Susan Bray-Hall, MD, was named CMO of VA Rocky Mountain Network on July 1. She had been serving as Interim CMO of the Denver-based U.S. Department of Veterans Affairs (VA) health system since November 2023. Prior to joining the VA Rocky Mountain Network, Bray-Hall served as chief of staff for the Oklahoma City VA Health Care System.
VA Rocky Mountain Network features 18,000 employees, eight hospitals, and a $5 billion operating budget. It has the largest geographic footprint of VA health systems in the lower 48 states, serving five primary states (Colorado, Montana, Oklahoma, Utah, and Wyoming) and portions of five other states (Idaho, Kansas, Nebraska, Nevada, and Texas).
One of the primary challenges of leading clinical care in such a large organization is listening and making sure that staff members are heard, according to Bray-Hall.
"I need to build relationships, spend time at all of the facilities, encourage the building of teams, and get staff to speak up," Bray-Hall says. "If I am listening to the staff, we won't miss important concerns."
For a CMO, listening is essential to promote patient safety, according to Bray-Hall.
"My primary approach to patient safety is empowering staff to speak up," Bray-Hall says. "I want staff to be able to comment on their concerns and have them taken seriously. They are the ones who are most likely to see patient safety issues."
Bray-Hall says her patient safety concerns include medication safety, surgical safety, and healthcare-associated infections, but she must be aware of the full spectrum of patient safety.
"I am concerned about taking care of patients' mental health, physical health, primary care and prevention, and all of the services in between," Bray-Hall says. "So, when it comes to patient safety for me, it is not a particular focus, it is always a global focus."
For a CMO, listening is also pivotal to promoting quality care, according to Bray-Hall.
"It is important to listen to your staff," Bray-Hall says. "The best ideas come from the frontline staff when they are taking care of the veterans."
Susan Bray-Hall, MD, is the new CMO of VA Rocky Mountain Network. Photo courtesy of VA Rocky Mountain Network.
The VA model of care
VA health systems are veteran-focused and provide comprehensive care, according to Bray-Hall.
"We embrace population health," Bray-Hall says. "We have special education for staff to care for veterans. We focus on the multi-morbid patients, so we are concerned about the global needs of our veterans. We do a ton of prevention. We provide comprehensive and coordinated care."
Given the needs of their patient population, VA health systems have several focal points, according to Bray-Hall.
"The data supports that the VA provides some of the best care in the country for cardiovascular care and preventative health," Bray-Hall says. "We are focusing on making sure that patients are getting the comprehensive care they need for their cardiovascular care in the primary care setting. Mental health and suicide prevention are core services."
Care coordination is a top priority at VA health systems, according to Bray-Hall.
"We have social workers that do care coordination and intensive case management for high-risk veterans. These are patients who have significant conditions and hospitalizations," Bray-Hall says. "We have nurses who do care coordination in primary care and that is their main job."
The VA provides care coordination in medication management.
"We have a single pharmacy record, which is extremely helpful because medications can get mixed up when a patient is going to multiple pharmacies and multiple sites of care," Bray-Hall says.
Prepared to lead
Bray-Hall is board certified in internal medicine, geriatrics, hospice, and palliative care, which provides a solid foundation to serve in the CMO role.
"I rely on my medical background all the time," Bray-Hall says. "Internal medicine gives you the breadth and knowledge base across the adult lifespan. My geriatric training taught me a lot about systems-based care and how to improve systems to provide quality care and take safer care of patients. My hospice and palliative care training taught me about listening and empathy."
Bray-Hall says her approach to leadership as CMO is to be accessible to peers and staff.
"I also share my successes and my failures," Bray-Hall says. "I want to always be authentic, which helps people feel they can come to me. I also have a connection with clinicians. I will be doing geriatric consultations via telemedicine for veterans who are frail."
Yale New Haven Health launched a major initiative four years ago to reduce variation in care at the health system's four acute-care hospitals and outpatient sites.
Yale New Haven Health is seeking to reduce variation in the delivery of care with the health system's Care Signature Initiative.
Decreasing variation has been a central goal of quality improvement since W. Edwards Deming pioneered the concept in the Toyota Production System in the 1970s. In care delivery, research has shown the consequences of inappropriate variation include underusing needed services, overusing unwarranted services, higher costs, and worse clinical outcomes.
Yale New Haven Health launched its Care Signature Initiative in late 2019 and early 2020, says Chief Clinical Officer Thomas Balcezak, MD, MPH.
"The intent was based on the idea that variation is bad and that we should develop a clinical consensus on how specific conditions should be evaluated, diagnosed, and treated," he says.
The initiative has developed more than 600 Care Signature Pathways that are used thousands of times per week. The first Care Signature Pathway that the health system developed was for COVID-19, Balcezak says.
"We updated the Care Signature Pathway for COVID-19 every time a new therapy was determined to be effective, or an old therapy was determined not to be effective," he says. "As it worked out, we were updating that Care Signature Pathway practically every other day."
The impact of that pathway, Balcezak says, was profound.
"Our mortality was not only among the lowest in the country but also no different if you were in our smallest hospital in Westerly, Rhode Island, or at our academic medical center," he says. "We were able to achieve good outcomes at all of our hospitals because no matter which facility patients touched, they got the same care delivered in the same way."
Care Signature Pathways are developed by Care Signature Councils, which consist of representatives from all of the disciplines involved in the care for a particular condition. Those councils also update pathways as new medical knowledge arises.
"We give the council space and time to drive to consensus around the appropriate diagnostic work-up tests and the appropriate therapeutics for a particular medical condition," Balcezak says.
Once a pathway is developed, it is integrated into the health system's Epic EHR. Once a pathway is available on Epic, clinicians can populate care plans for patients automatically.
"We can make physicians' jobs easier by using technology to deliver recommendations," Balcezak says. "For example, if they are trying to treat pneumonia, we have a Care Signature Pathway for that condition, and they can click on a button in the EHR that populates the order set."
Thomas Balcezak, MD, MPH, is chief clinical officer of Yale New Haven Health. Photo courtesy of Yale New Haven Health.
Generating results
Balcezak says the initiative has produced positive results.
"We have gotten to a reduction in variation that has been a bedrock of quality improvement for years," he says.
For example:
Alcohol use disorder: The health system's Care Signature Pathway for alcohol use disorder recommends a treatment plan and gives the physician a recommended order set. Before Care Signature Pathways were created, only about 14% of the patients received proper treatment; now roughly 85% of patients are getting that recommended treatment.
High-sensitivity troponin test: In February 2023, a new high-sensitivity troponin test became available. Troponin is an enzyme that is released by heart tissue when it is injured, so testing for troponin in patients who present with chest pain in the emergency department can determine whether they are having a heart attack. The health system has a Care Signature Pathway for the high-sensitivity troponin test that includes the level of troponin that prompts a cardiology consult and the level of troponin that allows a patient to go home safely. The pathway has led to significant reductions in emergency department length of stay and hospital admissions.
Blood cultures: On June 28, Becton, Dickinson, and Company informed Yale New Haven Health of a shortage of blood culture bottles, forcing the health system to reduce blood culture testing. The health system created a Care Signature Pathway to address the variation in stewardship for blood cultures, including appropriate reasons to do blood cultures, appropriate intervals for blood cultures, and protocols for conducting blood cultures such as the amount of blood required. Within three days, the health system reduced blood culture utilization by 65%.
Implementing Care Signature Pathways
When a Care Signature Pathway is developed, the primary goals of the health system for introducing them to clinicians are to achieve rapid change in clinician behavior and rapidly institute standardized practice to improve operations, throughput, quality, and safety, Balcezak says.
"Each one of those factors is intimately integrated with one another," he says. "You don't get high-quality and safe care without efficient, streamlined, and standardized operations. They go hand-in-glove."
Clinician adoption has a generational element, Balcezak says.
"Clinicians have changed over time," he says. "Today's generation of clinicians is much more likely to accept suggestions and Care Signature Pathways. In the 1990s, you would hear clinicians say, 'I do not accept cookbook medicine.' Today's physicians realize that standardization is not cookbook medicine—it is best practice."
The potential to make the lives of clinicians easier is a powerful incentive for clinicians to adopt the pathways, Balcezak adds.
"Clinicians are much more likely to accept a Care Signature Pathway because it gives them answers right at the time they are seeing patients, and pathways make it easier to do the right thing and harder to do the wrong thing," he says.
The older adult population is growing sharply, and patients over the age of 65 are high utilizers of healthcare services. CMOs must be 4 steps ahead.
With older adults constituting the majority of patients in U.S. hospitals, it is essential for CMOs to be four steps ahead, says the CMO of Burke Rehabilitation Hospital in White Plains, New York.
As we know, the number of Americans who are 65 or older is sharply rising and is expected to increase from 58 million in 2022 to 82 million by 2050. During this period, the share of the total population of Americans who are 65 or older is expected to increase from 17% to 23%.
Members of this segment of the population are high utilizers of healthcare services, which makes adoption of age-friendly care at health systems and hospitals imperative, says Mooyeon Oh-Park, MD, MHCM, senior vice president and CMO at Burke.
"We need to think about who is using healthcare," Oh-Park says. "The vast majority of people using healthcare services are older adults."
At Burke, 72% of patients are 65 or older.
In 2023, Burke joined the Age-Friendly Health Systems movement, which is led by the Institute for Healthcare Improvement and The John A. Hartford Foundation in partnership with the American Hospital Association and Catholic Health Association of the United States. The movement is designed to accelerate and spread evidence-based care for older adults. A primary goal of the movement is to push adoption of four evidence-based elements of high-quality care for older adults, known as the 4Ms: medication, mobility, mentation, and what matters most to older patients and their families.
"Using the 4Ms of age-friendly care developed by IHI is improving outcomes for older adult patients," Oh-Park says.
According to Oh-Park, patient experience scores at Burke have improved significantly since the hospital adopted the 4Ms.
Age-friendly care innovations
Burke has launched several innovations to support age-friendly care over the past two years, Oh-Park says.
One innovation is use of CatchU, which is a digital app developed by neuroscientists at Albert Einstein College of Medicine. The app focuses on assessing the risk of falls among Burke's older adult patients and older adults living in the community, Oh-Park says.
For people to be able to move around without falling, they are constantly integrating visual stimulus and the feeling on the bottom of their feet. People react to that stimuli, which is why they do not fall. A person's ability to integrate multiple stimuli can predict future falls, according to Oh-Park.
"The CatchU digital app can measure how well a person can integrate multiple stimuli," Oh-Park says. "Based on the results of these measures, we can make a recommendation such as whether a person needs more balance exercise or needs counseling to avoid falls."
Another age-friendly care innovation that Burke has adopted does not involve technology. In inpatient rooms, the hospital has hung a "Get to Know You Board." Patients are asked to post things that could be a surprise to know about them such as what makes them happy, Oh-Park says.
"Within a couple days after admission, patients list things about themselves on the board," Oh-Park says. "It is a tool to develop a relationship with the patient and to recognize what is important to them, which is one of the four primary elements of age-friendly care."
Challenges of providing age-friendly care
Age-friendly care involves implementation of evidence-based practice, says Oh-Park, adding that high-quality implementation is always challenging, especially in complex clinical settings.
"One of the greatest challenges is bringing everybody on your staff on the same page and maintaining the initial excitement about age-friendly care," according to Oh-Park. "Then you must continue the momentum. Learning how to overcome these challenges is extremely rewarding for an organization, and it requires leadership skills and creativity."
Monitoring mentation is an example of an element of age-friendly care that requires all members of a clinical staff to be on the same page, Oh-Park says.
When older patients are admitted to Burke, they may be confused because of anesthesia, medication, or the unfamiliar environment, according to Oh-Park. To make sure the confusion is not related to an underlying condition such as dementia, the hospital has provided education about mentation to physicians, nurses, and other clinical staff.
"We can change medications or be on the lookout for a developing infection or dehydration," Oh-Park says. "Identifying changes in mentation requires everybody to be on the same page, including doctors, nurses, physical therapists, and family members."
Physician reimbursement from Medicare decreased 29% from 2001 to 2024, according to the American Medical Association.
The proposed 2.8% physician payment cut in the 2025 Medicare Physician Fee Schedule is not sustainable, the CMO of a New Jersey-based health system says.
On July 10, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for the Physician Fee Schedule that would reduce the conversion factor for physician reimbursement from $33.29 this year to $32.36 next year. The conversion factor is the number of dollars assigned to a relative value unit (RVU), which is a key element of physician payment by Medicare.
If the payment cut is adopted in the 2025 Physician Fee Schedule final rule later this year, it would be the fifth consecutive year that physicians experienced a reimbursement cut from Medicare.
Physician reimbursement from Medicare decreased 29% from 2001 to 2024, according to the American Medical Association.
The proposed 2025 reimbursement cut would have a significant negative impact on health systems, hospitals, and physician practices, says Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer at RWJBarnabas Health.
"The cost of healthcare is rising," Anderson says. "There is clearly inflation in our economy, and having the reimbursement go down is absolutely the wrong direction. The Physician Fee Schedule model is not sustainable if the reimbursement is going to be cut. Reimbursement needs to keep pace with inflation and the cost of healthcare."
Medicare physician payment cuts are hitting the bottom line of healthcare organizations, according to Anderson.
"It handcuffs our health systems and hospitals to make the investments they need to make in infrastructure as well as to provide a fair wage to employees including physicians," Anderson says. "These reimbursements cuts are not going to help healthcare grow over time."
To cope with the reimbursement reduction trend, health systems, hospitals, and physician practices must reduce costs and find efficiencies, Anderson says, adding that these efforts include stewardship of services and resources, such as laboratory tests, radiology tests, and pharmaceuticals.
"We need to question ourselves and make sure we are using our resources judiciously," Anderson says.
According to Anderson, another area where health systems and hospitals can contain costs is throughput—moving patients through hospitals as efficiently as possible.
"Some of that is through better discharge planning," Anderson says. "Some of that is through better throughput in our emergency rooms. We need to focus on throughput efficiency while being safe at the same time."
In addition to proposing a 2.8% physician payment cut next year, CMS predicts that the Medicare Economic Index, which is the measure of physician practice cost inflation, will increase by 3.6% in 2025. The gap between the reimbursement cut and inflation places a significant financial burden on healthcare providers, according to Anderson.
"Medicare needs to match inflation with reimbursement and to make sure that this gap is not widening," Anderson says. "It is creating stress points financially on our healthcare system, and that is not a sustainable model."
After the pandemic, 78% of healthcare facilities report anesthesia staff shortages. Here's how to fix it.
The country is grappling with a critical shortage of anesthesia staff and several steps need to be taken to address the problem.
A recent article published in the journal Anesthesiology detailed the extent of the anesthesia staff shortage and offered solutions to rise to the challenge. According to the article, before the coronavirus pandemic, 35% of healthcare facilities reported an anesthesia staff shortage. Two years after the pandemic, the percentage of healthcare facilities reporting an anesthesia staff shortage rose to 78%, the article says.
"For me, the biggest challenge of the anesthesiologist shortage is patient safety," says Gulshan Sharma, MD, MPH, senior vice president and chief medical and innovation officer at The University of Texas Medical Branch at Galveston. "It's a different ballgame when you are putting a patient under anesthesia. You want to make sure you have a talented team of anesthesia professionals who can help manage the patient."
There are three primary strategies to address the anesthesia staff shortage, according to Sharma.
"One strategy is to make sure that anesthesiologists are paid fairly based on the market, which is one thing we have done to improve recruitment and retention," Sharma says. "A second strategy is to support anesthesiologist well-being, which is something we are working on. A third strategy is to staff low-risk areas with outside agencies. We have pursued all three of these strategies at UTMB over the past couple of years."
Tackling the problem
There are no short-term solutions, but several steps need to be taken to address the shortage of anesthesia staff, the lead author of the Anesthesiology article says.
A critical step is increasing the number of training positions for anesthesiologists, says Amr Abouleish, MD, MBA, professor of anesthesiology at UTMB.
"One approach is to increase the number of training positions in existing programs, which is my preference," Abouleish says. "The challenge is funding those positions—they are not free positions and residents need to be paid."
At this point, the Centers for Medicare & Medicaid Services does not pay for these positions, so hospitals must pay for them, according to Abouleish. The good news is that with anesthesiology staffing tight, CMOs and other healthcare leaders can make a good argument that funding resident positions actually saves money for hospitals because they don't have to hire costly locum tenens staff.
"Another approach is starting brand new training programs," according to Abouleish. "A lot of the new programs are partners in a nontraditional sense. We have a paradigm shift, where facilities such as HCA Healthcare hospitals and companies such as North American Partners in Anesthesia are partnering to create residency programs."
This is a paradigm change because residency programs have traditionally been at academic institutions or private practices.
Healthcare organizations need to promote retention of anesthesiologists and certified registered nurse anesthetists (CRNAs), Abouleish says.
"One of the things we must do is reduce burnout," according to Abouleish. "We are short people. And when we hire locum tenens anesthesiologists, they usually are not on call. In 2021, my department's anesthesiologists averaged five to six in-house calls per month. That was tolerable, but it contributed to burnout."
According to Abouleish, burnout is a hard problem because until hospitals recruit new anesthesiologists, existing clinicians are taking on too much call.
"UTMB has been addressing burnout—we have increased compensation to make our positions more attractive to boost recruitment, which makes us less stretched thin," Abouleish says.
Another retention strategy is to increase opportunities for anesthesiologists and CRNAs to have flexible schedules or part-time hours, Abouleish says.
As young anesthesiologists grow their families, healthcare organizations need to promote work-life balance as well as have flexible and part-time positions available to them, according to Abouleish, who added that when female anesthesiologists have a baby, they should be allowed to come back and work part-time.
Part-time positions are also important for anesthesiologists and CRNAs who are close to retirement, Abouleish says, adding that part-time positions can be the difference between anesthesia professionals leaving for retirement or staying at a reduced capacity for several years.
Hospitals need to effectively manage Non-Operating Room Anesthesia (NORA) sites and place them close to operating rooms, according to Abouleish. NORA sites include cardiac catheterization labs, gastrointestinal and endoscopy suites, and interventional radiology suites.
"At a freestanding children's hospital, NORA sites are almost 50% of the anesthetizing sites required," Abouleish says. "At UTMB, NORA sites are almost 30% of the anesthetizing sites. There has been an explosion of NORA sites."
Geographic isolation of anesthesia sites challenges understaffed anesthesiology teams, according to Abouleish.
"If I were to build a new hospital today, I would have all interventional patients on the same floor," Abouleish says, "the pulmonary lab, the gastrointestinal lab, the cath lab, interventional radiology, and operating rooms all on the same floor."
The new diagnostic test determines the level of activation of a patient's immune system, which reflects whether the patient has sepsis.
A Baton Rouge, Louisiana-based hospital has generated positive results such as reduced cost of care from using a new artificial intelligence-driven early diagnosis tool for sepsis.
Sepsis is the body's extreme reaction to an infection that can result in tissue damage and organ failure. Annually in the United States, there are at least 1.7 million adult hospitalizations for sepsis and at least 350,000 deaths from the condition, according to the Centers for Disease Control and Prevention.
Our Lady of the Lake Regional Medical Center, which is part of Baton Rouge, Louisiana-based Franciscan Missionaries of Our Lady Health System, has adopted IntelliSep, an AI-driven sepsis diagnostic testing system developed by San Francisco-based Cytovale Inc. IntelliSep gained Food and Drug Administration approval in January 2023.
IntelliSep determines the presence or absence of sepsis by measuring the activation of a patient's immune system, says Catherine O'Neal, MD, CMO at Our Lady of the Lake Regional Medical Center.
"As a patient approaches severe sepsis and septic shock, the immune system is more activated," she says. "IntelliSep measures the range of activation from a patient who is not activated at all to a patient who has a highly activated immune system against an infection. Highly activated patients tend to be more likely to have septic shock."
IntelliSep is one of several AI-driven sepsis diagnostic tools that have been developed in recent years. Other AI-driven sepsis diagnostic tools include the following:
Steripath, which decreases blood culture contamination to increase sepsis testing accuracy
Sepsis Immunoscore, which is an AI and machine learning software that is designed for rapid diagnosis and prediction of sepsis
Targeted Real-Time Early Warning System, which is an algorithm developed at Johns Hopkins Medicine that is integrated into electronic health records and is designed for early recognition of sepsis
Benefits of using IntelliSep
Our Lady of the Lake Regional Medical Center has generated several benefits from using IntelliSep.
The sepsis diagnostic test has improved efficiency in the emergency department, O'Neal says.
"It is getting patients through the emergency department more efficiently," she says. "You want your testing to pinpoint what is wrong with a patient as quickly and accurately as possible. The test can tell us within 10 minutes whether the patient is seriously ill from an infection or the patient is not infected at all and not seriously ill. By pinpointing who needs care faster, we can be more efficient with the rest of our testing and get patients through the ED faster."
IntelliSep has decreased the number of blood cultures taken at the hospital, says Christopher Thomas, MD, vice president and chief quality officer at Franciscan Missionaries of Our Lady Health System.
"Because we are concerned about sepsis and its high mortality in the United States, the Centers for Medicare & Medicaid Services tells us that every patient with a suspected infection must get blood cultures," he says. "If you don't know who is going to get sick, and you can't tell the difference between a patient with an activated immune system and a patient who does not have an activated immune system, then they all should get blood cultures."
Over the eight months that Our Lady of the Lake Regional Medical Center has used IntelliSep, the hospital has spared 1,800 patients from getting blood cultures, Thomas says.
"That's a big deal because it is a procedure," he says. "Not getting a blood culture is a big deal to me. It takes about eight minutes to collect each blood culture and you must do it perfectly. About 2% of the time, a blood culture comes back positive for an infection because of bacteria on the skin."
IntelliSep has reduced cost of care, Thomas says.
"We know from a study that we are saving patients who receive the IntelliSep test an average of $1,400," he says. "That comes from not having to prescribe an expensive antibiotic. That comes from avoiding blood cultures. That comes from patients spending less time in the hospital."
A recent study published in Academic Emergency Medicine found that IntelliSep correctly identified which patients did not have sepsis 98% of the time, making it an essential tool for clinicians to rule out sepsis and explore alternative diagnoses.
The accuracy of the test has been a boon at Our Lady of the Lake Regional Medical Center, O'Neal says. The impact of IntelliSep is similar to an electrocardiogram, she says, noting an electrocardiogram can tell a clinician whether a patient is having a heart attack or just has chest pain from another source such as indigestion.
"IntelliSep generates similar benefits," O'Neal says. "A patient may have an abscess, but IntelliSep can tell us whether we have time to observe the patient or let the patient go home. If IntelliSep indicates that a patient has sepsis and we identify it early, we can save lives through early intervention. We now have a tool that tells us who needs intervention quickly, just like the electrocardiogram tells us whether a patient is having a heart attack and needs care immediately."
Generating results
Data shows that IntelliSep has had a positive impact on patients and operations at Our Lady of the Lake Regional Medical Center, Thomas says.
The hospital conducted 1,800 less blood cultures in six months than the facility did in a six-month span a year ago
Since adopting IntelliSep, the hospital has saved nine days of nurse staffing time
Length of stay for sepsis patients in the ICU has been reduced by two days
Since adopting IntelliSep, the hospital has reduced sepsis mortality by 20%
"From the quality-of-care standpoint, we have never seen this kind of reduction in mortality at our hospital," O'Neal says. "It is hard to move the needle on saving lives."
The top clinical officers at Allegheny Health Network, UW Health, and Houston Methodist have made physician well-being a primary focus.
With a nation-wide shortage of physicians worsening, physician well-being programs are essential for retention and recruitment.
Physician burnout remains a concern across the country, and it spiked during the coronavirus pandemic. In a 2021 survey of physicians conducted by the American Medical Association, Mayo Clinic, Stanford University School of Medicine, and the University of Colorado School of Medicine, 62.8% of physicians reported experiencing burnout symptoms, which was up from 38.2% the previous year.
Health systems and hospitals have launched a range of interventions to improve physician well-being. The efforts range from initiatives to address basic needs such as taking meal breaks to more advanced approaches including improving efficiency of practice such as support for coding and billing.
The following HealthLeaders stories show how three health systems are addressing the well-being of physicians and other staff members.
1.Allegheny Health Network wellness program is improving the well-being of clinicians and nurses: AHN's wellness program started by focusing on basic problems such as making sure staff were taking meal breaks and staying hydrated. Several well-being initiatives that the health system adopted during the coronavirus pandemic have become permanent such as a peer support program. More recent well-being initiatives at AHN include hiring a wellness officer for each institute on the medical staff and creating an advanced practice provider council.
2.UW Health is following best practices for physician well-being: The Madison, Wisc.-based health system is using Stanford Medicine's well-being survey and implementing the Stanford Medicine Model of Professional Fulfillment. UW Health's physician well-being programs focus on a culture of wellness, efficiency of practice, and personal resilience.
CCO Hoda Asmar says the health system improved sepsis care during the first two years by focusing on two processes, including early administration of antibiotics.
After committing to improve sepsis care in 2021, Providence has significantly reduced deaths over the past three years.
Sepsis is an extreme response to infection, and it can lead to tissue damage, organ failure, and death. At least 1.7 million Americans develop sepsis annually, and one third of patients who die in U.S. hospitals have sepsis during their hospitalization, according to the Centers for Disease Control and Prevention.
"Sepsis care is a key focus for us," says Hoda Asmar, MD, MBA, executive vice president and chief clinical officer at Providence. "We have made significant strides, and we will continue to make strides. This is something we are going to be working on for years to come, and we are saving lives."
Asmar says Providence focused on two processes during the first two years:
The health system has more than doubled use of a standardized order set for sepsis patients. The primary elements are blood work and tests used to diagnose sepsis, administration of antibiotics, intravenous fluid resuscitation, and management of hypotension. Providence now uses the order set for 76% of patients presenting with sepsis and hopes to raise that rate to 80%.
The health system is also setting a goal to have the first antibiotic administered within one hour of identifying a patient with sepsis. It’s currently meeting this goal for 77% of patients, with a target of 80%.
Asmar says those efforts helped reduce sepsis deaths from 2021 through 2023.
"Our end goal is to be at a rate better than expected mortality," she says. "The way we measure sepsis mortality is the ratio between observed mortality and expected mortality. The expected mortality comes from a benchmark based on the acuity of the patients we see. We want to be better than 1.0 on the sepsis mortality ratio of observed mortality and expected mortality."
In 2021, Providence ended the year with a sepsis mortality observed-to-expected ratio of 1.11. In 2022, that ratio was 1.04, and in 2023 the ratio was 0.90.
Last year, the health system saved an estimated 1,250 lives of sepsis patients, Asmar says.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer at Providence. Photo courtesy of Providence.
New plans to save more lives
Asmar says Providence is now focusing on four more areas to improve sepsis care:
The health system is looking at gaps between its care performance and the Centers for Medicare & Medicaid Services' (CMS) sepsis bundle expectations, which include early antibiotic use, timing of blood cultures, fluid resuscitation, and management of hypotension.
Providence is looking at sepsis care through a health equity lens. Nationally, several patient populations experience worse sepsis outcomes than white patients, including Black patients and Hispanic patients. The health system wants to solve the unique challenges of vulnerable populations and is working on educational tools in languages other than English. A primary goal is to educate vulnerable populations about sepsis and sepsis care such as seeking care early.
The health system is also focusing on early intervention. The earlier that clinicians can identify sepsis and intervene, the fewer complications and deaths. Providence is focusing on key settings such as emergency departments and urgent care centers. One strategy involves using the EHR to monitor vital signs such as blood pressure, heart rate, and respiratory rate and give clinicians an early warning when sepsis is detected.
Providence is also using the EHR to manage care for patients who are admitted to a hospital for a different diagnosis but show signs of sepsis or septic shock.
"This is an ongoing journey," Asmar says. "There is not just one goal. We want to decrease harm and save lives. We are proud of our achievement in 2023, and 2024 is trending in the right direction to be below expected sepsis mortality."
The health system has focused on catheter-associated urinary tract infection, central line-associated bloodstream infection, Clostridium difficile, methicillin-resistant Staphylococcus aureus, and colon and hysterectomy surgical site infections.
Indiana University Health (IU Health) has significantly reduced healthcare-associated infections through a series of initiatives over the past six years.
On a daily basis, 1 in 31 of hospitalized patients in the United States has at least one healthcare-associated infection, according to the Centers for Disease Control and Prevention. Healthcare-associated infections have several negative impacts, including increased length of stay, hospital readmissions, and morbidity and mortality.
Healthcare-associated infections are a key element of patient safety, which is a top concern for CMOs. Health system and hospital CMOs can learn from IU Health's success in reducing healthcare-associated infections.
Over the past six years, IU Health has focused on several healthcare-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), Clostridium difficile (C. diff), methicillin-resistant Staphylococcus aureus (MRSA), and colon and hysterectomy surgical site infections.
Efforts to reduce these healthcare-associated infections at the health system have decreased these patient harms by nearly 50%, says Christopher Weaver, MD, MBA, senior vice president and chief clinical officer at IU Health.
"In 2017, we had more than 700 of these events. In 2023, we had 382 of these events," Weaver says.
According to Weaver, data and standardization have played key roles in IU Health's healthcare-associated infection initiatives.
"We have focused on good, clean, timely, and actionable data both in outcomes and processes. We have looked at data that shows how we are performing in care bundles," Weaver says. "We have also looked at our standardization of processes and supplies."
National benchmark data indicated IU Health could improve its healthcare-associated infection performance, Weaver explains.
"We looked at national benchmarks for these infections that gave us good data and recognition about the harm that these infections cause," Weaver says. "We were not performing at the level where we wanted to perform."
Christopher Weaver, MD, MBA, is senior vice president and chief clinical officer at IU Health. Photo courtesy of IU Health.
Healthcare-associated infection initiatives
To reduce CAUTIs, IU Health has focused on the care bundle for urinary tract catheters, educating staff on the insertion of catheters as well as the daily care for catheters, Weaver says.
"We started with standardizing the insertion kits—making sure that we had the same insertion kits across the health system, with all of the appropriate supplies in an easily used format," Weaver says. "When someone opens a kit, they have everything they need to insert a catheter."
For CAUTIs as well as CLABSIs, the health system has tried to limit the use of catheters whenever medically appropriate.
"We put a process in place for non-invasive urinary collection devices that avoided the use of invasive catheters. This effort had a tremendous impact in reducing CAUTI events across the health system," Weaver says. "We make sure we do not use urinary-tract and central-line catheters for the sake of convenience."
Daily chlorhexidine gluconate bathing has helped reduce CLABSI events, according to Weaver, adding patients or families were refusing the bathing, which decreased bathing percentages.
"We changed the language from saying it was a bath to saying it was a treatment, which has been more readily welcomed by the patients and just part of their standard care," Weaver says.
IU Health has strived to be more consistent in its efforts to reduce C. diff infections, Weaver says.
"We have standardized the testing of patients for C. diff. We have made sure patients have a positive indication for C. diff, so we are conducting better stewardship of patients who develop C. diff," Weaver says. "When we have a patient with C. diff, we optimize our isolation of the patient to limit the spread of the infection."
The health system has also bolstered efforts to promote hand hygiene and hand-washing among care team staff, which has helped decrease the spread of C. diff and MRSA, Weaver says.
"We also established a process for isolating patients with MRSA infection to drive those numbers down," Weaver says.
To reduce colon and hysterectomy surgical site infections, IU Health has looked "upstream" to focus on patients who are at high risk for a surgical site infection, Weaver says.
"We made sure patients were optimized before it was time for their surgery to decrease the likelihood of infection," Weaver says. "We evaluated patients who were at high risk for an infection and tried to get their medical issues under control. For example, we made sure we were managing diabetes and were giving nutritional supplements for patients at high risk."
The health system also made sure clinical staff were following care bundles for preoperative care, intraoperative care, and postoperative care. In addition, clinical staff focused on daily care of wounds after surgery, Weaver says.
Implementation tips
Weaver explains there is no "special trick" for avoiding these infections to take care of the problem and drive infection rates to near zero.
"In reality, much of the work involves conducting the basics of care and making sure all of our team members understand the importance of infection prevention," Weaver says.
As IU Health posted gains in some of its healthcare-associated infections, it was crucial to maintain those improvements before moving on to other initiatives, Weaver says.
"We were able to improve our performance on CAUTI, CLABSI, and C. diff, and it was important to keep that data in front of us to stay at an optimal level of performance," Weaver says. "Then we shifted our focus to more infections such as MRSA and colon and hysterectomy surgical site infections."
Sean Reinhardt says being successful in his new role includes admitting he does not have all the answers.
Humility is an essential quality for CMOs, the new CMO of Doylestown Health says.
Sean Reinhardt, MD, began his tenure on June 3 at the Doylestown, Penn.-based health system, which features Doylestown Hospital, a 247-bed community teaching hospital with more than 435 physicians in over 50 specialties. He has held several leadership positions at the hospital, including lead physician for the cardiology group, director of the medicine department, and president of the medical staff.
"You need to realize that you do not have all the answers, but there are people around you who probably do have the answers if you bring them in the loop," he says. "You need to lean on other people to help. You need to approach challenges humbly, and say, 'How can I make this better, and who can help me find the solution?'"
There are other qualities that can help a CMO succeed, Reinhardt says.
"It also helps to have a history with the organization, which helps you support the culture," he says. "You obviously must have people skills—you are not going to do well as a CMO if you can't work well with others. You must have good organizational skills because there is a lot thrown at you."
Sean Reinhardt, MD, is CMO of Doylestown Health. Photo courtesy of Doylestown Health.
At this early stage in holding the CMO role, Reinhardt says he has two primary priorities.
First, he wants to promote care quality at Doylestown Health.
"Quality is the center of everything we do," he says. "Nothing happens without good patient care."
"Our medical staff is robust and focuses on the quality of the doctors," he says. "We take very seriously any deviation from quality care, and deviations are investigated in a formal process and dealt with in a timely manner."
Reinhardt says quality is included in patient care metrics.
"Quality is reviewed regularly when we follow various metrics of performance, including door-to-balloon time for the cath lab and door-to-needle time for stroke," he says. "Everyone needs to be invested in improving quality."
Second, Reinhardt is playing a role in merger talks with Penn Medicine.
"Successfully completing that merger is a top clinical priority," he says. "If the merger goes through, success would be defined by maintaining our unique culture while garnering Penn Medicine's strengths and scale."
Reinhardt has clinical experience as a cardiologist, which he says helped prepare him to serve in the CMO role.
"As a specialty, cardiology has many different facets," he says. "There is noninvasive cardiology, which shares a lot of characteristics with primary care. There is interventional cardiology, which is much more procedural-based and involves interactions with surgeons, so I have a surgical background. Cardiology is a great place to develop experience and master the medical issues that come before a CMO."
Promoting patient safety
Reinhardt says he has three priorities when it comes to patient safety.
"My primary approaches to promoting patient safety are to make it the center of our culture, to make sure everyone knows it is essential to our culture, and to make it easy for people to report patient safety issues," he says. "We also need to address patient safety issues and to constantly re-evaluate how we are doing on patient safety. So, it is a continuous process, where you foster a culture of patient safety."
Like other hospitals, Doylestown Hospital has several metrics to evaluate performance on patient safety, such as hospital-acquired conditions, Reinhardt says. Patient safety is addressed at the highest levels of the organization, including a monthly Patient Safety Committee meeting.
Reinhardt says the health system makes an effort to avoid being punitive so that staff will feel more comfortable reporting patient safety issues.
"Everyone understands patient safety reporting is conducted so patients can receive better care," he says. "We all make mistakes. We all have bad days. Everyone knows that the patient safety reporting system is designed to have a teaching moment, where we can all learn."
Leading a medical staff
Reinhardt says his leadership style is focused on working together.
"Being collaborative is the only way to work with a medical staff," he says. "All physicians are very accomplished, and they are not going to be convinced by just saying, 'I told you so.' You must establish a collaborative environment, where physicians feel like solutions are developed with them at the table."
To do this, he says, a CMO must also be an effective intermediary.
"As the CMO, I am here to act as an interface between the administration and the clinical staff," he says. "When someone brings me a problem or challenge, my first reaction is how can I help them fix the issue, whether it is an administrator with a question about the medical staff or vice versa. I am the link between the two sides. I need to be able to speak both languages, so there is communication between the administration and the medical staff."
Susan Bray-Hall, MD, is the new CMO of VA Rocky Mountain Network. Photo courtesy of VA Rocky Mountain Network.
