Improved access to care is the most significant value associated with telehealth services, this new chief physician officer says.
Telehealth services deliver value for health systems and patients in several ways, according to the new chief physician officer of MultiCare Health System.
Todd Czartoski, MD, was named chief physician officer of MultiCare in June. Prior to being named chief physician officer, he served as president and CMO of the health system's Neuroscience Institute and virtual health service. Before joining MultiCare, he served as chief executive of telehealth and chief medical technology officer at Providence.
First and foremost, telehealth has proved its value in improving access to care, according to Czartoski.
"In the early days of telehealth, there was concern that people of lower socioeconomic status would not have access to a device that could support a telehealth visit," Czartoski says. "But there is data that shows this population may not have much money, but they still have smartphones that can conduct telehealth visits."
Telehealth is helping health systems cope with a growing physician shortage across the country in multiple specialties, including neurology, psychiatry, and primary care. Czartoski uses stroke care as an example.
"If someone has a stroke, having access to a board-certified neurologist or vascular neurologist via telehealth is incredibly important," Czartoski says. "So, telehealth can take specialized expertise and spread it across a geography."
There are more nuanced ways that telehealth delivers value, including patient satisfaction, cost savings, and a better experience for clinicians, according to Czartoski.
"With telehealth, clinicians often do not need a patient to drive two hours for a follow-up visit to collect information, then they can move on to the next patient," Czartoski says.
Traditionally, physicians have seen patients in a sterile environment at a clinic without any context of what is going on in their life. Telehealth generates value by allowing clinicians to get insights into their patients by conducting visits in a patient's home, Czartoski explains.
For example, if a physician sees a patient with gait instability or cognitive decline during a telehealth visit in their home, they can see the status of the home, such as whether there are rugs on the floor or stairs that have to be climbed.
"A physician can see what real life is like for the patient and see whether there are risks in the home," Czartoski says.
Todd Czartoski, MD, is chief physician officer at MultiCare Health System. Photo courtesy of MultiCare Health System.
Identifying and addressing healthcare inefficiencies
CMOs and other leaders can play a pivotal role for healthcare organizations by identifying and addressing inefficiencies and friction points. While identifying inefficiencies, healthcare leaders should rely on frontline caregivers. Czartoski explains that executive leaders should be cautious about weighing in on operational challenges at a healthcare organization.
"I'm a big fan of listening to people who are in the trenches doing the work," Czartoski says. "There is no substitute for talking with as many people as possible about the experience of providing care and any inefficiencies that may be present."
Listening to patients is also important.
"Patients can tell you what is working and what is not working," Czartoski says. "You need to get patient feedback."
In addressing inefficiencies or friction points, there are two initial steps to follow, according to Czartoski.
"First, I try to quantify the size of the problem and the impact that it is having," Czartoski says. "Is a friction point adversely affecting the performance of team members such as doctors and nurses? Is it adversely affecting patients? If we fix a problem, is it going to improve the experience of our staff and patients?"
"Second, you need to look at the level of effort that is going to be required to fix a problem," Czartoski says. "Is the solution going to require a whole new process or new technology?"
With these two steps in mind, CMOs and other healthcare leaders should focus on fixing inefficiencies with solutions that generate high value and require manageable effort, according to Czartoski.
Once the impact of addressing a problem and the level of effort required to fix it have been assessed, there are three steps to take if pursuing a solution is desirable, Czartoski explains.
The first step is to identify a place to launch a pilot program.
"You want to start small," Czartoski says. "For example, if you decide to fix a clinic process, you should pilot the solution in one clinic."
The second step is testing the results of the solution and looking for opportunities to improve it.
"In most cases, the first attempt at a solution is not going to be perfect," Czartoski says.
The third step is scaling the solution once it is working effectively, and the outcomes such as clinical outcomes and quality outcomes have been documented.
"You take the expertise you developed at one site, and you spread the solution to the entire enterprise because you can show that the solution is better for staff and patients," Czartoski says.
Measuring the success of a solution is crucial to scaling it, according to Czartoski. After a pilot is complete and the solution moves to new sites, CMOs must be able to tell the story of how the solution worked.
"You need to be able to show that the solution benefits providers and patients," Czartoski says. "You need to learn from the pilot, then articulate the results to the new sites where you want to apply your solution."
Operating a successful hospital at home program
Czartoski helped lead an effort to design and implement Providence's hospital at home program. The foundation for the program was established with the health system's COVID at Home program during the coronavirus pandemic. The program was so successful that the health system decided to launch a hospital at home program for other high-acuity conditions.
"For us, it was a matter of increasing capacity in our hospitals at a time when we were overflowing with patients," Czartoski says. "We also wanted to create value by finding a less costly location for care, and allowing patients to recover from an acute illness in their home made sense."
Most of the patients enrolled in Providence's hospital at home program came from emergency departments, and the program gave emergency medicine clinicians a new option to care for patients, Czartoski says.
Prior to the hospital at home program, an emergency room clinician had two pathways for patients. If the patient was very ill, they were admitted to the hospital. If the patient was not very ill, they were sent home with a care plan that could include medication and a recommendation to see their primary care provider within a few days.
"Hospital at home introduces a third pathway for patients," Czartoski says. "You may be sick enough to be in the hospital, but we are going to send you home and bring the hospital to you."
Czartoski emphasized that the most important factor for a successful hospital at home program is ensuring that patients are safe, which addresses skepticism among emergency medicine clinicians, patients, and families about treating acute illness in the home.
"We had to be very thoughtful about creating a hospital at home program from a change management standpoint and doing it safely," Czartoski says.
In a hospital at home program, patient safety starts with enrolling patients selectively, according to Czartoski.
"You want to be thoughtful about who you are choosing to be admitted to the program, [because] it is not for everyone," Czartoski says. "You need to select patients depending on the severity of their condition and their medical history."
The Providence hospital at home program promoted patient safety by having at least one nurse visit for the patients in the home on a daily basis as well as having physicians available to visit patients in the home in person or virtually. Patient monitoring was also a key component, Czartoski explains.
"You can measure patients' oxygen status, blood pressure, and heart rate," Czartoski says. "For congestive heart failure patients, you can monitor their weight to make sure they are not taking on too much fluid."
Patient safety for a hospital at home program also includes having a mechanism in place to get patients to a hospital quickly if necessary, according to Czartoski.
"We had rapid ways of transporting a patient back to the hospital if hospital care was required, which was relatively rare," Czartoski says. "Over 95% of the time, patients did fine at home."
The primary elements of physician development include effective onboarding, education, and mentorship, this new hospital CMO says.
CMOs and health systems need to be intentional about physician development, according to the new CMO of two Oklahoma-based SSM Health hospitals.
Mike Angelidis, MD, was recently named CMO of SSM Health St. Anthony Hospital-Midwest and SSM Health St. Anthony Hospital-Shawnee. He previously held leadership roles at Tulsa, Oklahoma-based Saint Francis Health System, including serving as system medical director of hospitalist services.
"When we talk about physician development, the first thing to note is that healthcare organizations and leaders need to be invested in education," Angelidis says. "Organizations and leaders need to invest in medical schools, residencies, and fellowships."
At SSM Health for example, the health system supports physicians who want to enroll in continuing medical education and degree programs.
"If you are a physician and you want to get an MBA, SSM will help support pursuing that degree with funding," Angelidis says.
Physician development starts with a strong onboarding program, Angelidis explains.
"You need an onboarding process, so when physicians come into your organization, they understand what they need to do to succeed in your organization," Angelidis says. "In addition, as part of the interview process, you want to make sure that you are bringing in physicians who can help build the culture you are trying to achieve."
A good onboarding program helps lay the foundation for physicians to play leadership roles in the organization, according to Angelidis.
"In that respect, you need to have an onboarding process that focuses on culture," Angelidis says. "You need to emphasize the culture of your organization and make sure that physicians are aligned with your mission and values."
Other elements of a good onboarding program include training in the electronic medical record and connecting physicians with a mentor in their specialty, Angelidis explains.
A building block for physician mentoring and coaching is building trust, according to Angelidis.
"You must have two people who want to be engaged in a mentoring relationship," Angelidis says. "As a mentor, it is important to show vulnerability, which helps to build trust."
A mentor should help establish goals for the person they are mentoring, Angelidis explains. With trust and goals established, a mentor should cultivate the relationship with a growth mindset to help mentees continually improve.
"If the goal is clinical, you can encourage a mentee to grow as a clinician," Angelidis says. "If the goal is leadership, you can encourage a mentee along that path such as joining committees and pursuing education in hospital management."
Mike Angelidis, MD, is CMO of SSM Health St. Anthony Hospital-Midwest and SSM Health St. Anthony Hospital-Shawnee. Photo courtesy of SSM Health.
Succeeding in quality improvement
Promoting quality improvement is one of the most rewarding aspects of being a CMO, according to Angelidis.
"You can impact a process. You can improve workflows and the satisfaction of your frontline staff," Angelidis says. "You can improve aspects of quality that impact thousands of people."
There are essential steps in starting a quality improvement project, Angelidis explains. When developing a quality project, the first step is determining the purpose of the project and the ideal end state.
"Then you need support from your organization," Angelidis says. "You need to make sure that the goals you are setting for the project are aligned with the mission and values of the organization."
Once the foundation for a quality improvement project has been set, CMOs and project leaders need to look at how they are going to attack the problem that the project is designed to solve, Angelidis explains.
"You want to determine the data that you need for the project to be successful," Angelidis says. "You want to determine whether there is going to be a single leader guiding the project or a group guiding the project. You want to determine the key stakeholders or champions who are going to help deliver whatever you are trying to accomplish."
CMOs and other healthcare leaders also need to be systematic in choosing an approach to a quality improvement project, according to Angelidis.
"You need to set key performance indicators," Angelidis says. "You need to set a clear path to the ideal state—you try to predict how long it will take to implement a project, set check-ins to monitor progress, and look for early wins."
Transformative leadership
A primary skill for CMOs is transformative leadership, Angelidis explains.
"Transformative leadership involves being the kind of leader who takes people on a journey," Angelidis says. "A transformative leader is someone who has a vision and has the ability to get people behind the vision to accomplish it."
Transformative leadership requires the ability to build relationships, according to Angelidis.
"You must be able to identify the key relationships," Angelidis says. "For example, if you are trying to expand a service line, you must be able to identify who the key players are and the players you need to have a relationship with, so they can believe in your vision."
A transformative leader needs to be a good communicator, Angelidis explains.
"Transformative leaders need to be able to communicate their vision and why it is good for the organization," Angelidis says. "They need to be able to communicate the end goal."
Just like a good physician mentor, transformative leaders have a growth mindset, according to Angelidis.
"A growth mindset includes the ability to think about how you can grow as a leader and how you can look at a problem and come at it with a different angle," Angelidis says.
A New York City hospital has reduced decedent release times with an initiative that includes strengthening community partnerships and providing key information to grieving families.
In a trend across the country, many hospital morgues have been overrun since the first surge of the coronavirus pandemic. Increased decedent release time not only creates a burden for families but also poses an operational challenge for hospitals, which are forced to supplement their morgues with refrigerated trucks.
Average decedent release times have increased from about three days before the coronavirus pandemic to as long as two weeks since the pandemic, according to Komal Bajaj, MD, chief quality officer at NYC Health + Hospitals/Jacobi | North Central Bronx, a hospital with two campuses.
To combat this issue, Jacobi | North Central Bronx hospital has launched a program to improve decedent release time. Jacobi | North Central Bronx hospital's Compassion for the Community: Continuing Care After Death program has reduced average decedent holding time from 13 days to five days.
View the infographic below to learn about the three primary elements of the program. Click on this link to read the accompanying HealthLeaders story.
Healthcare leaders can employ a range of strategies to ensure that patient safety is not compromised when care teams are stretched thin.
Inadequate staffing poses a challenge for maintaining patient safety, whether there is a shortage of staff or patient volume increases and puts pressure on provider-patient ratios.
Patient safety, including avoidance of hospital-acquired infections, is a top priority for health systems and hospitals. But what happens when a care team staff is understaffed?
In this episode of HL Shorts, Kevin Post, DO, CMO of Avera Health, gives his perspective on maintaining patient safety when patient volume increases and strains provider-patient ratios.
Click on the video below to see Post share his views.
To reduce readmission rates, hospitals must consider several factors such as standards for length of stay, medication management, and discharge planning, this new CMO says.
Hospitals need a multi-pronged effort to reduce readmission rates, according to the new CMO of the Orlando Health East Florida Region.
Michael McLaughlin, MD, was named CMO of the Orlando Health East Florida Region in June. The region includes Orlando Health Melbourne Hospital and Orlando Health Sebastian River Hospital. Previously, McLaughlin held several leadership positions at Orlando Health, including serving as CMO of the health system's hospital division.
Hospital-based care is complex, so reducing readmission rates requires a team approach, according to McLaughlin.
"You need team-based care that includes the physician, the nurse, and pharmacy staff," McLaughlin says. "You need to move the patient through a process of care and make sure there is a discharge plan, which should begin soon after a patient is admitted to the hospital."
To reduce readmission rates, hospitals should follow standards for length of stay, McLaughlin explains.
"For every patient that comes into the hospital with a condition or set of conditions, there is a recommended length of stay," McLaughlin says. "We know what the length of stay should be, with a plan of care and early attention to forming a discharge plan."
Exceeding the recommended length of stay poses risks for patients, including falls, medication errors, and hospital-acquired infections. These risks can contribute to readmissions, McLaughlin says.
Before a patient is discharged, care teams need to work with the family, so they know what to look for as far as recurrence of symptoms in the home. If there is recurrence of symptoms, the family can connect the patient with their primary care physician, which can avoid a hospital readmission, McLaughlin explains.
Ensuring that patients have their medications at discharge can limit hospital readmissions.
"Orlando Health has a Meds-to-Beds program, where medications are delivered to a patient's hospital room before they are discharged," McLaughlin says. "What we have found in the past is that patients may not get their medications after discharge because neighborhood pharmacies are closed by the time the patient gets home."
Hospital care teams need to make sure that a patient knows the medications they are taking and knows how to take them, McLaughlin explains.
"Patient compliance with medications is a huge part of avoiding readmissions," McLaughlin says.
Hospitals should have a transition care team, which helps manage patients after hospital discharge, according to McLaughlin.
"The transition care team makes sure that the patient gets follow-up appointments with their primary care physician or specialists such as cardiologists," McLaughlin says. "Follow-up appointments should be held between 72 and 96 hours after hospital discharge."
Finally, patients should know who to call if they are having a problem after discharge, McLaughlin explains.
"For example, we want congestive heart failure patients weighing themselves at home on a daily basis," McLaughlin says. "If they start to see their weight is going up, they should call the transition care team to help manage the situation such as contacting the primary care physician or cardiologist to help avoid them coming back to the hospital."
Michael McLaughlin, MD, is CMO of the Orlando Health East Florida Region. Photo courtesy of Orlando Health.
Improving operating room efficiency
McLaughlin's clinical background is in general surgery, including practicing as a general surgeon at Cape Canaveral Hospital for 28 years. Just as in the case of avoiding hospital readmissions, teamwork is essential to boost operating room efficiency, according to McLaughlin.
"It involves the surgeon, anesthesiologist, nurses, scrub technicians, anesthesia technicians, registration staff, pre-operative testing, and transport staff," McLaughlin says. "The transport staff plays an underappreciated role in getting patients in and out of the operating room in a timely manner."
Turnover teams are essential for operating room efficiency, McLaughlin explains.
"You need a team to move the patient to the recovery unit. You need a turnover team to clean the room before the next patient," McLaughlin says. "An operating room can be down for as long as 40 minutes as the operating room is prepared for the next patient."
One strategy to reduce operating room turnover time is to schedule the least complicated cases to a particular set of operating rooms, so the anesthesia tech, scrub tech, and inter-operative nurse can play a key role in turning over the operating rooms quickly, according to McLaughlin.
"Turning over an operating room is an involved process," McLaughlin says. "You need to remove all of the instruments from the previous case, and all of the instruments must be counted. This process is quicker with the least complicated cases."
How CMOs can balance priorities
A CMO must walk a fine line between promoting clinical care on the one hand and financial considerations on the other hand, McLaughlin explains.
"A CMO must navigate between patient care and the objectives of the business because a hospital that is not doing well financially will ultimately impact the community because the hospital is not going to survive," McLaughlin says.
For example, a physician may want a new robot, and the CMO must weigh the costs and the benefits, according to McLaughlin.
"A CMO needs to look at how much the robot costs and whether there is a true benefit to the patients," McLaughlin says. "If the finances do not make sense and there is no added benefit to the patients, the answer is going to be 'no' as long as there is an alternative that is just as good."
For a CMO, balancing clinical care with financial realities is part of the job, McLaughlin explains. CMOs are responsible for evaluating the clinical aspects of new procedures, new devices, and new technology.
"One of the considerations is whether any of these things benefit patients," McLaughlin says. "Another consideration is the finances, because without the hospital being financially stable the healthcare is going to suffer."
While it may be desirable to offer every possible service at a hospital, a CMO must weigh the needs of the community and financial feasibility, this new hospital CMO says.
There are several keys to success in expanding clinical services at a hospital, starting with assessing the needs of the community, according to the new vice president and CMO of Cleveland Clinic Medina Hospital.
Thomas Rogers, MD, became vice president and CMO of Cleveland Clinic Medina Hospital on July 1. He previously served as vice president and CMO of Cleveland Clinic Union Hospital. He joined Cleveland Clinic following his retirement from active military service as a colonel and physician leader in the U.S. Army.
When a hospital considers expanding clinical services, the needs of the community are a crucial component of the decision, according to Rogers.
"For example, I look at the community health needs assessment that is done every couple of years by the health department," Rogers says.
The next step is to determine whether offering a new service makes sense financially, Rogers explains.
"Just like a business deal, you should not proceed if you think you are going to lose money," Rogers says. "You need to at least break even on a new service."
A hospital should proceed cautiously when deciding whether to offer a new service that is expensive to provide, according to Rogers, who cited the example of launching a new radiation oncology clinic at Cleveland Clinic Union Hospital.
"When we launched the radiation oncology clinic, we had to buy new equipment, which was several million dollars," Rogers says. "We had to ask whether we would have enough patients to come in and get services as well as whether we would lose money."
With an aging population and increasing cancer rates, it was determined that adding the radiation oncology clinic was financially feasible. The hospital also looked at the capabilities of nearby hospitals.
"We had to look at where there was the nearest linear accelerator and the nearest CT simulator, and whether it made sense in a business-case analysis to have that equipment at Union Hospital," Rogers says.
When making a decision about expanding clinical services, a hospital CMO and other hospital leaders should consider partnering with another hospital in some cases, Rogers explains.
"We all want to have everything, but it is not feasible in many cases at smaller hospitals to have everything," Rogers says. "That is why you must be open to sharing services as well as expanding services depending on the need."
Thomas Rogers, MD, is vice president and CMO of Cleveland Clinic Medina Hospital. Photo courtesy of Cleveland Clinic.
Promoting patient safety
Ensuring patient safety is a top goal at a hospital and a prime responsibility for a hospital CMO, according to Rogers.
"No matter what we do, patient safety must be paramount," Rogers says. "It starts from the moment a patient checks in at the hospital—making sure we have the right patient at the right time."
Simple steps can boost patient safety, Rogers explains.
"We ask patients for their name and their birth date over and over," Rogers says. "It is important because just that simple piece of what we do every day makes sure that we have the right patient in the right place."
Monitoring statistics is essential in maintaining patient safety, according to Rogers.
"For example, you must look at catheter-associated infections. You must look at wound care. You must look at whether pressure injuries are happening in the hospital," Rogers says. "You must track these conditions on a daily basis, document them, and report them."
Transparency supports patient safety, Rogers explains. CMOs should tell the staff how they are doing.
"Adverse events happen—we are all human," Rogers says. "But if we do the things we are supposed to do every day, we make patient safety paramount, and we provide high-quality care, we are doing the best that we can and patients are safe no matter where they are in the hospital."
A CMO and other hospital leaders should establish a just culture to promote patient safety and to account for when an individual may have done something outside of the established process or policy, according to Rogers.
"With a just culture, we talk about the process, not about the person," Rogers says. "We want to encourage people to speak up. We want to have psychological safety, so people can speak up without fear of retaliation."
Succeeding as a hospital CMO
The are several components in being a successful hospital CMO, according to Rogers.
"A hospital CMO needs to make sure that their caregivers have what they need to do their job," Rogers says. "A CMO needs to make sure that doctors have what they need to perform at their best level such as proper staffing and necessary equipment."
A hospital CMO needs to make sure that they are coordinating and communicating with other hospitals, Rogers explains.
While patients are the primary responsibility of a hospital CMO, the well-being of staff is equally important.
"A hospital CMO needs to make sure that patient satisfaction and the services provided to patients are good," Rogers says. "At the same time, the CMO needs to take care of their staff. The well-being of your staff is crucial. The caregiver who is doing their best and taking care of themselves takes better care of the patients."
Kriel Ramcharitar, MD, MPH, vice president and CMO for value-based care at BayCare Health System shares his tips for running a successful accountable care organization.
Ramcharitar's leadership experience prior to joining BayCare in May includes serving as vice president and CMO of Memorial Hermann Health System's Accountable Care Organization and Population Health Service Organization.
There are several factors involved in operating a successful ACO, according to Ramcharitar.
"You need effective care coordination that is proportionate to the needs of your communities and populations," Ramcharitar says. "You need an evidence-based approach to pharmacy, including medication adherence and comprehensive medication management."
An ACO should have teams conducting outreach for quality gap closure, Ramcharitar explains. For example, an ACO should have outreach to patients who need breast cancer and colorectal cancer screening.
Find out about more of Ramcharitar's ACO tips by clicking on the video below. To read the accompanying HealthLeaders story, click here.
The initiative harnesses data, strengthens community partnerships, and provides key information to grieving families.
In a trend across the country, many hospital morgues have been overrun since the first surge of the coronavirus pandemic. Increased decedent release time not only creates a burden for families but also poses an operational challenge for hospitals, which are forced to supplement their morgues with refrigerated trucks.
Average decedent release times have increased from about three days before the pandemic to as long as two weeks since the pandemic, according to Komal Bajaj, MD, chief quality officer at NYC Health + Hospitals/Jacobi | North Central Bronx, which is a two-campus hospital.
To combat this issue, Jacobi | North Central Bronx hospital has launched a program to improve decedent release time.
Jacobi | North Central Bronx hospital's Compassion for the Community: Continuing Care After Death program has reduced average decedent holding time from 13 days to five days.
"First and foremost, there are implications for the loved ones of the individual who was lost; it impacts their grieving process and their journey," Bajaj says. "It also has significant operational consequences. Being able to release decedents in a timely fashion means that our community partners such as funeral homes can do the work that they need to do."
The Compassion for the Community: Continuing Care after Death program has three primary elements.
Data infrastructure: The hospitals built the capacity to track data in real-time to have a clear understanding of decedent hold time.
Strengthening community partnerships: The hospitals worked more closely with community partners such as funeral homes and places of worship to co-design processes that were more efficient.
Information resource: The hospitals created an informational packet that includes information on funeral homes in the area, resources for supporting funeral costs, and phone numbers that families can call at Jacobi | North Central Bronx hospital for help.
Through a multipronged effort, there has been a substantial reduction in decedent release time.
"There are certain things that healthcare delivery organizations require. There are certain things that funeral homes require," Bajaj says. "We have put this information in one place, and we have served as a guide for people on how to navigate the process."
The program is reducing delays in the decedent release time process, according to Bajaj. First, the program has reduced delays by giving families a clear understanding of the paperwork and other steps required with the passing of a loved one.
"With that understanding, the paperwork and steps are more likely to be completed in an efficient way," Bajaj says. "A process that previously took three or four days can be shortened to a day-and-a-half."
Improving coordination with community partners has also reduced delays, Bajaj explains.
"For example, if a funeral home is sending out a truck to pick up a decedent, and we know another family has decided to have a decedent go to the same funeral home, we can ensure that the truck can take both decedents at the same time," Bajaj says.
Komal Bajaj, MD, is chief quality officer for NYC Health + Hospitals/Jacobi | North Central Bronx hospital. Photo courtesy of NYC Health + Hospitals.
Taking a team approach
The Compassion for the Community: Continuing Care after Death program is operated by an interdisciplinary team, which includes staff from pathology, care experience, admitting, and finance.
"The department of pathology oversees the morgue, so they are the subject matter experts in operational processes and challenges in decedent release time," Bajaj says. "They are also experts in potential solutions."
Care experience teams and social workers have expertise in thinking about partnering with patients and their families.
"They support families through their grieving process," Bajaj says.
Admitting and finance staff have a good handle on how patients are flowing through the hospital.
"Working with them to understand the data parameters that were available was hugely important," Bajaj says.
The primary elements of effective medical staff governance include shared decision making, harnessing data, and strong physician leadership, according to this new CMO.
Michael Fiorina, DO, was announced as the CMO of Independence Health System on June 10. He joined the health system's administrative team in 2021. Prior to being named CMO, Fiorina served as vice president of medical education and associate CMO of Butler Memorial Hospital and Clarion Hospital.
There are six essential elements to succeeding in medical staff governance, according to Fiorina.
Strong physician leadership: This starts with engaged physician leaders who understand clinical, operational, and strategic priorities. These leaders must be identified, cultivated, and developed in a coordinated and intentional fashion.
Shared decision making: Physicians must be engaged in the decision-making process through committees, councils, and valuing their input.
Clear roles, accountability, and ownership: The goals of the work assigned to physicians need to be clearly defined and communicated. There must be ownership for the outcomes, particularly in areas such as quality and safety.
Effective communication: Frequent and transparent communication is critical to building trust and facilitating effective problem solving.
Harnessing data: Clinical data and performance metrics should be used to guide decisions to make meaningful and measurable improvements.
Interprofessional collaboration: There must be collaboration across disciplines, not just physicians, to get a comprehensive view of the challenges and solutions.
Michael Fiorina, DO, is CMO of Independence Health System. Photo courtesy of Independence Health System.
Succeeding in community-based care
CMOs and other healthcare leaders face barriers in providing community-based care, particularly in rural settings, according to Fiorina.
"This is a real challenge, given the evidence that many rural areas are struggling to provide care for the people in their communities," Fiorina says.
A primary strategy to provide community-based care is to build strong partnerships with community-based organizations. For example, Butler Memorial Hospital is a member of the Butler County Growth Collaborative, which is a group of political, educational, and business leaders who meet regularly to discuss their challenges and build strategies for serving members of the community. The hospital also involves care teams in community events.
"This puts faces to names and allows us to interact with the people who are our patients," Fiorina says.
Butler Memorial Hospital also shares its achievements with the community, Fiorina explains.
"When we win a quality award or have a provider achieve a new certification, we announce it to the public," Fiorina says. "We need to be our own greatest advocate."
Establishing residency programs
Securing the support of a health system's top leadership is essential in building residency programs, according to Fiorina.
"Our president and CEO was the one who originally approached me with the idea, and we had wholehearted support of the board of trustees," Fiorina says. "Without this foundational support, the concept could not have become a reality."
It is also crucial to gain the support of key stakeholders, Fiorina explains.
"It was vital to get the support of the medical staff through effective communication via the department chairs, who served as key liaisons to the broader medical staff," Fiorina says. "It was also imperative to communicate the goals of the residency program to the other disciplines that would interact with the residents such as nursing and physical therapy."
Next, a health system must build the infrastructure required for accreditation such as hiring faculty and staff to support a residency program, according to Fiorina. Without the proper infrastructure in place, accrediting bodies won't consider an organization a viable site.
"We also utilized relationships built with medical schools to assist us in the application process," Fiorina says. "These institutions are invested in having high-quality residency sites to send their graduates and are very interested in partnering with hospitals."
CMOs can learn from these two healthcare organizations that have different approaches to providing second opinions in cancer care.
A second opinion in any profession is the best practice.
That's why Karmanos Cancer Institute implemented a streamlined process to provide patients with second opinions within seven days of an initial diagnosis.
At Karmanos, a second opinion results in a revised treatment plan or even a new diagnosis up to 20% of the time, according to George Yoo, MD, CMO of the comprehensive cancer center.
"The second opinion allows for a more comprehensive and expert review by a multidisciplinary team of doctors who specialize in a cancer type," Yoo says. "This review includes reviewing the pathology slides and the radiology images."
Providing a second opinion also boosts the patient's peace of mind, according to Yoo.
"A second opinion can confirm and validate the treatment plan that the patient has been given," Yoo says. "This reassures the patient that they have made the right choice."
When a patient receives a cancer diagnosis, getting a second opinion is beneficial, according to David Peter, MD, MBA, CMO of The Clinic by Cleveland Clinic, which specializes in virtual second opinions.
"Cancer is a complex and, of course, life-changing condition," Peter says. "If you've received a cancer diagnosis, it's important to confirm your diagnosis promptly and ensure you're on the right path for your treatment. You owe it to yourself to leave no stone unturned."
Regardless of the result of a second opinion in cancer care, the patient benefits, Peter explains.
"A recommended change to your diagnosis or treatment plan can set you on a promising path," Peter says. "Alternatively, confirmation that you're already doing everything you should can help clear your doubts about the next steps in your journey."
George Yoo, MD, is CMO of Karmanos Cancer Institute. Photo courtesy of Karmanos Cancer Institute.
How Karmanos provides second opinions
Karmanos has implemented a four-step process to facilitate providing rapid second opinions.
First, Karmanos has made it easy for patients to contact the comprehensive cancer center for second opinions. Patients can either call 1-800-KARMANOS or fill out a form online.
Second, Karmanos has trained specialized oncology navigators who guide patients through every step of receiving a second opinion—getting records, arranging insurance coverage, and setting up appointments. The oncology navigators relieve stress for the patients and make the process easier.
Third, there is a pre-intake appointment involving a nurse practitioner, who calls the patient and makes sure all information has been gathered.
Fourth, the patient has an on-site appointment with an oncologist who specializes in the patient's type of cancer. The work of the oncology navigator and the nurse practitioner tees up the appointment with the oncologist, so it is easy for the doctor to communicate with the patient.
"We have a rapid process keyed by the oncology navigator gathering all the information," Yoo says. "We have a pre-appointment intake, where a nurse practitioner will talk with the patient and organize all the information. We make sure we have open appointment slots with our specialized oncologists, so patients can get in within seven days."
For cancer centers interested in replicating Karmanos' second opinion model, having oncology navigators is crucial, according to Yoo.
"You need to train your oncology navigators to focus on the information that is important to treat an oncology patient," Yoo says. "The navigators should be empowered to advocate for the patients."
David Peter, MD, MBA, is CMO of The Clinic by Cleveland Clinic. Photo courtesy of The Clinic by Cleveland Clinic.
The Clinic's approach
The Clinic by Cleveland Clinic makes it easy for cancer patients to receive a second opinion from an expert physician quickly and from the comfort of home, according to Peter. After a brief online registration, patients can quickly schedule a video visit with a nurse. During that intake visit, their nurse gets an understanding about their diagnosis, treatment plan, concerns, and questions.
"With the patient's consent, we then do the work of collecting their medical records and any relevant imaging or pathology on their behalf, which can save the patient significant hassle and anxiety," Peter says.
In the next step, The Clinic by Cleveland Clinic's clinical team identifies the cancer specialist at Cleveland Clinic who is best suited for the patient's particular case. That physician then reviews all of the relevant information to provide a thorough second opinion report, which is delivered typically a few days after records are collected.
"If the cancer specialist is licensed in the patient's state, the patient has the option to have a video call with the physician," Peter says. "Patients also have the opportunity to ask follow-up questions after their opinion is delivered."
In particularly complex cases, the cancer specialist assigned to the patient may determine the need to re-interpret the patient's pathology or consult with advanced subspecialists for additional insight.
"While not every case requires it, the opportunity for a deeper and multidisciplinary review can provide greater clarity and certainty about a patient’s diagnosis and treatment options," Peter says.
Todd Czartoski, MD, is chief physician officer at MultiCare Health System. Photo courtesy of MultiCare Health System.
Michael McLaughlin, MD, is CMO of the Orlando Health East Florida Region. Photo courtesy of Orlando Health.
Thomas Rogers, MD, is vice president and CMO of Cleveland Clinic Medina Hospital. Photo courtesy of Cleveland Clinic.
Michael Fiorina, DO, is CMO of Independence Health System. Photo courtesy of Independence Health System.
George Yoo, MD, is CMO of Karmanos Cancer Institute. Photo courtesy of Karmanos Cancer Institute.