Almost 10 years ago, the healthcare industry found that it might not be as safe as it thought. It was then that the Institute of Medicine released To Err Is Human, which noted that each year a million or more hospitalized patients are injured and as many as 98,000 die as a result of errors in their care.
Numerous reports, testimonies, and articles have examined the issue, but one aspect seemed to be initially missing from the discussion: Real people and real faces behind the statistics. Several years ago, this point was driven home as a Maryland mother, Sorrel King, began to speak to audiences of medical professionals across the country about how her 18-month daughter died in a hospital after a series of medical errors.
But King didn't want Josie just to be a number: She wanted to know how to prevent other families from experiencing the same tragic events. In a way, it became the beginning of her own movement to make patients safer through new ways of thinking and communicating, which she now recounts in her new book, Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe.
In the winter of 2001, Little Josie was within two days of going home—making a good recovery. But through a series of miscommunications, she began to deteriorate. As King describes it, her daughter's color seemed off—she seemed lethargic and extremely thirsty.
At first, she shrugged it off. After all, she thought, the child was at one of the premier hospitals in the country, Johns Hopkins Hospital in Baltimore. "I always tried to be a low-maintenance parent. I didn't want to get into anyone's way. I didn't want to ask questions," she said. "I just wanted to take care of Josie."
Through a communications breakdown, the child was administered a shot a methadone, which ultimately put her into cardiac arrest. She was rushed to the pediatric ICU where her organs began to shut down. The next day, King and her husband made the decision to take her off life support. "So, instead of planning a welcome-home celebration, we were planning a funeral," she said.
Eventually, the Kings reluctantly agreed to a financial settlement with Hopkins. "We didn't want the money. We thought that taking the money was almost as disgusting as offering up money for her life," King said. Their lawyer said that while they could leave the money, nothing good would come from it.
So they began to think what could they do for Josie—and the impetus for the Josie King Foundation was formed "with a simple little mission: To prevent children and patients from being harmed by medical errors."
First place to start: Johns Hopkins. "I wanted every doctor, every hospital to know what happened. To be honest, I wanted to do it out of spite," she said. "But then I realized that the story could transform doctors and nurses maybe—and how they listened to patients."
Helping her on her journey was Peter Pronovost, MD, PhD, a professor at Hopkins and medical director of its Center for Innovations in Quality Patient Care, who also found himself embarking on a new journey as well on the issue of medical errors.
"Josie's death was a tragic loss for all of us—obviously most important her parents. But it forced Hopkins and now I think the broader medical community to address this important issue of medical errors in a very real and concrete way," said Pronovost, who is also director of Hopkins' Quality and Safety Research Group.
"Prior to her efforts—including here [at Hopkins]—we didn't talk about mistakes too much. Doctors were expected to be perfect. If something went wrong, it was under the rug," he said.
King took the challenge, and started by talking groups of medical professionals at Hopkins. She met with residents who were unfamiliar with the Institute of Medicine findings on patient safety. Pronovost encouraged her to take her message to even bigger audiences, such as those attending meetings of the Institute of Healthcare Improvement.
In her message, she tells her audiences that she is not a physician or nurse and she has no medical background. "What I do tell them is what I see and what I saw and what I think they could fix," she said. And that the way to address many patient safety issues is "something as simple as communication."
But beyond just telling her story, King has seen new ideas implemented from her experiences—most notably the use of "Condition H" (where "H" stands for "help") in hospitals across the country. Condition H, which is discussed further in this month's issue of HealthLeaders magazine, encourages patients and/or families to dial a special number during hospitalizations that alerts a rapid response team to assist if a medical emergency is perceived. The program, which started at a University of Pittsburgh Medical Center hospital in 2005, is now being used nationwide.
The foundation has also implemented a family care journal project. A number of hospitals across the country are giving the journals to hospitalized patients and their families so they can monitor day-to-day activities—from daily goals to names of medications to the names of their medical team members. The journal can be seen as "a symbol of the hospital reaching out to the patient and saying: ask questions," King said.
"I think that she's touched the healthcare community in a way that few others have been able to," Pronovost said of King. "I go around the country and [I know] that there are thousands of hospitals that show [the recording] of King talking about Josie.
"But one of the pleas I make to hospitals—and I say this to senior leaders—is that we will know we're starting to make progress in safety when they have the courage to tell their own Josie story," Pronovost said. "It's easy to say this is what Hopkins did, and it's meaningful for staff and leadership.
"But [stories like] Josie's are happening at hospitals all over the country. What was transformative for Hopkins was that we accepted responsibility," he said. "It can't be just a Hopkins' story: It's got to be whatever hospital you're at—[to say] 'we own it now.'"
A new set of tables from the federal government shows a wide state-by-state variation in what Americans paid in premiums for employer based health coverage in 2008.
Not only does the total amount of premium cost vary, but also the share paid by the employer versus the share paid by the employee.
For example, workers with families in Alaska were covered by health plans costing on average $13,383 a year, while $3,248 was paid by the employee and $10,135 paid by the employer. At the high end, plans in Alaska cost $20,000 a year, $8,000 more than the national average.
In contrast, a worker with a family in Alabama was covered by health plans costing on average $11,119, and the employee's share was $3,265 while the employer's cost was $7,855.
"What we're trying to point out is how this data varies from state to state," says Jim Branscome, statistician and project manager for the Agency for Health Research and Quality.
"If you look at where the premiums are most expensive, it's usually in those areas where the housing costs and wages are higher. A lot of healthcare premium costs are driven by what it costs a hospital to operate in New York, for example, versus the Midwest," he says.
The set of tables was issued without a companion report, an unusual occurrence for the agency, Branscome acknowledged. "We will get around to doing a paper on this, but for now, we wanted people to know these special tables exist, and how the distributions have changed."
The state-by-state breakdown shows average costs for employees and employers depending on whether the plan covers a single person, a single person plus one, or a single person and his or her family.
The tables break down each state's premium payments in five categories to show how the most expensive plans in the state compared with the least expensive.
Other highlights show that for the nation as a whole, 10% of covered workers, or about 2 million—had family plans that cost $17,000 per year or more. The average annual premium for a family plan in 2008 was $12,298.
The cost figures may also vary depending on how much competition there is in each state. In a large number of states, for example, one or two insurance companies dominate the market, reducing the amount of price and plan competition.
A California-based consumer group is asking the state's attorney general, Jerry Brown, to investigate health insurance companies that have asked their employees to lobby against healthcare reform.
Consumer Watchdog singled out UnitedHealthcare and WellPoint/Anthem for its national campaigns to help employees write and speak out against health reform, including at town hall meetings. The group charges that the insurers' actions are "almost certainly illegal under the California Labor Code." Consumer Watchdog Research Director Judy Dugan said California's employee protections "against coerced participation in politics are the strongest in the nation."
"Both companies are urging their employees to lobby members of Congress and offering corporate assistance in doing so, including talking points and even the placing of phone calls for the employees," Consumer Watchdog wrote in its letter to Brown.
"WellPoint and UnitedHealthcare are no doubt tracking which employees respond to their demands," said Dugan in a statement. "To call such action 'voluntary' defies common sense."
The Wall Street Journal reported last month that the health insurance industry has been sending thousands of employees to town hall meetings and other forums to petition members of Congress to not support the public insurance option. America's Health Insurance Plans also issued a "Town Hall Tips" that warns health insurance employees who attend the meetings to expect harsh criticism directed at them and asks employees to remain calm and not yell at the elected officials. Robert Zirkelbach, AHIP's director of strategic communications, told the paper that about 50,000 employees have written letters and made phone calls to politicians or attended town hall meetings.
Consumer Watchdog alleges that these actions by the insurers violate Sections 1101 and 1102 in the state's Labor Code, which forbid companies from preventing employees from taking part in politics or directing them in political activities.
Though UnitedHealthcare labeled employee participation as "voluntary," Consumer Watchdog said the company was able to "monitor compliance" and its "instruction to take action on company time override any such disclaimer."
Dugan said the health insurers' efforts are merely a way for them to squelch health reform and continue to profit on the current healthcare system.
"These companies are intent on preserving their profitability, wastefulness, and inefficiency, at the cost of taxpayers and patients," said Dugan. "Now, in addition to their multimillion-dollar lobbying campaigns in Washington, they are enlisting their tens of thousands of employees to lobby as individuals."
Zirkelbach said the health insurance industry has been working cooperatively on health reform to "advance bipartisan, comprehensive healthcare reform" and has proposed guaranteed coverage, eliminating pre-existing condition exclusion, and an individual mandate to require all Americans to have insurance.
"The men and women in our community are proud of the work they are doing every day to help make the healthcare system better. They want to be constructive participants in the healthcare reform discussions and they have a right to have their voices heard," he said.
In response to the charges, UnitedHealth Group said in a statement that it is proud of its employees' involvement in the healthcare reform debate and it has not encouraged employees to attend anti-health reform rallies.
"We have stressed repeatedly that we strongly support bipartisan reform efforts to modernize healthcare and improve access to quality care on a sustainable basis for all Americans. We have made information available to employees for them to participate, voluntarily, only in publicly-announced Congressional town hall meetings, or to write or call their elected officials. As our CEO wrote to all employees, 'We encourage you to continue to lend your practical know-how and point of view to the healthcare reform debate, as always, in a respectful and collegial manner that elevates the discussion and that is consistent with the social values we hold as a company. Our mission is to help people live healthier lives. To do that, we know we have to listen closely to the people we serve and work together with them … We must remain mindful to bring that same spirit of service, respect, and cooperation to this important public discussion.'
When contacted for a statement, WellPoint responded, "WellPoint has not been contacted by the California attorney general and has not seen any complaint, therefore we cannot respond to any questions at this time. We believe it is important and permissible to provide up-to-date information about health reform to our associates."
Nearly one-third of physicians still practice in solo or two-physician practices, but nearly 20% work in practices of six or more doctors, according to a tracking study of U.S. physicians released by the Center for Studying Health System Change. On average, nearly half of physicians' practice revenue is derived from public sources (31% Medicare and 17% Medicaid), and about three quarters of doctors still accept all or most new Medicare patients.
A statewide survey of nearly 1,900 Massachusetts doctors showed that 31% felt stressed, 27% were dissatisfied with their work and 17% felt isolated from colleagues. Doctors who said their practices had quality problems were more likely to feel stressed, the survey found.
The health of Americans has changed significantly in the past 25 years that I have been practicing in medical school/university hospitals, as well as the private sector.
Poor nutrition and overeating have raised the average weight of Americans by 20%–35%. In addition, people are becoming overweight at a much younger age. This raises the risk of heart disease, hypertension, diabetes, and chronic illnesses in a younger population. When coupled with cigarette smoking in the United States, it is no wonder why health insurance premiums have soared over the past many years.
As the United States now spends close to 17% of the GNP (all dollars spent per year) on healthcare, we are in a crisis that must be addressed. The proposals range from keeping healthcare in the private insurance domain to raising the percentage of Americans obtaining healthcare from government funds, in a model similar to Medicare and Medicaid. The current healthcare programs funded by the government are already two trillion dollars in debt.
Changes in our system must occur to reduce costs, but this should not happen by moving to a government-owned single payer plan. This type of plan will not be as efficient or possess the quality of most private carriers. Not to mention the fact that physicians, especially specialists, will decrease in number across the country due to the government's strict regulations regarding specialist care.
I would recommend the following changes be made:
Divide the uninsurable population into risk categories. These risk categories would include age, prior medical problems, and exposure history (smoking etc.). People that are more likely to cost more for the insurance company to care for should be equally divided among the private healthcare insurance carriers (including Medicare) in all 50 states. These people will likely have to pay more of a premium depending on their health status. No one should be denied health insurance, especially due to a pre-existing condition.
Uninsured people not eligible for Medicaid or Medicare should be given financial assistance by the government based on their employment status and other financial factors.
The use of emergency care in all hospital systems needs revision. Patients who have minor illnesses need to be referred to step-down care facilities similar to a family doctor/minor care unit. This will reduce costs immediately as one ER visit can cost between $400–$1000.
No one should lose their health insurance coverage if they lose their job or are no longer able to work due to illness. COBRA should be available to these people for an extended period of time with government assistance.
Americans who remain healthy or become healthy should get reduced rates on their healthcare insurance costs on a year-to-year basis. Rewarding people this way will create incentives to stay healthy and cut out bad habits, such as smoking and excessive weight gain. This rule should also apply to any covered family members under a plan. A healthier America means fewer illnesses and lower costs to the insurance carriers and lower premiums for all of us.
Americans want to remain in control of their own healthcare choices. Changing to a national government run healthcare plan is not the answer. Our quality of healthcare and the amount of physicians available to treat our nation will become substandard. Our government needs to be part of the solution, but not in the proposed way.
Charles Hux, MD, maintains a private practice in New Jersey and is primarily affiliated with Monmouth Medical Center in Long Branch, NJ. His articles have appeared in the American Journal of Obstetrics/Gynecology, Prenatal Diagnosis, the New England Journal of Medicine, and Genetics.For information on how you can contribute to HealthLeaders Media online, please read ourEditorial Guidelines.
Consultation coding can be challenging for many physicians, and correct documentation is vital to correctly bill for these services. Many physicians learn about specific consultation requirements only after a third-party payer audit results in the reclassification of their consultations to new patient office visits or subsequent hospital visits.
To see how a physician's consultation coding compares with that of other physicians in his or her specialty, review the CMS data on physicians by practice, which shows the E/M codes physicians report most. When a physician's ratio of reporting consultation codes (99241–99245) to new patient office visit codes (99201–99205) is much higher than that of his or her peers, review the requests and documentation for the consultations to determine whether the physician has met requirements.
Remind physicians who have never been audited that CMS expects them to know the regulations related to billing and submitting claims to Medicare and Medicaid. The government outlines its concerns annually in the HHS Office of Inspector General (OIG) Work Plan.
The OIG included consultation coding in the 2002, 2003, and 2004 Work Plans and issued a report in March 2006 highlighting $1.1 billion in estimated Medicare overpayments made to physicians in 2001 for consultations (a 75% error rate).
In response to the 2006 report, CMS issued Transmittal 788, Change Request 4215 in the Medicare Claims Processing Manual. This transmittal includes:
Clarifications regarding the definition of a consultation
Documentation requirements
Clarifications regarding who may perform consultations
Clarification that physicians may not report consultations for split or shared E/M services
Since the 2006 OIG report, more private payers have audited physicians. And with the Recovery Audit Contractor (RAC) permanent program, which relaunched in March, now is a good time to review consultation coding. Even though the RAC permanent program has record limits, there are major concerns about each RAC's ability to extrapolate (i.e., apply the error rate to all claims). RACs must abide by the following record request limits per 45 days:
10 records for solo practitioners
20 records for partnerships (i.e., two to five physicians)
30 records for group practices (i.e., six to 15 physicians)
50 records for large group practices (i.e., more than 16 physicians)
If damages from billing physician E/M services are $150 per claim on average, and RACs can only request 10 records per 45 days for a solo practitioner, this adds up to only $1,500. However, RACs may turn these findings over to the OIG if they believe they have identified a pattern in reporting practices. After further investigation, the OIG can apply the error rate to the whole universe of claims or cumulative number of claims that fit the criteria for claims under investigation.
Therefore, if the OIG were able to apply the error rate to this significantly larger number of claims, that could total much more than $1,500.
Editor's note: Baklid-Kunz is the director of physician services at Halifax Health in Daytona Beach, FL. E-mail her atekunz@ bellsouth.net. This article was adapted from one that originally appeared in the September 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
It may seem that the healthcare reform debate has reached an impasse and genuine bipartisan agreement is a lost cause, but there is one issue remaining that has the potential to reluctantly unite Democrats and Republicans: Medical liability reform.
That is, assuming enough members of Congress are willing to set politics aside. There are Democrats who will not touch tort reform because of strong ties to trial lawyer lobbies, and there are Republicans whose desires to see a repeat of 1994 and make healthcare President Obama's "waterloo" cannot be placated by even substantial compromise.
But for those genuinely interested in improving an undeniably flawed system, medical liability reform has emerged in recent days as a potential bargaining chip. Former Democratic Senator Bill Bradley wrote in the New York Times this weekend that combining universal coverage with malpractice tort reform offered a final hope for a "grand bipartisan compromise."
Can meaningful healthcare reform happen without medical liability reform? Sure; medical malpractice tort costs plus malpractice insurance only account for about 1.5% of total medical costs. And although insurance costs have declined in states that have already enacted tort reform, total healthcare spending hasn't. There seem to be much more effective ways to "bend the curve" over the long term.
But tort reform has been a longstanding cause of the Republican Party, and it is incredibly important to the physicians on the front lines of this debate. And the indirect costs—in the form of defensive medicine—account for a larger chunk of total healthcare spending, although the exact amount is difficult to estimate.
What if Democrats offered to include malpractice reform in exchange for Republican support of legislation that included most of their proposals, minus the public option? Or even with the public option, malpractice reform may sway enough moderate members of both parties to move the legislation forward.
So far malpractice reform has been mostly absent from the debate on the Democratic side and a bit of a red herring on the Republican side. Opponents have criticized Democrats for neglecting the issue, but as my colleague Cheryl Clark reported last month, there is already an amendment in the House bill, sponsored by Democrats and Republicans, that will provide financial incentives to states that enact meaningful malpractice reform.
Both sides should take that existing amendment and run with it.
President Obama, Senator Max Baucus, and other key players have publicly indicated that they're willing to address the malpractice issue, as long as it doesn't involve caps on awards. This may be where the negotiations break down for some opponents.
But it shouldn't be. There are many effective alternatives to capping damages—health courts that peer review cases, "disclosure and offer" agreements that settle disputes outside of court, and safe harbors for physicians that adhere to care standards.
The House amendment rewards states for experimenting with some of these options. Rather than relying on the bluntness of damage caps, we can test combinations of measures that both reduce errors that lead to malpractice lawsuits and help fairly settle disputes after the fact.
Negotiations will undoubtedly be heated, but at least they would be covering a topic of substance. Instead of focusing on death panels and socialism, this is the type of discussion needed to move real, bipartisan reform forward.
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Medicare physician fee schedule payments may be "excessive" for a variety of medical services because efficiencies that occur when two or more services are furnished together are not reflected in the fee schedule, according to the Government Accountability Office (GAO) in a study examining Medicare physician payments and fees. GAO's review found that expanding Medicare's practice in this area could reduce payments by an estimated half billion dollars a year.
Medicare essentially could end up paying twice for those overlapping services, which do not involved surgery or imaging, GAO said. For instance, when two medical services are furnished together, a physician may only review a patient's medical record once, but fees paid would reflect that Medicare paid twice for that activity with both services.
The Centers for Medicare and Medicaid Services (CMS) has implemented what it calls "a multiple procedure payment reduction" (MPPR) policy for various imaging and surgical services when two or more related services are furnished together.
Under this policy, the full fee is paid for the highest priced service and a reduced fee is paid for subsequent services to reflect "efficiencies in overlapping portions of the practice expense component" for instance, clinical labor, supplies, and equipment. This could include, as an example, a nurse's time preparing a patient for a medical procedure or a technician's time setting up the required equipment is incurred only once.
This effort produced savings of about $96 million in 2006 for imaging services, GAO said. However, the scope of the policy is limited because it does not apply to nonsurgical and nonimaging services commonly furnished together. It also does not "specifically reflect efficiencies occurring in the physician work component" the financial value of a physician's time, skill, and effort.
GAO acknowledged that CMS is reviewing the efforts of a American Medical Association workgroup, called the Specialty Society Relative Value Scale Update Committee, which was created in 2007 to examine possible duplication for services furnished together. However, GAO said the workgroup has not focused on services that account for the largest share of Medicare spending—a point that AMA disputes.
GAO also noted that under the federal budget neutrality requirements, savings from reductions in fees are redistributed by increasing fees for all other services. Thus, these potential savings would "accrue as savings" to Medicare only if Congress exempted them from the budget neutrality requirement–as was done in the Deficit Reduction Act of 2005 for savings from the changes to certain imaging services fees, GAO said.
GAO suggested in its report that Congress consider exempting any resulting savings from federal budget neutrality so that savings accrue to Medicare.
Disruptive, offensive behavior on the part of providers is still such a significant and frequent problem in health settings, it jeopardizes patient safety, and can affect quality of care, despite Joint Commission guidance that took effect Jan. 1 to prevent such breakdowns.
Of more than 1,500 providers responding to an e-mail questionnaire, three-fourths said they had been the target of unprofessional, intimidating or inappropriate behavior within the last 24 months. Two-thirds said they considered leaving their job because of it and 41% said they actually did.
The 64-question survey was designed and distributed in May and June by the Center for Patient and Professional Advocacy of Vanderbilt University Medical Center and the Studer Group, an outcomes-based health consulting firm devoted to teaching evidence-based tools and processes, which works with providers to prevent such incidents. Healthcare professionals were solicited through blogs and by e-mail and were promised confidentiality.
The survey defined such behavior in almost the exact terms used by The Joint Commission: Intimidating and disruptive behaviors include "overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.
"Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Unprofessional behavior impairs or disrupts a healthcare team member's ability to achieve intended outcomes."
The survey asked respondents not to consider acts of sexual harassment or age, gender or racial discrimination in their responses because they are governed by specific laws.
In a sentinel event alert issued July 9, 2008, the accreditation agency said, "There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care. Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it."
James Pichert, professor of medical education and co-director of the Vanderbilt Center that guided the survey, says the project was launched in part to learn what factors influence a patient to sue his or her caregiver. It is known that patients who do sue would often report to offices of patient relations that they had witnessed disruptive behavior during their care, he says.
"And when the patient had a bad outcome, the patients felt that it was because the team was not working together," says Pichert.
In one case, for example, someone was on the operating table not fully anesthetized, and would hear an argument breaking out between staff members who gathered around, Pichert explains. "They'd say 'I could feel the tension in the room, and it did not give me confidence. And when I had a bad outcome, I had to wonder whether it was because they were more focused on the argument than they were on me.'"
Pichert says the study cannot be called a scientific one because it was not conducted in a random fashion, and those who answered may have been more likely to respond because they have fresh memories of a hostile encounter.
Only 15% of the 1,521 people responding said they had not been a target of such behavior, according to Colleen Thornburgh, Studer Group coach and speaker.
But Thornburgh adds that the graphic experiences described by those responding raises concerns that such behavior may very well affect quality of care and patient safety.
For example, she says, one technician responded that after being yelled at by a medical superior for asking a question, he now delays asking that person again or doesn't ask at all. "And that delay may be just enough to make a difference in outcome," Thornburgh says. "That's where we see a real threat to quality and safety, maybe not at that moment, but maybe downstream from that moment."
Thornburgh and Pichert believe the questionnaire's responses are a strong indication that a significant problem remains in healthcare settings. For example, some of those who participated gave these examples of their anger and frustration with their interactions with superiors or peers:
"A physician wanted to do something that put the patient in an unsafe situation, violated State and Federal laws and regulations and JCAHO standards. When I informed the physician he couldn't do this, and that he put patients at risk, he told me I couldn't do that and he would have me fired...The physician was yelling and using many expletives."
"I have been targeted by a physician that exhibits unprofessional behavior on a regular basis. He yells, throws charts and degrades nurses always looking for something wrong and someone to blame. He has told patients not to listen to the nurses; they don't know what they are talking about. His behavior is not addressed—he is one of our biggest admitters."
Those initiating such behavior most often were nurses, physicians, managers or administrators, according to the survey results.
The issue of intimidating and disruptive behavior among workers in healthcare settings is bound to receive more attention as hospitals attempt to comply with new rules and recommendations from the Joint Commission.
Effective Jan. 1, 2009, all Joint Commission accredited programs must have adopted leadership standards that address "disruptive and inappropriate behaviors" in two ways:
1. The hospital or organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors
2. Leaders create and implement a process for managing disruptive and inappropriate behaviors.
Additionally, the agency suggests 16 other actions, including adoption of "zero tolerance" for intimidating and/or disruptive behaviors, especially the most egregious instances...such as assault and other criminal acts," and "reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior."
The commission's Sentinel Event Alert references studies showing that disruptive and intimidating behavior "can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments."
