"I have a unique position, where I understand both the administrative and the clinical languages. The decisions then become more clinically integrated," says the CMO of Davis Health System.
The CMO role continually intersects between the worlds of the physicians and the executive leaders. And because of that, CMOs have the advantage of understanding the physician perspective and bringing that to the decision table in the C-suite, says Catherine "Mindy" Chua, DO, CMO of Elkins, West Virginia–based Davis Health System.
"I have a unique position, where I understand both the administrative and the clinical languages. I understand where doctors are coming from, so I can take that to the table. The decisions then become more clinically integrated and more patient-focused because we have the voice of the doctors," she says.
Chua has been CMO of Davis Health System since June 2016. In March 2020, she was appointed incident commander for the health system's coronavirus pandemic response. Prior to joining Davis Health System, Chua ran a private family medicine practice with her husband for 10 years.
HealthLeaders recently talked with Chua about a range of issues, including her role as liaison between the medical staff and the C-suite, recruiting and retaining physicians, and the keys to success in population health. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Davis Health System?
Catherine "Mindy" Chua: One of the biggest challenges is recruiting and retention in small towns. That has been difficult for the main hospital but even more difficult for our critical access hospitals. Trying to find ways to bring people in and keeping them here has been difficult.
Another difficulty is I am trying to manage both CMO work and operations work. I also work in the clinic.
HL: How have you been rising to the recruiting and retention challenge, particularly when it comes to physicians?
Chua: We have worked hard here to establish a culture where physicians are valued. We work actively to achieve a good work-life balance. We also engaged a recruiter who is not only from this area, but entire generations of his family are from this area, so he is invested and knows how to point people in the direction of what would be interesting to them outside of the hospitals. We understand that selling a place of work is not only just about the brick-and-mortar walls that you are working in, but also the things that recruits are interested in and how we can get them and their families involved and engaged in the community. We want our staff to have a fulfilling work life and a fulfilling personal life.
HL: How are you balancing your role as CMO with operational responsibilities?
Chua: I must make sure that I have good and capable directors and managers working for me. I am a big believer in managing from the ground up; so, I listen to the people who are doing the work rather than micromanaging. I recognize my role is to remove barriers and to mentor rather than being in the weeds doing the work. That allows me the opportunity to get a bird's-eye view of what is going on in my departments, while still being able to maintain my patient care. I have had to attenuate my patient care. I went from a full-time outpatient family practice five days a week to two days a week in the family practice.
Catherine "Mindy" Chua, DO, chief medical officer of Elkins, West Virginia–based Davis Health System. Photo courtesy of Davis Health System.
HL: What are the keys to success in population health?
Chua: Education is a huge factor. It is a fairly new concept for some people, so educating about what population health is and what it means to the organization is important. Education is important for physician buy-in. You also need administration buy-in to get a good population health program going.
Collaboration is the other key component because population health is not just within the four walls of a hospital. It involves bringing in community resources and community experts, so you can get a broad picture of what your community needs. That is the macro view. Then there is the micro view within the hospitals that has to do more with quality metrics and cost metrics. That goes back to education and buy-in because you must have doctors understanding why they must do documentation and what that means to them and the organization.
I am a big proponent of leading with the "why." If you just tell doctors that they need to do this, and you do not give them a broader perspective of why, then they will lack motivation to participate.
HL: How are you serving as a liaison between the clinical staff and senior administrators?
Chua: That is the key role of a CMO. The administrative C-suite has a different set of vocabulary compared to what physicians are taught. Having been in both private practice and as an employed physician, I have a good understanding of the physicians' point of view when it comes to how a clinic should be run or what patients need. I am also having one-on-one communication with patients every day, which the administrators do not necessarily have. I can walk up to a floor and walk into a patient's room, then ask them what I can do to make their day better. I can talk to the physician and find out about the barriers the physician has that I can help remove.
I have a unique position, where I understand both the administrative and the clinical languages. I understand where doctors are coming from, so I can take that to the table. The decisions then become more clinically integrated and more patient-focused because we have the voice of the doctors.
HL: You have served as an American Association for Physician Leadership mentor. What are the qualities of a good healthcare mentor?
Chua: Patience, humility, affability, and the ability to be a good listener are important. When I mentor people, I do not give them a lot of advice—I listen to what they have to say and help them to work through their problems. Mentoring is not about saying, "This is how you need to do this." People cannot grow or learn if they are being shown exactly where to go. If you can be that person who can steer somebody without pushing them—that is a good mentor.
National Committee for Quality Assurance health equity accreditation features six standards such as organizational readiness and availability of language services.
Health equity has become a top priority for healthcare providers nationwide. Last year, health equity was added as the Quintuple Aim for healthcare providers. In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
In July 2021, the Health Information and Management Systems Society conducted a survey of hospital executives for the consultancy BDO regarding the executives' plans to understand, address, and measure health equity challenges. The survey found widespread adoption of health equity strategies or plans to implement health equity strategies:
37% of the hospitals had a health equity strategy in place
37% of the hospitals were planning to implement a health equity strategy in the next 12 months
13% of the hospitals were planning to implement a health equity strategy in the next 12 to 24 months
9% of the hospitals were planning to implement a health equity strategy after 24 months
Only 5% of the hospitals did not have plans to implement a health equity strategy
NCQA health equity accreditation is based on six core standards:
Organizational readiness such as building a diverse staff
The ability to gather race, ethnicity, language, gender identity, and sexual orientation data
Availability of language services
Practitioner network cultural responsiveness to diverse populations
Culturally and linguistically appropriate services that meet the needs of diverse populations
The ability to use data to assess the existence of healthcare disparities and the use of quality improvement initiatives to decrease healthcare disparities
WellSpan's health equity journey
WellSpan took an innovative approach by building a comprehensive health equity program, says Michael Seim, MD, senior vice president and chief quality officer of the health system. "With the work that we did to achieve NCQA accreditation, we had to make sure that we had the underlying infrastructure to be successful. We are working on looking at every aspect of our work at WellSpan through the lens of health equity. For example, we are working on a children's health initiative to make sure we set up children under the age of 6 to be healthy."
A primary focus of health equity work at WellSpan is decreasing life expectancy disparities, he says. "Throughout the country, there are disparities in life expectancy based on whether you live in an urban or rural area, whether you have access to education, whether you have access to housing, and whether you have access to healthy food. So, we are working on this issue as part of our community health needs assessment, our community health improvement plan, and our strategic plans. We are trying to look at all angles, including through a lens of equity."
WellSpan is taking an innovative approach to reducing life expectancy disparities, Seim says. "That focus is innovative in the fact that we have to tie together every aspect of not only our clinical practices within WellSpan but also within our community health work and our partnership programs."
WellSpan's health equity work has been based on a step-by-step process, he says. "We have to do things like support education and businesses in our communities. We must be committed to our diversity, equity, and inclusion program to build a reflective workforce within our service area. We must find key partners who share our vision because we cannot address many of the social drivers of health without key partners. We must make sure our philanthropic work, charity work, and community benefits are being honed to our mission of health for all. Then we must engage our medical groups to say, 'OK. What are the leading causes of death within our communities and are we putting the resources in to address these causes of death?' For example, we are making efforts in smoking cessation, hypertension control, and screening for colorectal and breast cancer."
WellSpan started doing health equity work before the market demanded it, Seim says. "Going back to 2017, we set up the infrastructure to screen patients for social drivers of health. We set up the process of prioritizing health equity by building a health equity steering committee. Four years ago, we set up strategic goals by our board of directors as part of our annual plan to achieve measurable outcome results in health equity. There are other health systems that are just working on process measures, but we are committed to outcome measures where we can show that we have improved the health of our communities."
Health equity work outcomes
WellSpan is monitoring several metrics to gauge the impact of the health system's equity work, Seim says. These metrics include Healthcare Effectiveness Data and Information Set measures, kidney health, colorectal and breast cancer screening, hypertension management, immunizations, and food security and housing security.
WellSpan has made significant progress in health equity efforts related to severe maternal morbidity and mortality, COVID-19 disparities, and food and housing insecurity, according to health system data.
An outcome-based goal was established to decrease severe morbidity and mortality associated with pre-eclampsia (hypertension). In calendar year 2018, the total number of severe maternal morbidity and mortality cases was 39 with an overall rate of 7.6%. Fiscal year 2020 hypertension outcome data demonstrated a 54% decline in severe morbidity and mortality among all races. Additionally, a 61% reduction in the rate of severe morbidity and mortality related to hypertension among Black individuals as compared to the baseline was also noted.
During the initial stages of the coronavirus pandemic, Black and Latino families were disproportionally impacted by COVID-19. Through data analysis and comparing infection rates among diverse populations, WellSpan was able to make strategic decisions, build key community partnerships, and allocate grants early in the pandemic, which resulted in a significant rate reduction of COVID-19 infections among ethnic and racial groups. The fiscal year 2022 annual plan also identified a disparity in vaccination rates between patients who identified as being non-white or identified a primary language other than English when compared to white and English-speaking patients. WellSpan expanded community, patient, and family partnerships to understand the needs of the community and explore barriers to vaccinations and routine screening. This significantly decreased the vaccination rate disparity between populations.
Since calendar year 2020, screening for food and housing insecurity has increased. During the first year of the program, WellSpan screened 55,792 unique patients and 5% of those screened were identified as having a need for housing or food. From October 1, 2021, to April 22, 2022, a six-month screening period, 19,051 patients were identified with a food insecurity, 16,044 patients were identified with housing instability, and 11,133 lacked transportation, and they were referred to a community partner program, case manager, or WellSpan program.
The CMO of Robert Wood Johnson University Hospital Rahway found the way to support physicians in moving to team-based care when they did not see the need to change.
CMOs must help physicians shift their mindset of autonomy to partner with administrators to manage and deliver strong outcomes, says Carol Ash, DO, MBA, CMO of Robert Wood Johnson University Hospital Rahway. "CMOs must be role models, addressing the challenge by helping their physician colleagues move from a culture of autonomy to working as part of a successful team, with the patient as the first priority."
Ash has been CMO of RWJ University Hospital Rahway since June 2018. The hospital is part of RWJBarnabas Health. Her previous leadership experience includes serving as director of the ICU at Robert Wood Johnson University Hospital Hamilton.
HealthLeaders recently talked with Ash about a range of issues, including the challenges of serving as a CMO, becoming the first CMO of RWJ University Hospital Rahway, and the keys to success in case management. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of RWJ University Hospital Rahway? How have you risen to these challenges?
Carol Ash: The way physicians do things has not changed much since 1919, when the American College of Surgeons (ACS) published the principles defining physician professionalism. These principles promoted physician self-governance and autonomy. More than two decades ago, the Institute of Medicine's two watershed reports, "To Err is Human" and "Crossing the Quality Chasm," showed us that the way we were doing things was not resulting in high-quality outcomes for patients. Change was needed. The Affordable Care Act and the advent of electronic healthcare records were meant to improve healthcare performance to reach new, high-quality goals. The CMO has played—and continues to play—a critical role in ensuring physicians can work with organizations to meet those goals and remain competitive.
The challenge is that despite recognizing the need to transform and put the needs of the patient and community first, our nation's medical community remains entrenched in the mindset of the ACS model of professionalism.
When I arrived at RWJ University Hospital Rahway, I knew what had to be done. I had to clearly communicate our new direction to my colleagues, explain their roles, and help them understand what the change would mean for them. To rise to this challenge, I first had to understand my own mindset, motivations, strengths, and weaknesses. It was hard work.
Before I pursued the role of CMO, I spent 10 years gaining the knowledge and administrative skills necessary. This included attaining an MBA and pursuing fellowship status in the American College of Healthcare Executives. It was Dartmouth College's Master of Healthcare Delivery Science program that gave me the big-picture understanding of system science for healthcare redesign and the skills to successfully align and support the implementation of local innovation that could be taken to scale. Gaining this knowledge, plus my years of clinical experience, gave me the confidence to proceed.
Healthcare transformation is finally happening now, and I am excited to be part of it.
Carol Ash, DO, MBA, CMO of Robert Wood Johnson University Hospital Rahway. Photo courtesy of RWJBarnabas Health.
HL: You are the first CMO at RWJ University Hospital Rahway. How have you defined the role?
Ash: I was not only the hospital's first CMO, I was the first female CMO at an acute care hospital across our health system. Adding to that hurdle, a year and a half after I started, we had to respond to the COVID-19 pandemic. With no prior CMO to set the example, I challenged myself to use the power of the position to remove obstacles and create opportunities for my colleagues, our patients, and the community we serve.
Along with superb clinical and administrative knowledge, a CMO needs to be humble. I do not have all the answers, and I openly admit my mistakes. I try to let others do most of the talking, so that I can see things from their perspective. My goal is to be a resource for the people who are doing the work. I aim to build respect and trust as well as unite and unlock the potential of our team every day.
HL: What are the keys to success in case management?
At RWJ University Hospital Rahway, we successfully shifted most patients to case management by hospitalists. This allowed us to focus limited case management resources into a multidisciplinary team-based approach with a focus on accurately recognizing, diagnosing, and removing obstacles to management and discharge. The focus was delivering high-quality care in minutes, not hours or days.
Supporting cultural change is hard to do. It was especially hard at RWJ University Hospital Rahway because most staff physicians were in private practice, and they were resistant to change. My primary challenge was to support my physician colleagues in that endeavor when they did not see the need to change.
Ultimately, while dealing with the pandemic in a community hospital entrenched in a culture that still valued fee-for-service, we were able to achieve a significant shift in the number of employed physicians practicing in our hospital from zero hospitalists to 60%–70%. More patients are now under the care of a doctor employed by the hospital versus those in private practice.
What did this mean for our patients? These doctors now have the support of an entire team, which helps them raise the overall well-being of their patients. They have access to nurses, social workers, navigators, and professionals that can connect them with necessary services. We were able to shift care from a model focused on financial outcomes to a model focused on patient-centered outcomes. The best result has been a decrease in hospital length of stay.
Find out how top healthcare executives have developed solutions for their workforce shortages.
Workforce shortages are impacting healthcare organizations nationwide, and HealthLeaders has been talking with healthcare leaders to see how they are rising to the challenge.
Health systems, hospitals, and physician practices are experiencing a range of workforce shortages, including nurses, physicians, and medical assistants. The four stories below feature 10 different ways that healthcare organizations have addressed their workforce shortages.
Read about workforce shortage solutions from chief medical officers and chief nursing officers who participated in a HealthLeaders virtual roundtable. They discuss the role strong leadership plays in retaining healthcare workers, adjusting care models, and telehealth solutions.
See how a pipeline can propel students to healthcare careers, find out how artificial intelligence can more accurately schedule nurses, and read about succession planning as a tool to increase retention and lower costs.
Read about WellSpan Health's multi-pronged efforts to address workforce shortages, including becoming a preferred employer, enacting more efficient processes, and streamlining recruitment.
Establishing effective communication is crucial in leading a large health system, the chief medical officer of AdventHealth says.
At large health systems, it is essential to bridge the gap between the corporate leadership and the frontline, says Brent Box, MD, senior vice president and CMO at AdventHealth.
Box has been SVP and CMO of the Altamonte Springs, Florida–based health system since February 2018. His prior leadership experience includes serving as the health system's senior medical director and chief of hospital medicine.
HealthLeaders recently talked with Box about a range of issues, including the challenges of serving as CMO of a large health system, care transformation initiatives, and the keys to success in hospital medicine. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: AdventHealth is a large health system with more than 1,200 care sites, including 51 hospitals in nine states. What are the primary challenges of serving as CMO of such a large health system?
Brent Box: The biggest challenge is we are large and have significant diversity in the size and scope of the services we provide to the different communities we serve. For example, in Orlando, Florida, we have more than 1,000 beds in a group of facilities, but we also have rural hospitals with less than 70 beds. So, there is a difference in the work that we do in different communities.
What we have done at AdventHealth is we are highly focused on safety and quality. So, despite the diversity, you must have common goals. We have common goals for our acute care facilities. Particularly with the Centers for Medicare & Medicaid Services (CMS) star ratings, we want every hospital to be four or five stars. We want all of our facilities to earn an "A" from Leapfrog, and we want all of our facilities to be in the top quartile for mortality. We want to meet external measures and pay continuous attention to the data and information you must have for our leadership teams to make decisions and achieve improvements.
There are other challenges.
First, communication is a challenge. We are a large organization geographically. There is a lot of space between leadership and the frontline, particularly leadership at the corporate level and the frontline. So, we need to make sure that communication avenues are open bi-directionally and effectively. Leadership needs to listen. We need to make sure we know who the operators are in terms of the folks who are taking care of patients in the markets, and we need to listen to their expertise as we make decisions.
Second, we need to be intentional about not working in siloes. It is easy to have siloes in a large organization. We work hard at building partnerships—such as partnerships between the markets, partnerships between the clinical staff and supply chain, and partnerships between the clinical staff and marketing. We are always working hard to be on the same page.
HL: Since coming to AdventHealth, are there initiatives or programs that you are particularly proud of?
Box: When I first came to AdventHealth, my job was in hospital medicine. We have a large number of hospitals across the footprint of AdventHealth, and organizing hospitalists and working toward common clinical improvement goals is something I am very proud of.
We started a clinical excellence program, which is our effort to achieve improvement in CMS stars ratings and mortality.
I am very proud of the work we did in COVID-19 care. This is a large organization, and we came together in ways that we had never come together before. We achieved some great clinical results treating a disease that we knew nothing about initially.
Finally, we have been rolling out a high reliability program for about four years. We call it HRO-Unit Culture. The program gives voice to our teams at the frontline to improve care and achieve reliability in the care that we provide. It is about the culture you need to have at the unit level to achieve high reliability.
HL: Give examples of care transformation initiatives that you have worked on.
Box: We have a sepsis initiative. Sepsis is one of the highest volume diagnoses, particularly when it comes to mortality and cost of care. We are working on a systemwide effort to reduce morbidity and mortality by improving early recognition of sepsis and early intervention. As a health system, we are already top quartile in sepsis mortality, but we believe this is an area we can focus on to save lives. All of our facilities are working on a sepsis plan, order set usage, and achieving compliance with the SEP-1 bundle.
We are also working on length of stay for two reasons. First, it is about the clinical care that you provide as well as the effectiveness and efficiency of the care. Second, it is also a marker of value. The length of stay initiative involves boosting teamwork; working with our care managers, nursing teams, and physicians; and providing interdisciplinary care that is more effective and efficient.
Brent Box, MD, senior vice president and CMO at AdventHealth. Photo courtesy of AdventHealth.
HL: What are the keys to success in hospital medicine?
Box: Hospital medicine is a particular interest for me because I spent several years as a hospitalist as part of my clinical career. We have more than 800 hospitalists across our system, and they take care of 80% of our hospital patients. There are four keys to hospital medicine:
1. We must have a common "why" across our system. When I started working at the corporate level in 2016, the "why" became that we wanted every patient attended to by our hospitalists to receive the best clinical care, we wanted patients to have great communication and coordination of healthcare services, and we wanted it all done with uncommon compassion.
2. We also focused on the fact that every patient deserves a "captain of the ship." We lifted up our hospitalists as the captain of the ship for their patients.
3. We have spent a lot of time over the past five or six years developing hospital medicine leaders. We have a yearlong hospital medicine leadership program to develop leaders to align with our system goals.
4. We have common measurements for success. Across AdventHealth, all of our hospitalists and hospital medicine leaders know what the measurements are, they know what they are after, and they synchronize with our clinical agenda.
HL: What are the primary elements of achieving high clinical quality at AdventHealth?
Box: We have had a consistent strategy for achieving high clinical quality. We have a recognition that good healthcare is the continuum of care. It is not just what happens in the four walls of the hospital—it also involves the primary care clinics, the ambulatory care arena, the emergency departments, and post-acute facilities.
To achieve excellence, we feel we need four other things—three of them are pillars and the fourth is an undergirding process:
A good infrastructure. For example, we need to have a systemwide electronic medical record. (Editor’s note: Box explained AdventHealth is about 85% of the way through rolling out Epic as an organization.)
Good data. We have been focused on data and analytics as well as understanding that we need to communicate data and help leaders across the health system use data to achieve improvement.
Clear systemwide goals for mortality and trying to be the safest healthcare organization in America. So, we want to reduce measurable harm and reduce unnecessary variation.
Undergirding those three structural elements in our strategy, we want to recognize that clinical culture is extremely important in achieving high reliability. That's our HRO-Unit Culture program.
One more thing is you must have committed leadership at every level to achieve high clinical quality, and we have that here.
HL: You have a clinical background in internal medicine. How has this clinical background helped you serve in physician leadership roles such as CMO?
Box: I spent more than 20 years in direct patient care before I came to AdventHealth—some of that was in private practice and hospital medicine. That experience grounded me in what it takes to provide good care to patients. When you spend time taking care of patients, you learn that often the work is long, the work is hard, and the work is exceptionally rewarding. That experience is key to leading clinical care teams because it is hard to lead unless you have been there and done it.
HL: You have served in medical education roles. What are the qualities of a good medical educator?
Box: You must know your subject; and more than that, you must be willing to spend time preparing to teach. You must [also] have a passion for teaching. Not everybody has a passion for teaching, and the best teachers are passionate. They are passionate about cultivating curiosity.
Finally, a good medical educator must be patient and must start with the belief that you are building the caregivers of the future … so you must constantly both educate and build up students to be great clinicians.
Many health systems and hospitals consider it crucial to be clinician-led organizations.
As part of HealthLeaders' chief medical officer Q&A series called "The Exec," many CMOs have said that physicians play active roles in their organizations' administrative leadership.
According to the CMOs, physicians serve in a range of administrative roles at their health systems and hospitals, including hospital president, medical directors, and department chiefs. In playing administrative roles, physicians can help ensure that clinical care is a paramount concern at their organizations.
The following is a list of The Exec HealthLeaders stories that include descriptions of how physicians serve in administrative leadership roles.
The Exec: How to Successfully Lead a Large Medical Group: At RWJBarnabas Health, physician leaders and nurse leaders typically co-lead quality, safety, and patient satisfaction projects with dyad nurse leadership and physician leadership driving initiatives.
The Exec: Respect Primary Element of Physician Experience: Banner Health has an eight-week long leadership program for physicians called Advanced Leadership for Physicians. Physician leadership roles at the health system's hospitals include medical executive committees and we medical directors for nearly every clinical department.
The Exec: How to Succeed in Value-Based Care Payment Arrangements: At Yuma Regional Medical Center, the hospital has physicians serving as executive medical directors overseeing surgery, medical specialty, and primary care. Under them, there are physicians serving as medical directors in areas such as trauma, stroke, and intensive care.
The Exec: 'I Strongly Believe That All Physicians Are Leaders': At Providence Newberg Medical Center, physicians serve as chairs of clinical departments, and each department chair serves on the hospital'smedical executive committee, which governs the medical staff.
Scripps Health has physicians in the C-Suite and leading the medical staff.
Physicians are playing key administrative leadership roles at Scripps Health.
Physicians are well-suited to succeed in administrative leadership roles. With health systems, hospitals, and physician practices nationwide facing tight finances, physicians can be pivotal in helping organizations maintain high standards of patient care with limited resources.
Ghazala Sharieff, MD, MBA, corporate senior vice president as well as chief medical and operations officer for acute care at Scripps Health, says the San Diego-based health system has a strong physician leadership infrastructure that has been strengthened over the past three years.
"Scripps President and CEO Chris Van Gorder divided the CMO role into two sides—I am the acute care CMO and Dr. Anil Keswani is the CMO on the ambulatory side. As of this year, Van Gorder has assigned me and Dr. Keswani operations responsibilities as well. We are driving to both clinical and operational excellence. What that means on my side of the house is the hospitals report up to me, including pharmacy, supply chain, and support services. So, starting with patient experience and quality, we are driving change all the way through the organization by aligning administration and physician leadership," she says.
Ghazala Sharieff, MD, MBA, corporate senior vice president as well as chief medical and operations officer for acute care at Scripps Health. Photo courtesy of Scripps Health.
Physicians play crucial leadership roles at the health system's five hospitals, Sharieff says. "We have a physician operating executive at each hospital—they are a dyad partner to our chief operating executives, so they help run the hospitals on a day-to-day basis. They report up to me. We have about 80 medical directors who report up to the physician operating executives. We truly have alignment up and down the organization. The medical directors help us with our patient experience, quality metrics, and cost control. We also have strong chiefs of staff. I meet with them at least twice a month. They are now becoming more involved in operational leadership decisions. The chiefs of staff are in charge of our medical staff. They align bylaws across all five hospitals. So, they are in charge of the physicians on the medical staff. The chiefs of staff also govern peer review if cases do not go as expected."
Physicians also have a voice in capital expenditures, she says. "One of the things we started this year is a brand new medical equipment and imaging capital process. We have our service lines, which have a dyad partner with physicians, and they prioritize the list of things we are going to need for next year because we can't have everything. They prioritize, then we have our chief operating executives, regional directors, and physician operating executives look at the list and prioritize what they think we really need for the next fiscal year. In the end, we will have one list by site that is transparent to the entire organization. We can't do this process without physician leadership."
Selecting physician leaders
The most important qualities of physician leaders are being open to change and being situational leaders, Sharieff says. "As we saw through COVID, there were times when we all had to be directive but there were also times to be collaborative. So, being fluid in your leadership style is critical as well as being able to pivot quickly. You must avoid always standing firm—just because one decision is made, that may not be the way it always has to be."
For physician leaders, having years of experience in clinical care is more important than a particular background, she says. "Physicians are not going to follow somebody who is one year out of residency. What I advise my junior physicians who want to be in leadership is to get clinical credibility first, then they can advance their leadership journey. People are not going to respect you as much if you have not been working on the frontline."
Physician leadership is often not about compensation, Sharieff says. "There are so many committees and so many ways to get involved. At Scripps, we started what we call Sprint Teams, which address issues that arise. We ask for volunteers to be on those committees, which is a great way to get known as a leader. We will pull you up if we see leadership skills. The way we grow leaders is to give them an opportunity to be involved. It's awesome when we launch a Sprint Team and there are many physician volunteers who want to be involved in the committee. Physicians want to be involved because they realize funds are tight, but they want to make sure that we make the best decisions for patient care."
Physician leaders and the healthcare system
Physician leaders at health systems can have a positive impact on the broader healthcare system, she says.
"Physicians in leadership at health systems can be incredibly instrumental—if the state and federal agencies are willing to listen to those of us truly on the frontlines. The practical experiences that physicians bring to the table are invaluable in guiding smart policy and planning decisions. In San Diego, we formed a regional chief medical officer group, which worked closely with county health officials during COVID to help coordinate COVID practices and have regional alignment. That being said, often decisions are made at levels by people who really have no insight as to what happens at the frontlines of patient care, so I hope for more collaboration, especially in the face of unfunded mandates."
The chief medical officer of Providence Newberg Medical Center says physicians are natural team leaders.
The chief medical officer (CMO) of Providence Newberg Medical Center says her clinical background in internal medicine prepared her for physician leadership by providing insight to giving care at the bedside.
Amy Schmitt, MD, has been CMO of the Newberg, Oregon-based hospital since March 2013. She took on the role of interim CEO in June. The hospital has 40 inpatient beds and 15 emergency department beds.
HealthLeaders spoke with Schmitt recently about a range of issues, including the challenges of serving as CMO of the hospital, balancing the roles of CMO and interim CEO, and lessons learned during the coronavirus pandemic. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Providence Newberg Medical Center?
Amy Schmitt: Providence Newberg is a relatively small community hospital. We function at a much higher level than most hospitals our size. We have a relatively small medical staff, but we hold ourselves to the same quality standards and other aspirations of larger hospitals.
With a small medical staff, leadership is always a challenge because we have only a few capable and dedicated individuals who are willing to be leaders and to be tasked with multiple hats. You find someone who is really good, and you ask them to participate in many ways.
Another challenge is also related to our size. We are held to the same quality standards as other hospitals. We want to meet the infection ratios that the Centers for Disease Control and Prevention recommend, but because we don't see the volume of patients that larger hospitals see, many times our threshold for an acceptable infection rate is zero. For example, we may only be allowed 0.4 catheter-associated urinary tract infections, which essentially equates to zero infections. Zero is a difficult standard for us to hold ourselves to, but we do it. There is no margin for error for us in meeting quality standards.
HL: Do you characterize the communities you serve as rural?
Schmitt: We are not technically a rural hospital. We are about 25 miles outside of Portland. However, we have a rural population in that they like being outside of Portland, and they prefer not to go to Portland unless they absolutely have to go. So, we try to do what we can to meet the needs of our community at our hospital. We offer services that other hospitals our size would not typically offer.
HL: In addition to serving as CMO of the hospital, you have been serving as interim CEO. How are you balancing these roles?
Schmitt: It has been interesting. Since becoming interim CEO, I have been dedicating more of my time to the CEO role, which is new to me in many ways. Thankfully, I have been the CMO here for 10 years, so I have that piece down well and we do not have any medical staff upheavals at the moment. I have been able to pull some of my time from the CMO responsibility to take on new tasks.
There is some overlap between the roles. Previously, the CEO and I partnered on many of the contracts and medical staff engagements. Now, instead of the two of us working in those areas, it is just me.
The other piece is having a great team that has been able to fill in the gaps and to help bring me up to speed. We have a great executive team and administrative team as well as great managers in all our departments. They are largely self-sufficient, but they come together when they need support; and when I need support, they are right there to help me.
Amy Schmitt, MD, chief medical officer of Providence Newberg Medical Center. Photo courtesy of Providence health system.
HL: You served as CMO of the medical center during the coronavirus pandemic. What were your primary learnings from this experience?
Schmitt: It took healthcare to a new level of having to become more interdependent on our community. Healthcare used to be more siloed than it is now. We have learned to partner with other health systems and with our county health departments. To promote public health, it caused us to create lines of communication and collaboration that were weak before. We were able to learn best practices from each other, and we figured out how to navigate the pandemic together rather than each of us trying to go through it individually. It was good to see the connections with Oregon Health & Science University and Legacy Health as well as some of the other major healthcare providers in our area.
Another piece was the critical nature of being consistent both in our approach between hospitals and clinics as well as having constant communication about changes. What created more problems than anything was when one hospital may have done something differently and a patient was going back and forth between different health systems and getting mixed messages about the best ways things could be done. Coming together and deciding best practices was crucial.
Things changed rapidly with COVID, so what we said one week could change two or three weeks later based on expert advice or new data. We were constantly going back to our staff and trying to be transparent about what we knew and did not know. We would have to say that as new data comes forward and new studies are completed, we may have to revisit things and change the communication over time. Things that we were doing early in the pandemic changed over time, and it was a very fluid process.
HL: What is the approach to patient safety at the hospital?
Schmitt: We started a journey of high reliability in 2013. That journey started with trying to figure out how we could create an environment where patient safety was at the center of everything we did. When we started, the journey was reactive, and we tried to create psychological safety so that everyone within our walls felt comfortable raising safety concerns—whether you were an environmental services worker, a nurse, a provider, a technician, or other staff member. We wanted everyone to be able to say, "I'm concerned about this process because it may not be safe for our patients." Then, we wanted to be able to react to concerns and put corrective processes and systems solutions in place.
As we have developed our high-reliability efforts over time, we have tried to become more proactive to prevent situations that impact patient safety. Part of that is every decision, every change, and every new workflow is viewed through the patient safety lens.
We still want to have psychological safety, and we want to treat everybody with respect and dignity, so they feel comfortable raising concerns; but at the same time, we want to be proactive in looking at our processes and preventing people from getting into a situation where they have to report and speak up.
One of the ways we track our progress is by how many Datix reports we get. Datix is the system we use for anyone in the hospital to be able to speak up regarding an unusual event or something they feel is out of the ordinary. They can file an electronic report such as near misses or an error that reached a patient. We track those Datix events and categorize them as reaching the patient, causing any injury, or near misses. We want to see a high volume of Datix reports because that means people are comfortable reporting; and when we started our high reliability journey, we saw an increase in Datix reports. The goal over time is to decrease our safety events. Over time, we have seen a dramatic decrease in our serious safety events.
HL: What is the role of physicians in administrative leadership at the hospital?
Schmitt: This is my passion. We have physicians at all levels of leadership. Sometimes, physicians get shuffled around, and as one leaves a role, we pull them into another position because when you have a capable leader, you do not want to lose that expertise.
We have several layers of leadership. We have our department chairs, who work side-by-side with nurse managers in each department to make sure that their department is high functioning, has good quality standards, and they can meet patient care needs. For our medicine department, we have a medicine department chair paired with our med-surg nurse manager for surgical services. We have a surgery department chair. We have an OB/GYN chair. These chairs provide local expertise that is needed to develop processes and to make sure everything they are doing is up to date.
Each of the department chairs serves on our medical executive committee, which governs our medical staff. We nominate a president of the medical staff, who chairs the medical executive committee. Together, that group, with administration in attendance, makes decisions such as whether we have the right composition of our medical staff or whether we need to recruit new physicians or whether there are quality standards we need to rally around as a medical staff. If there are disciplinary actions that need to be taken, the medical executive committee is in charge of that process.
HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you to serve in physician leadership roles such as CMO?
Schmitt: I strongly believe that all physicians are leaders whether they choose to embrace leadership or not. Just by the nature of their training and experience, physicians are natural team leaders whether it is in an office with medical assistants, an operating room with a surgical team, or another setting.
As I have gone through my training and career, I have been willing to embrace leadership. All physicians have opportunities to embrace leadership—it is a matter of who is willing to develop it.
The internal medicine training I received was an opportunity to be at the bedside. I have been a clinical hospitalist since 2005. Even as a CMO, I have maintained that hospitalist work. It gives me the perspective of what it is like at the bedside as well as what our physicians, nurses, and advanced practice providers are facing day in and day out, and how I can ease their way as a leader.
Recommendations range from universal masking to more flexible approaches.
Healthcare facilities should continue to have masking policies despite the fact that the crisis phase of the coronavirus pandemic has passed, according to a new journal article.
Universal masking in healthcare facilities was adopted during the pandemic based on research that indicates masking could reduce the risk of respiratory viral transmission. Many healthcare organizations have lifted universal masking requirements since the end of the COVID-19 public health emergency earlier this year.
The new journal article, which was published this week in Annals of Internal Medicine, calls on healthcare facilities to continue masking requirements either universally or under specific circumstances. "In our view, the ongoing disease burden among persons at highest risk for severe COVID-19, the large proportion of transmission from asymptomatic and presymptomatic cases, uncertainty about the future course of the pandemic, and the effects of post-COVID-19 conditions merit integration of lessons learned from the pandemic into healthcare precautions and policies," the new journal article's co-authors wrote.
The new journal article's co-authors agree with another journal article published in Annals of Internal Medicine in June that calls for healthcare facilities to adopt one of four approaches to masking:
Require masking in healthcare settings year-round
Require masking in targeted settings with high-risk patients such as transplant, oncology, and geriatric units
Require masking during specified months of the local respiratory viral season
Require masking when the community burden of respiratory viruses is at a critical threshold as determined by "appropriate metrics"
Healthcare facilities should not go back to limited masking policies that were in place before the pandemic, the new journal article's co-authors wrote. "Our appreciation and understanding of both patient and healthcare system impacts associated with SARS-CoV-2 and other respiratory viruses have been reshaped as a result of the COVID-19 pandemic. We should be mindful of continuing areas of uncertainty while integrating the lessons learned into our hospital-based practices to prevent harm to vulnerable patients rather than reverting to suboptimal pre-pandemic behaviors."
There are several reasons why healthcare facilities should continue masking, the lead author of the new journal article told HealthLeaders.
"First and foremost, COVID-19 continues to circulate in our communities and there continues to be uncertainty about the future course of the pandemic. This is especially true as new variants emerge. We also know that hospitalizations and deaths, while lower than at other periods during the pandemic, are still occurring and disproportionately impact people at higher risk for severe disease. This includes people who are older and people who have chronic conditions. No. 2, we are only beginning to learn more about post-COVID-19 conditions also known as long COVID. We know that people of all ages are at risk for post-COVID-19 conditions. Even people with asymptomatic or mild acute COVID-19 are at risk for post-COVID-19 conditions," said Eric Chow, MD, MS, MPH, chief of Communicable Disease and Immunization for Public Health at Seattle and King County, clinical assistant professor of epidemiology at University of Washington, and clinical assistant professor of Medicine-Allergy and Infectious Disease at University of Washington Medicine.
Masking is also needed to safeguard healthcare workers, he said. "Masking protects healthcare workers. Many health systems are desperately trying to maintain their healthcare workforce capacity and implementing masking in healthcare facilities will help prevent infections and outbreaks among healthcare workers. This can help mitigate additional shortages of healthcare workers."
Universal masking in hospitals may be the safest option, Chow said. "This is one of the approaches we have recommended in our article, and it avoids having a patchwork of policies within a hospital system. It also acknowledges that masking reduces the risk of infection not only in patient encounters but also between and among healthcare workers, which is another source of infection. Targeted masking policies are implemented in units where there are high-risk patients, but this is a less perfect approach because there are high-risk patients who are admitted to different parts of a hospital."
Improving communication while masked is a consideration for healthcare providers, he said. "There is a need to provide safe care and to improve communication while wearing masks. Some approaches include discussing with individuals about their own preferred approach to improving communication. Healthcare providers can allow for extra time for patient encounters, choose a quiet location for patient encounters, and speak clearly and slow down their talking speed. Other approaches could include alternative forms of communication such as written communication or assistive technology to maximize understanding."
Staffing company says nurse practitioners have led employment searches for three consecutive years.
Recruiting incentives for physicians and advanced practice providers (APPs) have increased significantly over the past year, according to a new report from the staffing company AMN Healthcare.
The employment market for physicians and APPs is as tight as it has ever been. Traditional healthcare providers such as hospitals and physician practices are competing to employ physicians and APPs with market disruptors such as retail chains, urgent care centers, and telemedicine platforms.
The new report, "2023 Review of Physician and Advanced Practitioner Recruiting Incentives," was produced by AMN Healthcare Physician Solutions (formerly Merritt Hawkins). The report is based on a representative sample of the 2,676 permanent physician and APP search engagements AMN Healthcare Physician Solutions had ongoing or conducted from April 1, 2022, to March 31, 2023.
The report has several key findings.
Nurse practitioners (NPs) were the No.1 requested provider search for the third consecutive year
Average starting salary offerings for NPs increased 9% year-over-year
AMN Healthcare conducted more searches for APPs than for primary care physicians, which reflects a patient shift away from primary care practices to retail chains, urgent care centers, and telemedicine platforms
Although demand for primary care physicians has flattened, family physicians were still the second most requested search engagement in the new report
Most of AMN Healthcare's search engagements (64%) were for physician specialists, with radiologists ranking third in the company's requested search engagements
Obstetricians/Gynecologists ranked fourth on the list of AMN Healthcare's most requested search engagements, with starting salaries for OB/GYN's up 10.5% year-over-year
Psychiatrists fell from fourth on the list of search engagements last year to sixth on this year's list, which likely reflects the shortage of psychiatrists and healthcare organizations turning to psychologists and APPs to fill behavioral health provider positions
Average starting salary offers for many specialists increased, with starting salaries for dermatologists up 22% year-over-year, starting salaries for psychiatrists up 19% year-over-year, and starting salaries for orthopedic surgeons up 12% year-over-year
Average starting salary offers for primary care specialties were flat year-over-year, with family physician starting salaries up 2% year-over-year, pediatrician starting salaries up less than 1%, and starting salaries for internal medicine physicians unchanged
Orthopedic surgeons posted the highest average starting salary for physicians ($633,000)
Pediatricians posted the lowest average starting salary for physicians ($233,000)
The average signing bonus for physicians increased sharply from 2022 to 2023, rising from $31,000 to more than $37,000
Interpreting the data
Market disruptors are driving the demand for NPs, Leah Grant, MBA, president of AMN Healthcare Physician Solutions, told HealthLeaders. "Demand for NPs is being driven by the spread and increase of convenient care. We are seeing expansion of convenient care such as retail clinics, urgent care centers, and telemedicine—all of which are expanding using their APP staffing model, while before they depended on physicians."
NPs are also a cost-effective alternative to hiring physicians, she says. "APPs can provide many of the services that a physician can provide, and the number of states where they can practice autonomously keeps on growing. We are seeing more healthcare organizations take advantage of NPs than in the past because they often do not need to be paired with a physician. Now, nurse practitioners are the pillar of rural healthcare in many states."
The "Seven Ps" are driving demand for physician specialists, Grant says.
"First, there is population growth—the U.S. population is projected to grow from 332 million people today to 423 million by 2050. Second, population aging is a significant piece to the demand for physician specialists. By 2034, there will be more seniors over the age of 65 than children 17 years old or younger. Third is provider aging. While we are seeing the general population aging, we are also seeing providers aging. About 30% of physicians in active patient care are 60 or older. Fourth, we are dealing with provider burnout, with about 58% of physicians feeling burned out. Fifth, there is pervasive ill health. About 6 in 10 of American adults have a chronic medical condition such as diabetes, and about 4 in 10 have two or more chronic conditions. Sixth, there are pipeline problems. Federal funding for physician training was capped in 1997. So, we will continually see the effects of that as the years go on in terms of supply and demand. Seventh is changing practice styles. Many physicians are embracing different practice styles that reduce full-time equivalence with locum tenens work and part-time hours. Population aging is probably the most important piece in the demand for specialists."
A couple of factors account for the flat starting salary offers in primary care, she says. "They are just not as much in demand as they were several years ago, when everyone was setting up primary care networks or buying primary care practices. Family medicine is our No. 2 search, and I foresee that to continue. However, there is a ceiling for primary care salaries as opposed to specialists. The main reason for that is specialists can generate more revenue. Our physician billing report shows that an orthopedic surgeon can bill more than $9 million a year to commercial payers, while a primary care physician is going to generate half as much billing."
The No. 1 reason for the steep increase in physician signing bonuses is the demand for physicians, Grant says. "The demand for physicians has continued to increase. With that demand, a lot of healthcare organizations are trying to figure out how to be more competitive and how to get a provider in the door faster. The faster you can get a physician into your clinic or hospital, the more revenue you are going to generate. You can also decrease patient wait times, which are a concern in the market. Decreased wait times can make you stand out in the market as a preferred provider."
Market disruptors such as retail chains, urgent care centers, and telemedicine platforms are not only driving the market for APPs but also changing the healthcare landscape, she says. "The wait times to see a primary care provider have grown 24% since 2004. So, the market disruptors saw an opportunity presented by the physician shortage and the long appointment wait times associated with the physician shortage. There has also been a societal shift toward convenient care. The disruptors have realized that the healthcare market is increasingly about customer experience. If you are able to provide a better experience, you are going to have an advantage. Now, hospitals are moving to outpatient care and trying to compete with the disruptors."
Given the employment market conditions, offering recruitment incentives beyond starting salaries is becoming the norm, Grant says. "Signing bonuses are no longer a perk—they are an expectation. Nine times out of 10, the return on offering incentives such as continuing medical education allowances, relocation allowances, and medical education loan forgiveness is above and beyond the financial value of the incentives."
Catherine "Mindy" Chua, DO, chief medical officer of Elkins, West Virginia–based Davis Health System. Photo courtesy of Davis Health System.
Brent Box, MD, senior vice president and CMO at AdventHealth. Photo courtesy of AdventHealth.
Amy Schmitt, MD, chief medical officer of Providence Newberg Medical Center. Photo courtesy of Providence health system.
