Next spring, Mountain States Health Alliance will accept the National Quality Forum's 19th annual Quality Healthcare Award for meeting quality-focused goals and achievements.
Since 1990, MSHA President/CEO Dennis Vonderfecht, has led the Johnson City, TN-based health system that serves 29-counties in a mountainous four-state region that includes Tennessee, Virginia, North Carolina, and Kentucky.
Vonderfecht recently spoke with HealthLeaders Media about the health system's decade-long journey toward patient-centered care.
HL: When did MSHA adopt the patient-centered care model?
DV: I had about 10 years ago been reading quite a bit about patient-centered care and some leading edge organizations that were implementing that primarily on the West Coast. I became interested in it to see if it did make a difference in how we related to our patients. I took about 14 or so of our key leadership to the West Coast to visit a couple of hospitals.
They were among the first in the nation to do this. I felt like our group going there and interfacing with the leadership of those two organizations would really tell us if there was a difference or not. We did see a difference and we were very impressed.
We came back and formed a steering committee and from that we developed our patient-centered care philosophy statement and the 10 Guiding Principles. Over time we've done a lot with that.
HL: What was it you were seeing 10 years ago that needed to be improved upon at MSHA?
DV: What I saw then and really what exists too much today is the processes and systems we put in place in healthcare are very much geared around our own team members as opposed to the patients and their families.
Some new ideas at that point involved going directly to the patients and their families and asking them 'what do you want to see? What is the ideal interaction you would have with your healthcare provider? How would you structure that?' It gives you a whole new way of looking at things.
One problem very clearly was visitation hours. A good example was our ICU units at the time before we implemented patient-centered care had very restrictive visiting hours and that was strictly for the convenience of our staff.
We generally had an attitude of 'you're getting in the way. We don't need you here. We know what we are doing for your loved one and we will inform you when we see the need to do it, but not any sooner than that.' So, one of the things we did early on, one of our guiding principles is that family and friends of the patients are considered an essential part of the care team. We opened visitation hours.
We came to realize that our patients, most of the time, when they come to us have a family member or friend who has brought them there and they stay with them a good part of the time while they are patients.
Many times they are the caregivers for that patient after they leave us. We put together the Very Important Partner program. If a patient desires to have a family member or friend to be that VIP then that VIP will get some training from nursing staff.
And they are actually involved in helping do some of the care for the patients knowing they are probably going to be the caregiver for the patient when they leave us.
HL: Can you provide some examples of how patient-centered care changes processes at MSHA?
DV: In the past, with construction projects or even equipment purchases, we as the caregivers would decide what we were going to get for the patients. We would build something or buy that equipment and find out it didn't work for the patients. For some reason we never bothered to ask them.
We changed that. A few years back we put beds out in the mall in Johnson City and we let people try them and rate them. We ended up making a bed selection off of what the people were telling us they would like if they were a patient at our hospitals.
In almost all of our construction projects consumers are involved with the architects to help lay out the design from the patients' standpoint. That is a change in philosophy that we never had before. Other times we will ask patients in the hospital, 'We are in the process of buying this equipment. What do you think?' We let them try that out in the hospital.
We created out of this a book about three- or four-inches thick with all the patient-centered care parameters that our construction projects are going to have. We didn't do any of that before. Now we use a lot of natural light, [for] way finding. All the things The Center for Health Design said you should be doing our hospitals have in them.
HL: Asking the patients' input seems so obvious. Why wasn't it done before?
DV: We got so centered on us having all the answers as caregivers that we didn't really think about the patient actually being the one using the services and really having the answers. It gives you a whole new way of thinking about it that seems so commonsensical you think we would have done it. But we weren't.
HL: How do you get staff to buy into the mission?
DV: Whether you provide direct patient care or indirect patient care, we are all considered caregivers because we are all here for the benefit of the patients. That is something that is taught to all new team members at orientation.
We have created our highest awards in the system, called the Servant's Heart Award, around patient-centered care principles that honor those who truly are the epitome of those principles and actions not only in our organization but in our community as well.
We do videos of these folks and what they mean to the organization. There are community testimonials from fellow team members, physicians and managers. They are available on our Web site. It really provides that example for our team members of what they need to strive to emulate.
HL: What's next for MSHA as you continue on the patient-centered care journey?
DV: I see two areas that we are focusing our attention on. No. 1 is putting metrics to these 10 Guiding Principles. We have patient advisory groups in MSHA and we asked them 'here are these guiding principles. What do they mean to you?'
It was interesting because the definition of what we thought it meant was different from what the patients thought it meant. We want to define them from the patient standpoint to tell us if we making progress with this principle or not. That is new to us this year and we are already seeing some great value there.
Secondly, we just need to figure out a better way to engage physicians than what we have now. About 400 of our approximately 1,200 physicians are employed but each person will have to buy in for themselves no matter if they are employed or not.
When it comes to recruiting physicians, it's like this: Rural hospitals have to work harder, talk to more candidates, and expect more rejections.
Of course, this should come as no surprise to anyone familiar with recruiting clinicians to rural America. And the data backs it up. These concerns are detailed in the 2012 In-House Physician Recruitment Benchmarking report from the Association of Staff Physician Recruiters.
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The report suggests that the increased demand for healthcare services, which are expected with the full implementation of the Affordable Care Act, is going to make recruiting doctors even more difficult for rural providers in the coming years.
"There is no indication whatsoever that rural recruiting is going to get any easier," says Shelly Tudor, chair of the ASPR Benchmarking Committee and member-at-large of the ASPR Board of Directors.
"In fact, the report shows that the cost of recruitment is going up, [which will make it] it harder for rural healthcare organizations to compete. A clear correlation exists between the facilities' population size and acceptance rates, with offers from organizations in larger populations much more likely to be accepted than those in smaller populations."
The ASPR benchmark shows that interview-to-hire ratios are much lower in urban areas than in rural areas. "In lots of respects, the process favors urban providers. Physicians are coming to urban areas and they are looking for jobs, whereas rural providers have to go out and target physicians that are likely to come to their area," Tudor says.
"Their interview-to-hire ratios are going to be much, much higher. Their sourcing-to-interview ratios are going to be much higher, too, because they have to filter through a lot of people to find the right one who is willing to come in and even look at the opportunity."
Further hampering rural hospitals' efforts to attract physicians is the potential distraction of overworked in-house recruiting officers wearing multiple hats.
"When you get in these rural areas, you are talking about small hospitals and the in-house recruiter might also be responsible for credentialing, and on-boarding, and administrative responsibilities, and any number of other things," Tudor says. "She may need help identifying candidates just to even look at."
For both urban and rural hospitals, the ASPR benchmark reaffirms larger nettlesome trends in physician recruitment. [The benchmark report includes data from 151 organizations representing 4,808 searches conducted in calendar year 2011.]
Between 2011 and 2012, there was an increase of 18% in positions unfilled.
Seven in 10 (71%) of searches are done by hospitals/integrated delivery systems, up 10% from 2011. Referrals and Internet job boards remain atop the sourcing list. However, 12% of candidates contacted hospitals directly through their websites, indicating the importance of an organization's online presence.
Median time-to-fill was 155 across all physician specialties (222 days on average) compared to a median of 120 days (208 days on average) from 2011.
Median time-to-fill for primary care physicians was 151 days compared to 125 days last year. Time-to-fill for advanced practice providers, such as nurse practitioners and primary care physician assistants, was only 90 days for both the 2012 and 2011.
A decline can be seen in the number of searches that were filled (51% in 2012 vs. 60% in 2011) and an increase in those that remained open at the end of the year (42% vs. 36% in 2011). Specialties that were least likely to be filled during 2011 were: med-peds, neurosurgery, dermatology, urology, and otorhinolaryngology.
Unfortunately for rural providers, there is no easy fix. "What is driving that is personal preference on the physicians' part," Tudor says. "The vast majority of physicians and their families want to be in areas where there is access to good schools and good entertainment. It's a lifestyle decision, at the end of the day."
Admittedly, the news from the benchmark is downbeat. But let's not forget that providing healthcare in rural areas has sublime appeals.
"One of them is satisfaction," Tudor says. "If you are inclined to that type of work there is a great deal of satisfaction from helping those people and their communities. They tend to be very grateful for the care they get, versus a metro area where we have certain expectations of what a physician should be. People in rural areas tend to be grateful that they even have a physician."
Rural hospitals can also provide financial incentives to recruit physicians using funding that is made available if they are designated as a healthcare workforce shortage area by the Health Resources Services Administration. "That can be a good incentive for someone who comes out of medical school," Tudor says.
"I spoke with someone the other day who is $400,000 in debt from her medical school training. So rural hospitals do have some advantages in that respect, but you still have to find the people who are willing to go out and explore those possibilities."
In our annual Industry Survey, only 10% of CEOs described their organization's physician recruitment and retention efforts as very strong and just 38% characterized it as strong. Another 19% rated it as weak or very weak. What trends are you seeing, and what are the actionable strategies to achieving an exceptional physician recruitment and retention program?
William Riley, MD
Chief Medical Officer
Memorial Hermann Sugarland, Texas
My hospital is the smallest of nine acute care hospitals in our system. Each hospital recruits physicians and physician groups based on the dynamics of their individual market. The primary strategy in the system is clinical integration, not individual physician recruitment. We have around 2,600 physicians in our clinical integration model, which brings a lot of leverage to bear in today's healthcare world and unites a lot more doctors in a major urban area than if you were strictly following in a pure recruiting and employing model..
The system has offered a menu of options for doctors. If they want to be employed, they certainly can be. It is fair to say that that is an increasing trend. But once again, it is not as steep a trend in terms of growth in our system as it is in other systems in the country.
When you have the infrastructure that we already have in our system, it plays to the physicians' basic desires to retain a small or solo practice, or even a large group practice, but at the same time have some of the benefits of being aligned with a big hospital system.
J.G. Schaaf, MD
Chief Medical Officer
Shenandoah (Iowa) Medical Center
Our recruiting is fair to good. It is variable depending upon the time and the need. There has to be a commitment by medical staff to be really actively involved in that since we are a small rural hospital. We are starting earlier and earlier. Recently I did a tour for a young lady who is about to enter medical school. She has a family connection to our community and happened to be in town.
We've had actually some luck with seeing young people. Sometimes an early start is well worthwhile. Involve these people with the institution. Give them a commitment. Make them feel welcomed and they feel kind of like, "Gee, that is a place that really wants me and I want to work there."
By the time they are in their residency a lot of people have already made up their mind where they are going to go when they finish their specialty training. If we can get to some of these people earlier, we can hopefully present to them some good reasons why they might consider us when as a general rule we wouldn't otherwise be on the radar.
Bob Kahn
CEO
Orthopedic Specialists of Texarkana, PLLC, Texas
We are not recruiting. We're a seven-physician independent practice. We plan to remain independent as long as possible. We make all of our money off of direct patient care so we have sold off all of our ancillaries. The youngest member of the group is 42. At this point we don't see any benefit to recruiting, especially if we have to pay $400,000 to $500,000 for some guy who is either right out of school or near the end of his practice.
Everybody who has come into this practice has asked to come in. There are 10 orthopedic surgeons left in Texarkana. All of the people within our practice are from the area and this is very profitable practice. I'm not sure the hospitals in the area would be in a position to purchase us because the incomes of all of the physicians in the group are well within the 90th percentile. The kind of money they would have to pay and the guarantees they would have to give us would probably cause regulators to look a little suspiciously. We have the W2s to prove it.
As long as my doctors continue to see patients and remain healthy or unless something significant happens with reimbursement we pretty much can do what we want for as long as we want.
Benjamin D. Anderson, MBA
CEO
Ashland (Kan.) Health Center
On finding a strategy that fits:
Our organization has a wonderful physician recruitment and retention plan. Our board progressively approved a plan to give all of our physicians eight weeks of paid time off that many choose to use for international mission work. Coinciding with that, we are building a culture in this organization that focuses on domestic and international service, not just among medical providers but with all of our staff. That has been attractive particularly for the millennial generation of physicians.
On the melding of missions:
Before we could recruit mission-focused physicians we had to be a mission-focused organization. Our board went through a comprehensive strategic planning process where it redefined the organization's mission, its vision, its core values, and its goals. We were able to recruit physicians whose personal mission matched the mission of our organization, which has been effective.
On the return on investment:
We are taking their vacation time, sick time, personal time, and CME time and wrapping it into one eight-week policy. We aren't giving them excess time off. We are just giving them control over the time off they do have. The additional cost is not significant, especially when you compare it with the locums' coverage costs; we were paying to get coverage that was not as consistent. When we took a look at the total cost of coverage we are actually paying less than we were before we had these providers because we were paying locums' rates. We just can't afford not to do this.
Officials with the Office of the National Coordinator have issued an "all hands on deck" call to accelerate meaningful use certification for more than 1,000 small rural hospitals by the end of 2014.
ONC's Mat Kendall, director, Office of Provider Adoption Support, and Leila Samy, Rural Health IT Coordinator made the call in a blog post last week, and announced that ONC will provide up to $30 million in supplemental for Regional Extension Centers to make it happen.
"We need everyone rowing in sync," Kendall and Samy wrote, "including leadership and staff in every critical access and rural hospital, EHR vendors, hospital associations, and state offices of rural health in every state, Rural Health IT Network Development grantees, ONC grantees, and many more public and private, Federal and local partners."
The federal government is finally applying nautical metaphors to problems with meaningful use attestation that rural healthcare providers and advocates have complained about for months — namely that smaller rural hospitals have been given short shrift in the move to meaningful use.
Kendall and Samy enthusiastically note that more than 1,220 critical access hospitals and rural hospitals have enrolled with an REC for assistance with meaningful use attestation.
"This is great news because it provides data supporting the anecdotal evidence that Critical Access Hospitals and rural hospitals along with the clinicians working in these hospitals recognize the value of health IT and want to offer their communities healthcare services powered by the benefits of meaningfully using certified EHRs," they write.
No kidding!
Yet Kendall and Samy concede that other meaningful use data for rural hospitals is less rosy.
In August the Centers for Medicare & Medicaid Services reported that while 1,333 hospitals—roughly 25% of all hospitals in the United States—had successfully attested to meaningful use and would receive incentive payments. However, only 186 of those certifications were for critical access hospitals, a number that represents about 15% of the nation's critical access hospitals.
The federal fiscal year started on Oct. 1. Even though hospitals have until Nov. 30 to achieve meaningful use certification for FY2012 and thus receive the first of four years of incentive payments, it looks like the vast majority of critical access hospitals won't make the cut.
Chantal Worzala, director of policy at the American Hospital Association, welcomes the notion that federal officials are putting money up to address the "digital divide" for rural hospitals.
"Clearly the data show that rural hospitals are behind their urban counterparts," Worzala tells HealthLeaders Media. "Given that particularly critical access hospitals are by definition smaller and have fewer resources, we did from the very beginning worry that they could be left behind by this program."
"It is about money," she says.
"They don't have the same resources as large academic medical centers or urban facilities, partly because of their size, but also because they have a smaller population. They do struggle to be able to afford the workers needed to support EHR. That is not just technical staff, but clinical staff that can bridge the technical and clinical. Of course attracting people to an area that doesn't have all the urban amenities makes it a challenge as well."
Tehachapi (CA) Valley Healthcare District recently became one of those critical access hospitals to achieve meaningful use attestation. CEO Alan J. Burgess says going through the process made it clear that rural hospitals were an afterthought when the federal government devised the criteria.
"I don't think ONC really understands rural health. The rules clearly were written for large municipal hospitals with all the different services," he says. "The standards weren't very flexible in light of small and rural facilities. Sometimes you have to keep patients longer because there is no step-down available within 100 miles. Those are issues that I have to deal with every day that most big city hospitals don't have to deal with."
Brock Slabach, senior vice president for the National Rural Health Association, says rural providers also have been slower to implement meaningful use because of continued uncertainty about what is actually covered under the reimbursement.
"With that uncertainty comes paralysis," he says. "If you have a $1.5 million project on the table and you don't know if only $1 million is available at the accelerated reimbursement or $1.4 million is eligible, obviously these small facilities that are already cash-strapped don't want to take a risk of having $400,000 disallowed from the higher reimbursement rates and so they are just not moving forward."
Slabach says he is heartened to see that ONC is plunking down another $30 million to help with meaningful use implementation.
"We will see how that plays out. I am not sure about the details and I'm not sure they are either," he says. "But if they have the resources those would be welcome to address the glaring problems that we are experiencing."
He cautions, however, that the Centers for Medicare & Medicaid Services is ultimately responsible for the meaningful use program, not ONC.
"Obviously we will need to work with CMS as a partner in this to make sure the right hand and the left hand know what is going on," Slabach says. "CMS has made some changes recently that we are encouraged by, for example allowing for lease purchases to be considered part of what is being reimbursed at the higher rate. That was a significant policy change."
Even with the call to accelerate meaningful use implementation in rural areas, Worzala notes that many critical access hospitals will still find it challenging getting HIT vendors to "pay attention" to their needs.
"Of course rural hospitals are not the largest clients and we are very much in a situation where demand outstretches supply for vendor solutions," she says.
Burgess says TVHD ran into a string of problems with the HIT vendor they'd contracted.
"We ended up debugging a lot of their software. That was very frustrating for the staff. We are still working out the issues. It is a continuous process of improvement but we are getting there," he says.
"With that incentive money, so many hospitals have contracted and gone out and tried to make it work that we have overwhelmed the industry to the point that industry is no longer capable of providing the level of support that I want, need, and expected with an installation startup and training for a new system."
As for whether or not ONC can reach its goal of meaningful use attestation for 1,000 rural hospitals by 2014, Missourian Slabach tempered his optimism with Show Me State skepticism.
"That would be yet to be seen," he says. "But we do have to have a goal and concentrating everyone's efforts toward those goals and seeing what policy levers we need to change in order to accelerate this migration is important."
We hear a lot about "employee engagement" in healthcare human resources.
Unfortunately, in many hospitals, efforts to engage staff may vary depending upon the job title. Most of the engagement talk appears to be directed at nurses, which is understandable, considering how expensive it is to recruit and retain nurses.
However, getting nurses and other highly skilled clinicians to buy into the mission does not mean that lower-tiered staff should be ignored. No hospital or any business can say truly that it has engaged employees unless all its workers are engaged.
One class of workers that engagement efforts have generally ignored is the cleaning crew. But that appears to be changing as more hospitals understand the difficulties and costs of fighting hospital-acquired infections and the positive and immediate effects that an engaged and informed cleaning staff can have on that fight.
Maryn McKenna, author of Superbug: The Fatal Menace of MRSA, and a noted blogger on hospital-acquired infections, says she is seeing attitudes change as hospital leaders come to understand that it is easier and more cost-effective to prevent these increasingly common and alarmingly drug-resistant and life-threatening HAIs on the front end than it is to treat patients after they become infected.
"You can't look at something that is highly resistance and say 'there is another drug on the shelf to treat this patient,' because there aren't. As a result, prevention of these infections becomes much more important because there is no treatment on the back end," McKenna tells me.
"I don't think that that connection was really made or at least emphasized before. People thought it was important to have the hospital clean because a hospital should be clean. But the job performance of the environmental services staff actually having a direct effect on infection rates is a relatively new realization and institutions are still working their way through that."
The prevailing wisdom for a long time, McKenna says, was that cleaning staff was not important on the hospital hierarchy. "They are all the way at the bottom. People assume there is going to be high turnover. They don't pay them well or train them well. For a significant number of them English is a second language. Nobody thinks about the difficulties of that. They think of them as these faceless people chugging through the room doing these basic necessary tasks," McKenna says.
"Then all of a sudden they realize, 'Wow we have to turn our understanding of our hospital hierarchy on its head because these people who we have always taken for granted might turn out to be the key piece of the puzzle.'"
Swedish Covenant Hospital got the memo. The 320-bed hospital in Chicago was featured in Not Just a Maid Service, an HAI prevention video put out by the Illinois Department of Public Health that stresses the role of cleaning crews.
Gregg Gonzaga, infection control manager at Swedish Covenant, says Clostridium difficile infection rates have fallen 20% since they instigated a collaborative in mid-2010 that engaged cleaning staff in the fight.
"One thing we initially noticed was that certain departments in the hospital were in silos. For housekeepers it was 'this is my job. I just clean the rooms,'" Gonzaga says. "We wanted the environmental staff to understand that we don't look at them as housemaids. We look at them as an integral part of our infection prevention effort. We approached them and said 'we know that what you do in the hospital is very important and we want you to be a part of our team.' They understood that."
Swedish Covenant supervisors took the time to explain to staff what C. diff. is, how it is spread, and what it can do to a patient. They made it clear to staff that their jobs could literally be a matter of life or death. They explained why it was necessary to provide a thorough cleaning and to avoid shortcuts.
Supervisors daubed florescent markers on high-touch areas before cleaning and then doubled back when the cleaning crew finishes to make sure rooms were properly disinfected.
Initially the results weren't very good, Gonzaga says, and only 50%-60% of high-touch areas were cleaned. One housekeeper wept when she was told that her patient rooms failed inspections. "She was upset because she felt like she did not do a good job. She said 'I clean this room like it is my own house,'" Gonzaga says.
"We told her the goal is not to punish you when we do these inspections, but to make sure we can identify the housekeepers who need to be retrained so they can be consistent in their jobs and make our hospital safer."
Ben Modica, manager of environmental services at Swedish Covenent, says the 80 or so people on cleaning staff have come to embrace the inspections because they "understand why we are doing what we are doing and that we want their opinion. We could be dictators and tell them to do this and that. But they need to know why and sometimes they have better methods than we do."
In addition to improved safety, Modica says the engagement with cleaning crew has improved retention. "Since I have been here, the turnover has been very low. I don't have the exact numbers, but I know because I do the hiring," he says.
There is a lot to like about what they're doing at Swedish Covenant and at other hospitals that understand the important role of cleaning crews. Beyond the obvious and positive effects that this has on decreasing HAIs, there is also the effect that this engagement has on the employees themselves and how they view the job that they do and the place where they work.
Everybody wants to think that their work matters. Good things happen when supervisors take the time to explain to their cleaning staff that what they do can greatly affects the lives of patients. When mistakes are seen as opportunities to improve instead of failures that must be punished, employees will try that much harder.
Staff will respond when they understand what's on the line, when their opinions are asked for and acted upon, and when they are given the tools they need to get the job done.
First the bad news: Supplemental payments to Medicare-dependent hospitals will expire on Oct. 1, the start of the federal fiscal year, because a do-nothing Congress failed to extend the provision before it adjourned last week.
This means, of course, that a critical funding source is no longer available for the 212 rural hospitals across the nation that are classified as Medicare-dependent and that need those payments to keep their doors open.
Now, the good news: It is highly likely that when Congress returns on Nov. 13 it will pass the bipartisan Senate Bill 2620 (HR 5943), which will renew for one year funding for Medicare-dependent and low-volume hospitals. Assuming the bill passes, those additional MDH payments that would have gone into effect on Oct. 1 are expected to be added retroactively.
Maggie Elehwany, government affairs and policy vice president for the National Rural Health Association, acknowledges that inaction in Washington, DC has left rural providers "in a lurch," but she is upbeat about the prospects for the bill.
"We have about 24 sponsors on the bill, which is good news. We anticipated that this would expire on Oct. 1, but our goal is to make retroactive payments," Elehwany tells HealthLeaders Media. "Congress has done this in the past. When the sustainable growth rate expired, they made retroactive payments to physicians as seamless as possible. It’s not ideal, but it’s the only situation we have right now. We are going to continue fighting for it in the lame duck session."
These days, it’s rare to find optimism for the success of any legislation, especially if it has a price tag, in this gridlocked and dysfunctional Congress. Elehwany, however, says rural providers have a strong and bipartisan argument for the legislation that makes fiscal sense and addresses critical access-to-care issues.
"Once we have their ear, the story is very compelling," she says. "It is not a costly provision. The budget score estimates are about $100 million over 10 years. That is a decimal point by Congressional standards. Once we give them the empirical data that shows the cost effectiveness of rural hospitals and they can provide Medicare coverage at 3.7% less than urban areas and have that primary care focus the argument makes itself."
"Even the most fiscally conservative folks—a lot of them are on the bill—see the importance of keeping that hospital open for their local communities and it makes sense for the taxpayers as well. It’s a strong argument. We are just running out of time."
Enacted by Congress in 1987, MDH status requires that hospitals be in a rural area, have no more than 100 beds, and show that Medicare patients represent at least 60% of their inpatient days or discharges.
A study done for NRHA found that in 2009 MDHs operated at a negative 4% margin on average. Without hospital-specific and transitional outpatient payments, the study estimated that those MDH margins would have fallen to negative 12.6%.
Elehwany credits rural hospital advocates from across the nation with generating much of the support for SB2620 when they rallied at the Capitol in late July to push for the bill.
Unfortunately, with the fiscal pressures and partisanship facing Congress, Elehwany is not optimistic about a long-term fix for MDH. Like the sustainable growth rate formula, she believes that MDH status is something that rural providers may have to fight for every year.
"We definitely think it needs to be made permanent, but this is a tough climate," she says. "It’s kind of all about treading water right now and just making sure that patients maintain access to care and we keep those hospitals open and that is probably the best we can hope for in this climate until a new Congress comes into town."
And while the prospects look good for SB2620 in November, Elehwany says now is not the time for complacency. Members of Congress are back at home preparing for elections and they are particularly sensitive to the concerns of hospitals, which are often the biggest economic drivers in their communities.
"Your representatives are going to be home for six weeks," she says. "Make sure you go to the district office and the state office and talk to the members of Congress. Invite them to your hospital. Show them the work you do in that community. That hospital CEO is the best advocate we can possible have. No member of Congress wants to see a hospital close in his or her district no matter what side of the aisle they’re on, especially when they see the great work these folks do. So we are having a significant grassroots push during this time and hopefully we can transfer that back to Washington, DC, when they come back into town."
Doctors are working less, seeing fewer patients, and many would quit if they could, a sweeping survey of 13,575 physicians from across the nation shows.
The survey, A Survey of America's Physicians: Practice Patterns and Perspectives, was commissioned by The Physicians Foundation. It is the latest, and perhaps the largest and most comprehensive of a number of surveys that have identified wide, deep and increasing discontent among the nation's physicians regardless of their age, gender, specialty, location, or employment status.
"It is downbeat and it is a concern. What we are documenting here is a trend and the trend is pretty solid," Walker Ray, MD, vice president of the nonprofit foundation, told HealthLeaders Media.
"Physicians feel powerless. They don't feel like their voices are being heard. They don't feel like they were heard on the run up to healthcare reform and they don't feel like they're being heard now."
"The problem to summarize it is there is an imparative now for physicians to care for more patients, to provide higher perceived quality at less cost with increased tracking and reporting demands in an environment of high liability and problematic reimbursements," he says.
Physicians report working about 6% less than they did in a 2008 foundation survey. "That doesn't sound like a whole lot until you calculate the full-time equivalent physicians who are lost from the workforce," Walker says.
"If this trend continues that would be 44,250 full-time equivalents lost from the physician workforce over the next four years and there is every reason to think that this will occur."
The survey shows that 52% of physicians have already limited the access of Medicare patients to their practices or are planning to do so and 26% have already closed their practices to Medicaid patients, blaming higher operating costs, time pressures and falling reimbursements.
One hundred thousand physicians will transition to employees over the next four years, and more than 50% of physicians will cut back on patients seen, will switch to part-time, switch to concierge medicine, retire, or take other steps that will result in about 91 million fewer patient encounters, the survey shows.
Walker says that 75% of physicians don't believe that the migration to employment is a positive trend. That includes 62% of employed physicians who consider it a negative. Those physicians who are opting for employment are doing so, he says, for economic security and relief from "an extreme regulatory environment."
"Physicians think of themselves as being autonomous in making decisions in the patient's best interest, but employed physicians have to have one ear open to what their employer is saying. Otherwise they put their jobs in jeopardy," he says.
Most physicians just want out.
"We found that 60% said they would retire today if given the opportunity. What was worrisome is that this is up from 45% in 2008," Walker says. "We also know from the survey that we disaggregated it into certain categories, 47% of physicians under 40 said they would retire today if given the opportunity."
Walker acknowledges that some physicians could be speaking out of frustration and that they do not intend to leave practice. "But even if only a small percentage follow through on any of that it could be worrisome to the workforce," he says.
"We have 75 million Baby Boomers transitioning to Medicare starting last year over the next 12 or so years. We have a growing population. We have 32 million people who may be gaining health insurance and yet we have the same number of doctors. We have a bottle neck for training. We are training 25,000 or so doctors a year and the fact that we are finally building some new medical schools is not going to increase the doctor supply because the residency level is fixed at 25,000 or 26,000 positions."
The online survey was conducted from late March to early June by Merritt Hawkins with an overall margin of error of less than 1%. Phil Miller, vice president of communications at Merritt Hawkins, says physicians are caught amid crosscurrents in healthcare delivery and it's proven challenging to find incentives that work for everyone.
"We have a doctor shortage, so we want doctors to stay busy and be productive and see a lot of patients. But you are rewarding them with a salary which they know they are going to get regardless of how many patients they see. So you try to build in incentives that will keep them focused on volume," Miller says.
"At the same time, you have this crosscurrent that says 'let's not reward them for volume. Let's reward them for quality and patient satisfaction and these subjective metrics.' So we have two trends working at cross purposes and at the end of the day the doctors are going to take the salary. They may achieve some of their production bonuses, but it is going to be more of a nine-to-five, do-your-job-and-go-home-type of profession," Miller says.
Walker says the issues that zap physicians' enthusiasm run deep. "We have to improve the medical practice environment and the things physicians are most concerned about are autonomy, regulatory issues, liability issues, and reimbursements," he says. "We've got to fix some of those things to keep the workforce together because we not only want to train more physicians, we want to retain more in their practices and that is not happening now."
Your chances of being struck by lightning are greater than your chances of being shot in a hospital.
That doesn't means you should dance in a cornfield in the middle of a thunderstorm. Nor does it mean your hospital's patients, visitors, or staff should take cover and comfort behind long odds and the laws of probability.
The report from four researchers from Johns Hopkins University School of Medicine, published this month in the Annals of Emergency Medicine online, examined 11-years of data on 154 hospital shootings that resulted in 235 dead or injured.
The data showed that 30% of the shootings at acute-care hospitals occurred in the emergency department, and 50% involved the firearm of a police or security officer which was either used by security to fire at a suspect or stolen from the officers to shoot victims. The study notes that no hospital is immune from shootings. Zero risk is not attainable.
Gabe Kelen, MD, the report's lead author and the director of the Johns Hopkins Department of Emergency Medicine, said in the study that it would have been difficult to prevent many of the shootings they reviewed because the crimes involved a "determined shooter with a specific target."
Common motives for shootings included grudges or revenge, suicide, and euthanizing an ill relative. The report examined the years 2000–2011 and included a Sept. 16, 2010 shooting at the Baltimore-based health system in which a distraught gunman shot a physician, and then killed his ailing mother and himself.
Rather than spending money on metal detectors and other security checkpoints, the report suggests that the best deterrents include specialized training for hospital law enforcement and security teams, with an emphasis on the proper securing of firearms.
Metal detectors create a false sense of security, the report said, and do nothing to address the more than 40% of shootings that occur on hospital properties outside of buildings. Plus, hospitals have unique demands for 24-hour public access that require multiple entrances and exits to accommodate large numbers of people.
Bryan Warren, president of the International Association for Healthcare Security & Safety, tells HealthLeaders Media that every hospital should undergo an annual or biannual security assessment by a qualified expert. "The first thing is have someone come in and look at what you've got and do a gap analysis versus best practices and regulatory standards," says Warren. "What are the must-haves, should-haves and like-to-haves?"
Warren, who is also senior manager for corporate security at Charlotte, NC-based Carolinas HealthCare System, says the report correctly notes that no hospital is too small to ignore the security of patients, visitors, and employees.
"You need to have a professional well-trained knowledgeable security staff on board," he says. "If you have a 25-bed critical access hospital out in the middle of somewhere can you afford to have the same level of security as a 1,500-bed urban hospital? No. I'm not saying that. But you do need to have a dedicated professional to at least help assist in setting up your program and you need to follow some of the best practices."
After years of mistakenly thinking that hospitals are sanctuaries from violence, many federal and state officials are coming to realize that hospital security has not been given the attention it deserves. Warren says attitudes changed when the Department of Homeland Security included hospitals on its critical infrastructures list.
"People now realize that regardless of what the incident is in the community, if it results in injuries or potential injuries they are all going to end up at the hospital," he says. "So the hospital is very different from the industrial or manufacturing or retail environment because we get people no matter what. If it's a train wreck, a car wreck, a terrorist event, a shooting they are all going to end up at a hospital. Security at hospitals is a more complex issue."
Warren says the federal Occupational Safety and Health Administration also has shown a renewed interest in workplace safety at hospitals and other healthcare facilities. "OSHA is taking what once would have been a workplace violence issue and placing it under their general safety clause, which says that regardless of your industries you have to provide a safe working environment for employees," he says.
"We are seeing that more and more in a number of hospitals. I would like to say that hospitals are changing because they saw the light but it's more because they are feeling the heat, quite frankly."
All of this is occurring as reports of workplace violence in hospitals appear to be on the rise.
"I couch it because there hasn't been a clear determination. Are there more incidents or are reporting mechanisms being observed more closely? I think it is a combination," Warren says.
"We are seeing the ripple effect of the weak economy. There are a lot of people who maybe they are behavioral health patients who can't afford their medications any longer. You've got longer waits in emergency department. All those things are contributing factors."
But it's also a generational thing. Years ago it was thought to be part of the job. ‘If I am going to work in the ED I expect I am going to be spit on and cursed at.' You are seeing a generation gap where people are saying that is not part of the job and it's unacceptable," Warren says. "You are seeing a rise in the number and acuity of incidences but at the same time I think that a proportionate number of that increase is due to the simple fact that people are reporting it more often, as they should have all along."
Everything is complicated and laced with qualifiers in the hospital setting, even the definition of workplace violence. "Does it mean physical contact? Does it include psychological intimidation? Does it include physical violence without intent? If you have a patient coming out of anesthesia and they flail their arms and strike someone is that workplace violence? These are the questions that are difficult to answer and haven't been addressed when you look at these studies," Warren says.
Because of the complex nature of hospital violence, Warren says individual hospitals should be allowed organizational discretion to set parameters and use discretion. "It has to be looked on at a case-by-case basis," he says. "But each facility should have some hard and fast bright lines about what the criteria should be. They should have some process policies and procedures in writing so they have an idea of when they are going to prosecute and when they are not."
For healthcare clinicians and executives contemplating security issues at their hospitals, Warren offered several links to free services and guidelines.
A report that warns against "stop-gap" substitutions of nurse practitioners for primary care physicians may have rekindled the long-smoldering border skirmish between the clinician associations.
The report, Primary Care for the 21st Century, was issued this month by the American Academy of Family Physicians, and reaffirms its support of physician-led, patient-centered medical homes as the best method of transforming primary care delivery.
In sharp contrast, the AAFP says advocating "independent practice by a single health professional," namely nurse practitioners in place of physicians, "flies in the face" of studies supporting the cost-effectiveness and quality outcomes of the physician-led care team approach.
"We are not trained to do the same things, so to imply that one can substitute for the other is just incorrect," Roland Goertz, MD, chair of the AAFP Board of Directors, told HealthLeaders Media. "The educational backgrounds are different. Even nursing leadership says 'we are not trying to be doctors,' but policy setters tend to simplify things, which is a kind way of saying it."
Goertz says physicians are also concerned that the public could be "easily confused" if caregivers aren't transparent about their roles and scope of practice. "If you ask a patient when they went in for care and they saw someone with a white coat, the vast majority of the time they're going to think it was a physician that provided the care," he says.
"You have to be clear about who is providing care and what the training is that has substantiated that ability to provide that care. Our organization has nothing against creativity and entrepreneurism in the delivery model but we believe you have to be careful when changing abilities and skills and knowledge without understanding that there is a huge difference between the training models."
Goertz says the intent of the report is not to restart the long-running scope-of-practice debate with nurses' associations but he also acknowledged that the report would do exactly that.
"What tends to happen is it becomes you are warring with the nurses again,'" he says. "That is not the point of the report. The point is we have a better model that uses everybody appropriately and the proof is in the model."
Lisa Summers, CNM, a senior policy fellow, at the American Nurses Association, told HealthLeaders Media there is "a basic level of agreement" with the AAFP on the increased need to shift focus away from the costly and inefficient illness care model and toward primary care and preventive medicine.
Beyond that she says is "where the contention comes in."
"I have mixed feelings when reports like this come out," she says. "The bottom-line feeling at the ANA is that these turf battles that these kinds of reports turn into don't do a lot to benefit moving ahead the agenda of coordinating care, a shared goal of providing the best care for patients. That is our focus: How do we build truly integrated teams that keep the patient at the center of focus?"
Summers says that organizations and stakeholders as varied as the Joint Commission and AARP have for several years developed accrediting guidelines and policy statements addressing access to primary care that refer more broadly to the role of "clinicians" and move away from the physician focus.
"What this report points out to me is that it is a continued effort by organized medicine to preserve the status quo by focusing on physicians," she says. "Folks are beginning to reject this antiquated notion that they only way to deliver high-quality, patient-focused care is to have this captain-of-the-ship model."
Summers also takes "exception" with the report's contention that the shortage of primary care physicians is the primary driver for independent practice for nurse practitioners.
"That certainly is part of what is driving the discussion, but all kinds of health policy think tanks have come out in the last couple of years with policy statements supporting the need to remove barriers for advance practice registered nurses," she says.
"So what is behind those proposals and that support isn't just the shortage. It's the fact that there are decades of evidence to support the safety and quality of care by nurse practitioners and other advanced practice nurses."
"People are beginning to realize that the restrictions we have now on autonomous practice don't do anything to increase the quality of care. We know they impair access. They lead to duplication of services. Once you slow down and duplicate services, you start increasing healthcare costs."
Summers says the scope-of-practice debate will always be around and continually evolving, and not just for doctors and nurses, but for all clinicians. "No intelligent healthcare professional practices 'independently' in the way they are suggesting in this report," she says.
"We talk about independent practice as the ability and responsibility of any provider to use the knowledge skills judgment and authority that they have to practice to the full extent of their licensure and education. That is true about anybody, registered nurses, psychologists, pharmacists. This report sets up a false dichotomy between team-based care and APRN's practicing 'without a physician on staff.' "
"That is an odd way to frame it, because when we talk about meeting the needs of patients, anybody who has experienced the healthcare system realizes there is no one individual provider who can do everything a patient needs."
Summers says nurse practitioners are well equipped to provide primary and preventive care and manage chronic diseases and when the needs of the patients fall outside of their expertise they will refer to a physician, just like a family physician will refer patients to a specialist.
"It no more reasonable to talk about APRNs practicing without a physician on staff than it would be to talk about a family physician practicing without a cardiologist on staff," she says.
Goertz says much of the tension in the scope-of-practice debate is found at the 20,000-foot-level between rival policymakers, and not at the point of care delivery, where "you have these understandings in place."
"If you are talking about on-the-ground activity where the teams are taking care of patients, there is not a lot of contentiousness about this. Everybody understands the patient is the focus of attention. In the actual act of delivering care, I don't see a line-in-the-sand problem," he says.
"Where I see it is in the higher level of leaders of some nursing schools who want to essentially change the model of care delivery and they have already succeeded in doing that to a certain extent. Our issue is that there is not one single profession that can solve this problem. We all need to work together and the patient-centered medical home is a far better model than simply expanding nurse practitioners."
That is all we are trying to say. Since there is a difference in education and training, we need to honor those differences and work within them."
It's already tough enough for rural healthcare providers to survive.
There are a number of reasons why. One the biggest is that rural providers generally care for a sicker, older population that includes a higher mix of Medicare, Medicaid, and indigent patients, so reimbursements tend to be smaller.
A study published in the Journal of Rural Health now shows that it's not going to get any easier. University of Florida researchers found that 40% of rural residents are obese, compared with 33% of urban residents. No pun intended, but this is huge.
Earlier studies had already shown that overweight and obesity is a bigger problem in rural areas, but those studies put the difference in the 2% to 3% range. That estimate is now doubled. With about 60 million people live in rural America , and assuming that the UF findings are valid, 24 million rural residents are obese as measured by the Body Mass Index of height and weight.
"The problem [is that] the earlier studies were based on surveys that asked people to self-report height and weight," UF study author Michael G. Perri told HealthLeaders Media. "The study we did was based on measured heights and weights. One thing we are well aware of is that people tend to underreport their weight and over report their height. Everybody is five to 10 pounds heavier than they report and an inch shorter than they claim."
Obesity is a preventable condition that is linked to any number of serious and expensive-to-treat chronic diseases and other medical conditions such as Type 2 diabetes, coronary heart disease, high-blood pressure, cancer, sleep apnea, osteoarthritis, liver and digestive tract complications, and even mental illness.
As the nation's obese population grows larger in size and number—and there is no indication that this trend is reversing—these are all conditions that rural provider will have to contend with more frequency and in numbers disproportionately higher than those of their colleagues in non-rural settings.
"We simply cannot ignore the link between obesity and poverty, and the disproportionate impact this is having on rural America," Alan Morgan, CEO of the National Rural Health Association, said on the advocacy group's Web site. "If we truly want to decrease healthcare costs and improve the nation's health status, we are going to have to start viewing obesity as a top-tier public health concern for rural Americans."
This greater demand to provide and manage care for the obese will come as healthcare reform turns towards reimbursement models that reward quality outcomes and prevention over fee for service. Rural healthcare providers must get on the front end of this epidemic and emphasize prevention. Unfortunately there doesn't seem to be much coordination for this in any broad fashion.
"I don't think there is any single entity that will be able to turn the tide on this epidemic of obesity both in the nation and specifically in rural areas. It is going to have to be a convergence of many factors coming together," says Perri, who is also a professor and dean of the UF College of Public Health and Health Professions.
He believes the most cost-effective route may be to use existing infrastructures to provide nutrition and health education to rural families.
"One thing that jumps out is cooperative extension services in almost every county throughout the country. Part of their mission is nutritional education," Perri says. "In rural areas the extension office is highly valued as a place to go and get assistance. Often the extension offices are the places to go for the WIC (Women, Infants and Children) Program. We can teach family and consumer science agents in the offices how to do weight management programs targeting children and adults and families."
Perri points to another UF study that he co-authored that tracked 298 obese adults in six counties using cooperative extension as the venue for treatment. "We taught the extension agents how do to standard lifestyle behavioral treatment programs. We also were interested in how do we get people to maintain the changes that they have made," he says.
"We were able to produce weight losses that were equivalent or even better than those seen in diabetes prevention programs."
In the second phase of the study, the researchers randomized people for different follow-up care programs, either by mail, by telephone, or face-to-face. "We were particularly interested in effectiveness and cost effectiveness," Perri says.
"We showed the follow-up programs that were face-to-face or by telephone were significantly better than the follow-up by mail. That suggests that once we get people to lose weight we may be able to help them sustain it without having them come in for additional sessions other than telephone follow-up sessions."
Perri says related studies have demonstrated effectiveness in educational nutrition with just the parent rather than the entire family. "Particularly for school-age children, the parents often are the gatekeepers of food preparation and intake. We found you can get equal effectiveness whether the parents are alone or have the kids come in as well," he says.
All of this was accomplished outside of the traditional rural healthcare system of hospitals, clinics, and physicians' offices. "The nice thing is that it takes it out of the whole medical reimbursement arena and the other piece is you don't have to establish a new infrastructure. The kind of activities fit nicely with the mission of the extension services," Perri says.
This may makes perfect sense, but Perri says the idea is embraced neither by rural providers nor extension services.
"They are coming from totally different angles. We have people with different world views," he says. "The folks in cooperative extension are coming largely from the perspective of agriculture. They feel somewhat uncomfortable moving towards healthcare as part of their mission. The folks in hospitals and clinical care see cooperative extension as the folks who help farmers and run 4-H clubs. There hasn't been a concerted effort to bring the two groups together."
This has to change. I suspect that it will. A big motivator will be money.
Providers are entering a new world of disease management, coordinated care, quality outcomes, and smaller reimbursements. It behooves them to step beyond the confines of the healthcare establishment to find new and nontraditional partners who can effectively and cost-effectively educate rural families about nutrition.
