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Every physician has stress, but today’s physicians may have even more stress than when they started practicing. Along with newer pressures in recent years of financial obligations and an uncertain future, physicians are now dealing with the stress of practicing medicine during a pandemic. This stress and burnout will continue long after the COVID-19 pandemic subsides.
This stress can cause physicians to lose their passion for medicine, become cynical about the healthcare system, and become less humanistic.
Physicians often feel that they cannot express their dissatisfaction with healthcare because they will be seen as weak. Instead, they often throw themselves so completely into treating their patients that they often cut themselves off from outside sources of stress relief, such as friends and family. The result is that physicians suffer terrible stress and become more susceptible to anxiety disorders and substance abuse.
U.S. lawmakers are hoping to get green cards to physicians and nurses as soon as possible. A bill introduced this week by House Democrats would allow physicians on the frontline of the COVID-19 pandemic to bypass long wait times for a green card.
A similar bill was recently drafted by Republican senators: the Healthcare Workforce Resilience Act would redistribute unused green cards that had been approved by Congress, allowing upwards of 40,000 medical providers to remain permanently in the United States and provide clinical care.
“Consider this: one-sixth of our healthcare workforce is foreign-born. Immigrant nurses and doctors play a vital role in our healthcare system, and their contributions are now more crucial than ever. Where would we be in this pandemic without them,” said Senator Dick Durbin (D-Ill.) "It is unacceptable that thousands of doctors currently working in the U.S. on temporary visas are stuck in the green card backlog, putting their futures in jeopardy and limiting their ability to contribute to the fight against COVID-19.”
The legislation would give green cards to 25,000 nurses and 15,000 physicians, ensuring that rural areas especially have the appropriate number of healthcare professionals.
"Rural areas, which make up much of my district, remain especially vulnerable and are already experiencing a shortage of medical professionals. We need all hands on deck to address this generational crisis,” said Congresswoman Abby Finkenauer (D- Iowa).
A green card, known officially as a Permanent Resident Card, is a document issued to immigrants to the U.S. as evidence that the bearer has been granted the privilege of residing permanently.
The filing period for the recaptured visas would be limited to 90 days after the end of President Trump's emergency declaration due to the coronavirus pandemic.
As a space created for the provision of high-quality care, hospitals have the right to implement policies that they believe enhance patient care.
Hospital policies concerning social media use and even mobile device use may prove extremely beneficial both in preserving the reputation of the hospital's clinicians—and by extension, the hospital—and ensuring high-quality care.
Zanzi suggests having a policy that "prohibits use of the clinician's personal mobile device to communicate patient information because of the security risk associated with that, unless that mobile device is appropriately secured through software provided by the hospital."
Instituting a mobile device policy guards against HIPAA violations by prohibiting the sharing of information on platforms that are not secure.
2. Ban social media use on-site.
Zanzi recommends making this policy straightforward, with hospitals explicitly saying to their clinical staff, "When you are on-site, and you are working here, you cannot use your personal social media."
Hospitals should actively discourage personal social media use while on the clock because it can be extremely distracting to employees who are meant to be working.
3. Encourage the use of patient portals.
While Zanzi recognizes that patients are seeking more convenient means of connecting with their physicians and other clinicians, she cautions against communication between physicians and patients over social media.
Since microhospitals are currently subject to regulations developed decades ago and with larger acute care institutions in mind, they can run into compliance obstacles that their traditional counterparts don’t often encounter or are better equipped to handle. Compared to a tertiary hospital, resources can be tight and clinical expertise narrowly concentrated in a scaled-down facility.
"In the acute care setting, in most cases, you presume you’re going to have a full-fledged medical staff and most of the ancillary support services to get you through whatever condition rolls in," says John A. Gillean, MD, executive vice president and chief clinical officer at CHRISTUS Health. The microhospital’s "more limited scope" can leave staff scrambling to provide compliant care in unanticipated situations.
For example, microhospitals that offer emergency services are subject to the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to stabilize and treat any patient who visits an ED, regardless of his or her insurance status and ability to pay, or the hospital’s typical service focus.
For facilities with limited staffing and equipment, this requirement can prove especially burdensome, says Gillean, who urges organizations to ensure that their microhospital can handle patients with emergent needs beyond the facility’s typical scope of service. During the planning process, account for high-risk scenarios that could play out in the real world, like a walk-in patient who’s having a heart attack and requires immediate stabilization before he or she can be safely transferred to a tertiary hospital.
"You want to be able to have enough support services there so that you can manage that patient and truly stabilize them," says Gillean. "Think through the types of patients who might show up and what you would need to have available for that immediate scope of care to manage them and stabilize them before you transfer them."
The paper based its estimates on data on physician turnover rates due to burnout and turnover costs. The cost of replacing a physician is estimated to be two-to three times the physician’s annual salary once recruitment, onboarding, and lost patient care revenue are factored in.
The paper suggested system-level solutions to burnout. These include re-framing the dialogue from burnout prevention to creation of systems that support resilience and well-being, adopting a metric for humanity that focuses on understanding the causes and consequences of emotional thriving and resilience, and creating a plan for a systematic culture shift to a human-centered care system.
Fortunately, there are ways to resolve the situation—or to avoid it altogether. Adhere to two important principles when creating criteria that could potentially be disputed.
First, ensure that all the concerned voices participate in the process. Any specialties that have a stake in the establishment of a particular privilege must have a forum in which to put forth their perspective, as well as any supporting data or documentation that may help them establish or amend criteria for a privilege.
Most organizations encourage participation in one of two ways. In the first approach, representation from each involved specialty is a formal part of the criteria development group. In the second approach, each specialty submits information to such a group either in writing or in person, sometimes both. To quell anxieties, it is usually better to allow an in-person presentation. Doing so gives groups the greatest assurance that they have been heard.
The second principle is that the decision should be mediated through a non-biased source.
If a criteria committee includes representation from all specialties, then such representation should be equal and the majority of the committee should be practitioners in specialties that do not have a direct interest in this resolution. If the committee does not have representation from the specialties, then all members should be free from direct interest, and the presentation opportunity should be equal for all the involved parties. Your organization’s policies and procedures should include language to this effect.
In addition, clinical privilege criteria can be very technical, and specialty training in a given procedure area may vary by provider. Therefore, most organizations benefit from having the involved specialties equally represented and directly participating in the privilege criteria development group.
In short, when it comes to privileging criteria disputes and their resolution, remember that economics and politics must be excluded from such deliberations to the extent possible. Final decisions should always reflect the group’s sense of what will be best for the patient, rather than what is best for individual practitioners or for the organization.
A review of more than 2,000 neurosurgical cases found no greater risk of post-operations complications for patients operated on by surgeons conducting overlapping surgeries.
The study, published in the Journal of the American Medical Association, examined patients who underwent neurosurgical procedures at Emory University Hospital in Atlanta from 2014 to 2015. Of the cases reviewed, about 43% had the surgeon remain with the patient through the entire procedure. In the other 57% of cases, the primary surgeon performed two procedures in different operating rooms.
In the 90 days following their operations, no difference was found in morbidity, mortality, or worsened outcome measures between the two groups of patients. The researchers concluded that this data suggests overlapping neurosurgeries are safe and may benefit patients by allowing sought-after specialists to see more patients.
Legal cases have significantly affected how health plans operate with regard to their credentialing practices. There are several ways in which managed care organizations can be held liable for their actions or for the actions of their providers related to the care received by members.
Take for example the 1998 court case, Boyd v. Albert Einstein Medical Center, Health Maintenance Organization of Pennsylvania, Dr. Rosenthal, Dr. Dornstein and Dr. Cohen (Surgeon) 547 A.2d 1229. Chardella Boyd underwent a breast biopsy during which the chest wall was perforated, causing a hemothorax, and requiring two days of hospitalization. Over the next several weeks, the patient experienced chest pain and other symptoms that were treated by both her surgeon and primary care physicians. Her condition worsened, and Mrs. Boyd subsequently died as a result of a myocardial infarction.
A Pennsylvania Superior Court found that the health maintenance organizatoin (HMO) was negligent for not overseeing the physicians and hospital that were acting as its agents (or employees) when providing medical care. This was based on the theory of ostensible or apparent agency, meaning that the HMO was responsible or liable for another because of the appearance of control. This decision was based on the fact that the HMO advertised that it evaluated physician competency and based on documents it provided to its members, in which it identified itself as the care provider and guaranteed the quality of care.
Another example is Harrell v. Total Health Care, Inc. 781 S.W. 2d 58 (Mo. 1989). Sara Westbrook Harrell underwent a surgical procedure and, due to complications, required further surgery. The physician, hospital, and Total Health Care were named in a lawsuit. It was discovered that the doctor had prior lawsuits and quality complaints on his record, including complaints to the state medical board; however, no privilege actions were taken by the hospital. It was proven that the HMO had not performed reasonable inquiries into the doctor’s competence, which would have uncovered the malpractice claims history.
This case determined that an HMO owes a duty to the patient to conduct a reasonable investigation of a physician’s credentials and reputation in the community. The corporate responsibility doctrine applies to managed care providers. Although it was ultimately held by the Missouri Supreme Court that Total Health Care was immune from liability due to an unrelated statute, it did uphold the theory of corporate liability.
Representatives from The Joint Commission, URAC, DNV-GL, the Healthcare Facilities Accreditation Program (HFAP), and National Committee for Quality Assurance (NCQA) took the stage at the 2017 NAMSS Educational Conference & Exhibition to share what they have learned from this year's accreditation surveys and to tell audience members what standards changes they need to be aware of.
The Joint Commission announced four areas of focus:
The SAFER Matrix: Implemented in January 2017, this matrix has nine boxes that measure the likelihood to harm a patient on one axis and scope of occurrence (limited, pattern, widespread) on the other.
Antimicrobial Stewardship: The CDC reported that 20-50% of antibiotics were prescribed unnecessarily or inappropriately. Medical staffs must reduce their antimicrobial use and have a medical staff process to demonstrate an effective use of antibiotics or antimicrobials in their organizations.
Ligature Risks for Behavioral Health Care Units: Due to the increasing rise of inpatient suicides (1,200–1,500 each year) 70% of which are by hanging, ligature risks are no longer acceptable in areas specified for the treatment of behavioral healthcare patients with suicide risk.
Culture of Safety: Leaders must ensure a culture of safety and identify areas to improve culture of safety. Staff must be comfortable and able to report issues of safety to leadership. This is already a standard under leadership and will become a medical staff standard in 2018.
According to Louis Goolsby, MD, FACOG, FACHE, the most common citations from the medical staff chapter still come from MS.01.01.01, specifically EP3 (specific requirements and associated details are included in the medical staff bylaws) and EP5 (the medical staff complies with the medical staff bylaws). Another common citation is MS.03.01.01 (practitioners only practice within their scope of privileges).
From the Encarta Dictionary, the definition of alignment is “the correct position or positioning of different components with respect to each other or something else, so that they perform properly.”
If the hospital and physicians are not aligned, reaching the desired destination will be a significant challenge. The above definition works because the medical staff and healthcare system must become aligned to reach the Triple Aim of the Institute for Healthcare Improvement, which is:
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of healthcare
It certainly sounds like a noble task that should be relatively easy to accomplish, especially since making people better is what healthcare is all about. But ask any physician, hospital executive, or hospital board member if this is easy and you will be greeted with a resounding “no.” The medical executive committee must have a basic understanding of alignment, but what should its role be in fostering alignment?
According to an article in Trend Watch, “To achieve clinical integration, we need to promote changes in provider culture, redesign payment methods and incentives, and modernize federal laws.”
This involves the concepts of set, communicate, and achieve buy-in to expectations. An example of this is standardized order sets and pathways. The MEC needs to have oversight of the development process such that the most scientifically up-to-date evidence is used and that there is a method to decrease variation that does not add value.
Whether the MEC mandates the use or just creates a process that makes following the protocol the easy thing to do is a cultural choice. The self-proclaimed “expert” may not really be the expert, so a solid medical staff process to review the evidence and ask the question, “Why are you different?” needs to be monitored by the MEC to enable a culture of continuous performance improvement to thrive. Clinical alignment may also be negatively impacted by economic alignment/integration.
Hospitals and physicians are not aligned financially. This provides an easily understood example of why hospitals and physicians may not be economically aligned. A subtler example can occur when quality is not aligned with quantity. Medicare helped physicians learn that when you get paid per widget, you make more widgets. The ugly example of this is the “Medicaid mill,” where the less advantaged population with limited access to care is pushed through the healthcare system so fast that even the most astute provider would be unable to provide a high-quality service.
We all know that some physicians are faster and more efficient than others when it comes to evaluating patients or performing procedures. The MEC should develop a method of oversight, which is most often accomplished through the peer review process. For example, a routine competency metric may be colonoscope withdraw time. If the metric is “Scope withdraw takes at least six minutes,” and you have an endoscopist that schedules patients every 10 minutes and can stay on schedule, you may have an issue. The idea is not to punish the efficient but to make sure that you don’t allow financial gain to eclipse quality.
Whether you perceive cultural alignment as the hardest or easiest alignment-related issue depends upon your current culture. Culture, previously defined as “the way we do things here,” is a major factor in the alignment process. The MEC, hopefully composed of the best and brightest of the institution’s clinical leaders, must set, monitor, and demonstrate the behaviors of the culture your facility wishes to maintain or attain. Collaboration and teamwork must replace the silo mentality that not only exists between nursing, administration, and the medical staff but also exists within the medical staff (i.e., between departments).
“Us and them” must become “we.” “Either/or” must become “and.” This is often more difficult for physicians who were trained to be the captain of the ship with complete autonomy and absolute power (somehow we missed that the captain needs a crew to run the ship) than it is for the more recently trained that have been more exposed to team building and collaborative practice. Culture will eat strategy for lunch every day. The MEC must constantly strive to create and maintain a culture of patient safety, quality, and continuous performance improvement.
As healthcare reform becomes the new reality, the ability of institutions to survive depends upon the ability of the medical staff and hospital to align and integrate. Those that can achieve this first will have a competitive advantage. Alignment is not a one-time fix, but an ongoing process that needs vigilance and nurturing. Just as in continuous performance improvement, the MEC must keep what works and discard what doesn’t to strengthen the alignment.