
"For example, during our huddles, we look at any kind of immediate safety issues, and we try to manage them right away," he says. "If there is an issue, we determine how we are going to solve it and identify who is going to own it. If there are any barriers, the issue can be escalated to someone in the C-suite. It is key to have line of sight into quality and safety."
Hospital-acquired conditions are a primary concern at the health system. For example, catheter infections can lead to prolonged hospital stays, prolonged morbidity, and even mortality if the infection is severe. Reddy says the health system is using technology such as the electronic health record to reduce catheter infections.
"What we do with technology is we identify the patients in the hospital who have catheters, and we have physicians and nurses try to figure out which lines can be removed, and who is at risk of getting an infection," he says. "As we get increasingly wired, we want to see how we can leverage technology and move away from manual processes of writing down who has catheters. We want to use technology to generate reports and streamline workflows to prevent harm."
Prevailing in population health
Reddy, who also previously served as associate medical director of population health for Henry Ford Health, says partnerships and risk assessment are essential for population health initiatives.
"At Henry Ford, we had a large population of patients who did not have access to things like primary care," he says. "So we partnered with another group, which looked at patients' medications and reviewed them to see whether there were any kinds of gaps that could be referred to our primary care practices."
There are several approaches to risk assessment, he says: "Some of it is doing community needs assessments, but you also need to do interviews with patients and analyze why patients are readmitted. You need to analyze why individuals are showing up at your hospitals and ambulatory clinics. You can use technology to investigate, but you also must get into the weeds with individuals to find out about gaps."
A pair of chief clinical officers share their strategies for managing length of stay.
Managing length of stay in hospitals is a primary concern for chief medical officers and chief clinical officers.
Reducing length of stay cuts costs by decreasing the labor associated with caring for patients. Reducing length of stay also decreases the risk of a patient suffering an adverse event in the hospital such as a hospital-acquired infection or fall. In addition, length of stay reflects the efficiency of processes and clinical care in the hospital setting.
Length of stay is ultimately a key metric for how well hospitals care for patients, says Marjorie Bessel, MD, chief clinical officer of Banner Health. "When your length of stay is appropriate, it means that everything that sits under that—how well you take care of patients, how well you work them up, how well you treat patients once you understand what disease process they have, and how well you anticipate the patient's needs post-discharge—is functioning well. From a chief clinical officer's perspective, having the hospital function well is ultimately our responsibility."
Weak management of length of stay is a driver of emergency department boarding of patients, says Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market. Bon Secours is part of Bon Secours Mercy Health, and the Bon Secours Richmond market features seven hospitals.
"Oftentimes, we find that some of the initial testing and treatment for patients may not be started when they are boarded in the ED. Boarding can also overwhelm an ED. As we discharge patients appropriately out of the hospital, we can free up inpatient beds and pull patients from the EDs to start their inpatient care," he says.
Reducing length of stay
Bessel and Charvat say there are six primary strategies for reducing length of stay.
1. Preventive care: Health systems should encourage their patients to receive preventive care. During the coronavirus pandemic and in the post-pandemic period, many patients did not receive routine preventive care, which has led to sicker patients in hospitals and longer lengths of stay. "During the pandemic, there was concern that people were not getting preventive care and in the post-pandemic era people would have late presentation of disease. We are seeing some of this effect," Bessel says.
2. Operational efficiency: Hospitals need to focus on the efficiency of their internal operations, Bessel says. "How fast can you get things moving? How fast can you get a patient worked up to get a diagnosis? How fast can you get the right treatment for the patient? And how quickly can you help the patient recuperate so they are stable enough to be discharged to the next level of care?" she says.
3. Manage transitions to post-acute care: Sometimes, length of stay is extended because of limited access to post-acute care services such as skilled nursing or home health. "Post-acute placement such as with skilled nursing, inpatient rehab, and home health care can be problematic if our post-acute partners are not able to provide services on a timely basis," Charvat says. Hospitals need to start their discharge planning early and hold conversations with post-acute care partners as soon as possible, he says.
4. Managing high-demand services: Hospitals need to coordinate high-demand services such as MRI exams or move high-demand services to the outpatient setting when possible after a patient is discharged, Charvat says. "Is there an evidence-based best practice for determining which patients need to be admitted and which patients need testing such as high-tech imaging? If you can standardize your approach, you may be able to decrease the demand for some inpatient services. The other consideration is looking for opportunities to shift to outpatient services. So, if a patient does not need a test during the inpatient stay, you can schedule that test in the outpatient setting after discharge," he says.
5. Embrace a team approach to discharge: Hospitals can use daily rounding on patients in the morning to identify barriers to discharge and work through those barriers, Charvat says. "We have the hospitalists, nurses, care management team, and other members of the care team going through each patient every day. The team looks at the goals for discharge, the expected discharge date, how the patient is tracking toward discharge, the tests and treatment needed, and successfully transitioning the patient from the inpatient setting. We work through the barriers and often follow-up with an afternoon huddle to go through any last-minute issues," he says.
6. Establish mobility: One of the more recent efforts to reduce length of stay at Bon Secours has been to establish early mobility of patients, Charvat says. "The sooner that a patient who is admitted can get up and start having mobility, we can identify a safe disposition for the patient and whether the patient needs any ongoing therapy or special services at home or in the post-acute setting."
Chief medical officers and other top clinical officers are playing an active role with financial teams.
Chief medical officers and other top clinical officers are more closely involved in financial affairs than in the past.
One of the most salient observations at this summer's HealthLeaders Chief Medical Officer Exchange was that top clinical officers are being encouraged to engage with chief financial officers and their staffs to help address financial challenges at health systems and hospitals. This cooperation is essential as health systems and hospitals face tighter financial margins.
Aimee Becker, MD, CMO of UW Health, says she works closely with the Madison, Wisconsin-based health system's chief financial officer. "All of our leaders are expected to possess a business acumen, including our physician leaders. That business lens has to be part of how we care for patients. Our physician leadership structure includes triads and dyads, where our physician leaders work in partnership with our administrative colleagues. Through these partnerships, we are executing on the right patient care in financially responsible ways."
UW Health sees financial opportunities in providing value in care, she says. "One specific example is inpatient flow optimization work. When you think about patient navigation, whether it is through our emergency departments, through elective admissions, or through surgical processes, patient flow is key. From a process improvement standpoint, by being more efficient and providing the patient with the right care when they need it, there is a financial benefit that comes with that."
Value-based care requires cooperation between clinical leaders and financial leaders, says Daniel Durand, MD, chief clinical officer and chair of radiology at Baltimore-based LifeBridge Health.
"We are looking at the current value-based contracts that we have and the different terms of the contracts. We look at which contract terms that we like, which contract terms that we want to do more of in the future, and which contract terms that we want to do less of in the future. On an annual basis during the budgeting cycle in combination with others such as the chief operating officer of the medical group, we look at the value-based contracts that we are in and think about the new budgetary items we need to focus on—we look at the capabilities that we don't have today that we need to excel in value-based care such as actuarial analytics, physician-facing reporting, contract alignment at the physician level, access solutions, and patient navigation hubs," he says.
Durand and LifeBridge's physician leaders are also focused on cost-cutting, he says. "In cost cutting, we are getting rid of unused space in our bricks-and-mortar facilities, minimizing inventories, getting rid of high-cost supplies that have acceptable alternatives, and limiting premium labor. These are great ways for a health system to focus resources on where they are needed most and get rid of waste."
Optimizing clinical documentation
A primary area where clinical activity has financial implications is clinical documentation.
Accurate and timely clinical documentation is a top priority at UW Health, Becker says. "We are trying to make it easier for physicians and advanced practice providers to do accurate and timely documentation. That work has a host of secondary benefits, including improved risk adjustment, meeting quality metrics, and coding integrity. It makes sure we get paid, but it is really about doing the right thing for patient care, and it is part of our professional obligation as physicians and advanced practice providers."
At UW Health, there are coding reviews that occur behind the scenes to ensure the integrity of clinical documentation, she says. "The clinical documentation integrity team is fact based and data driven. We have a physician medical director who is involved with this work, too. They work to leverage the functionality of our electronic medical record, Epic, using standard, templated note documentation to improve both the integrity of the documentation in real time as well as to make it easier for busy physicians on the front-end."
The coding team works closely with clinicians, Becker says. "Our coding team conducts coding reviews and, sometimes, they seek clarification through coding inquiries with our physicians. As we have done this documentation integrity work at the clinical service level, we have seen that the coding inquiries have decreased considerably. It has been a big satisfier for our physicians who have been part of this work on template review and optimization."
Technology plays a key role in clinical documentation, Durand says. "Whenever you have some kind of documentation solution, usually they are electronically oriented. No one is using paper charts or paper billing anymore. All of this is now digital, meaning that it all can benefit from tools such as natural language processing and artificial intelligence as well as electronic workflows. Every one of these solutions that we put in play gets vetted by both compliance and information technology staff."
There are multiple paths to good clinical documentation, he says. "One is a delayed loop, where you have coders looking for key patterns to generate insights for physicians, so that when they document in the future, they include certain key information. There is obviously a lag in this pathway, and there are people who will say that you get your biggest bang for your buck when you present clinicians with information in real time in their workflow. We have a variety of different pilots and operational programs that fit that description, where people are prompted with an algorithm that is doing natural language processing. When clinicians use certain words, it has reimbursement implications and sometimes it has penalty implications, too. Often, penalties arise unnecessarily when clinicians do not use clinical terms thoughtfully. That can result in miscoding."
Clinical documentation is a primary responsibility of clinicians, Durand says. "The future of clinical documentation will be more and more digital. The physician will be focused on a process to make sure that they have done a truthful and complete documentation. We want to be truthful because we do not want to ever over-document, but we want to be comprehensive because we do not want to under-document and either underrepresent the patient's medical risk or underrepresent the services that were provided."
"RVU was supposed to solve compensation problems, but I believe it has now become the problem because people are defining it in too many ways," says Northwell Health's EVP and Physician-in-Chief David Battinelli.
A physician compensation model "must be tailored to what you want physicians to do," says David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
Prior to his current role, Battinelli served as Northwell's senior vice president and CMO. While working as CMO, he also served as the chief operating officer for the Feinstein Institutes for Medical Research. Other leadership positions he has held at the health system include chief academic officer and senior vice president of academic affairs.
HealthLeaders recently talked with Battinelli about a range of issues, including physician compensation models, his challenges as physician-in-chief, how physicians are involved in administrative leadership at Northwell, and physician engagement. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the physician-in-chief of Northwell?
David Battinelli: Obviously, the size and complexity of the organization is a challenge. The additional complexity that most people don't know is that the physician-in-chief is also the dean of the health system's school of medicine. It is structured that way because the school of medicine is co-owned and operated by Hofstra University, which grants the degree, and Northwell, which executes most of the clinical and research enterprises of the school. So, at least half of my job is running the school.
To lead as the physician-in-chief at Northwell requires that I have a team of people at Northwell who help in all the domains that a physician-in-chief has at the health system, which includes the clinical enterprise, quality issues, and related issues that a chief medical officer would have in their responsibilities. The advantage is that I have experience in various roles such as academics and research, and as chief medical officer, which gives me a line of sight into who would be best to put into various positions so that things run as smoothly as possible for me as physician-in-chief and I can align the medical school and the health system in the clinical and research enterprise.
HL: You mentioned that the size and complexity of the health system is a challenge. How are you rising to that challenge?
Battinelli: The role of the physician-in-chief is oversight of the clinical and research activities in a 90,000-person organization. No amount of leadership at the top can compensate for the lack of local leadership. So an enormous responsibility of the physician-in-chief is to ensure strong local leadership. Talent acquisition, alignment, and selecting the right leaders at the various locations of the organization is critical.
Someone might ask how we run the health system's 23 hospitals. The answer is you have 23 good people leading those hospitals. Coping with the size and complexity of the health system requires scaling talent acquisition, alignment, and staff development across the enterprise.
HL: What are the main elements of Northwell's physician compensation model?
Battinelli: With 5,000 employed physicians, the good news is that we do not have 5,000 compensation models, but we do have a lot of them. The compensation model needs to be tailored to what you want people to do. So, our compensation model is variable, but there are some commonalities. Part of the commonality is the compensation models have a clinical component, there is a teaching component, and for somebody who is a primary researcher there is a research component.
Most of the compensation models are geared primarily toward the physician's primary job—whether it is clinical, education, or research. For those jobs that are blended, we blend the qualities of the compensation models into a single piece.
Where we are headed is moving away from primary incentives to models that make more sense for individual physicians. You can chase money and chase relative value units, or you can focus on how physicians are spending their time. This is opposed to grinding out the work and logging as many relative value units as you can until you burn yourself out. Having a stable job description and alignment is handled much better than chasing after a relative value unit model. Physicians are hesitant to align themselves with RVUs these days. Twenty-five years ago, the RVU was supposed to solve compensation problems, but I believe it has now become the problem because people are defining it in too many ways.
HL: How are physicians seeking to define RVUs in different ways?
Battinelli: Some physicians say they need academic RVUs. Others say they need research RVUs. Others say they need clinical RVUs. If it is a relative value unit, the clinical value has been pretty much worked out—you get a certain amount of money for a certain amount of work. But if a physician is doing research or academic work, it is more difficult to set an RVU—what would that value be?
David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Photo courtesy of Northwell Health.
HL: How are physicians involved in administrative leadership at Northwell?
Battinelli: We have our Physician Leadership Development Program, which is an executive leadership program. We take physicians we have targeted as leaders and are likely to take jumps in their positions from six to 18 months. We firmly believe in physician leadership.
We have several physicians leading our hospitals. We have about 40 chief medical officers who are all physicians. Given the size, scope, and complexity of the organization, you need people with a clinical perspective as a physician to help non-physician leaders understand what is important to our physicians. It is not just money—money is important to everybody, but it is not more important than some of the other aspects of a physician's work.
HL: In addition to yourself, are there other physicians in the C-suite and at the vice president level?
Battinelli: There are other physicians at the executive vice president level, senior vice president level, and vice president level. In the C-suite, there is a substantial number of physicians. When I first joined Northwell in 2006, there were only two physicians in the C-suite, but there are many now.
HL: What are the benefits of having physicians serving in administrative leadership roles?
Battinelli: For better or worse, physicians are not the easiest group to communicate with. They are more likely to listen to physicians than non-physicians. It is similar to patients—patients from certain ethnic and racial backgrounds prefer a physician from a similar background because the patients feel these physicians understand them better. With physicians, they will take the same message from a respected physician leader better than they will take the message from a respected non-physician leader.
It is easier to promote alignment and engagement physician-to-physician.
HL: What are the primary elements of physician engagement?
Battinelli: I explain effective physician engagement and leadership in a few ways. One is you want people who are respected clinicians to engage physicians. Physicians are a tough group—they do not like to listen to non-physicians. They will listen to a doctor if they think that person is a good doctor.
Second, you need to have a certain amount of selflessness, meaning that the physicians you are communicating with have to believe that this is about them succeeding, not you succeeding. They are not against you succeeding, but they are against you succeeding without them.
Third, effective physician engagement requires good governing skills, meaning you must be fair, equitable, trustworthy, and possess integrity. Trust is probably the most important word—the decisions you are making as you are helping to align physicians must be in their best interest.
HL: In addition to serving as dean of the medical school, you have served in several other academic roles. What are the primary qualities of a good medical educator?
Battinelli: There are some people who believe your role as a teacher is to get students to do what you want them to do. The educators that I believe are most effective are the ones who are interested in inspiring people and helping people achieve what they want to achieve. With medical school students, you are dealing with adults. In that setting, a good educator supports and inspires rather than motivates and directs.
Phoenix Children's Hospital has added a new emergency department and will open two free-standing hospitals in 2024.
Balancing growth with operational excellence is the primary clinical challenge at Phoenix Children's Hospital, says Jared Muenzer, MD, MBA, chief physician executive for the pediatric health system and chief operating officer of Phoenix Children's Medical Group.
Muenzer was named chief physician executive in August and has been chief operating officer of Phoenix Children's Medical Group since 2016. His prior leadership roles at the pediatric health system include physician-in-chief, associate director of the emergency department, and vice president of the medical staff.
HealthLeaders recently talked with Muenzer about a range of issues, including physician leadership, physician engagement, and the keys to success in managing service lines. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges you’ve seen as chief physician executive of Phoenix Children's?
Jared Muenzer: The biggest challenge for me is balance. We have set out on a massive growth campaign—we have added an emergency department in the West Valley, we are adding 40 beds on the main campus, and we are adding two free-standing hospitals in 2024. Balancing that growth with operational excellence, a strategic plan for operational improvement, workforce development, and workforce growth, and putting it all in one package and getting it to function and flow are the biggest challenges.
The beauty for us is that the team within the medical group and the hospital both from a physician leader standpoint and an administrative leader standpoint are definitely up to the task. They are the ones who drive the improvement and the change.
The other challenge I would add is technological advancement. We need to slide technological advancements into our changes. We need to make sure that technological advancements fit and drive improvements for our patients and our families.
HL: How do you address those challenges?
Muenzer: We have tremendous physician leaders in this organization. In Phoenix Children's Medical Group, we have 34 division chiefs, and we are helping them understand their book of business and working with them to understand what their needs are. We are partnering them with administrative leaders.
When I took over as chief operating officer of the medical group in 2016, I had two directors and about two dozen managers, and that has grown to four vice presidents, a dozen directors, plus about 30 managers. The partnership of the physician leadership and the administrative leadership allows us to develop the cadence and the projects as well as tie in the technology so that all of the challenges I have talked about get addressed.
HL: What are the keys to success in physician engagement?
Muenzer: With the growth, we were at 300 providers in 2016 and we are at more than 800 today. We had 26 divisions and now we have 34. Physician engagement is really about the development of the leaders. My goal for them is to say, "You own your book of business—you run it." I want to empower them to do that and find out about their needs and resources.
Then I want people at the executive level to say, "We still are a children's hospital with limited resources, but how can we maximize those resources to give all of our physician leaders and all of our books of business the attention they need to drive world-class healthcare for our patients and their families?"
Jared Muenzer, MD, MBA, chief physician executive for Phoenix Children's Hospital and chief operating officer of Phoenix Children's Medical Group. Photo courtesy of Phoenix Children's Hospital.
HL: How have you managed growth strategies and process improvement for the medical group?
Muenzer: It is all about the data. We need to understand our patients and families, our community, our state, and the Southwest in terms of what the needs are in pediatric healthcare. We need to utilize the data. What are the wait lists in our divisions? Where are patients coming from in the state? What procedures do they need? For the things that encompass healthcare, understanding the data behind it allows us to focus not only on areas of growth but also what pace we need to grow at. We determine what growth needs to be then develop individual strategies to do that.
One of the big areas of growth has been our residency program and our fellowships. We are now up to 30 fellowships across this health system, which helps serve growth from a provider standpoint.
We also have a large contingent of advanced practice providers in this organization, and we have relationships with numerous colleges that produce nurse practitioners and physician assistants. Those relationships drive advanced practice providers here for rotations, which helps them fall in love with pediatric healthcare and drives workforce development.
HL: What are the primary elements of physician leadership?
Muenzer: Servant leadership is important. Accountability is important. One of the things that I love about our physician leaders goes back to the book of business and the dyad model of leadership. When our physician leaders take accountability for their book of business, their growth, and their strategic plan, it helps me and the organization drive change and the growth that we need. It also helps them because when they hold themselves accountable, it helps their groups to be accountable.
The other big piece of physician leadership is effective communication. When my physician leaders effectively communicate not only with their physicians and staff but also with me and the organization, it is a game changer to drive necessary change.
HL: How do you define servant leadership?
Muenzer: It involves accountability; support; open communication; listening to the people around you; engaging the people around you; putting together the needs, wants, and asks of the people around you; and being willing to translate growth and cadence of growth. A servant leader makes sure the people around them feel that their voices have been heard.
HL: How are physicians involved in administrative leadership at Phoenix Children's?
Muenzer: Physicians play an important role as division chiefs.
We also have developed numerous channels and avenues for our physicians to have a voice and to engage in leadership. We have committees in the medical group, which involve understanding operations, understanding strategic growth, and understanding patient safety and quality. We have aligned physician leaders in the medical group with physician leaders in the hospital, so that the medical group and the hospital are aligned. That applies to patient safety and quality, so we have patient safety and quality leadership as well as medical directorships on most of the floors in our hospital, in our emergency department, and in ambulatory clinics that align with nursing quality leadership and quality office leadership. So we are all aligned.
We also have alignment across operations as well as across compliance and the regulatory function, so we have a system that drives partnerships that support the goals of the whole institution.
HL: You have helped to add or expand several divisions at Phoenix Children's, including nephrology, infectious diseases, anesthesiology, and neonatology. What are the keys to success in managing service lines?
Muenzer: With our growth, one of biggest challenges is that when you bring new groups in, or when you are growing a group from scratch or growing a group fast, is to make sure you understand culture and you understand the best avenues for communication. In the growth stage or the onboarding stage, you set the tone for the future. We have tried to make sure that everyone feels like they are part of the Phoenix Children's family and part of our culture, which is striving to provide the highest quality of care possible. We have supported our new or expanded groups to meet that goal.
Healthcare organizations need to develop a plan to promote professionalism among their staff members, according to an expert at Vanderbilt University School of Medicine.
About 3% to 5% of physicians, nurses, and other healthcare workers have a pattern of unprofessional conduct, says Gerald Hickson, MD, Joseph C. Ross chair of medical education and administration as well as professor of pediatrics at Vanderbilt University School of Medicine, and founding director of the Vanderbilt Health Center for Patient and Professional Advocacy (CPPA). Unprofessionalism is any behavior that "gets in the way" of healthcare teams or effective care for patients, he says.
Unprofessionalism in the healthcare setting can come in many forms, Hickson says. "Traditionally in medicine when we have thought about unprofessional or disrespectful behavior, it has been the notion of aggressive behavior. In our research, it is clear that passive and passive-aggressive behaviors are more common and can be just as interfering with our intent for good outcomes."
Examples of unprofessional behavior include throwing equipment, yelling at colleagues, and willful disregard of hand hygiene, he says. "These behaviors get in the way, and 3% to 5% of physicians, nurses, and other medical professionals have patterns of these behaviors that can have an extraordinary impact on healthcare teams and the patients we serve."
Unprofessional behavior has several negative impacts on healthcare teams and their patients, Hickson says. "We know that if physicians or nurses are disrespectful of the patients they are serving, it decreases the willingness of the patient to come back for care, to share their concerns, and to follow care plans. As you escalate unprofessionalism into a larger health system or a hospital, physicians, nursing professionals at the bedside, pharmacists, and other professionals need to play as a team. If a healthcare professional is disrespectful of colleagues, if they belittle questions from colleagues, or if they fail to perform a professional duty, it decreases the willingness to ask the healthcare professional for help and it decreases willingness to share information about a patient, so team function falls, and bad outcomes occur."
For surgeons who engage in unprofessional conduct, research has shown that patient outcomes are impacted, he says. "If you see one of those surgeons and you have a surgical procedure, you are 20% to 30% more likely to get a surgical site infection, you are 20% to 30% more likely to have to be readmitted to an intensive care unit, and you are more likely to experience a host of avoidable complications because the team is not functioning well."
Unprofessionalism can drive healthcare workers from the field, Hickson says. "When we interview nurses who leave their positions, 20% to 40% of them cite having to work with a problematic physician as the reason they leave. When you look at the cost of replacing a nurse, that is a problem. Unprofessionalism is a huge driver of the retention problem we are seeing in medicine now."
Rising to the unprofessionalism challenge
Healthcare organizations can effectively address unprofessionalism, Hickson says. "No. 1, leaders such as chief medical officers need to model professionalism themselves. If leaders are committed as professionals, the first thing they do is look at and self-assess their own performance."
Health systems, hospitals, and physician practices need to have a plan that promotes professionalism, he says. "The plan is built on the observations of patients, families, and healthcare team members. They see and experience unprofessional conduct, and individuals need to be able to address those behaviors in the moment. Reports and stories of unprofessionalism can be funneled into an office of patient relations or reported in a safety event system by coworkers. If those reports are mined or looked at routinely, you can identify at-risk individuals."
Plans to promote professionalism have several elements, Hickson says. "The plan for promoting professionalism begins with the onboarding of new hires to be sure they understand their roles and their importance in the organization. It involves wellness resources because some of the individuals who get identified as unprofessional have personal, family, or illness-related issues that need to be addressed. You need to have mental health and physical health resources because you just can't tell someone, 'Go get better.' There also needs to be a commitment to terminate the rare number of employees who refuse to respond."
To address instances of unprofessional conduct, healthcare organizations should provide feedback to problematic employees early and often, Hickson says. "In organizations that are committed to professionalism, they have trained peers who take the stories and reports that have come in, and they address the problematic professionals within a day. They sit down with their colleagues, and say, 'Here at this institution, we are committed to do everything we can to maximize outcomes for patients. We have a story of an event, and we want you to review this event, and if there is anything you can think of to do differently, we know you will do the right thing in the future.'"
Healthcare organizations need to promulgate standards for professionalism, he says. "You must have general communication, so people know the expectations for professionalism. Everyone in the organization must know that issues of professionalism are taken seriously."
The best practice for addressing unprofessionalism in individual healthcare workers is direct communication, Hickson says. "There is no more effective way educate and share professional standards than one-on-one communication in a private setting. When a peer comes and knocks on your door, you are not being called to the principal's office. The peer comes in and shares an observation. The peer shares all of the events that have arisen. The peer is not going to diagnose the situation, they are going to say, 'I know there are two sides to the story, and I just want you to reflect on the events.' The other issue in engaging people who have been unprofessional is letting them know that they are trusted to do the right thing. If there are ongoing reports of unprofessionalism, the problematic employee must be told that they are going to get another knock on their door. The good news is that in the majority of cases, the unprofessionalism does not happen again."
Among physicians, healthcare organizations can address unprofessionalism whether physicians are employed or practicing independently, he says. "Every physician who walks into a hospital must have privileges. You may be employed or a physician in your own practice; but in both circumstances, you must have privileges to practice care. If you have a health system, hospital, or physician practice where everyone is employed, all physicians operate under the same rules. If on the other hand, a physician has a separate practice, to work with patients that physician has to agree to certain standards and be held to those standards."
CMOs must work collaboratively with organizational partners to address unprofessionalism among physicians, Hickson says. "We have learned that HR is a critical partner in delivering safe care. CMOs need to recognize and understand that they have an important role in moving a health system, hospital, or medical group forward. To do that successfully, they must understand and respect the roles of HR, legal departments, safety departments, and risk management. They need to see them as partners."
The Vanderbilt Health CPPA is holding a two-day course on addressing unprofessionalism in December. To register, click on this link.