HealthLeaders Media Council members discuss owning or partnering with convenient and urgent care clinics.
This article first appeared in the September 2017 issue of HealthLeaders magazine.
Mark Thompson
CFO
Regional Health
Rapid City, SD
We own urgent care sites throughout our markets. Regional Health’s flagship facility is in Rapid City, South Dakota, and we have community hospitals and clinics throughout Black Hills and western South Dakota.
We have two dedicated convenient care centers in the Rapid City market, and we have urgent care hours and extended hours in our primary care clinics in our rural markets. For some patients, this is an alternative to going to the emergency department, and it’s quite an improvement. We were wondering when we first began offering convenient care whether convenient or urgent care centers would have an impact on our emergency department volumes.
We have not seen any real drop in those volumes, but we do think that there’s always better and more efficient ways to provide care.
Like many communities, we have a shortage of primary care providers in our area, and this is another outlet that enables our patients to access care.
I think what we’ve done in our rural communities is a good example of how smaller healthcare organizations can get involved in convenient care. I know other organizations have considered partners you would find in other markets, such as drugstores, but the partner opportunities just weren’t available to us.
So, in many cases, we simply extended the hours of existing facilities to meet our patients’ demand for nontraditional hours of clinic operation.
Rick Nordahl
CEO
Sanford Sheldon
Sheldon, IA
We do participate in convenient care clinics through ownership. We’ve extended the hours of our primary care clinics, now closing at eight in the evening rather than at five in the afternoon, Monday through Thursday, and we are open from eight in the morning until noon on Saturdays.
We’re working on creating late hours for Friday nights, Saturday afternoons, and a portion of the time on Sunday to expand some hours.
That may take place in our hospital instead of our primary care clinic, and be serviced by our ED providers. I’m not sure when we’ll be able to get that started, but we’re looking at the regulatory requirements right now, to make sure we can do it most efficiently and effectively. We were inspired to expand our convenient care clinic hours because we need to value and respond to the patients’ time.
There’s a huge gap between being provider-driven and being patient-driven, and we need to close that gap. We need to educate our providers to service patients when the patients have time and need, versus sending them to the ED after hours.
Other options providing greater flexibility for our patients are video and e-visits via telemedicine. I think both need to be available to truly serve our patient populations effectively, whether they’re rural or urban.
Bill Munley, MHSA
Vice president of orthopedics, general surgery, and professional services Bon Secours St. Francis Health System
Greenville, SC
We participate in convenient care at every level of the continuum. We had a few choices when we first started out: Were we going to enter the convenient care field through ownership, or through a partnership? Did we want to start this now, or in three years? But ultimately, we started by opening a couple after-hours urgent care centers in two of our physician practices three-and-a-half years ago.
Last year, things were really taking off for us in the convenient and urgent care area, so we also partnered with one local urgent care center corporation that had a total of five locations. This has been going on for about a year now, and we’ve found that the clinics are a good access point to our system.
We’ve opened another clinic in a residential area, so we’re up to six urgent care centers and two convenient care centers, with plans for more in the future. We would consider everything along the spectrum, up to and including freestanding EDs, in the future. However, we have no current plans for investigating a freestanding ED at this point.
The bigger picture: Initially, we said this interest was because we wanted to grow our volumes and partner with urgent care centers to gain patients. But now, as we get into population health and with the rise of patient-centered medical homes and ACOs, this is almost like keeping the patient in the family; you want them to go to your urgent care center.
If you’re trying to keep costs down you don’t want them going to an emergency department and racking up a big bill, especially if it’s not in your ED—you want them going back to your centers, seeing your doctors.
This article first appeared in the July/August 2017 issue of HealthLeaders magazine.
HealthLeaders Media Council members discuss the metrics their organizations use to track employee satisfaction.
Lynette Walker
Vice President, Human Resources
Baptist Health Hospital
Lexington, Kentucky
We do not use just one metric; we try to utilize various measurements. We do stay interviews at 30 days, 90 days, and one year; we do biannual engagement surveys to determine down to the department level what concerns employees might have.
And, of course, there’s the traditional HR metrics: turnover, vacancy rate, and time to fill a position. If we see that we have increased turnover, that speaks for itself. We also know that sometimes certain departments and units get reputations as not being particularly great places to work, so we pay attention to things like whether it’s taking us longer to fill positions on a particular unit, and we do a little detective work to find out why that is.
In short, we try to look at this up and down, sideways, and all through the spectrum to gain insight into how our employees perceive the organization and the decisions we make.
We have changed the way we do our awards and recognition based on feedback that we receive through our engagement survey. It has also helped us review our onboarding process and our orientation programs for certain positions.
We’ve additionally looked at our attendance policy; workers thought we were being a little too strict, so we looked at how we needed to change that, and we instituted greater flexibility in scheduling. All of this is based on feedback we’ve received from our employees.
Alex MacLennan, PHR, SHRM-CP
Chief Human Resource Officer
Tahoe Forest Health System
Truckee, California
HR metrics are incredibly important. The role of human resources continues to transition from an administrative-function wing position within organizations to a strategic partner. With the use of data, we’re able to benchmark and use it to develop strategies that can engage workers.
We partner with Press Ganey Associates for both our employee engagement and patient satisfaction surveys. We created several other surveys internally that we use to measure engagement as well. Some of the themes of these surveys include environment, pride, teamwork, recognition and opportunities, and trust.
We send these internally created surveys out to 30–50 employees out of our approximately 750 healthcare workers at random every few months to get a snapshot of how we’re doing as an organization. It allows us to measure over time how we’re doing.
We’ve also started looking at employee turnover as a metric. We started to ask each of our managers to review their previous month’s terminations, whether by resignation or by a disciplinary action, and then report back to us whether those employees had been high performers, average performers, or low performers. That tells us whether we’re losing our best workers, or if the turnover we’re seeing is among lower performers.
Becky Rauen
Director, Human Resources
Maple Grove (Minnesota) Hospital
I did some research around employee engagement metrics last year, and it was frustrating. There really aren’t many resources available outside of going through the survey process and spending oodles of dollars, and we think that doesn’t maintain the necessary, intentional, and ongoing conversation engagement should be.
So I started looking into other metrics around the hospital, realizing that they were part of the story and what’s really going on with regard to engagement.
Because I was struggling to find perfect metrics, I decided instead to go with the imperfect ones that invited conversations with workers, managers, and teams.
We’ve cobbled together a series of metrics that I think give us good insight into our relationship with our workers. We still do a formal engagement survey once a year, but we try to rely on informal metrics. We use a scorecard with different topics that examine the mood of every department.
Some of the traditional HR metrics we use are related to engagement, such as employee turnover and first-year turnover. We look at the amount of recognition funds we use—we allow each department to have some dollars they can use to recognize employee contributions, and it’s good to see the correlation between spending and engagement.
We look at things like the number of employee referrals to recruitment, and we look at funds used and requests for internal training and development. We also look at attendance: how often people are calling off their shifts, and attendance for team meetings.
Patricia Webb, FACHE
Executive Vice President/Chief Administrative
Officer and Chief Human Resources Officer
Catholic Health Initiatives
Englewood, Colorado
We conduct an annual employee engagement survey across our enterprise. We also have a board of trustees that has pinpointed employee engagement as a key area for us to track and measure.
We focus primarily on the concept of being a member of this organization; whether the employee is proud to be a part of our organization, how engaged he or she is in the success of the organization, and whether the employee knows how to engage within the organization.
We recently had a fairly in-depth cultural assessment and we got a lot of participation, and we occasionally conduct pulse-check surveys.
On deciding which data to measure: As a healthcare organization, we have sought to align our engagement, satisfaction, and quality scores, as we know from research that a highly engaged employee base translates to increased patient satisfaction. Our survey contains 50–60 questions, but the highlights are pride in workplace and motivation.
We have conducted research that has determined that pride in working for a particular organization is an indicator of engagement, so we began measuring that.
It is the same with highly motivated employees: Are employees motivated to contribute to the success of the organization? Do they find their work environment rewarding? If so, they are likely to be highly engaged. These two factors are indicators of engagement that should serve as benchmarks not only in healthcare, but across industries.
Errors are known to spike during late night hours, but guidance from managers can help nurses adjust to the night shift.
Healthcare is a 24/7 business and, while shift work is a necessity, working the night shift can be hazardous both to employee health and patient safety.
The Nurses’ Health Studies, in its third iteration since 1976, found nurses who worked rotating night shifts were at increased risk for colorectal cancer, breast cancer, and coronary heart disease.
In addition, it found that errors and on-the-job injuries both spiked after hours, says Ann E. Rogers, PhD, RN. She is the Edith F. Honeycutt chair of nursing and professor and director of graduate studies at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.
"We know that during night shifts, no matter how well rested you and your colleagues are, everybody will experience some fatigue and may have to fight sleep. You simply are not as alert as you should be," says Rogers, who researches the effects of sleep deprivation and shift work on nurses. Even seasoned night shift workers can experience sleepiness while on the clock.
Thankfully, there are steps managers can take to help nurses combat the effects of working the night shift. Rogers offers these three ways to address common night shift challenges,
1.Don’t Ignore Signs of Fatigue
"All of us can hide the symptoms [of sleep deprivation] with coffee," says Rogers. But being under the influence of caffeine only masks the symptoms of fatigue. Caffeine doesn't restore attention to detail, grant patience in the face of frustration, or improve coordination, which are all consequences of sleep deprivation.
Other signs of fatigue include slowed reaction time or responses, irritability, poor memory, lack of attention to detail, and excessive consumption of caffeinated beverages.
If a usually calm and collected worker shows signs of fatigue, it wouldn't be out of line to ask him how he's adjusting to working the night shift
2.Tamp Down External Cues
Imagine a clinician wrapping up a 12-hour shift at the hospital to go home and get some rest, only to feel themselves suddenly perking up as they walk outside and are greeted by sunshine and bustling streets.
That wakefulness will likely persist once the worker is at home, lying in bed, desperately trying—and failing—to fall asleep. Along with circadian rhythms, people rely on external cues to tell them when it's time to get up, go to sleep, or eat meals.
Even if a worker has been awake for a long time, it can be difficult to fall asleep after exposure to bright sunlight and street noise. Rogers suggests encouraging shift workers to wear dark sunglasses on their way home from the hospital and discouraging caffeine use during the latter part of their shifts.
She also advises that workers use earplugs to block out daytime noises and to hang dark curtains in their bedrooms if they need to sleep during daylight hours.
3.Work Schedules Should Encourage Sleep
Even with environmental checks in place, it's up to hospital managers and administrators to set rules that can protect workers and patients.
The first is to ensure proper scheduling so workers can get the proper amount of sleep, says Rogers.
She has written that the likelihood of a clinician making an error can increase by as much as 36% after working 12-hour shifts on consecutive days. "We know that workers only use half of their time off to sleep," says Rogers.
"If a nurse has 10 hours off, they will sleep for about five hours, which is not enough rest for anybody."
It's also important to ensure that shift workers take breaks. Because fewer restaurants and shops are open at night, many shift workers neglect taking lunches and scheduled breaks. Have clinician supervisors and managers encourage their reports to take their scheduled time off, and keep an eye out for workers who skip lunches or work through their breaks.
Additionally, most hospitals don't allow workers to nap during breaks, says Rogers. She believes this policy is a missed opportunity.
"Allowing a nurse to do that will encourage alertness for the rest of the night," she says. The night shift may not be the first choice for most healthcare workers, but by acknowledging its unique challenges, hospital administration can help keep workers awake, alert, and present in their jobs.
HealthLeaders Media Council members discuss their organizations’ executive compensation structure.
This article first appeared in the June 2017 issue of HealthLeaders magazine.
Debra Palmer Chief Human Resources Officer and Corporate Compliance Officer Fairfield Medical Center Lancaster, Ohio
I think we’re in the majority of organizations, in that we have a strong structure for our compensation. We do an annual review of it, so unless the market changes significantly, I don’t see a large change in actual structure of the program.
For our C-suite, our base salary is set at the 50th percentile of the regional market and then modified based on years of experience for each candidate. All usual employee benefits apply, plus we give a leadership fringe of $100 monthly, which they can use to offset benefits costs, deposit into their 401(k) or 403(b) plan, or enter into their 457(b) plan.
We provide C-suiters with a 20% bonus structure, with organizational goals comprising 85% of the bonus, and 15% of the amount around individual goals. We all have the same organizational goals, and most of us have one to two personal goals. We also give them additional PTO of 40 hours yearly, long-term care is paid for and provided by the organization, and we give them 2.5 times their annual salary in life insurance.
I’d say that you need baseline compensation as a part of your incentive plan. Also, if the candidate is moving to accept this job, you need to support their moving expenses. If the new executive is not moving and their current residence is driving distance, you might substitute a sign-on bonus for relocation fees. But I think the most important thing to attract new talent is competitive base compensation.
Lewis Marshall Jr., MD, MS, JD Chairman, Ambulatory Care and
Community Health Services,
Brookdale University Hospital Medical Center Brooklyn, New York
On why the time is now to update compensation structure: One of the greatest indicators that now is the right time for a change is the movement to value-based purchasing. As organizations move to the new process with their managed care organizations and payers, executive compensation structure should change, too.
With value-based purchasing, an executive compensation package might look at some type of incentive based upon the organization’s ability to meet the goals of the value-based payment program. It should be set up so that executives are compensated, but you need to have some type of incentives to incentivize the executives to do the best they can and to improve the system from within.
On the impact of value-based care on compensation: I don’t think value-based care has really impacted executive compensation for the majority of executives in the healthcare industry yet, but some leading organizations are starting to look at executive compensation as it relates to value-based payment programs they are developing, and whether they should and can weather the storm between inpatient-centric and ambulatory-centric systems, as well as developing the criteria or the benchmarks for their value-based purchasing programs.
Right now, I think this is in the beginning stages; I don’t really think a lot of organizations are making significant changes in that direction just yet. But I think there are some, and ours is one of them.
Brian Wetzel, CNMT, RT, RN Administrative Director, Diagnostic Imaging, Cardiology, and Vascular Lab Our Lady of Lourdes Hospital Binghamton, New York
Because we’re part of a larger organization called Ascension Health, we’ve incorporated its policies regarding local, state, and national markets around titles that are particularly difficult to recruit, and around the task of ensuring our compensation is at the right level to fit the market as it currently stands. We don’t have to be at the top of said market for our region, but we at least like to be at the middle of the pack, or slightly above.
This is an area where we’re going out there and trying to utilize the market analysis to adjust salaries of potential executives appropriately while staying within the budgetary guidelines of the hospital, which is sometimes hard to do in this competitive, often uncertain healthcare situation we’re in as a country right now.
You want to look at the degree of leadership turnover, the availability of qualified individuals to fulfill these roles, and, of course, you’ll want to look at how in demand these roles are in your specific region and adjust accordingly.
We’re currently analyzing and utilizing the knowledge that is out there to adjust our recruiting methods so that we can meet these leaders’ salary needs while staying true to both our budget and culture.
HealthLeaders Media Council members discuss how they have redesigned care delivery to support population health management in their organizations.
This article first appeared in the May 2017 issue of HealthLeaders magazine.
Renee Broadbent
Associate Vice President
Population Health and IT Strategy
Office of Information Systems and
Clinical Integration
UMass Memorial Health care
Worcester, Massachusetts
We have a designated entity within our organization called the Office of Clinical Integration, which functions as a population health management organization. Through that department, we have established value-based and population healthcare services, including care management.
We’ve also provided tools that create alerts when our patients are admitted to nearby hospitals, so we can better manage the patients and ensure their conditions are monitored and that they’re getting necessary care. In addition, we are evaluating our entire workflow so we can care-manage the self-insured population. We are in the process of moving toward a more comprehensive care management platform.
In addition, we have a variety of folks in our care management organization, including social workers and navigators who help our patients move through the system and access services.
The technology around population health is really interesting. While there were few vendors in the field a couple years ago, we’re almost saturated at this point. While the programs used to specialize in one specific kind of data, they cross-specialize more today, with care management programs getting into analytics, for example.
You need a good, robust care management tool that does a lot of things that allow your care managers to interact with it. Our organization is currently in the middle of transitioning to EPOCH, with plans to go live in October.
Jonathan Ringo, MD
Interim COO of Sinai Hospital
Vice President of Clinical Transformation
LifeBridge Health
Baltimore
The move to population health is a part of a larger series of changes we’ve made in the last few years to meet requirements regarding how healthcare is reimbursed in this country and in the state of Maryland, as well as to meet the changing needs of our community as we move from a
fee-for-service model to a value-based one.
We’ve made structural, organizational, and operational changes to meet those needs. We have significantly expanded our care management responsibilities both inside and outside of the hospital, looking at clinical pathways, registries, and chronic disease clinic programs. We have invested heavily in our IT infrastructure to support all of that, both from a clinical interoperability standpoint and from a predictive analytics standpoint.
We’ve been working with our local providers to have them certified as a patient-centered medical home, as well as getting them certifications in chronic diseases such as diabetes. We have a lot of clinical programs specifically focused on high-utilization diseases such as congestive heart failure, COPD, asthma, and diabetes. We launched case management in our emergency rooms to prevent readmissions, and have trained our community health workers to do a lot of work around preventing admissions to the hospital.
Telemedicine is something that we’re also expanding, and we expect to see some big changes in the coming year as we endeavor toward the aim of providing the right care, in the right place, at the right time.
James Bleicher, MD, SM
Regional President Physicians’ Organization and Ambulatory Services
SSM Health St. Louis
When I look at how other organizations responded in your survey, I have to say, “Yes, this is us, and this is what we’re experiencing.” We have a care management team that is focused on our risk-based panels. We have some risk-based contacts, but they are by no means the majority—they only make up about 10% or 15% of our populations.
Some of the recent steps we’ve taken include special gaps-in-care processes, redesign of our primary care department, and running a patient-centered medical home, and we are working on critical programs by disease state, and also within each of the service lines, including cardiovascular, ortho, and oncology.
We’re redesigning our compensation model, and it’s set to go live in July. We’re adding quality, experience, and value-based measures to our physicians’ compensation. We recently hired 17 care managers and eight care coordinators. We’ve also brought on a new VP of population health.
Internally, we’ve been talking a lot about cost reduction, utilization, and improving quality of care. I think that a new emphasis on population health has helped us to realign our priorities back to where they should be for healthcare—the best care for every patient, and not just from a quality perspective, but from an efficiency perspective, too. It’s getting us back to evidence-based care. I’d say that this is a positive culture change.
Greg Weaver
Chief Operating Officer
Coteau des Prairies Hospital
Sisseton, South Dakota
On implementing population health in a rural setting: Our organization consists of four health clinics, three of which are rural health clinics, and one that is fee-for-service. What they all have in common is that all have historically been reactive. You come in when you’re sick, we fix you, you get a prescription, and you leave.
I’m a bit newer in this organization, having been here for about a year and a half. When I got here, there wasn’t any proactive healthcare going on, much less population health. I knew from previous jobs that electronic medical records could be helpful and contribute to proactive healthcare and population health. We [needed] to use our EMR to its fullest capabilities.
We switched over to an EMR that offers managed services and proactive population health management. Staff at our EMR vendor athenahealth calls our patients and reminds them of diabetes screening, colonoscopies, anything that will help patients to manage their health proactively.
On new roles in population health: We have also designed an in-house team with a case worker and a dietitian. They pull reports, look at charts, and call the patients to help monitor their health, such as those struggling with diabetes or obesity.
They manage the care of approximately 130 patients in our care who are at the greatest risk. They also work closely with patients who have more than one morbid condition.
Improving efficiency doesn't have to mean extinguishing the heart or the soul of the hospital.
Do more with less. Run lean. Cut costs. Thrive in change.
These expressions and sayings have been said so many times over the last decade that they've become healthcare clichés, but that doesn't mean that they don't strike fear in the hearts of hospital clinicians.
"Efficiency" and "good for the bottom line" tend to be synonymous with layoffs, downsizing, and other strategies that aren't exactly people friendly, but one hospital CFO says that done right, efficiency works in everyone's favor.
"I know this is weird coming from a CFO, but I'm genuinely not looking to cut staff, and I'm not looking to take time away from the patients' bedside. What I am doing is asking how I can give [clinicians] more time to do things that are adding value to our patients," says Andrew Wampler.
He is vice president and chief financial officer at Pardee Hospital in Hendersonville, NC. In a recent interview he spoke about how efficiency can benefit everyone in the hospital.
1.Shrinking Costs and Operating More Efficiently
Staffing and people are for most hospitals, their greatest cost, accounting for up to 50% of operating costs. It's really top of mind for them," Wampler says.
Additionally, there is the perennial struggle of ensuring the right staffing levels in the face of tighter budgets. "The struggle is making sure that organizations have enough people, and that those people are the right people."
But by keeping turnover down and staff engagement high, hospitals can save themselves time and money, he says. The key is to keep workers engaged and occupied with the right level of work. Turnover and overstaffing are costly and time-consuming.
"If you can avoid hiring new workers and operate more efficiently with the ones you currently have, you will be able to save the system both time and money," Wampler says.
2.The Move to Value-Based Care
To say that the progression to value-based care has or will be difficult is an understatement, says Wampler. "I think we can say it's the biggest change to healthcare culture for staff members… They're used to looking at their area of healthcare as a silo."
But that can't continue in a value-based world. Sharing information, working collaboratively as a team, and treating the patient in a more holistic way is just too valuable.
"The industry has been transitioning to more of an integrated care model, and taking the standpoint that primary care physicians have had for years that we need to consider the patient, their care, and their health and wellness as a whole," Wampler says.
3.Physician Engagement
As more physicians are seeking employment in hospitals and health systems, it makes sense to up physician engagement efforts, says Wampler. It's true that both the physician and the leadership camps can view physician engagement as tedious or a waste of time, but Wampler strongly advises sticking with it.
"In the long run, it does help be more efficient. There is a ramp-up period where you have to work to get that alignment and make sure you're all rowing in same direction. But once you do that, it will provide a higher value."
Engagement helps improve physician productivity and improves loyalty to the organization, says Wampler. "I think that engagement helps with alignment, and that alignment focuses around the patient. As care and employment models change… that alignment helps to keep us all on track over the long run."
Many hospital and health system leaders are still working out the kinks to these changes, but Wampler still believes these new situations will improve patient care as well as life in the hospital for staff.
"I think these changes have brought some people out of their comfort zone, but I think we're also going to see some great benefits."
"It has to get better," a young man implores his hopelessly out of touch high school counselor. "The way we treat each other and look out for each other. It has to get better somehow."
In the recently released (and controversial) Netflix series 13 Reasons Why, the audience, along with the series' protagonist, a teenager named Clay Jensen, spends thirteen hours questioning how a community could have prevented a suicide.
While 13 Reasons Why focuses on the death of a teenager, Clay's plea has a universally applicable point; in an era of increased social isolation, many people could benefit from an improved system of checking up on the well-being of their friends, colleagues, and neighbors.
While many physicians would deny it, they might benefit more than other groups, says Michael Myers, MD, professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, NY. He specializes in treating physicians, medical students, and their families.
On average, one American physician dies by suicide every day, says Myers. "For male doctors, these numbers are about 1.4 higher than men in general, and for female doctors, it's about 2.3 times the numbers of women in general."
Even more concerning, many physicians do not get help when they need it. Myers estimates that 10 – 15% of physicians who go on to commit suicide never received any treatment.
"The culture of medicine is based on strength and perfectionism. Everyone is expected to be on top of their game," says Myers.
1.Start Talking
The first step in preventing suicide, says Myers, is to talk about it. Especially when something seems amiss or it is known a physician is going through a rough time personally or professionally, Myers suggests reaching out to that individual. "People often worry that they're making worse the situation worse or intruding on privacy," he says.
But the benefits outweigh any risk. "It's possible you might upset them, but you also might save a life."
It's important to let physicians know that in most states and most instances, they cannot lose their licenses for seeking mental health care, says Myers.
"It's a common concern, but in most states and jurisdictions, it's overstated."
Most licensure and renewal applications no longer ask if a physician has ever sought mental health care; most now ask if in the past two years they have suffered from or been treated for any illness that necessitated taking time away from medical practice or studies, says Myers. A weekly therapy session likely wouldn't count.
2.Train Physicians to Know the Signs
Not only HR should have the tools to prevent suicide and address depression—physicians and other members of the hospital community need the tools to be able to evaluate their colleagues, too, says Myers. Signs that a colleague might need help can include:
Seeming distant or preoccupied. A typically attentive colleague seems to have something on his or her mind
Changes in personality or appearance. When a usually fastidious doctor starts showing up to the hospital in rumpled scrubs, it's time to start asking questions
Seeming tired or hopeless for more than a couple days. Everyone gets a bit down occasionally, but sleeplessness or hopelessness for more than a few days is often a symptom something is wrong.
Self-medication. Whether with illegal substances, prescription substances (whether self-prescribed or prescribed by a colleague), or with alcohol or marijuana, are all cause for concern.
3.Promote Balance
Prevention and awareness will be an uphill battle in many organizations. Starting in medical school, many physicians are trained to be competitive, to work more than is healthy, and to function in survival mode. These habits do not foster a culture of openness or wellness.
"Sometimes, [burnout] feels like a badge of honor. I'm hard-working and I'm miserable," Myers says to describe the prevailing attitude. The best way to combat this, he says, is through cultural change. Physicians, along with other healthcare workers, need to know that the organization they work for values work-life balance, a message that often starts in HR.
Myers says he thinks it's worth it.
"To not feel well and to just accept that they are not [feeling well] is so hard for doctors," he says.
To function as a community—to get better at looking out for each other and treating each other better is an important first step.
When hospitals and health systems are implicated in legal cases, it can hurt reputations, morale, and the bottom line. Here's what HR can do to minimize the damage.
Federal and state governments are ramping up enforcement around the over-prescription of painkillers and other scheduled medications, and doctors and pharmacists are at risk for being caught in the government's net, warns one attorney.
"It's very hard for medical professionals and those in upper management, such as hospital CFOs, CEOs, and CMOs, to see themselves as criminals," says Jack Sharman, partner at Lightfoot, Franklin, and White, a law firm headquartered in Birmingham, AL.
"This difficulty to perceive what someone else might think merits a criminal investigation impedes judgement and slows internal response."
While physicians might not see themselves as criminals for managing patients' pain or making sure they had enough pills to get through a holiday, it's not hard for others to come to that conclusion, says Sharman.
"I always remind people that a prosecutor, investigator, or regulator can view you any way they wish, and it has nothing to do with your credentials or how many people you've helped," he says.
It often falls on HR to make sure someone is keeping an eye on compliance, while staying aware of how things might look to those outside the hospital.
Sharman discussed with Healthleaders recently what HR leaders need to know to keep doctors and pharmacists on the right side of the law. This transcript below has been lightly edited.
HL:What can you tell us about the current legal landscape regarding scheduled medication compliance for healthcare providers?
Jack Sharman: Over the last three years, the government has taken a much more aggressive stance. It has been prosecuting physicians, both within their own practices and those affiliated with a health system, for performing unnecessary medical procedures or dispensing what the government has determined to be unnecessary medications.
This is a fairly recent phenomenon, at least with the robustness that we’ve been seeing.
It’s very troubling to lots of people within healthcare. Doctors and pharmacists are asking themselves, "if I write this prescription, three years from now, will I see it blown up on monitor in a courtroom?"
HL: What are some factors that can call legal attention to a hospital or health system?
Sharman: Usually, these things are kicked off by someone either outside the organization or inside who sees themselves as aggrieved. Most often it's a disgruntled employee or a dissatisfied patient.
The next thing that could catch law enforcement's eye is volume. They'll look at Medicare data and private payer data. High volume by itself doesn't tell you much of anything—the doctor could be busy, or you could run a popular, high volume hospital or health system.
But prosecutors will always look at volume.
Another flag to watch for is impaired healthcare professionals. At one organization I defended, there were two nurse practitioners employed, both of whom were very qualified and competent. But both of them were addicts.
They tried to get clean, but they were using while working. Needless to say, this didn't look good when it came out that the organization was dispensing high levels of scheduled meds.
Addicted people are also very vulnerable to government pressure. FBI agents show up and scare them, then say something like, "We're not looking to put you away. Help us out; we can help you."
And if the case gets to the point of a trial, [the fact] that addicts worked in your facility sounds awful. Whether you win or not in court, you'll lose in the court of public opinion.
HL: What is the right thing for HR and hospital leadership to do when staff when they are accused of inappropriate behavior around dispensing or prescribing medications?
Sharman: At this point, you need to take it seriously. I know it sounds obvious, but you would be surprised how often responsibility shifts from one person to another as if it were just a claim on a form.
Make sure it doesn’t get ignored. Little things could become big things.
There will be a demand for documents, and you want to be sure somebody knowledgeable is put in charge of collecting those documents. Make sure they're organized, that you know where each document originated, and that you have something to refer to.
Beyond that, your organization may need to conduct some level of internal investigation.
Also, you'll want to make sure people don't panic and start destroying documents, which happens frequently.
People aren't intending to destroy evidence of a crime, but they might have something embarrassing, such as porn, on their work computer. They'll wipe the entire file, and that becomes a bigger crime.
HL: Are criminal charges something health systems should be worried about?
Sharman: Even the most aggressive prosecutors are usually reluctant to charge an entire health system. But that doesn’t mean health systems can shrug off this threat.
The civil implications and reputational damage can be significant, even if the organization is not charged criminally. These things can be disruptive and expensive. Ultimately, a lot of bad things can happen, even if the organization is never charged criminally.
Direct care is one of the fastest growing areas of healthcare employment, but low wages, nonexistent benefits, and a lack of opportunity for advancement threaten to jeopardize outcomes and disrupt quality of care.
"Can you believe how little they pay such important workers?"
I was having lunch with a friend who has been considering making a career change. A naturally caring, kind, and empathetic person, direct care appealed to her. Job prospects look good. The bureau of labor statistics anticipates employment growth for personal care aides to grow by 26% through 2024, and that of home health aides to grow by 38%.
Then, she saw the hourly wage.
"Twelve dollars an hour," she told me, shaking her head in disbelief. "That's what they pay them. I earned more than that when I worked in retail. And God forbid the car breaks down or you need dental work."
Given the high levels of responsibility entrusted to these providers, my friend couldn't believe the pay for these jobs was so low. Many direct care workers start at as little as $8.00 per hour in some places. (My friend and I live in a state where the minimum wage is $11.00 per hour.)
She's not alone; many are surprised to learn about the low wages and paltry benefits commonly paid to providers of direct care.
Recently, the American Network of Community Options and Resources (ANCOR), a non-profit trade association that represents more than 1,000 private community providers of services to people with disabilities, published a research paper examining the current situation of workers in the direct care field.
The results weren't pretty.
"We compared direct care providers to several different fields, including retail, food servers, and janitors," says Esme Grant Grewal, senior director of government relations at ANCOR. "We found that direct support professionals are making less than those careers are making in terms of hourly wages."
In short: The guy who made your latte this morning likely earns more than many direct care providers. Considering the value and importance of quality of care along the continuum, that's a problem.
Beyond Penny Pinching
You don't have to be a do-gooder or obsessed with the hot-button topic of wage equality to see the very practical downsides of keeping wages for these workers low, says Gabrielle Sedor, chief operating officer at ANCOR.
High turnover isn't just an annoyance for direct care workers or the health systems that employ them; it impacts the quality of care patients receive, too.
"It's very difficult [for patients] to go from worker to worker," says Grewal. These workers bathe, feed, and dress them; every time a direct care worker leaves, the patient must start over and learn to trust a new person.
And high turnover is expensive for the organization employing the worker, says Sedor. "Every time someone leaves, the organization must spend thousands of dollars onboarding a replacement."
Additionally, finding qualified workers willing to work for these wages isn't easy. The regulatory requirement for these roles are rigorous, and a criminal background check is an absolute must.
Sedor describes the current situation as a staffing crisis, which she says she expects to only intensify as the Baby Boom generation reaches the age when they need greater support and become consumers of direct care in greater numbers.
And as health systems consolidate and become responsible for more services, including long-term care, care coordination, and care transitions, more healthcare leaders will find themselves making decisions regarding providing livable pay and benefits.
Fair Trade
But HR leaders are in position to ease this crisis and improve quality of care, and not just by increasing direct care provider wages, although that's a good start.
Another way to say thank you is to provide these workers with something they can use, such as benefits.
"The majority of direct support professionals are women of working age, and many have young children. Many don't have a lot of support outside of work. Any assistance with childcare or health benefits are very important," says Grewal.
Creating career options matters, too. But obstacles to this goal are inherent to the system. Moving from an hourly to a salaried position could mean the loss of much needed overtime pay, or loss of Medicaid benefits to these workers.
"Sometimes, it feels like we're stuck in a hamster wheel," says Sedor.
It's important to recognize the areas that need improvement and to attempt to close these gaps by increasing wages, creating a career path, and offering competitive benefits.
If you're willing to do that, I just might know a caring, kind, and empathetic aspiring direct care worker I can send your way.
HealthLeaders Media Council members discuss how they engage physicians in strategic planning.
This article first appeared in the April 2017 issue of HealthLeaders magazine.
Joy Henry, RN CNO Faith Community Hospital Jacksboro, Texas
Physician engagement is different when you're in the country. At our small rural facility, our entire clinician team consists of four physicians and two nurse practitioners. Our C-suite consists of four people including our CEO. When it comes to strategic planning, or discussing and deciding where we are headed as an organization, we sit around two tables and our CEO states his opinion, then asks everyone, "So, how do y'all feel about this?"
When practicing rural medicine, physician alignment is really about finding someone who cares for the community. Our doctors all have to work as a team—they pick up patients for each other when they are busy or go out of town. It's all hands on deck sometimes—you never know when you'll need to pitch in, or where. But having a small, cohesive group in our hospital has its advantages. We're a team, we are neighbors, and we're all taking care of patients from our community.
Cliff Robertson, MD CEO CHI Health, a division of Catholic Health Initiatives Omaha, Nebraska
A couple years ago, we launched an initiative to restructure our service lines, and, as part of that initiative, the key objective was to engage clinicians in particularly meaningful decisions around strategic planning.
Our service lines are now specialty-based, and we've engaged physicians, both independent and employed, into our leadership council. One of their primary objectives is to make decisions around the strategic planning across our enterprise, which we have found keeps these physicians engaged.
There are difficulties created when you have both independent and employed physicians working together. While they are collaborators within their service lines, they are competitors as well. You must be prepared to acknowledge that there will be conflict. What we've elected to do is to plan how these conflicts will be resolved; and most often, they are resolved on a system level by our own leadership.
There will be situations where competing practices of physicians will not necessarily be able to agree on the right path forward. One example is that two groups may agree that a new surgeon will need to be hired in the next year. But what they can't decide without conflict is whether they will recruit the physician into the independent practice or employed practice, or if both practices will recruit, and whichever group finds that surgeon first wins. This level of involvement keeps the physicians engaged, but it also creates conflict.
Michael Mayo President Baptist Medical Center Jacksonville, Florida
We consist of five hospitals. My facility, Baptist Medical Center in Jacksonville, is the adult flagship tertiary care center for the Baptist Health System of northern Florida. But the activities we're doing around physician alignment and engaging our physicians go across our entire system. One of the key things we're doing happens to mirror the results of your 2017 Physician Alignment Survey. While we have for many years sought input and engagement from our physicians on key decisions early on in the decision-making process, this is now a higher priority than ever. We have a dyad organizational structure that places an administrator and a physician in key positions as the leaders for each service line. That kicks off the process of placing coleadership in each of those positions, and brings together a forced opportunity for collaboration and communication, and getting input from physicians.
Additionally, we have a program that is offering leadership training to our physicians. It can be described as a yearlong program that brings potential leaders through an educational program that meets quarterly with different topics of study and discussion. It also becomes a panel for communicating challenges or issues the system or an individual hospital may be facing. And finally, we are making a concentrated effort to place physician leaders in key administrative leadership roles beyond those traditionally held by physicians.
Pat Keel Senior Vice President and CFO St. Jude Children's Research Hospital Memphis, Tennessee
On activating stakeholders: Philosophically, I think all employees should play some part in the organization's strategic planning. Even if they're not in the main group that maps out the final strategy, I think it's important to activate all stakeholders and ensure that they have a shared value system and agree with the mission.
On meaningful engagement: First, make sure the physicians have the time. Our physicians are employed, but if the physicians in question are not employed, you have to make sure they can carve out enough time to really participate. The last thing you want to do is to ask them to see patients all day and then participate in "engagement activities" for four hours at night.
The participation has to be meaningful participation. If you are going to ask physicians to give you input, you have to make sure that you keep them engaged throughout the process, that they understand what you do with their input, and explain why you used it, or why you didn't.
Also, you have to make sure that the doctors are educated about the things you are talking about, especially if the topic will require them to get up to speed on background data. You really shouldn't expect them to come into the conversation blindly.
Once you get through that process, I think you have to make sure you recognize them for it. So often, organizations do a strategic plan, only to put it on the shelf. It's not a great recipe for engagement.
