The American Medical Association gives physicians a platform to air their grievances about electronic health records systems, but the technology is here to stay, says an executive with the College of Healthcare Information Management.
Longstanding physician dissatisfaction over electronic health record systems, Meaningful Use, and the federal regulations behind them lit up a town hall-style meeting Monday night, hosted in Atlanta by the American Medical Association and the Medical Association of Georgia and webcast live.
Rep. Tom Price, MD, (R-GA), formerly medical director of the orthopedic clinic at Grady Memorial Hospital in Atlanta and co-host of the town hall kicked things off with one specific complaint of doctors, "inconsistency is a problem." The event was part of the AMA's Break the Red Tape campaign, which aims to postpone the finalization of MU Stage 3 regulations.
AMA President Steven J. Stack, MD, told attendees that the meeting was an opportunity for them to be heard. "This is not for you to hear me talking to you, but for me to hear you talking to me... Has workflow in your office changed?" he goaded the crowd. At least 80% raised their hands. A sole hand remained raised when Stack asked if the change was for the better.
Almost immediately, physicians gave voice to the barriers to care they say are caused by electronic health records systems. Over the course of the 90-minute meeting they raised concerns over reduced productivity, the security of private patient medical records, interoperability, and government regulation.
"We're removing the science from medicine," said one physician who described having to check "yes" and "no" boxes rather than being able to note subtle nuances his patients reported.
"Thank God I learned to type in high school—I never thought I'd use it," said another, explaining that she now has to make sure every employee she hires can type, regardless of the job for which they are hired.
Some physicians tweeted their frustrations during the meeting, using the hashtag #fixEHR.
Point of No Return Physicians' experiences with EHRs vary widely, says Bill Bria, MD,executive vice president of medical informatics and patient safety at CHIME, (the College of Healthcare Information Management.) "An EHR is complete patient information, right there, whenever you need it, wherever you need it," he said by phone hours before the town hall.
Being able to find detailed patient records in just a few moments without digging through files, calling the pharmacist to check a prescription history, or attempting to rely on memory is far superior to the alternatives, he argues.
"We're not going back to the paper age," says Bria. "That era is over."
Ann Shepard, RN, vice president and chief informatics officer at Colorado-based Catholic Health Initiatives, in an interview Monday afternoon, said she generally agrees with Bria—and even that the federal push to implement an EHR has benefitted CHI, even though its implementation has not been seamless.
Shepard compares CHI's experience to building a house. "We're getting there… you have to first build out a firm foundation, which is what we've been doing. And I'd say that we're in a good place. This has not been a negative experience for us."
"Meaningful Use was a significant driver for us and our EHR adoption. Before the HITEC Act, we were using a combination of paper files and just minimal electronic records, but legislation pushed us a little faster than we were going."
Pointing to BCMA as an example—a barcoding of medicine administration system—Shepard says that certain innovations nurses now rely on would not be possible without EHRs. "It's allowed for enhanced patient safety... When a busy nurse goes to the medicine cabinet, she's usually trying to remember what she's already given out, the dose, the route, what she still has to give out that day—and there are opportunities for error in those situations. No one ever means to make a mistake, but it happens," she says.
With BCMA, nurses have the ability to build in safety checks. A barcode on the patient's bracelet helps keep track of which meds are due to the patient at what time, and the right dose, all while double checking that this is the correct patient.
"These and other innovations that utilize EHR systems decrease errors that cause harm to patients," says Shepard.
Breakdowns in EHR implementation and design do happen, Bria concedes. "Usually, when I see an organization having problems with EHRs, it's because they're configured inappropriately," he says. "EHRs should be in complement to the office's workflow. But sometimes… there are inappropriate settings, and they become interruptive." This can be caused by treating them as though they are "only billing machines" rather than clinical tools. Anyone in that situation should consider reconfiguring their system, he says.
While the physicians attending Monday's town hall made their dissatisfaction clear, Bria feels strongly that it's too late to reverse the EHR trend—and high time physicians embraced it. "It's just a cost of doing business," he says.
The DOL has proposed new regulations that will make many more workers eligible for overtime pay. Here's what you need to know about these upcoming changes now.
Get ready for some changes to overtime policy. The U.S. Department of Labor is planning to expand OT eligibility in 2016. While the proposed rules are still out for public comment through September 4, now is the time to start preparing and planning for the new regulations to take effect.
I talked with Jonathan Kozak, employment litigator with the workplace law firm Jackson Lewis, about what the new regulations mean for hospital HR departments, including which employees are expected to become nonexempt, how long the new regulations have been in the works, and how this might change employment in hospitals.
Jonathan Kozak
HealthLeaders Media (HLM): To get started, can you explain a bit about what's been proposed by the DOL?
Jonathan Kozak: What's proposed is a change to salary basis minimum requirement for application of what are known as the "white collar exemptions" under section 541 of the DOL's regulations. For most of the white collar exemptions, there are two essential components or requirements: The first is a salary basis not less than the minimum set forth in the regulations, which is currently set at $455.00 per week; and second, that the individual's job duty is exempt work, the nature of which is spelled out in the regulations.
The proposed change will increase the minimum weekly salary basis amount from $455 weekly to a level equal to the 40th percentile of earnings for full-time, salaried workers in the Bureau of Labor Statistics annual earnings report. For 2016, that level would be $970.00 weekly.
So, essentially, you're going from a minimum salary requirement for many of the white collar exemptions of roughly $23,600 annually to $50,440. So, it's a substantial increase, and it's also an increase that will be tied to the BLS report, so it has potential to increase year to year.
HLM: Other than people who earn more than $50,440 annually, what kind of workers will not be eligible for overtime under the new regulations?
Kozak: The exempt tests are not limited to the salary basis; exempt tests require employers to demonstrate that individuals for whom they're claiming the exemption have as their primary job duty exempt work. The change in the salary basis level is just one part of the test for who is exempt from earning OT and who is not.
In giving some thought to the types of positions in hospitals and medical facilities most affected, you’re looking at roles currently classified as exempt. Physicians are exempt professionals. This is not going to change anything for doctors—first, because the regulations don't require [overtime pay] to professionals who are doctors and lawyers, and second, because their compensation levels are usually well above $50,000 yearly.
While registered nurses could qualify as exempt professionals if they're paid on a salary basis, my experience is that many RNs not paid on salary basis. Many RNs are treated as nonexempt and overtime-eligible for various labor relations reasons—oftentimes because they're represented by a union and they're following a [pay] scale.
Where I think the greatest impact could be is in respect to administrative positions, where you have individuals who are paid on a salary basis but earn under $50,000, and mid-level management positions who may otherwise satisfy an executive exemption but are paid less than $50,000. Should rules go into effect as proposed, as soon as they are effective, those persons are automatically nonexempt regardless as to their job duties and are entitled to overtime pay when work in excess of 40 hours weekly.
Other roles that are likely going to be impacted in hospitals include information technology positions, depending on method and rate they're paid, their responsibilities, and primary job duties; and social workers, if their annual salary is less than $50,440, may no longer be exempt.
HLM: What are some strategies leaders who wish to avoid paying their employees overtime might take?
Kozak: What's going to happen is, with more workers falling into the nonexempt category—the DOL estimates that 4.6 million employees that are currently classified as exempt will no longer be exempt simply by increasing the salary basis level—employers are going to need to control hours worked by those employees who are newly nonexempt. Otherwise, their costs will increase.
When a newly nonexempt employee works, the employer will most likely be getting less work out of that worker. When the employer get less work out of workers, the employer will also get less productivity, and [that] will probably result in lower wage rates. I think employers who are seeing less productivity or who are going to require the same amount of work are going to have to weigh cost of paying overtime for same level of work as opposed to the cost of hiring more workers to accomplish the same amount of work.
Other employers are simply going to adjust wage rates to account for the extra work or overtime work that will have to be accomplished. The cafeteria manager who earns presently a salary of $40,000 and works 50 hours weekly will become nonexempt—and his or her employer has option to adjust the wage rate to accommodate the overtime hours that they work. It would just be a matter of doing the math.
HLM: How long have these new regulations been in the works? And how much lead time will hospitals and businesses have to prepare for them to take effect?
Kozak: The new regulations didn't come out of nowhere. The [Obama] administration has talked about doing this for some time. It's believed to have been a specific directive from the president to the DOL to modernize existing overtime regulations. It's really not a leap to look at the current salary base level and to suggest, as many have, that it has not kept pace with economy.
In terms of lead time, there will be a 60-day public comment period. It's possible that it will be requested that the comment period be extended. During the last update in 2004, the comment period was extended to 90 days. The DOL will receive and evaluate the comments and prepare the final versions of the regulations.
The effective date won't be until second quarter of 2016, at the earliest. There may be litigation that will impact the effective date—it's happened in the past. When the final version goes through, the lead time may be written into regulations themselves.
In any case, the final rule is not expected to be issued before 2016. Even after final rule is issued, there will be some lead time before rules are in put into practice.
Improved scheduling processes cost little and can open up pathways to better access to healthcare, researchers say.
Access to healthcare is wildly variable throughout the US, but one obstacle to access—patient wait times—can be reduced by the implementation of systems-based approaches in scheduling, research from the Institute of Medicine suggests.
Gary Kaplan, MD
Chairman and CEO
Virginia Mason Medical Center
Wide variations exist in wait times for care; wait times can range from hours to months. And no single factor determines how long a patient is made to wait. Variables include location, services required, and provider demand.
Delays are not predictable, and neither are they limited to primary care or a particular specialty, nor region of the country, says Kaplan. They are endemic to healthcare as a whole. And "there are quite a few consequences, including negative outcomes and poor patient satisfaction [scores]."
Healthcare on Demand The primary question Kaplan and his coauthors sought to answer was which practices would allow greater access to care and remedy the inefficiencies that cause delays in access. "How do we actually see patients when they want and when they need to be seen? How do we look at this from their perspective?"
The study found that the greatest cause of scheduling problems was "mismatched supply and demand," says Kaplan. Other factors: provider-focused approach to scheduling, an outdated care supply model, and priority-based queues.
Process Refinement Kaplan is an advocate of Lean process improvement. "Our care system needs to be designed with systems that lend themselves to improvement in mind. We need processes and policies in place that allow you to create flow." He also believes that healthcare administrators should be learning best practices from other industries, such as the hospitality industry.
The report also suggested that using telemedicine and "non-physician clinicians," such as nurse practitioners could help create more appointment times for patients, leading to expanded access to care and improved efficiencies in scheduling.
A Different Approach Nick Fabrizio, PhD, FACMPE, FACHE, a principal consultant at the Medical Group Management Association, warns that Lean process improvement is a buzzword so overused, its original meaning has been long lost. "Lean can be 100 different things to 100 different people."
"I don't get too excited when I hear someone say that they're a Lean organization," he says. His advice for improving scheduling efficiency is to re-evaluate each organization's scheduling process and ensure uniformity within each system.
"Let's say we are both specialists, and I tell my administrator that I want to see new patients every hour, while you tell your admin that you only want to see them every hour and a half. My follow-ups are every 30 minutes or 20 minutes, while you want them every 15 minutes. By design, we've already limited patient access to care, as you'll be fitting in more bodies daily than I am, even though we're working the same hours and same number of days."
This sort of arrangement creates a major inefficiency, says Fabrizio, especially when it occurs within the same specialty. These inefficiencies are common, says Fabrizio, noting that about 90% of practices he consults could improve their scheduling processes.
He does agree with Kaplan, however, that healthcare would benefit from best practices gleaned from other industries. "Healthcare could benefit from almost every single industry out there. If we spent enough time with… leaders in other industries, we could learn a lot."
Fabrizio points to both banking and air travel as industries that have securely improved access to vulnerable account information and streamlined scheduling, creating user-friendly systems despite heavy regulation.
Kaplan says he will remain a steadfast believer in Lean improvement processes. "Manufacturing is where some of the systems engineering approaches are most evident… I would say that [doubters in healthcare] ought to open their minds. We owe it to our patients we serve to do everything we can to improve their care experience."
Many organizations have found staffing benefits or cost savings through outsourcing, offshoring, and partnerships with vendors. But each has its downside.
Outsourcing has somewhat unfairly earned a bad reputation in recent years, but nevertheless, it has made its mark on the American business culture and in hospitals, which are finding that there are benefits in augmenting employed staff with contract workers.
The right outsourcing arrangement will boost efficiency, cuts costs, and be beneficial for everyone involved—but these arrangements must be planned strategically.
Sometimes, it's a question of finding a temporary employee through a staffing organization, or creating a managed services agreement tailored to a hospital's needs. Other times, hospitals benefit from more traditional outsourcing agreements, like teleradiology or telemedicine.
Vendor Partnerships One strategy is to develop an exclusive relationship with an organization that is willing to tailor an agreement to a hospital's needs—whether in terms of staffing, consulting, equipment, or all of the above.
James V. Rawson
"I wouldn't consider it to be outsourcing," says James V. Rawson, chairman of radiology at Georgia Regents Medical Center(GRMC) in Augusta, a 478-bed academic medical center. GRMC has a managed services agreement with Philips, which assumes ownership, management, and maintenance of medical technologies used at GRMC and also manages, trains, and supplies many of the employees who use it.
"This is a great way for us to get different perspectives. Some might look at this as more of a tech deal, but it's really about people," says Rawson. "While I have a lot of high tech equipment in my department, the greatest benefit of this partnership is the people."
In addition to employees who operate the equipment, GRMC has also been able to take advantage of Philips' consultants, who advise on topics ranging from training to strategic planning to process improvement. GRMC's agreement with Philips is valued at about $300M and is contracted to last for 15 years.
Therein lies one downside to such long-term agreements is contract length: Fifteen years is a long time to be exclusively linked to a single vendor. Another downside: the potential for workplace problems when some workers are hospital employees and possible union members, and others are contractors or employees of a partnership organization. And managing workers who are not employees can create friction, especially regarding benefits, time off, or pay.
At the two-year mark, Rawson says that the deal has saved GRMC about seven million dollars.
An additional benefit to bringing in outside-contracted employees can be exposure to the knowledge and skills an outsider can bring to the table. One of the greatest perks of GRMC's agreement with Philips has been the ability to bring in well-trained workers who can teach their skills to hospital staff, says Rawson.
Even for organizations that would shy away from managed partnerships, there are options for more short-term arrangements. "Many travel nurses have been able to pick up a ton of best practices," says Bill Heller, president of RN Network, a travel nurse staffing company headquartered in Boca Raton, FL.
In fact, some hospitals intentionally hire temporary healthcare professionals specifically for a certain skill set, says Heller. "Forward-thinking organizations can tap into [travel] nurses," he says.
Some look for nurses who have worked at prestigious hospitals, then ask them about their experiences there. "Just ask, 'how did they do this at Johns Hopkins?' Let's say you just got a new piece of equipment in— find out from a travel nurse how do to get most out of it." He has also seen travel and temporary nurses help train incoming nurses and share their decades of experience. However, a few hospitals have noted issues with workers provided by staffing agencies, and it is important to keep an eye out for staff quality issues.
Outsourcing and Offshoring And then, there are the benefits of offshoring entire processes or jobs to remote workers living abroad.
"There's a whole sector of teleradiology called 'nighthawking,'" says Bruce Carothers, vice president of workforce technology at AMN Healthcare, a healthcare recruiting firm. "They find US- licensed physicians who live overseas who can look at images on weekends and at night."
Some hospitals find that this is a good way to ensure all radiology results are in by Monday morning, and it's also an area where hospitals can cut costs by employing foreign workers, often at a fraction of the cost of US employees.
One potentially big downside of both outsourcing and offshoring this kind of work: The quality of the work must be monitored and patient privacy and data security must be safeguarded.
Sometimes outsourcing doesn't have to be to a far-away land—most telemedicine and virtual care providers are based in the United States. Telemedicine work is growing in popularity as an option among older clinicians with decades of experience and wisdom behind them who are in the process of winding down their professional lives. It is likely to gain traction as licensing laws help it become an option for more hospitals, especially in remote parts of the country where there just aren't enough clinicians to go around.
Outsourcing and offshoring and partnerships with vendors are options, but it's important to evaluate the potential effects on workplace culture and cost savings, and to determine whether alternative staffing is the most efficient solution. Before committing, make sure there isn't a better solution closer to home.
Time spent on needlessly laborious or unnecessary tasks can silently ratchet up job dissatisfaction rates among physicians and nurses.
Healthcare is an industry where seconds count, and not just in the case of saving lives.
Imagine the simple act of walking down the hall to collect a piece of paper from a printer. "It might only be an additional 30 seconds each time, but if [clinicians] visit that printer 20 times in a day, that's an extra ten minutes daily," says John Jenkins, MD, vice president and executive medical director of the primary care collaborative at Cone Health in Greensboro, NC.
That time could turn in to almost an hour after just a week, and an entire extra eight hours after as little as a month.
Physician dissatisfaction has increased in recent years, with six in ten physicians saying in a 2012 survey that they would leave the profession if given the opportunity for a career do-over.
The knee-jerk reaction to physician dissatisfaction is often to improve compensation or benefits, but Jenkins believes that the secret to burnout prevention is simpler and more cost effective than you might think.
The key, Jenkins says, is to identify inefficiencies that clinicians encounter daily and, with their help, create a more efficient workflow that will shave time off of those tasks.
"Many physicians are experiencing a lack of doing what they feel they were trained to do," says Jenkins. "Quite a few of them feel they have become very highly paid scribes, not doctors… we've also seen more box checking and proscribed steps that physicians are required to take with every single patient than we used to."
Physician Compensation, Dissatisfaction Ratchet Up
Unsurprisingly, the lack of physician job satisfaction is not good for retention numbers. "We're seeing physicians retiring early," says Jenkins. "Physicians used to often work well in to their late sixties, but we're now seeing them seek retirement in their early sixties" Physicians who are too young to retire are considering alternate careers in greater numbers earlier generations, he says.
Those who remain in the profession may exhibit negativity, which in sufficient quantities, has the potential to cascade through an organization, and turn it into a toxic work environment.
Hidden Inefficiencies
Soon after Jenkins began his job at Cone Health, he encountered many physician complaints about the amount of time spent on tedious tasks and not enough time spent helping patients. Jenkins began looking for ways to improve efficiency and morale within the organization. He decided on Lean process improvement, which Jenkins says led to creating a dialogue with clinicians around how to improve their roles.
Chances are, there are many time-wasting inefficiencies hiding in your hospital, each draining productivity from clinicians' days, causing them to feel like the work never ends—feelings that can easily lead to physician burnout, says Jenkins.
"Many providers take between one and two hours of paperwork or documentation-related work home with them each evening," says Jenkins. A worthy goal for any healthcare organization is for clinicians to be able to complete their work during their workday, rather than taking it home with them.
Creating Efficiencies
Adding medical scribes to a hospital's lineup is a solution many healthcare leaders like using to ease physician workload woes, but be aware that under Medicare regulations, there are some EMR-related tasks that scribes are not allowed to complete, and scribes are not a panacea for all data-entry related ailments.
Creating an improved workflow so that the organization's staff will close gaps in efficiency and allow the clinical team can focus on caring for patients and creating care plans. "That creates a better flow so the cycle time is reduced," says Jenkins. "There's less burden on the provider."
Other steps Jenkins suggests are ordering medical supplies that are geared toward cutting down on prep time (pre-filled syringes, for example), improved pre-appointment planning, and implementing patient engagement tools. Ergonomic equipment and workflow software can be helpful, too—anything that takes seconds and minutes out of a busy physician's day can help.
But Jenkins also says it's even more important that healthcare leadership engage with clinicians regarding efficiency. "You must involve the physicians in the solutions. The people who actually do the work are going to be the most valuable for spotting the inefficiencies," says Jenkins, who says town hall style gatherings and small focus-group meetings helped his organization to identify areas that need to be addressed.
"That's where the solutions approach comes from, and how you step someone through the process of improvement," he says. Physicians often love finding solutions to efficiency problems and will usually run with process improvement once they get started, he adds, and that becomes an added small benefit of a hospital's culture.
It's the little things that add up the most, says Jenkins, harkening back to those 30-seconds saved by moving a printer. "What we have to realize is that small increments of improvement [can] make maximal change over time."
The average amount of time infection preventionists spend reporting hospital infection data to federal health agencies outweighs time spent on staff and patient education, policy development, and other infection-fighting tasks, researchers find.
At the expense of activities that might directly avert the spread of disease, infection preventionists spend more than half their timecollecting and reporting hospital infection data, research shows.
Five hours a day is the average amount of time spent collecting and reporting hospital infection data to federal health agencies, according to a study to be released Saturday at the APIC(Association for Professionals in Infection Control and Epidemiology) conference in Nashville.
But it wasn't until Parrillo looked at the fine print of a government reporting form and noticed the amount of time a government agency estimated a specific reporting task should take that she realized how much extra time was actually being consumed by data-related tasks.
So she begin tallying the amount of time it took to perform each function associated with the collection and reporting of data in her 355-bed hospital.
The time spent on tasks associated with reporting NHSN data during a period in which the hospital was at approximately 60% capacity— five hours and eight minutes—did not include time spent reporting to state or local agencies.
"We knew we were spending a lot of time on it, but to put a calculation on it and see it on paper was very eye opening," says Parrillo.
Time Better Spent She believes the data is important, but wishes her team members had more time to dedicate to other tasks, such as "environmental rounding, staff and patient education, policy development, evidence-based research, hand hygiene enforcement, and emergency preparedness."
Infection prevention teams are typically small and strapped for time, even without the additional responsibilities of reporting, she says. "These findings are not a surprise to any of us who are working in the infection prevention field. If you talk to any practitioner, they will tell you they spend most of their day on mandatory reporting."
Parrillo says that collecting and reporting device-denominator data—data that shows which devices are in use and by which patients—took 160 hours total during the four months of the study. And her hospital's EHR does not automatically configure this data for reporting or report it to agencies.
Streamlining Reporting That infection preventionists spend more than five hours per day on reporting doesn't sound like an exaggeration to William Bria, MD, executive vice president of medical informatics and patient safety at CHIME, the College of Healthcare Management Executives.
He contends that improved data governance and database structuring would help ease the workload. Parrillo's EHR notwithstanding, Bria believes that most EHRs do have the capability to automatically compile or report data to federal agencies, and that infection prevention teams should be taking advantage of it.
Better organization of data and standardization of databases are key to streamlining the process and to improving efficiency, he says. "Four [or] five hours for a report for a very large data set would be very contingent upon the structure of the database."
Other steps that might cut reporting time include using pre-selected "pick-lists," automating reporting so the data is pulled overnight and sent automatically, and making sure that the data is entered into the system uniformly and in an organized fashion.
But Bria recognizes that these things are easier said than done, and empathizes with infection preventionists. "Trying to retroactively fix very messy, poorly structured data is never a good use of anybody's time…. The idea that they should just 'suck it up' is very dismissive to the difficult jobs of infection control staff… We need to focus on analytics that matter."
Parrillo hopes federal agencies and hospital leadership develop a greater appreciation for the difficulty of her role. "This data is not unimportant; it can help protect patients at the bedside. But I hope to shine a light on how our departments are staffed… to make sure we're being supported in a way that makes sense. Hospitals across the country should reevaluate their [infection prevention] programs and make sure they have enough staff."
Employee incivility that bleeds into workplace harassment has the potential to destroy a hospital's reputation and its finances. Leadership holds the potential for stopping it in its tracks.
Want to kill your employee retention numbers and productivity while damaging your hospital's reputation? Of course not. But neglecting to properly address employee concerns about harassment or stop it from happening can be an organization's downfall.
Take, for example, a recent case in Indiana in which a former resident alleged sexual harassment. She sued the hospital for $8 million when the associate director of her residency program gave her a negative performance review and later dismissed her after she called off a sexual relationship with him.
The case has been settled out of court, but it likely cost the hospital more than $1 million and hurt both employee morale and the hospital's reputation.
Understanding Harassment
It's not always easy to differentiate harassment from general rudeness in the workplace, but it's very important to understand what sets them apart.
Ernie Haffner
"Minor rudeness is not illegal," says Ernie Haffner, senior attorney advisor at the U.S. Equal Employment Opportunity Commission(EEOC). Being gruff, generally unfriendly, or a disagreeable person is not a crime. Also, a single incident (for example, an offhand sexist comment) is usually not enough to be called harassment, although management should make it clear that such behavior will not be tolerated.
When does rude or unprofessional behavior become harassment? Here are some indicators that bad behavior has crossed the line:
Employees are repeatedly subjected to abusive or humiliating behavior that makes them feel uncomfortable
This behavior targets what is considered to be a protectedcharacteristic, which includes ethnicity, gender, religion, national origin, disability status, or age
The discomfort of the employee is intentional—this was not a slip in judgment, an isolated incident or caused by awkwardness, but a situation where someone is deliberately trying to make an employee feel unwelcome, threatened, or offended
The best way to draw the line between genuine harassment and a social gaffe or gruff behavior is to look at the intention.
Haffner cites coworkers neglecting to use correct pronouns with transgender employees as an example. "Did their coworker simply forget and accidentally say 'he' when they should have said 'she,' or did they deliberately use the wrong gender?" The first is simply a mistake which can be excused; the second, if repeated, can constitute harassment.
To invoke EEOC laws, the harassment must be based on a protected status, such as race, gender, pregnancy status or religion. "Some people, unfortunately, are more comfortable bullying minorities," says Haffner. "Minorities, women, and other members of protected groups are simply harassed more often than others," he says, explaining why it's necessary for some groups to be considered protected.
How to Handle Harassment It is the responsibility of employers to research allegations of employee harassment and to attempt to rectify them and prevent them from happening in the future.
"If you know harassment is taking place, but don't do anything about it, well, that's an EEOC violation. As an employer, you have legal responsibilities to take action, and to make sure that it stops." You'll want to listen to what both sides have to say and try to understand what's actually going on in order to attempt to resolve the situation.
"Don't fire anyone off the bat," Haffner says. Instead, engage in an investigative and disciplinary process. Be aware that harassers and bullies rarely target only one person over the course of their careers, and that serial harassers have likely done this in the past.
Make sure that the alleged harasser understands that retaliation is unlawful. Especially if the alleged harasser is the supervisor or manager of the employee who has reported the grievance, keep an eye on that department. It is to be expected that people will be uncomfortable if someone complains about them, but try to make sure there is no retaliation, deliberate or otherwise.
"Without realizing it, a manager could begin subconsciously downgrading an employee's performance. Things get complicated in these situations," says Haffner.
Preventing Harassment The best way to prevent harassment is to foster a friendly, open workplace, says Haffner. While it might not be illegal to be a jerk at work, it's not good for morale, and can encourage the kind of environment where harassment is more likely to happen.
It's also vital to offer avenues outside of employees' direct supervisors where they can report harassment or unfair working conditions—and that employees trust those channels to help resolve issues if they are brought to them.
"It is important that people feel they can come forward… Make sure people know how to report harassment, and that they know what's illegal and what constitutes harassment," says Haffner.
And, once someone does come forward to report harassment, it's vital to act in a timely fashion—not only to be compliant with the law, but also to help employees see that they are valued and to foster trust between them and the hospital. "What you don't want is for employees to bring a situation to HR, and then nothing happens," says Haffner.
Ultimately, everyone deserves a workplace where they feel valued and comfortable coming to work, and where they feel safe—and it's HR's job to lay down the law when that doesn't happen.
Emergency physicians are spending time devising workarounds for shortages of IV solution and at least one life-saving drug because suppliers can't meet demand—in part because of manufacturing problems.
Like lots of emergency physicians, Carol A. Cunningham, MD, is used to occasional medical supply shortages and knows how to adapt. Finding workarounds and making modifications in the moment is simply a part of her job.
But her patience was sorely tried last winter when supplies of saline solution ran short.
Cunningham, who is state medical director for the Ohio Department of Public Safety's division of emergency medical services and emergency physician at Akron General Medical Center, says "It became really scary when we didn't have saline. I felt like we were practicing medicine in a third-world country. There was just no way of giving fluid resuscitation or treating dehydration intravenously."
While the saline and IV solution shortages have been among the most noticeable to clinicians and hospital staff over the last year, they have not been isolated supply chain problems. Basic supplies such as epinephrine, dextrose-filled syringes, and nitroglycerin injections have also been scarce.
Carol A. Cunningham, MD
"People think, 'we can use another drug,'" says Cunningham. "But… not all drugs are appropriate for all patients." Besides allergies or interactions, many drugs that are safe for adults are completely inappropriate for children. For some supplies, such as epinephrine, there is no clinically acceptable substitute. "For pediatric resuscitation, this is the drug," says Cunningham.
Room for Error
The experiences of William Jaquis, MD, chief of the department of emergency medicine at LifeBridge Health in Baltimore, mirror Cunningham's. "Sometimes, not even second-choice drugs have been available," he says. Jaquis says his team is often forced to figure out a substitute on-the-fly, then scramble to find supplies and calculate the correct dose.
"It delays the patient's treatment, and in the emergency room, minutes have impact. Those few minutes in these situations can be crucial," he says.
Jaquis also says he fears being held liable should a patient suffer a poor outcome as a result of being treated with a non-first choice medication, or due to delayed treatment. "It's a possibility we face every day anyway, and with the extra levels of complexity caused by dealing with these shortages, it creates even more potential for that to happen."
Quality Concerns "The number of [medical product] shortages have increased, and it's concerning," says Curtis Rooney, president of the Healthcare Supply Chain Association (HSCA). He says serious quality issues have slowed down production and that has kept basic medical supplies such as saline out of stock over the last year.
"There have been manufacturing challenges. Upon inspection of IV bags, particles, and sometimes fungus or glass were found by inspectors. These are some serious issues you really don't want on market," he says. Rooney reports similar quality issues in the manufacturing of epinephrine and dextrose.
Bona Benjamin, director of medication use quality improvement at the Center on Medication Safety and Quality at the American Society of Health-System Pharmacists agrees that there have been major quality problems.
Bona Benjamin
"We've held several meetings with stakeholders to try to figure out what's going on, but it's hard to say overall." She says that each manufacturer has stated a different reason for coming up short.
Benjamin uses a popular non-opioid anesthetic, Ketorolac, as an example. Its current shortage is caused by crystals having been found in vials of the product. "It's not of [the] quality you would want to see issued from a plant. This is now considered to be a contamination… You can't have injectable medications with crystals in them," she says.
Having plants taken offline to remedy production issues has cut down on manufacturers' ability to supply the basics. "When you have a small number of manufacturers in a market and one drops, it increases the likelihood of a shortage. Other manufacturers just can't pick up the slack fast enough," says Rooney. His organization recently wrote a letter to the Food and Drug Administration urging a faster process for approving new manufacturers.
"We're very interested in bringing new entrants into the market," he says. "State and federal government entities are very limited in what they can do, which is why we've suggested new abbreviated new drug application approach."
In the meantime, Rooney's advice to hospitals is to attempt to work with their suppliers to see if they can get more of the supplies they might be low on. "I would call your [group purchasing organization]. If that doesn't work, you can try calling another local hospital, ask if they have anything to spare. Also, try wholesale distributors."
No End in Sight
Cunningham was surprised and relieved when the FDA began allowing saline from Europe to be imported to the United States last year, but she and the other leaders at her hospital felt the sticker shock. "The price went way up—it was five, maybe six times what we were accustomed to paying per bag. But at least we had some access to it," she says.
Cunningham also worries that community hospitals are especially vulnerable to shortages because suppliers might overlook them in favor of larger health systems, who are larger accounts. "If you are running a pharmaceutical company and there are not enough drugs to go around, and you if have one contract with a large, well known healthcare system and one contract with a small community hospital, who do you want to make happy? The winner will be the big-money client," she says.
Jaquis is also concerned about cost to his hospital and availability of these supplies. "There's generally a secondary market for these commonly used medications. It's a more competitive market than when you go through normal channels. It's like going to a ticket dealer the night before Ohio State plays Michigan for a Big Ten Championship. They have a limited supply of these basic materials, and your buyer is competing with a bunch of other people to get same medications."
Jaquis says his hospital tries to avoid doing this unless it's absolutely necessary, but sometimes, it's "something that we absolutely have to have."
Rooney hopes the FDA will consider approving more manufacturers in the near future, but he says it will be a long time before emergency department staff can breathe a sigh of relief. "Everyone is doing the best they can with what they have, but I'm not seeing the light at the end of the tunnel here."
The focus in hospitals on outcomes and patient satisfaction and on the use of electronic health records systems is changing clinical duties and job descriptions.
If your HR department is like most, it is recruiting more nurses with advanced degrees, looking to hiring a team of care coordinators, and possibly seeking out tech-savvy docs.
These hiring trends are not occurring in a vacuum. Healthcare reform is transforming how all levels of hospital workers—from physicians and nurses, to social workers, IT professionals, and senior leaders—do their jobs.
Bryan Bassett
"Over time, healthcare may be changed in a really positive way," says Bryan Bassett, managing director at Health eCareers, an online recruitment firm headquartered in Denver, CO. "We're now going to be much more focused on patient satisfaction, on treating the patient as a customer. The focus is now on outcomes, and not just any outcomes, but truly successful outcomes. There's much more of a 'lessons learned' mentality, which is a very positive thing, but it will take us time to get there," he says.
Here are a few healthcare jobs that have changed as a result of healthcare reform.
1. Nurse Navigators and Care Coordinators
As treatment plans grow in complexity and reimbursements have become tied to outcomes, it is necessary for some patients, especially the very ill or those who see multiple specialists, to have a navigator or coordinator to help them make sense of it all and ensure that everyone is onboard.
For example, some nurse navigators specialize in coordinating cancer treatment, ensuring that all clinicians and social workers engaged in treating a patient with cancer are aware of a patient's current treatment plan. Some nurse navigators specialize in elderly patients, patients with a serious diagnosis, or patients with multiple conditions.
The care coordinator role is similar, although as many candidates come from social work or other backgrounds as nursing and there's greater emphasis on keeping the patient out of the hospital after their release by taking steps like calling the patient at home to see how they're doing, scheduling appointments for them and making sure they take their medications, always with an eye on cutting down on readmissions.
"Nurse navigators focus on helping patients get the care they need when they need it," explains Jess Judy, senior vice president of provider relations at LifePoint Hospitals. This is especially important in coordinating care for patients in ACOs and other managed care environments.
Jess Judy
2. Clinical Pharmacists and Advanced Practice Nurses
Clinical pharmacists and advanced practice nurses have always been important, but their professional scope and capacity are expanding, says Judy. "We're seeing a real expansion of the clinical pharmacist role. Patients are on multiple medications, and it’s the clinical pharmacist's job to ensure the meds they take cause no adverse reaction."
Judy predicts an uptick in hiring and increased responsibilities for this role over the next decade, as the aging population continues to receive more prescriptions.
Another job seeing its role expand is that of the advanced practice nurse. "We're seeing a whole lot more advanced practice nurses than we used to," Judy says. In many ways, this is prompted by the popularity of [changing] top of license policies, he says.
"Instead of a physician counseling a patient about their medication or the care of feet if they're a diabetic, someone else who has that training can do it. In short, we want to make sure everybody is practicing to the maximum level of their skill level."
3. Physicians and Anyone Who Interacts with EHRs "The day-to-day jobs of almost all physicians have been transformed. It used to be that many physicians worked in private practice, but now, doctors know that they will go directly in to a health system or hospital when they complete their education and training," says Bassett.
"The demands of the [PPACA] in terms of legislation around ACOs and electronic health records means that you just can't survive as an independent physician in a small practice. This is a massive transition in the way that role does its job," he says.
But there are positives to this change, says Bassett—being an employed physician might mean greater work-life balance and the opportunity for more flexibility in a physician's career.
Source: Health eCareers
Another massive policy change related to the PPACA that has changed the physician role is payment models. "It used to be based on volume," says Bassett. "Now, everything is outcomes-oriented. This changes how a physician looks at [his or her] daily routine."
The implementation of electronic health records marks another big change for clinicians. "Anybody who interacts with EHRs or EMRs just has different job requirements than they used to. There's a new expectation of technical competence, and just a general pressure to beef up on tech savvy employees."
While some of these transformations have been sudden and even dizzying to the industry, they are all important steps to progressing toward the value-based care model, which Bassett is convinced will remain in place for years to come. "The train has left the station," he says.
Violations of even the most fundamental rules can leave hospitals and health systems open to criminal risk, HIPAA-related risk, and civil suit risk. Insurance can help, but to what degree depends on many variables.
"Why are you doing this? We're a hospital. No one will want our data," was a comment Holly Meyers, RN, FACHE, then the senior vice president of quality, risk management, and insurance at Sylvania Franciscan Healthfrequently heard when she decided in late 2007 that carrying insurance to protect the seven-hospitals system in the event of a cyberattack or a data breach was a responsible choice.
"At the time, no one had really heard of any hospitals having security breaches, but we felt things had changed, or were about to," says Meyers, who left Sylvania Franciscan Health recently. "We were looking at what we had, at all the personally identifiable patient and employee information. We knew that if there was ever a cyberattack, we couldn't handle it all by ourselves."
Ross Koppel, PhD, FACMI
But it wasn't an easy or intuitive task. "Back then, no one knew back then what 'adequate coverage' meant" for cybersecurity insurance, she says. She and her team ended up deciding on an $8 to $10 million policy which included access to a team of specialists in law, public relations, cybersecurity, and computer forensics. The policy cost around $100,000, Meyers says.
Meyers had purchasing discretion, but her team met with an internal quality and risk management panel yearly to discuss their activities, current policies, and products they purchased. "Our system CEO sat in on the meetings, too," she says. "It wasn't about getting permission, just explaining what our [security and insurance] portfolio looked like."
Massive Risk "The risks here are massive," says Ross Koppel, PhD, FACMI, adjunct professor of Sociology at the University of Pennsylvania and affiliate professor of medicine who specializes in research on how health information technology influences society.
"There's the criminal risk. The HIPAA-related risk. There is civil suit risk as patients have data exposed. Even in highly secure situations, such as in military intelligence, he has seen professionals compromise security by violating the most fundamental rules such as writing passwords on sticky notes and keeping them near the computer.
Health records, which contain social security numbers, dates of birth, and insurance information, are a prime target for data thieves. The stereotypical data breach is caused by a hacker lurking on the Dark Web, but often, the threat is much closer to home.
"There's the nasty hospital employee looking for their neighbors' chart, or that of a celebrity who came to the hospital for treatment,"
For Sylvania Franciscan Health, the decision to buy cybersecurity insurance turned out to be a good one. While the policy went unused for almost eight years, the hospital experienced a breach in December 2013. Meyers describes the incident as "a brute-force attack of foreign origin." She and her team never knew for sure whether any data was stolen, but they were required to notify those affected. Approximately 405,000 patient and employee records were affected.
The insurance Meyers and her team had purchased covered most costs above the retention associated with the hack, including notification costs, public relations costs, and ongoing identity protection for patients and employees who may have had their information stolen.
Austin Morris, Jr.
"I feel like my organization and I received exactly what we paid for…. And you can't always say that about the things you buy," Meyers says.
Cybersecurity Insurance Basics "When it comes to security breaches, no one is bullet-proof," says Austin Morris, Jr., president of Morris Risk Management, a Philadelphia-based risk management consultancy. He says any cybersecurity policy should have, at minimum:
Liability coverage
The most basic part of the coverage. This will protect the hospital against claims for damages due to loss, theft, or unauthorized disclosure of information.
The event causing the loss, theft, or disclosure of data doesn't have to be a malicious breach of patient data—any time private data (including employee information) leaves the hospital's care, custody, or control, the policy is triggered. "If you have any suspicion that data may be lost or taken, call the insurer, and they will start calling and pulling levers, bringing in specialists to clean this up," says Morris.
Regulatory fines and penalties coverage This another basic benefit. If a breach occurs, the hospital can expect regulatory fines around HIPAA, the HITECH act, and state regulators. "Regulators are often trying to send a message," says Morris. "They've been toughening the penalties for violations recently, trying to make sure that hospitals, medical centers and healthcare professionals are working toward better standards of security, better protocols, and better training."
While these fines might be designed to deter errors, they can also easily bankrupt a hospital.
Business interruption coverage This would be invoked of the hospital were unable to participate in normal business due to damaged databases or loss of network use.
Other expenses for which hospitals typically consider insurance coverage include
Legal costs,
Costs related to a class action lawsuit,
Costs related to forensics and investigation,
PR costs,
System monitoring costs,
Credit monitoring
Identity theft repair for victims of the breach,
Staffing budget for the hospital call center to handle increased inquiries in the aftermath of the breach.
Coverage Benchmarks for Healthcare Organizations
Annual revenue: $100 million
Aggregate limit: Between $1 and $4 million Retention: $25,000 to $100,000
Annual revenue: $500 to $600 million Aggregate limit: $5 to $10 million Retention: $50,000 to $250,000
Annual revenue: $1 billion Aggregate limit: $10 to 15 million Retention: $100,000 to $1 million
Going Without While most hospital operating expenses are structured and planned expenditures, cyberattacks are sudden events, with unpredictable expenses. Skimping on cybersecurity insurance is never a smart gamble, says Morris. "If [you are] willing to take that risk, with no loss control, you will possibly be putting hospital out of business—unless you have deep pockets."
Most cyberinsurance carriers keep security vendors on call. A hospital attempting to recruit a team of specialists to respond to a breach would likely be challenged to secure the necessary resources. Morris says, "If something goes wrong and you have [a breach] without insurance, you will have to pay out of pocket. Do you have millions of dollars to pay for [cybersecurity] expenses?"
He also points out that any delay in notifying victims or rectifying the situation can cause harm to a hospital's reputation. "I would want to know I have professionals on call to help my team handle this within minutes of learning there was an event. Figuring out what I'm buying or waiting two weeks to figure it out is not optimal."
Ultimately, choices around cybersecurity insurance are a question of preparation and taking responsibility, says Morris. "You want people on call who can help you shut this down, and who will do the right thing for your employees and patients."