The Center for Patient and Professional Advocacy at Vanderbilt has spent two decades building a professional accountability model. Its director discusses how co-worker observations can be leveraged to promote greater accountability among physicians.
What happens when a lower-ranking healthcare worker observes bad behavior in a physician or another advanced practice professional?
In many organizations, that worker will keep the information to himself.
But that's not necessarily the case at Nashville-based Vanderbilt University Medical Center, says William Cooper, MD, director of the Vanderbilt Center for Patient and Professional Advocacy. He recently co-authored a study regarding peer feedback and physician behavior modification.
Establishing a culture that values safety is mandatory for a program like this to work, Cooper told me in a recent interview. "You have to have commitment to it, and it has to permeate the entire culture." The transcript below has been lightly edited.
HLM: Tell me a bit about the background of this study.
Cooper: The Center for Patient and Professional Advocacy has spent the last 20 years building a professional accountability model, which was originally created for identifying and intervening with physicians at risk of medical malpractice.
We began to recognize over the years that there are also ways physicians and other healthcare professionals interact with team members that might have an impact on key performance and quality.
Our malpractice work has used patient complaints as a source of [identifying] high-risk physicians. We know that 3% to 5% of physicians account for 45% to 50% of patient complaints. And, those same physicians account for 50% to 60% of medical malpractice risk.
But we hadn't had the chance to explore whether staff complaints were also non-randomly distributed. What we found was that in three years' worth of staff complaints, 3% of our physicians accounted for almost half of our staff complaints.
Over the course of a two-to-three-year period, we were able to create a system for bringing concerns to healthcare professionals that were generating complaints by other staff, particularly those who generated more than their fair share.
HLM: How do you intervene when you receive a complaint about a clinician?
Cooper: The model for intervention is based on a peer-to-peer conversation. A nonjudgmental conversation with a peer can actually be quite effective in changing behavior. Based on academic detail and research that Vanderbilt did… [regarding] physician prescribing behavior… if you sent a physician to have a conversation with another physician, and [their peer] showed them… data [regarding their] peers' [behavior], they can self-regulate and change their prescribing behavior.
We've used [this model] for reducing patient complaints, and now with this most recent paper, we've been able to address staff complaints as well.
HLM: What is the conversation like?
Cooper: We do this in a non-public place, so there's no public embarrassment. It usually takes about 90 seconds to two minutes, and usually goes something like, "we received this report about an interaction you had with one of our team members. It's inconsistent with the values that we have here at Vanderbilt, and all we want to do is make you aware and tell you a bit about what happened."
Afterward, I'd ask for your views. I'd then end the conversation by saying, "I appreciate your time."
HLM: By what percent were patient and staff complaints were reduced once this model was adopted?
Cooper: What we find is that in our patient complaint model, 80% of physicians who received "peer messages," or a peer-to-peer intervention, will self-correct. In the early experience we have had, around 70 – 75% have had no subsequent staff complaints after receiving a physician conversation.
What's especially interesting about this is that these are sometimes people who have been doing these behaviors for years, and no one has ever told them [their behavior was unacceptable].
HLM: Does this program only apply to physicians, or to nurses and other employees as well?
Cooper: We do share these concerns with our advanced practice nurses as well.
HLM: What's a good example of disrespectful or unsafe behaviors that might trigger an intervention?
Cooper: Some might include something like a physician receives a call about a patient, then comes to the nursing unit where the call was received. He then says something like, "this patient is fine, I can't believe you wasted my time on this call. Don't ever call me again." Or maybe a physician has an outburst in a procedure room.
It's not all about cussing and spitting and throwing scalpels, though. Sometimes, these behaviors are more passive.
Not returning phone calls or not answering pages can create challenges with our goals to provide high-quality care to our patients. As leaders, we want to make sure to give the physician a chance to self-correct.
HLM: What would you say to concerns that this policy asks employees to tattle on each other?
Cooper: We definitely are mindful to the fact that in an ideal circumstance, [workers] could have… conversation [with offending clinicians] directly. But we recognize that within an organization, there are often barriers to that kind of conversation.
But we need to give people an opportunity to share their observations. This [set up] also provides a great way to [collect] data, because if a physician works in multiple areas of the organization, and we don't have a centralized way of seeing this data, we'll never know that this [behavioral] pattern is developing.
But to do that, team members have to trust that they'll be safe, and that no one is going to retaliate.
We analyze the data to make sure we don't have super-reporters, or groups of nurses ganging up on a physician, for example. But we've found that super-reporters are almost non-existent. Which is good, because that would be unprofessional, and that team member would have to get feedback about that unprofessional behavior.
HLM: Has leadership noticed the results?
Cooper: Recently, I was sharing some data with our CNO. She told me that she's had two nursing managers come to her recently and say, "I don't know what happened to Dr. Y, she used to be so mean, but she's been just amazing to work with recently." The CNO didn't know, but Dr. Y had recently received an intervention.
That's how you begin to get traction for this kind of culture change.
HLM: What advice do you have for leaders who wish to pursue a similar cultural change?
Cooper: One of the most critical lessons we learned in putting this together is that you have to pay a lot of attention to having the right people and processes. You have to have leaders that are committed. They have to align with the organization's values, align with the policies and procedures, and you need an intervention model to identify those [best suited to intervene] and train them to give non-judgmental feedback.
In our October 2015 Intelligence Report, healthcare leaders cited a variety of population health initiatives. HealthLeaders Media Council members discuss efforts that are important to their organization's population health management strategy.
This article first appeared in the April 2016 issue of HealthLeaders magazine.
Ann Oasan President UniNet Healthcare Network CHI Health Omaha, Nebraska
Physician and patient engagement are probably the most critical parts of population health. We've had care management in place in our primary care clinic for the past three to four years, and we've been very successful, but now we are focusing more on physician engagement.
Our use of care coordinators actually helps get physicians onboard for population health. When there is a patient who has a social need, physicians have a care coordinator who they can refer that patient to, and know they'll get the best care. The care coordinator has those resources at their fingertips, while a physician may need to do a lot of research to find some of these things.
We do receive claims data from many of our payers. Some of our payers are providing financial assistance to help manage those patients, which is helping pay for the infrastructure costs of our population health program. Several of our payers are recognizing that providers and payers need to work together, and they have been willing to sit down with us to design a program.
Julia Andrieni, MD Vice President of Population Health and Primary Care, President and CEO of Physicians' Alliance for Quality Houston Methodist Houston
There are many important components to population health. Our research has yielded similar results to yours, although I might put the initiatives in a slightly different order, with an engaged primary care physician network at the very top, which would include both aligned and employed physicians. You need a pretty extensive geographic network for covered lives and population health, and aligned independent physicians outnumber employed physicians by a 2:1 or 3:1 ratio nationwide; you need them both to be engaged.
The second asset I'd say is key for us is a robust care management program. On that team, we have a clinical pharmacist, nurses, assistant nurses, certified diabetic educators, and more—it's a team-based approach that is utilized based on the health risk of the population, with more intensive management of the high-risk population we care for. The third-most important factor is participant engagement. To sustain outcomes and results, you need to engage participants in their own health. You can do all the work in the world for individualized care plans, match people to primary care networks, coordinate between the nursing care navigator and a primary care physician—but to sustain those results, I think you have to create an education and awareness for the patient.
M. Michelle Hood, FACHE President and CEO EMHS Brewer, Maine
We have brought on several new roles due to population health initiatives. We had care coordinators previously, but they focused primarily on discharge planning and related issues. We have reorganized that function, and our population health team manages our care coordinators systemwide. We have brought on additional staff resources to do that.
Most of our care coordinators are nurses, but because of the high incidence of depression and other mental health issues that we encounter, we also have some clinical social workers and mental health professionals in the care coordinator role.
We've also hired pharmacologists who work with providers around medication management and we have one biostatistician, with plans to hire more.
We've been using home monitoring for some time, but we've increased the number of homes in our home monitoring program that are connected in real time to our care center. We've also used telemedicine effectively for a number of years, but we're seeing an expansion of that as well, particularly telepsychiatry.
We're looking to upgrade our data warehouse, and have hired a chief medical information officer and chief nursing information officer. They report to the chief medical officer, but oversee clinical analysts. We've had a variety of initiatives around data reliability and integrity.
John Holland CEO LHP Hospital Group Plano, Texas
On setting priorities: The top three you've listed are definitely our top three, too, but I would put them in a slightly different order. I would say that physician engagement would be by far the top issue that we're working on across our different hospitals and markets. Second for us would probably be care management, and the third top issue would be patient engagement.
On getting clinicians onboard: Once you communicate and educate, clinicians understand why population health is necessary and what's in it for them. We've set up a clinical integration network, and we've worked hard to develop specific tactics around bundling and development of narrow network products with some of our insurance partners. We've also seen the need to integrate our work, whether it's in the outpatient physician setting, the hospital, or the ambulatory settings. On the physician side, I think it's important to foster strong communication and have great physician leaders who are advocating for their colleagues to sign off on population health and join us.
On patient engagement strategies: Most of our market has really been around what I call "the traditional blocking and tackling," which in a nutshell is making sure that our care strategies, the service we're giving the patient, and the interaction with any of our facilities or clinicians is a very pleasant experience. We've focused on ensuring the patients understand the care they're getting, and that they're engaged in their own care.
HR is in an unusual position to facilitate a culture that emphasizes philanthropy—but it's important make it a part of every level of the hospital's culture.
Should encouraging philanthropy be part of HR's job?
Some would say that's the hospital foundation's job, but that would be a missed opportunity, says Heather Procaccino, director of development and major gifts at St. Mary Medical Center in Langhorne, PA, which is part of the Trinity Health network.
Healthcare workers who participate in philanthropy within their organizations are more likely to be engaged at work than those who do not, she says. "And employee engagement is critical. An engaged colleague is a happy colleague—and that means patients will be well cared for."
"From an HR perspective, you have an opportunity to educate the leaders of departments and make sure they are talking about the value of a culture that embraces giving and thanking. You have an opportunity to create an attitude of gratitude."
HR has the power to shape and educate their organizations and communities about the importance of giving, Mountcastle and Procaccino say. "Philanthropy is… not about money, it's about how we act, and about how everyone can articulate the case for giving," says Mountcastle.
How can HR executives create an engaged, giving-oriented culture in their hospitals? Like many cultural changes, it starts at the top.
Set the Right Example
As with other cultural changes, it's important that those at the top model the behaviors and attitudes you hope to spread throughout the organization, says Mountcastle.
The CEO and their fellow C-Suite members need to be among the most committed to philanthropy, whether it's by hosting benefits for the organization, fundraising, or donating their own monetary gifts. "They need to be able to advocate for the organization and be a champion for it—always," says Mountcastle.
Teaching employees to think about philanthropy and how it relates to the culture of the hospital is key, he adds. "When you think about organizational culture, it's really how people think, act, and behave as an organization. As a business function, HR has the ability to shape, form, and build the culture they hope to see. HR can educate leaders."
Look to Colleagues
But it isn't all about what the people at the top do. Hospital employees can make an even bigger impact, says Procaccino, and she's seen it firsthand. St. Mary Medical Center started its Colleague Giving campaign in 2006. Since then, more than $1.5 million in donations have been given to the campaign, excluding physician donations.
But it didn't happen overnight. Procaccino spent more than a year laying groundwork for this ambitious program.
"I spent a year going to every single department meeting in the hospital… I wanted to meet the entire staff and tell them what I did, why raising money is important, and why giving is important to colleagues."
Procaccino made sure to explain what donations are used for—equipment and upgraded facilities that allow the organization to provide advanced patient care. She explained what it meant to work for a non-profit system, and why gifts helped the hospital be sustainable.
She also took time to explain to everyone how they could encourage philanthropy, just by being an excellent nurse, a thoughtful environmental services worker, or an attentive frontline employee.
Contributing to excellent patient experience is key, says Procaccino. "If a patient's experience is excellent, when they hear from [fundraising or development], they will be more willing to give a gift," she says.
St. Mary Medical Center's Colleague Giving Campaign was implemented through its fundraising department, but many HR departments could do something similar within their own health systems, says Procaccino.
Values Matter
While your eye is on your colleagues, ask yourself about the kind of physicians and physician leaders you want your organization to recruit and promote. What kind of nurse managers will be encouraged to take leadership roles?
The people who are promoted within the hospital should be illustrative of the culture you are trying to promote.
Mountcastle also believes that getting healthcare workers into the philanthropic spirit might not be much of a challenge, as many workers who are drawn to healthcare are driven by the opportunity to help their fellow man.
"They're philanthropists in the literal sense," says Mountcastle. "They love mankind."
But it's important to remember why people donate, whether they are members of the C-Suite, part of your workforce, patients, or members of the community.
Donors see healthcare philanthropy as a chance to make a lasting impact. Philanthropy is a chance to be connected to something greater than oneself, to be a part of something big. Allowing donors to feel connected to their community, to other patients, and to something lasting is vital, says Mountcastle.
"Philanthropy is not about money. [Donors] want to know they are part of the solution, and are doing good work."
In our November 2015 Intelligence Report, healthcare leaders cited a variety of skills they find important for the CEO's executive team to possess. HealthLeaders Media Council members discuss areas of expertise that their organization will find valuable in the next few years.
This article first appeared in the May 2016 issue of HealthLeaders magazine.
Glenn Crotty, MD
Executive Vice President, COO
CAMC Health System
Charleston, West Virginia
My organization has taken on systematic review and development of our leadership system. In our leadership system, we have defined requirements for leadership, including defined competencies for leaders. There are some basic qualities we think a leader must have to even be considered for a C-suite role.
A potential leader must be able to [be a] role model and an effective communicator. Those are qualities a leader needs before he or she even gets in the door.
With those satisfied, the competencies we think that the leader must have or quickly develop is to build commitment, be able to motivate, have the ability to self-review and adjust, make change last, be able to reward and recognize, and raise the performance of the organization.
The leader also must share our values of quality, respect, stewardship, safety, integrity, and service with compassion.
Referencing Darwin, the most adaptable survive. One of the key attributes we search for in C-suite candidates is adaptability. Most plans that are developed will last about six months, and then something will happen—there's a new regulation that comes out, or a new edict, a new something will come. We need leaders who can roll with these punches.
Regarding the physician CEO trend, it depends on the need. If the need is mergers and acquisitions, then the pendulum will swing away from physicians, because they usually don't have that skill set. But if the need is continuously improving quality and safety for patient care and fulfilling the Triple Aim, then I think the physician CEO trend will continue.
Ronald Paulus, MD
President and CEO
Mission Health
Ashville, North Carolina
Cost containment and physician alignment experience would be pretty high on my list of sought-after skill sets, but there are a few areas that are missing from the survey results or embedded in the broader categories.
Also, the cost containment skill set is not just about cost containment, it's the ability to create better outcomes at lower costs. We believe firmly that when you create better outcomes, you lower costs.
One aspect that's missing from your survey results would be consumer engagement. I view the market as being in the midst of a transformation from its historic provider focus with traditional, fee-for-service care to a future that features a different way of engaging with consumer-patients, relating to them in ways and manners that meet their needs.
We put a lot of emphasis on consumerization of our system, so I would add consumer optimization as being one of the core skills for which I'm increasingly looking.
Another vital skill I would list as important is resilience. It's not likely that everything is going to work or that our industry is going to become easier—from here on out, it's a marathon, not a sprint. Someone who can stay upbeat, focused, energized, and stick with a game plan is highly desirable in this climate.
David Fitzgerald
CEO
Proliance Surgeons
Seattle, Washington
On cost containment ability: Cost containment ability is very important. Our business is much more focused on cost than a hospital, not because costs are good or bad, but because the net goes to the physicians' payroll, so costs are always much more immediate and much more "in your face" than at a hospital.
On IT skills: So much of healthcare is becoming data-driven. What you want is not just to have data, but to turn that data into good, useful information. All of a physician's decisions are based on data. The physician looks at x-rays, labs, feedback from the patient, and then he or she makes a decision—that's data.
Now physicians have to look at new things, and it's not data they had before or knew how to synthesize into that same decision-making. I want a leader who can take that IT piece and turn it into truly actionable data.
On determining an executive salary: [The individual's] experience and [the compensation of] peers are probably the two biggest elements in setting salaries. I look at the published averages for these positions, and I look at the candidate's level of experience. Have they already been doing this, more or less? Those are the greatest factors that go into my decision.
John Bishop, CPA, CEO
Long Beach (California) Memorial Medical Center
Miller Children's and Women's Hospital Long Beach and Community Hospital Long Beach
What I'm looking for on my team is people who are capable of learning from the past, but who are looking forward and embracing change. We're at a point right now where everyone talks about moving from fee-for-service to population health, yet there's a lot of uncertainty about exactly how to get there.
It's going to take considerable forethought, coordination, and vision to get us to the point where we're effectively taking care of our community under a population health model. It's about being forward-looking, adaptive, and really embracing change, because what we've done in the past isn't going to work in the future.
To me, culture is everything. You can have a great strategy, but if you don't have a team that works together and is really committed to the mission of the hospital and the health system, it's not going to be effective.
So, we're looking for a team that is not only visionary, but is committed to providing the best patient experience. The key differentiator as we're moving forward isn't just good outcomes—that's to be expected—but it's the patient experience. It's the little things, like the extra measure of empathy and compassion, making the patients know that you are there for them and not treating them as a unit of work.
Concerns about increased overtime pay extend beyond the HR suite to clinical concerns about quality of care.
Businesses may balk at paying workers overtime rates for a variety of reasons, most of them financial.
But some healthcare professionals believe that changes to federal OT regulations slated to start this year could negatively impact quality of care, says Gabrielle Sedor, chief operating officer at American Network of Community Options and Resources. ANCOR is a non-profit trade association for providers of care to patients with disabilities.
The coming changes will have unforeseen consequences for managing the continuum of care, says Sedor. As vulnerable patients go back into their communities, care coordinators and others who depend on a robust community health system could find that they have fewer resources than they do now.
This is because there is a dependence on Medicaid dollars, she explains. "Most of these people are relying on support that doesn't have a margin to deal with mandates like this proposed rule. If, all of a sudden, our service providers are required to pay overtime… they're going to have to find those dollars somewhere within their organization. They can't pass the cost on to the consumer, because the consumer is being funded by Medicaid and state dollars."
But hospital administrators are in a unique position to advocate on their own behalf—and that of other care providers, she told me recently. The transcript below has been lightly edited.
HLM: Why are disabled populations particularly vulnerable to the consequences of expanding overtime pay?
Sedor: We have a [healthcare] workforce crisis as it is. The work is incredibly demanding and very intense, and it takes a special kind of person. We've got a huge turnover percentage. Some folks report up to 30 to 40% turnover, which is very costly for employers, but also a real challenge in the quality and continuity of care as well. If you've got someone helping you with your most basic of needs, and that person is a different person week-over-week, it's a real problem.
As I mentioned, our rates our fixed. And, to top it off, about 20 states are on a two-year budget cycle. So, if you are reliant upon that state appropriation, it's not going to catch up to you in time to adhere to this rule.
That's what makes [the services] so tricky; it's that the money is going to have to come from somewhere, which could result in providers rethinking the services they're offering. They might need to constrict the number of services they provide or the number of people they provide them to, or they might need to adjust wages to try to compensate for the overtime that they're going to have to pay.
Let me be clear: We know that it's time to update [overtime pay]; it hasn't been updated since 2004. We absolutely agree that people who provide these kinds of services—direct support professionals—are valued and should be paid what they're worth, right?
But, at the end of the day, this is paid for by Medicaid dollars. And we can't pay what we don't have and 70% to 80% of the funding that providers get will go to workforce.
HLM: What should hospital HR leaders know about how the regulations are going to impact their business?
Sedor: They're going to have to start planning now how they're going to accommodate this.
One thing [hospital administration] might see is that people with disabilities may have limited staff accompanying them. Traditionally, if our members were supporting someone who had to go to the emergency room or ended up in a hospital setting, they almost always sent someone with them, especially if that person didn't communicate well, or didn't communicate at all.
Hospitals may see less and less of that, because we're struggling with such a workforce issue here, and the OT [regulations] will exacerbate that. [Hospitals] may need to be prepared to offer more support for people with disabilities. We're all dealing with this unfunded mandate, and [are figuring out] how to fund the costs to address that.
HLM: What steps should hospital HR and administration take to protect their patients?
Sedor: We're asking for at least a temporary increase in Medicaid funding, so our organization will have time to adjust for the rule and time to catch up. Hospitals may want to consider whether they want to advocate.
Some folks are more comfortable with that than others, but you may want to advocate with the DOL and the administration to consider a lower threshold, for example, or a more incremental implementation of the rule. This is going to be really tough for all employers across the board, but especially folks that have more regulations they have to live with, which includes hospitals.
At this point, the rule isn't final yet. It's moving, and it's moving quickly. There is a limited amount of time for review, but I think there's still time for advocacy, and that's something I would encourage hospital administrators to consider.
HLM: If HR leaders have concerns about the proposed regulations, what should they do?
Sedor: HR leaders should reach out to their congressional delegations. They should make sure that their representatives in Washington, DC., know that this will be an issue. While the official opportunity to comment to the DOL is closed, reaching out to congressional offices is still a good way to express concerns.
They are the people best able to tap the DOL on the shoulder and say, "hey, want to know what I'm hearing from a business that employs hundreds of people in my district?"
HLM: What are some advantages that hospitals and other larger organizations have that smaller organizations do not?
Sedor: There's strength in numbers, especially if you can mobilize the people who are relying on the services and make a compelling case to your workforce that these rules will probably not [result in increased pay]. On paper, the regulations look great, and I think it's going to be a hard sell to your workforce. But I do think that there's a way to do it, if you look at the big picture.
Most hospitals already have good relationships with their congressional delegates, and state and local representatives as well, in part because they are such significant employers and they provide such vital services to people in their communities, which is something else they have going for them.
The dangers of burnout and fatigue, both physical and mental, go well beyond job dissatisfaction or frustration for nurses. Know the signs and intervene before things go from bad to worse.
If there's one thing healthcare leaders can agree on, it's that a good RN is hard to find. But sometimes, the bigger challenge is keeping them onboard once they've been discovered.
Between the constant pressure to do more with less and the long hours and heavy workload expected of nurses, it's no surprise that nurse burnout is prevalent. "Nurses are at risk for burnout due to the demands of the role of a nurse today," says Rusty McNew, RN, regional chief nurse executive for the Texas region at Tenet Healthcare Corporation.
The dangers of burnout and fatigue, both physical and mental, go well beyond job dissatisfaction or frustration for nurses. The Bureau of Labor Statistics ranked nurses fifth of all occupations in 2010 in the number of workdays missed due to occupational injuries and illness, and as many as 20% of nurses are estimated to suffer from a substance abuse disorder.
But there are strategies to stop burnout in its tracks and avoid nurse turnover, and HR can help.
Burnout-Busting Policies
Human resources leaders are in an excellent position to prevent burnout by setting hospital policies that discourage dissatisfaction from brewing in the first place.
One example is the use of overtime and time off. It's not uncommon for some nurses avoid taking vacations and to volunteer to cover shifts at every opportunity.
"Sometimes, nurses know no limits," Waddill-Goad told me in a telephone call. "They take on work that will consume them." Although society often equates being busy with success, taking on too much is sometimes a coping mechanism for those who are burned out, she says (and can be a sign of employee drug diversion).
Without time to relax and recover away from work, jobs become more difficult, stress causes fatigue, and physical and mental tolerances weaken, which can lead to burnout, explains Waddill-Goad.
Unfortunately, this kind of overwork is common in healthcare.
"There are nurses working six days a week… What kind of impact does that have [on] safety? I find it to be concerning—not only for employee safety, but for patient safety," says Waddill-Goad.
Setting policies that grant healthcare workers permission to take time for themselves, like a cap on overtime or preventing unused vacation time from being carried over to the following year are ways to make it clear that your organization takes burnout seriously.
Know The Signs
While there are many signs of burnout, a change in appearance should be an obvious symptom that something is wrong, says McNew.
"My scrubs don't always fit me, and I always look like I just got out of bed," he says. "But, if it becomes exaggerated…. that's when the red flag goes up."
Other common symptoms of burnout include a sudden change in attitude at work, general disengagement, and absenteeism. It's important to distinguish between an employee having a bad day and an employee who is disengaging, but when in doubt, it usually pays to check in and make sure everything is alright.
See Something, Say Something
The most important step toward keeping nurses engaged is to talk to them, say McNew and Waddill-Goad. An HR department that fosters a culture of openness and encourages clinician leaders to engage regularly with their departments will have a leg up here.
Find out what issues nurses are struggling with. For example, if asked, night shift workers might complain that there are no food options other than the vending machines late at night. That could leave them have hungry for employment opportunities where they can get a slice of pizza or a healthy entrée at 3:00AM.
What about concerns around a specific nurse who seems to be disengaging?
It's even more important to open up lines of communication in such times says McNew, who can relate a personal experience he had where he kept a talented nurse onboard by asking her to share the obstacles she was facing in the workplace that were causing her to burn out.
" [She]was working a number of hours, and was the sole supporter of her family," he remembers. The nurse lived a bit farther away from the hospital than was convenient and was raising two teenaged children on her own.
"Her work started to slide a little bit… her appearance was just a little bit different… but the biggest thing was her joy for work and her overall [attitude]."
McNew remembers seeing the nurse's facial expressions while she was working and knowing that something was wrong. He decided it was time to open a dialogue with her. He kept his conversation with the nurse professional and mostly focused on work, but it sounded like "there were a lot of issues at home," he says.
"There's a certain amount of stuff you can talk about and give guidance on as a… manager," he says, but at some point, personal situations must be turned over to a professional who can serve as an objective third party. McNew suggested his employee talk to Tenet's employee assistance program.
Through guidance from the EAP, the nurse was able to resolve her personal issues, and was better able to tackle frustrations at the hospital and re-engage at work.
Not all interventions will be as successful as McNew's, but between sending employees the right message by setting policies that fight burnout and creating an open dialogue with nurses and their leadership, nurses can be more engaged and energized at work.
No administrator of an employee health plan will have to pay the so-called Cadillac tax earlier than 2020, but arguments against the "frightfully complicated" and unpopular provision of the healthcare reform law will continue, says a legal specialist.
The provision of the Patient Protection and Affordable Care Act known as theCadillac tax (and also known as the as high-cost plan tax, or HCPT) threatens to jolt employers and employees alike.
The tax is meant help curb the growth of healthcare costs, but in doing so, threatens the future of flexible spending accounts and will impose a 40% hike on high-value health insurance plans. An analysis by the Kaiser Family Foundation estimates that more than a quarter of employers will offer HCPTs by 2018.
Catherine Livingston is a partner at Jones Day, a Washington, DC- based law firm. She specializes in healthcare law, specifically, the Patient Protection and Affordable Care Act. Livingston spoke with me recently about Cadillac tax and other regulatory developments stemming from the PPACA and their potential impact on employers. The transcript of our conversation has been lightly edited.
HLM: What does the December 2015 Omnibus Appropriations Bill change regarding the Cadillac tax?
Livingston: The December legislation delayed the effective date on the Cadillac tax from January 1, 2018, to January 1, 2020. That means that no insurer and no administrator of an employee health plan will have to pay any tax earlier than 2020.
It also ordered a study because the tax is supposed to have adjustments. The tax works by taxing the excess over specified thresholds, which are supposed to be adjusted for certain age and gender factors. Another thing the legislation does is order a study on whether or not the thresholds should be changed in order to make them appropriate, suitable, and sensible.
HLM: What are your thoughts on the future of the Cadillac tax?
Livingston: I think we're likely to see significant debate about the Cadillac tax once the presidential election is over. It's been raised by multiple candidates as something they would like to review, if not repeal. It's certainly not popular with a wide and varied array of constituencies, from organized labor to large employers.
There's a significant-sized coalition lobbying for its repeal called the Alliance to Fight the 40, which has a very diverse set of members. All of those different forces will no doubt prompt debate about the future of the Cadillac tax.
There is a revenue cost associated with repealing it completely, and given concerns over federal deficits and the budget, it remains unclear whether a full repeal could be achieved in the broader context of budgetary concerns. There may be a series of delays because those have a lower budget cost—they were able to do [the December] delay because they only had to pay for turning off the tax for two years.
Another significant possibility is that the mechanism gets changed. The Cadillac tax is unpopular not only because of the economic incidence of the tax, but also because it's frightfully complicated and there are many unanswered questions about how the mechanism works.
Another option that has been floated by different voices in the policy debate is to replace the Cadillac tax with a cap on the exclusion for employer-provided healthcare. That's a much more straightforward mechanism. Certain questions would still have to be answered, such as how you determine what the cost of coverage is, so that it would be known when the cap is exceeded.
But that is already underway in the guidance process that the Treasury Department and the IRS have initiated, and many other questions that arise with the Cadillac tax could be avoided.
I am confident there will be much discussion, and there are a variety of different options for how that discussion could ultimately play out. Of course, there are voices speaking up firmly to say that the Cadillac tax is one of the most important mechanisms, if not the most important in the entire PPACA for trying to control the overall growth and cost of healthcare.
So, if it were repealed entirely, would there be any mechanisms left to meaningfully control costs? That's another element to the ongoing debate.
HLM: What activity can we expect around state applications for PPACA waivers?
Livingston: There will certainly be a number of states that will seriously work to develop proposals. As of summer 2015, there were at least half a dozen that launched initiatives in one form or another regarding the possibility of pursuing a waiver. But, to submit a waiver application requires a significant amount of work, not only to conceive of what the state would like to do to deliver health coverage, but also to do the economic analysis to demonstrate that what's being proposed is budget-neutral.
There are also two levels of required notice and comment. One that has to happen at the state level before the state submits its proposal, and another that happens at a federal level once the proposal is submitted. So, it remains to be seen how many states will actually run the full gauntlet.
One would also expect that states that have a heavy investment in their own state-based exchanges are far less likely to pursue the waivers. The waivers offer an infinite amount of flexibility. The state can waive everything from the individual mandate to the employer mandate to redeploying the funds that would otherwise go into the premium tax credit and other kinds of subsidies.
They don't have to use an exchange at all to determine eligibility for subsidies or deliver subsidies. It would seem that a state that's made a heavy investment in standing up and operating a successful exchange would be far less interested in the time cost and controversy that could potentially ensue with pursuing a state waiver.
HLM: What other PPACA or health insurance-related legislation do you think we can expect this year?
Livingston: I think we've hit a point in the evolution of health reform where there has been heavy investment of time and effort in understanding what the new law requires and understanding the many complicated mechanisms it puts in place to deliver what it offers, whether that be the mechanism of the exchange or the subsidies that come with it, or the Pioneer ACOs, or the new requirements for group health plans, or the premium stabilization programs, each of which has a huge array of details, and very complicated infrastructure.
So, at this point, I think people are looking around and saying, 'OK. We see what this law has given us, we're seeing most of it in operation.' But we—whether 'we' are the public at large or employers—are still asking why healthcare comes across as so expensive, and for some people, unaffordable.
I think that's going to push the debate toward looking at some of the drivers of underlying costs, which would include prescription drugs, and the continuing evolution from fee-for-service to value-based payment arrangements.
Certainly, consumers are increasingly interested in lower-cost options for access to care, such as telemedicine and retail clinics. It's not clear whether those topics will become the subject of legislation, but they will certainly be the subject of lots of discussion and the continuing public concern and frustration about being able to afford actual healthcare—not just coverage, but care.
The employer concern about the continued growth in cost is likely to ultimately arrive at legislative proposals. It's unclear whether that will be a 2016 phenomenon, or something that will wait until after the presidential election.
In a recent HealthLeaders Media Intelligence Report, most healthcare leaders said the status of their care transitions for care continuum providers or services was sufficiently strong, but indicated that there was room for improvement. HealthLeaders Media Council members discuss where they are finding success in improving care transitions outside of their facility.
This article first appeared in the January/February 2016 issue of HealthLeaders magazine.
Mitch Fillhaber
Senior Vice President for Corporate Development and Managed Care
The Shepherd Center
Atlanta, Georgia
The Shepherd Center is a 152-bed specialty clinic that functions as a rehab hospital with its own ICU. We have one of the youngest rehabilitation populations in the country, and we have a significant MS population who uses our outpatient care facilities. The continuum is a bit different for us than at a typical acute care hospital, and our care transitions are inevitably more complicated.
For many years, we've had a transition-support program that manages the return of high-risk patients and their families to the community, whether it be here in Atlanta, elsewhere in Georgia, or anywhere across the country.
As our patients are discharged, we're assessing the follow-up providers' capability and, if needed, providing education that creates a secure care environment for our patients who are going home. We're also working to provide education to patients and families to make sure they can maintain a positive health status once they've returned home.
Sandra Bailey
Vice President of Care Transitions
Methodist Healthcare
Memphis, Tennessee
We've found that employing care navigators has improved care transitions in our facilities. Navigators utilize multiple strategies in their roles, including leading interdisciplinary care teams, meeting with families, and determining resources the patient will need when they go home.
We have an evaluation team that determines whether the patient will benefit from home care. If they will, their physician then talks to the patient and tells them that they've recommended home care for them. We find it's a more proactive way to address the situation.
We also have teams that meet with high-need patients, and then those patients have a comprehensive discharge plan that's developed along with the family of the patient. That is initiated at the beginning of the hospital stay, revised throughout the stay if the needs or condition of the patient changes, and then, at the end of the stay, is coordinated by the case manager and a social worker along with the patient and their family.
We are also working with local churches in several areas that high-need patients live in. These churches are offering to help families with their special needs.
Patient education is critical. Methodist Healthcare is partnered with the Mayo Clinic system, so we have access to its educational material that we can add to our own ongoing education for patients and their families.
Jill Barber
Director of Managed Care Operations
and Revenue Integrity
Southwest General
Middleburg Heights, Ohio
The seemingly counterintuitive answers to the survey don't surprise me. Everyone thinks that their continuum resources are sufficiently strong for how we have practiced healthcare in the past, but, as we get more involved in things—such as readmissions penalties, as well as being concerned about bundled payments and other alternative payment models—we're realizing that what has been good enough in the past is going to need improvement, or will no longer meet our needs at all.
We are really pushing forward in developing a preferred provider network for postacute care. In the near future, there are going to be rules about how postacute providers play within that network, how they join, how they receive referrals, and how they are also removed and replaced with another provider.
We are starting to realize that there's no one flavor of home health, there's no one flavor of skilled nursing, that one size doesn't fit all. For example, home health for a congestive health failure patient will be very different from home health for a patient with a knee replacement. We are trying now to coordinate a better postacute care model and care-continuum flow with a set process for each of our patient populations. We want to recognize that while also setting standards that providers must work within.
Terry Preite
Benefis Spectrum Medical
and Regional Relationships
Great Falls, Montana
On patient education: Educating patients is everything. We continue to modify our processes to incorporate more education throughout the patient's stay, and to our postdischarge programs. An example of that is our Safe Landing program, which is an extension of the discharge planning process. A nurse visits the patient's home and goes over the discharge instructions with them to ensure they understand everything.
On discharge planning: Discharge planning is no longer the last step in the process; it's the focus of the entire stay. What is this patient going to need when they go home, or go to their next level of care? We focus on patient education and on engaging patients in the healing process, both during and after their hospital visit.
On rural challenges: Benefis is the major tertiary center for a region that spans 40,000 square miles. Many towns in our service region have fewer resources available to care for patients. It's been difficult at times to ensure that patients returning to their homes have the support that they need. Improving communication with primary care providers in the patients' hometowns is part of this challenge. CMS recently awarded a grant to Liberty County Hospital—a member of our Northcentral Montana Healthcare Alliance—to work on improving care transitions to these small communities along with local critical access hospitals.
In our September 2015 Intelligence Report, hospital and health system leaders indicated that physician engagement is the most difficult aspect of aligning physicians. HealthLeaders Media Council members discuss ways they have succeeded in improving physician engagement.
This article first appeared in the March 2016 issue of HealthLeaders magazine.
John Haupert
President and CEO
Grady Health System
Atlanta, GA
The No. 1 initiative we've taken to improve physician engagement is addressing and resolving the operations pain points physicians felt were interfering with their ability to be efficient in their work. Our physicians felt they were having to create workarounds in order to work through the system, so we extended efforts on operational process improvement using Lean and Six Sigma to streamline the processes that the physicians touch most, such as scheduling, electronic medical record optimization, and reducing the number of steps physicians have to take to access patient data.
The second area we've improved is communication with the medical staff by keeping them in the loop and involving them more in governance of the organization. We've created more positions for physicians on our board of directors and added senior executive rounding alongside physicians so that there's better communication between our docs and upper management.
We've also implemented yearly physician engagement surveys. We make it a point to ensure that the physicians know that their opinion is heard, as we create action plans for the organization based on the survey results.
I think physicians respond best to an environment where they can do the best work possible—the work they enjoy doing—with the operational and bureaucratic barriers that sometimes frustrate them eliminated.
Lewis Marshall, MD
Chairman of Ambulatory Care
Brookdale University Hospital and Medical Center
Brooklyn, NY
The first thing we attempted was direct employment for all docs practicing in our hospital. Previously, we had some nonemployed primary care and specialty care physicians, and we converted them to hospital employees. When you provide the physicians with a salary, benefits, malpractice coverage, office space, and support, it can be a meaningful step toward getting them on board. We learned, however, that this is no guarantee of engagement.
Our next step was to get these physicians involved in our processes. We decided to involve physicians in decision-making in areas that will improve patient experience or care, reduce hospitalization, or save money. We also developed an education and training program around meaningful use, which we got our entire staff involved in—nurses, doctors, even housekeeping and security, so that everybody understands that everybody has a role.
The next thing that we're trying to do is identify physician champions of different healthcare processes. For example, I've been a physician champion for information technology for years. I have three or four colleagues who have also become champions for information technology. I have them test out new things before I implement them in the hospital at large. So that's another way that we're trying to get physicians engaged: We identify champions among the medical staff and further engage them.
James Irwin, MD
Medical Director of Anesthesia and retired Chief Medical Officer
Samaritan Healthcare
Moses Lake, WA
On the obstacles: The greatest obstacle to physician engagement is time. Most physicians are trying to balance their professional lives with their home life and earning an adequate salary. That's one of the greatest hurdles to getting people involved. Helping doctors to find the balance between home, work, and reimbursement might improve this. Another barrier can be the electronic health records, although, as EHR systems become more sophisticated, I do think it is becoming less of a burden.
On the solutions: We've found that physician engagement is really about getting the right people involved. In other words, you don't put somebody in medical staff leadership just because they've been in the organization for 20 years. You put in people who are interested in expanding their horizons, but you also have to provide support.
We're finding more and more that many times we are having to provide some type of reimbursement for physician leadership. If they're employed, that's relatively easy; if they're a member of another organization, hopefully your relationship with that organization is good enough that you can get them to make sure they get RVU credit for their time spent leading hospital committees, or something similar.
My advice to anyone taking ownership of this would be to be careful who you select as an engagement leader, and continue to mentor and nurture them. Don't just turn them loose. Provide them with some expectations and develop the engagement program with them.
Jeffrey DiLisi, MD
Senior Vice President and Chief Medical Officer
Virginia Hospital Center
Arlington, VA
I think the greatest obstacle toward keeping our physicians engaged is the amount of things we're asking of them. Between new EMRs, ICD-10, quality, and cost initiatives, there's just a lot on their plates. It's important to be transparent, and that transparency is a big part of getting physicians on board. There are many different initiatives and pressures on hospitals to be more efficient and really provide the best value to patients, and to be able to do that, you need your doctors to be part of the conversation.
In our hospital, we make decisions based on what will be best for the patient, and we believe that encouraging your medical staff to think in a patient-centric way really helps.
For example, if you want to extend office hours, a doctor might object, saying you're already asking so much of them, and now you want them to work nights and weekends, too. They might not like that, but if you can get them to see it from the patient's perspective—when does the patient have time to see the doctor, when is most convenient for them?—they might better understand. Organizations that will thrive in value-based care will be the ones that can encourage a collaborative atmosphere among their staff and get the most physician engagement.
Despite the popularity of workplace wellness programs, little has been understood about how employees respond to incentives. Until now.
Workplace wellness programs that encourage and incent employees to adopt healthful habits are widely popular with hospitals and health systems. Upwards of 80% of large organizations offer some sort of wellness program.
But their effectiveness is up for debate.
The programs are notoriously difficult to incentivize. Many employees who respond well to incentives for goals such as smoking cessation, more physical activity, and weight loss are already motivated, says Mitesh Patel, MD, assistant professor of medicine at the Wharton School of Healthcare Management in Philadelphia.
Until recently there was little research on financial incentives to boost physical activity. But Patel recently published a study in the Annals of Internal Medicine, suggesting that greater accessibility and proper framing of incentives can lead to greater effectiveness.
Mitesh Patel, MD
"A lot of challenges around workplace wellness programs are around engaging employees who need it most," says Patel. "We wanted to learn how best to design an incentive to do that." Patel spoke with me about his findings. The transcript of our conversation has been lightly edited for clarity and length.
HLM: What can you tell me about why you chose to study workplace wellness program financial incentives?
Patel: Some of the reason we did this study is that workplace wellness programs are growing in popularity across the country. More than 80% of large employers offer financial incentives for health promotion to their employees to help them achieve health goals, which includes things like physical activity. But the best way to design these incentives to help improve outcomes hasn't really been consistent.
HLM: How did you design your study?
Patel: We conducted a study using 281 people, randomly assigning them to four groups. We asked them to achieve 7,000 steps daily, tracking their steps using an app on their smartphones. We gave everyone daily feedback for 26 weeks based on whether or not their daily goal was met. At 13 weeks, three of the groups got a financial incentive based on whether or not they achieved that 7,000 step goal.
A quarter of them were a part of the game arm, which utilized an approach similar to what most employers use when designing workplace wellness invectives. If they did the work to meet their goal, we would pay them $1.40 for each day they met their goal once the study was completed.
Then, there was a lottery arm, featuring a lottery where the subjects could win money for the days they met their goal.
There was also a loss-framing arm, in which on day one of every month for three months we told the participants that $42.00 had been placed in a virtual account for them, and for every day that they didn't meet their goals, we'd take $1.40 away from that account.
We told all three of these groups was that at the end of the study, we'd send them a check with all of their accumulated earnings. So, everyone was getting paid the same way, we were just framing the incentives differently.
There was also a control arm, in which people just got daily feedback with no financial incentive.
HLM: Which group performed best?
Patel: The loss arm achieved their goal about 45% of the time, which was 15% higher than the control group. It is statistically significant.
The control arm achieved their goal about 30% of the time.
The lottery arm achieved their goal 35 to 36% of the time, which is slightly higher, but statistically no different from not paying them at all, which was very interesting. We found that paying people $1.40 a day to achieve a fitness goal was really no different from not paying them at all.
HLM: What are some takeaways from your study that can help HR teams design better wellness program incentives?
Patel: There are a couple of key takeaways from our study. The first is that many people are interested in using incentives, but they often don't pay enough attention to how they design of these incentives. Our study found that design is critical to success.
More specifically, we can leverage insights from behavioral economics. From that area of study, we know more people are motivated by losses and engaged by variable rewards more than they are by constant rewards. Also, they want to be rewarded now, in the present; people want immediate gratification.
They're less motivated by rewards that are offered later, and less apt to do something that will benefit them far in the future. Incorporating these lessons from behavioral economics into wellness program design can lead to better outcomes.
HLM: How can a wellness program be designed to engage more employees?
Patel: A challenge for many workplace wellness programs is that they attract employees that are already very motivated and physically active as opposed to the people who are sedentary or sitting at their desk all day and could benefit the most.
We designed our study to try to attract those people who could benefit the most, enrolling only people who were overweight or obese. The mean BMI in our sample was 33; BMIs of 30 and above are considered obese. So, this was a very heavy sample, and more high-risk than an average workforce.
We've also found that many workplace programs use higher goals, like 10,000 steps, because it's a nice, round number. But there's no evidence that number is particularly good for anything other than attracting people who are already fairly physically active. So, we aimed for 7,000 steps, because that's supported by the American College of Sports Medicine as the minimum you need to start gaining benefits from physical activity, and because it's 40% higher than the national average, which is 5,000 steps.
It's a reasonable goal to engage people who are sedentary at a baseline. We found that 96% of people finished the entire six-month study. That's even after turning the incentives off at three months. That's far higher than you'll see in a typical workplace wellness program.
We think part of the reason why so many participants continued even after the incentives were turned off had to do with the design of the study. It was a reasonable goal, and we used smartphones to track their steps.
It's easy, because 70% of Americans have smartphones. They're already used to carrying them everywhere they go and charging them, and we can pull the data passively from their phones and give them feedback without them having to do any work. We think the smartphone approach might be scalable to larger populations, such as employers who are very large.
HLM: Does this study indicate that using "carrots" or "sticks" is more effective?
Patel: It's really important to note that our study did not use "sticks," in that we did not take any money away from the employees' pockets.
We framed a carrot in three different ways, the most successful of which was that we would give it to you up front for not doing anything, and then take the carrot back if you didn't meet your goals.
Some people might interpret this finding as "sticks" being more effective than "carrots," but I think it's more about framing the reward differently. It's about being more creative and thinking about ways we can leverage the irrational tendencies to achieve better success.
