At UW Health, the process to address medical errors is not punitive.
When medical errors occur, health systems must learn from the experience and conduct root cause analyses, says Aimee Becker, MD, MBA, chief medical officer of UW Health.
Becker has been CMO of the Madison, Wisconsin-based health system since August 2018. Prior to her role as CMO, she served as the interim chair for the UW School of Medicine and Public Health Department of Anesthesiology. Previously, she served as chief of anesthesia and director of operating rooms at the William S. Middleton Memorial Veterans Hospital in Madison.
HealthLeaders recently talked with Becker about a range of topics, including the challenges of serving as CMO at UW Health, clinical care quality and patient safety, and the role of physicians in healthcare administration at UW Health. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of UW Health?
Aimee Becker: Broadly speaking, the challenges we face at UW Health are similar to other healthcare organizations. We are navigating financial headwinds and we are feeling challenges with inflationary pressures. Additionally, workforce shortages pose a significant challenge, particularly as we are still feeling the impact of the coronavirus pandemic.
Addressing the staffing shortages is one of our highest priorities, and linked to this is the well-being of our workforce. This is so critical. Our healthcare teams have had to weather a lot of stress and changes stemming from the pandemic and supporting them has been and continues to be a top priority. As an organization, we recognize the challenges our care teams face, and we want to ensure that we are supporting them not only through staffing but also across the full spectrum. When considering the challenges we face as an organization, we must start with the well-being of the individuals that make it work.
HL: How are you supporting the well-being of your staff?
Becker: It is through multiple measures and many different levels. We have a team dedicated to well-being across our organization. We have a strong physician partner—our chief wellness officer, who works specifically on the well-being of our physicians and advanced practice providers as well as our residents and fellows.
Through the pandemic, we developed several resources. At baseline, our leaders are very engaged with our frontline teams, and they spend a lot of time rounding to hear from and learn from our frontline teams. We want to know what their issues and barriers are and try to mitigate those. We developed a robust, cross-functional multidisciplinary team for peer support. We have employee well-being resources across an entire portfolio of different options, whether that is peer support, confidential mental health services, or our response to stressful incidents. It is a multipronged approach to well-being.
HL: You are responsible for clinical care quality and patient safety at UW Health. What are the primary elements of clinical care quality?
Becker: We are fortunate in that we have a strong quality and safety team that reports up through our chief quality officer, who is a physician. Associated with this, we have robust structures and processes to support our goal of achieving remarkable healthcare outcomes. All of this is tied to our operational framework. So, our management triads and dyads are key to engaging our frontline team members.
Quality and safety are part of the work that we do every day, and each one of us is responsible for quality and safety, and we are accountable to our patients and each other. So, while we have excellent patient care outcomes, we are dedicated to continuous improvement. We have set expectations for our behaviors at work, and we empower our frontline teams to lead improvement work, stop the line when necessary, and hold each other accountable.
HL: What are some of the primary mechanisms for ensuring patient safety at UW Health?
Becker: How we interact with each other is important. We know that respectful work environments are safe patient care environments. How we operate day to day and communicate is key. We have a real-time management structure, where we huddle with our teams to ensure patient safety and to address issues. We have quality improvement initiatives that are always evolving to make sure that we are targeting the patient care needs of today.
HL: How do you handle medical errors?
Becker: It is important to have a just culture. As an organization, we are going down that path formally. You must have a process around evaluating errors that is non-punitive, and you must be able to learn from your mistakes and identify the root causes. We have a robust root cause analysis structure that is aimed at understanding all of the root causes. In addition to that, we have the infrastructure to address and mitigate medical errors.
We have a reporting system for medical errors, near misses, and any safety concerns. This is a key ingredient of our quality and safety portfolio. Anyone can put a concern into the reporting system.
Aimee Becker, MD, MBA, chief medical officer of UW Health. Photo courtesy of UW Health.
HL: What role do clinicians play in healthcare administration at UW Health?
Becker: At UW Health, physicians play a significant role in healthcare administration. We have physicians engaged in healthcare administration at many levels. To start, we have a physician CEO. For our inpatient operations, we have a triad model for our hospital leadership that includes a physician leader, a nursing leader, and an administrative leader. For our ambulatory operations, we have dyad partnerships that include a physician and either an administrator or nurse leader, depending on the location. The aim of the collaboration is not for physicians to take over the roles of our administrative and nursing leader partners—the intent is to support operations and patient care with physician input.
HL: In general, do you think physicians are playing a greater role in healthcare organization administration?
Becker: In short, yes. I hope we have shifted from the past, when physicians viewed hospital administration separately as "the suits." Certainly, physicians provide valuable administrative leadership in healthcare.
Very often, our physician leaders continue to take care of patients. That lends a lot of credibility to the broader patient care team, and it gives physician leaders a unique perspective when they are directly engaged in patient care.
HL: You led clinical care at UW Health during the pandemic. What were your primary learnings from this experience?
Becker: The silver lining with all the COVID challenges is that we learned so much. First, as a healthcare organization, we learned that we could weather a storm by being in it together. The tremendous collaboration across all aspects of the organization was inspiring during very tough times. We also learned that despite being a large integrated academic health system we can be flexible and nimble when the situation calls for it. This will continue to be important as we face ongoing headwinds.
We also learned the value of telemedicine. Our patients and our care teams appreciate this, and we learned the value of working from home. The flexibility has been important for our workforce. Having the flexibility to work from home has improved the work-life balance. Working from home is not for everybody, but the fact that the option exists when the work is applicable and our team members can have a say in that is empowering.
HL: You have a clinical background in anesthesiology. How has this background helped prepare you to serve in the CMO role?
Becker: For me, patient care is my first love. I love being an anesthesiologist, which has taught me a lot of things. First, getting to care for patients is a privilege, and with that privilege comes obligations and responsibilities, including continual improvement. Being an anesthesiologist has taught me that patient care is a team sport, and that each one of us on the team wants to be valued and respected for our unique contributions to patient care.
Working as an anesthesiologist has also taught me that there is no room for "us versus them" in patient care. In healthcare, there are many opportunities for us-versus-them situations, and we strive to mitigate that. For example, as we think about the importance of being valued and respected for the unique contributions to patient care, emergency department care is different from inpatient care, and each of those are unique and valuable, but neither is better than the other or more important than the other.
You need to value and respect everyone's contributions; but more broadly, we need to promote that we are all in this together for patient care. There is no us-versus-them scenario that I can think of that improves patient care.
The coronavirus pandemic compromised the ability of hospitals to work on patient safety, the president and CEO of The Leapfrog Group says.
During the coronavirus pandemic, hospitals lost ground on patient safety, says Leah Binder, president and CEO of The Leapfrog Group.
The Leapfrog Group recently released the watchdog organization's spring 2023 Hospital Safety Grades. There are fewer "A" grades and more "B" grades largely because of an increase in three hospital-acquired infections: Methicillin-resistant Staphylococcus aureus, central line-associated bloodstream infections, and catheter-associated urinary tract infections.
The pandemic compromised the ability of hospitals to work on patient safety, Binder says. "Hospitals had a great deal of difficulty managing a public health emergency while also maintaining vigilance on patient safety. They were somewhat overwhelmed and, in some cases, very overwhelmed by the response to the coronavirus pandemic, and that caused them to be unable to handle some of the important day-to-day business of running a hospital. What we need to do is make sure hospitals can be more resilient in the future, so they are able to manage both a public health emergency and their day-to-day business, which includes protecting the lives of patients."
Leapfrog also noted patient experience scores at hospitals declined, she says. "A hospital was not a great place to be during the pandemic. As a patient, you usually could not have your family visit. Frequently, there were either serious restrictions on visitors or no visitors allowed. That had a major impact on patient experience. It also had an impact on workforce experience—I have heard from many nurses that not having families in the room was demoralizing for them. They had no feedback, and they did not have the extra set of eyes that families provide when caring for patients."
Uncertainty associated with the pandemic along with changing rules and regulations created a stressful environment in hospitals, which had a negative impact on patient experience, Binder says. "What we saw from that is patients reported their experience declined. The declines we saw in patient experience were serious declines. Patients reported not being comfortable with the medications they were prescribed and poor nurse communication. There is research that correlates those kinds of patient experiences with outcomes. So, it is something that we must watch closely, and it is something we will be tracking as we look at the recovery from the pandemic."
In the spring 2023 Hospital Safety Grades, 29% of hospitals received an "A," 26% received a "B," 39% received a "C," 6% received a "D," and less than 1% received an "F." While the performance is similar to recent Leapfrog Hospital Safety Grades, there was slippage, she says. "There are slightly more 'B' hospitals than there were in the last rounds and fewer 'A' hospitals. That is directly related to some of the challenges we saw in infection rates and other safety factors."
Binder says she expects improvement in the next round of Hospital Safety Grades. "We definitely have seen a major setback that has to be turned around immediately. That said, I am optimistic that hospitals will turn it around. They will improve. They know how to do it, and they want to do it."
Factors supporting the hospital-at-home trend include an aging population, advances in technology, and the search for more value in healthcare.
The Ohio State University Wexner Medical Center is bullish on hospital-at-home care.
The Medicare waiver for 24-hour nursing in hospital-at-home care has been extended until December 2024. With waivers granted by the federal government since the beginning of the coronavirus pandemic, more than 100 health systems across 37 states have launched hospital-at-home programs.
Ohio State launched its Hospital Care at Home program in January. The Medicare waiver for 24-hour nursing in hospital-at-home care is a good sign, says Rachit Thariani, chief administrative officer for Ohio State's Post-Acute and Home-Based Care Division. "In general, I feel confident that payers will cover this care. However, because this is still a somewhat evolving model of care, this two-year window provides a great opportunity for all of us who are in this space to comprehensively assess the value that this program creates. The value equation is always going to be the cost at which we provide the care and the quality and outcomes associated with this program."
Hospital-at-home programs need to generate data that shows the programs are effective, he says. "If the healthcare industry and the folks who are in this space can design and generate that evidence, we can prove that it is comparable to alternative models. Then I feel good about the fact that we will continue to see payers and the Centers for Medicare & Medicaid Services make this part of the mainstream of how healthcare is delivered."
There are four factors that indicate hospital-at-home care will be a trend in the future, Thariani says.
"First, you can look at the demographic changes and the aging population. Currently, about 17% of our population is above the age of 65. It is projected by 2040 that we will see about 81 million people who will be above the age of 65. It is one of the fastest growing segments of our population, and if you think about the needs of that population, hospital at home is perfectly suited to that population."
"The second piece is technology, which has come a long way and it is getting further and further advanced. That allows us to do things in the home that were not possible even five years ago. The advances in technology will help deliver higher acuity care models in the home."
"Third, there is a constant search for higher value in healthcare. Value is better outcomes at a comparable or lower cost point. As health systems and other players in healthcare such as payers and employers search for higher value, models such as hospital at home will be extremely interesting to them."
"Fourth, we have some large health systems making significant investments in hospital at home, so it is not something that we should under-estimate because those investments help develop the processes and technologies. Those investments help create a significant infrastructure that we can deploy for this model and understand its true efficacy."
Ohio State's hospital-at-home model
The Centers for Medicare & Medicaid Services (CMS) launched its Acute Hospital Care at Home program more than three years ago. Ohio State has embraced the CMS model, Thariani says. "In our hospital-at-home model, we have modeled it around what the CMS waiver permits. A patient needs to originate either in the emergency department or an inpatient setting and we can discharge them early to home. … The requirements are that there should be a daily provider visit, which could be completed by a physician remotely or an advance practice provider or a nurse practitioner in person. There is also a requirement for two daily visits completed in person by a registered nurse and potentially by an emergency medical technician. The requirements also state that we have access to care providers 24/7 for patients who are admitted to the program."
To provide staffing for Ohio State's Hospital Care at Home program, the organization has partnered with Dispatch Health, he says. "They recruit the physicians, nurse practitioners, and registered nurses for us. They are the ones who are seeing patients in the home. The services that Ohio State provides directly include pharmacy dispensing services, durable medical equipment, and physical, occupational, and speech therapy. It is kind of a hybrid model that includes clinicians who are employed on our behalf by Dispatch Health and certain services that we can provide."
Dispatch Health provides a 24-7 command center that is staffed by registered nurses, Thariani says. The command center oversees remote patient monitoring and interacts with the patients virtually.
Dispatch Health plays a key role in remote patient monitoring and patient data collection, he says. "As part of our relationship with Dispatch Health, they work with a remote patient monitoring company. When a patient is transferred to hospital at home, each patient receives a cellular-enabled tablet, and the tablet can constantly gather patient readings and vital signs. All of the documentation goes into our electronic medical record system—Epic. So, the data either goes directly into Epic, or when the in-home care team is with the patient, they go into Epic and conduct documentation. Our folks back in the hospital can understand what is going on with a patient at any given point in time."
Ohio State is collecting data for several hospital-at-home metrics, Thariani says. "CMS requires three metrics—patient volume, care escalation rates (how many patients were admitted into the hospital-at-home model but had to be brought back to the hospital), and mortality. However, we are working toward capturing a more comprehensive set of metrics. These include operational metrics such as length of stay and additional quality metrics such as readmission rates, infection rates, and falls. We are also collecting patient experience metrics such as patient satisfaction."
Phoenix Children's Hospital is also successful in retaining clinicians.
With an aggressive growth strategy, Phoenix Children's Hospital has been able to recruit and retain significant numbers of clinicians.
There is a tight clinician labor market nationwide. "The physician recruitment market is tighter than ever," Tara Osseck, regional vice president of recruiting at Jackson Physician Search, told HealthLeaders earlier this year.
Phoenix Children's Hospital is expanding from one hospital to three hospitals. Phoenix Children's Hospital—East Valley Campus is expected to open this summer. Phoenix Children's Hospital—Arrowhead Campus is slated to open next year. As part of the growth effort, Phoenix Children's has increased the organization's medical group from 25 to 34 divisions, and the surgical department has increased from 27 to 90 surgeons.
"The growth of the medical group has been based on numerous factors. Number One is the growth of the system—moving from a single hospital to three hospitals sometime in the next 12 to 14 months has driven the need for the overall growth. If we were not growing the system, we would not have had to worry about growing the number of clinicians," says Daniel Ostlie, MD, surgeon-in-chief and chair of surgery.
Phoenix Children's has powerful selling points for clinician recruits, says Jared Muenzer, MD, physician-in-chief. "Whenever I interview anywhere from senior leaders on the business side to senior leaders on the clinical side to junior physicians, I start with the most amazing things about Phoenix Children's Hospital are people and potential. The potential is looking at where Phoenix Children's fits in the Southwest—you look at our level of competition and we own the tertiary and quaternary market of children's healthcare in this region. It makes us a place that people are interested in. They want to hear about it."
In terms of people, Muenzer says part of the reason Phoenix Children's draws clinicians is world-class training programs. "Our faculty come from training programs at the best children's hospitals in the country. Then you add the layer that we have grown our training programs from the mid-teens to close to 30 fellowship programs, and we have been growing our own clinicians over the past decade. It's feeding on itself now, which puts us in a great position. We are still able to recruit clinicians despite a tight labor market."
High patient volumes across a range of specialties are also a selling point in clinician recruitment, Ostlie says. "We have a significant advantage because of the volume and population that this children's hospital supports with very little competition in our market. There is a small local children's hospital, but they don't really pose any market competition. I can hire a general surgeon and that person is going to be very busy. We can go out and hire a neurologist who focuses on mobility or rare diseases and because of the population that we have here—a million children—we know that neurologist is going to see patients that fit the specialty."
Phoenix Children's is also able to recruit clinicians in subspecialties, Ostlie says. "We just recruited a surgeon from Nebraska who specializes in osteogenesis imperfecta, which is brittle bone disease. We know we can bring her here, we can put her in an established orthopedics division, and she is going to be able to grow the osteogenesis imperfecta program just because of location—the airport is easy to get to—and we have a million kids here already. We also have all of the supporting structures such as genetics and orthopedic surgery that will allow her program to grow in a way that it would not be able to grow in other places."
Clinician retention
Annual evaluations help Phoenix Children's to retain clinicians, Muenzer says. "When Dan and I took over about seven years ago, one of the things we did not have was a way to evaluate and reward our clinicians every year. Now, we have a yearly evaluation program for all of our providers across the entire enterprise. For our over 750 clinicians, which is both physicians and advanced practice providers, they get evaluated every year, and that evaluation has an impact on their compensation. It allows us the opportunity to try to remain competitive in the market. The evaluations also give clinicians the sense that their accomplishments are being recognized."
Retention is also about empowering clinicians, Muenzer says. "Dan and I have 34 divisions, and we have empowered leaders to not only go out and recruit the number of providers they need but also the specialists and subspecialists they need to build a book of business in areas such as neurology, gastroenterology, and orthopedics. We gave them the power to build those programs. By doing that, it empowers those leaders to say, 'This is my book of business as a leader, and Dan and Jared give me the authority and the power to go out and build my program.'"
Phoenix Children's wants providers to have every opportunity to grow and mature and to be what they want to be, which boosts retention, Muenzer says. "For example, if you want to be a world-class clinical provider and deliver world-class clinical care and that is what your goal is, that is OK. If you want to be a researcher, if you want to be a medical director, if you want to build programs, if you want to be an educator, if you want to be a division chief, all of those tracks are available at this organization to all of our providers."
Pfizer Global Supply features 36 manufacturing sites, 11 distribution and logistics centers, and 31,000 manufacturing and distribution workers.
Scale is a primary way Pfizer has been rising to supply chain challenges during the coronavirus pandemic and as the crisis phase of the pandemic has passed, says Martina Ryall, vice president for strategy and operational excellence at Pfizer Global Supply.
The pandemic disrupted healthcare supply chains around the world. In the early stage of the pandemic, health systems and hospitals struggled to secure essential supplies such as personal protective equipment.
Pfizer has an impressive supply chain scale, Ryall says. "Today, Pfizer Global Supply consists of 36 manufacturing sites, 11 distribution and logistics centers, and 31,000 manufacturing and distribution colleagues who essentially enable supply to patients around the world. On an annual basis, we supply more than 50 billion doses across 180 countries, and we have hundreds of partnerships with manufacturing organizations and suppliers."
Scale allows Pfizer to minimize supply chain risk, she says. "One of the primary ways that we are reducing the risk of supply chain disruptions is through scale. We scale our operations and diversify our network. For example, we use multiple suppliers to minimize the risk of supply interruptions for essential medicines. So, instead of relying on a few suppliers in a particular region, we have a broader ecosystem or web around the world."
Supply chain resiliency is a top goal for Pfizer, Ryall says. "We are building in resiliency by establishing parallel supply chains through the United States and Europe. We also go to the traditional levers as well—implementing inventory management strategies that support thoughtful and purposeful over-production in certain areas of essential medicines. We also have a workforce that we can scale and flex depending on the need."
Supply chain lessons learned from the pandemic
The pandemic presented challenges and opportunities for Pfizer's supply chain, she says. "During the pandemic, one of the key things was being able to leverage our speed, our scale, and our science. However, the pandemic has shown us that so much remains outside of our control. Rather than try to navigate all of the volatility, our teams try their best to act proactively. One of the things that we learned was that while volatility may be disruptive, it is also a catalyst for us to engineer new and innovative ways of doing our work."
Pfizer's supply chain had to navigate chaos and complexity during the pandemic, Ryall says. "While it was uncomfortable, it did force us to grow in directions that we may not have dreamt of otherwise. We started to see a lot of new opportunities and better ways to get to our patients. Embracing that chaos and volatility is part of our "light speed" culture through which we have evolved operations to move with speed, eliminate unnecessary work, and trust each other to make decisions so we can get breakthroughs to the patients."
The pandemic has driven change in Pfizer's supply chain, she says. "We have learned that we could put in place nimble structures and a network of trusted and reliable suppliers. We had teams of interconnected problem solvers. We also harnessed digital tools—they are becoming a critical part of our manufacturing supply chains. In the past two years, digital technologies have enabled tremendous improvement in our service and cycle times because you can see the data. So, we are putting all of those learnings into practice."
Embracing drone deliveries
Drones have been an "exciting endeavor" for Pfizer, Ryall says. "It has given us access to remote locations that we were never able to get to before. We have partnered with Zipline. It has been a fantastic partnership that has enabled us to deliver to many remote areas during the pandemic. One of the first countries for the partnership was Ghana. We were able to reach communities in Ghana with poor road access—there were geographic features that impeded our traditional distribution methods."
Drone deliveries are part of Pfizer's long-term supply chain strategy, she says. "Drones were something that we were already working on before the pandemic, but the pandemic amplified drones as a method of delivery. Rather than it being a one-off method of delivery, drone shipments are something that we want to embrace and embed as one of our methods of reaching patients. Zipline is a pioneer in delivering medical products in remote areas, and we want to advance this partnership to other remote areas of the world. Drones are here to stay, and they will grow in terms of use."
Indiana University Health's vice president of supply chain has three decades of experience in purchasing roles.
Indiana University Health is working closely with suppliers to limit the impact of inflation at the Indianapolis-based health system, says Sam Banks, chief procurement officer and vice president of supply chain.
Prior to joining IU Health, Banks worked at medical device manufacturers for nearly 14 years, most recently serving as vice president of global procurement at Wright Medical Group. He also worked for nearly two decades at Honda, mainly in purchasing leadership roles.
HealthLeaders recently talked with Banks about a range of subjects, including coping with inflation, supply chain challenges at IU Health, and engaging physicians in supply chain. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How are you coping with inflation in your purchasing efforts?
Sam Banks: Inflation is tough for us. IU Health committed to the state of Indiana that we were not going to raise prices for five years. So, we do not have a lot of ability to absorb inflation. So, we are seeking significant cost savings this year.
We are working closely with our suppliers to make sure they understand that we need to push back on cost increases, and they need to find ways to take cost out. In some areas and contracts, we have protection against inflation or at least a cap on prices. That has saved us in quite a few situations.
We are trying to change the way we are working with our suppliers. We are engaging with their leadership teams, so they understand our current situation and our future plans. We want them to know we are a good partner as we continue to grow and continue to try to consolidate the supply base. We are also digging into their financials to understand the actual costs of their products. I am a firm believer that the better we understand how their products are made and their input costs, the better our ability is to push back on cost increases.
We are also asking suppliers about ways they can help us. If we are doing things that drive inefficiencies into their operations, we want to know that. Allowing suppliers to say something that is less than positive to the customer gives them the freedom to be honest with us.
Sam Banks, chief procurement officer and vice president of supply chain at IU Health. Photo courtesy of IU Health.
HL: What are the primary challenges of serving as chief procurement officer and vice president of supply chain at IU Health?
Banks: I joined IU Health last year, right as we were coming out of COVID. My whole supply chain experience has been almost 20 years with Honda and another 14 years in the medical device world, so IU Health has been a big change for me. When I started at IU Health, it was clear that the team was fatigued, and we were understaffed due to workforce shortages.
I was fortunate that my boss, who is the senior vice president of systems services, is a great leader and he understood what it took to get me onboarded and up-to-speed quickly. He had also put some good leaders directly under me, so I am fortunate to have a great team that reports directly to me that knows leadership and supply chain.
One of the biggest things that we struggle with is trying to find the right talent and dealing with attrition. We are challenged to compete in the marketplace because many organizations are raising salaries. So, we are trying to make sure that we have a great total offering—not just wages.
We are also challenged in supplies. The backorder situation and the disruption is getting better, but these challenges still exist. It has started to transition away from not as many backorders to more conversations with suppliers about cost increases.
Finally, our struggle is with data. We have a ton of data, but we do not have an efficient way to use it, process it, analyze it, and visualize it to help us drive our business to make it better. We need to start looking at process improvement, becoming more efficient, and taking our supply chain expertise to the next level.
HL: How have you been rising to the data management challenge?
Banks: We have been working closely with our information technology colleagues. We are also working closely with our third-party suppliers—they are getting us a lot of data and we are pushing them to help us understand how to use their services better and optimize the relationships. We are working to see how we can use that data to drive our business forward.
We are also looking internally at how we can write reports and to make sure that we have the right people in the right spots with access to the right data.
HL: Do you have a group purchasing organization?
Banks: We use Vizient. The GPO works on our behalf and negotiates national contracts to leverage the volume of not only our health system but also other health systems to get us the most competitive price offering that we can get. What a lot of people might not understand is that we use the GPO's suite of data for spend management and benchmarking. We also use the GPO's suite of data for our clinical side, with safety, quality, and efficiency metrics.
HL: IU Health has an integrated service center. What are the primary elements of this facility?
Banks: The ISC is a 296,000 square foot facility. About 150,000 square feet is warehouse and distribution. We use that space to stock between 30 and 90 days of inventory of more than 3,300 products. About 40% of our supplies flow through the ISC. The main functions there are warehousing and distribution. It is also a supply chain headquarters—it is where leadership sits as well as purchasing, business analytics, value analysis, and strategic sourcing. We just added pharmacy, so soon our pharmacy folks will be working out of that building and doing the pharmaceutical piece of our business there.
HL: How do you engage physicians in the supply chain?
Banks: We work closely with our clinical effectiveness team—they are our main liaison with the physicians. We participate in the physician-led councils. We bring physicians opportunities and they help us decide which direction we want to go. For example, we may have a category that has six suppliers, and we want to take that down to three suppliers, while maintaining safety, quality, and delivery with improved cost.
For example, we will have a physician-led council on orthopedics. We will talk about preferred suppliers and product usage. Doctors will give us feedback on how things are going. We will say this is how we are performing to the contract; and if there is an initiative that we have to work with the supplier or change suppliers, that conversation will occur with the physician-led council.
Sometimes, physicians will help us with supplier negotiations. It can be helpful to have physicians in those conversations.
We also have collaborative groups and nursing councils, which has been critical for us the last couple of years as backorders have come up and there has been a need for substitution. We are able to work closely with those nursing councils and collaborative groups to quickly decide whether a substitute is appropriate or not.
In improving operational efficiency, the chief medical officer of Duke Regional Hospital makes sure that the medical staff has a voice in the effort.
Adia Ross, MD, MHA, chief medical officer at Duke Regional Hospital, says she relies on the expertise of provider leaders to solve problems.
Ross became CMO of the Durham, North Carolina, hospital in 2020. Previously, she served as medical director of hospital medicine service at Duke Raleigh Hospital and assistant medical officer of quality at Duke University Hospital.
HealthLeaders recently talked with Ross about a range of issues, including challenges of leading clinical care at Duke Regional Hospital, her primary learnings as CMO during the coronavirus pandemic, and advice to other female physicians interested in administrative roles such as CMO. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Duke Regional Hospital?
Adia Ross: There are a couple of challenges. One is dealing with provider and clinician burnout, and trying to come up with ways to make sure we can foster community and a sense of well-being in a time when there is a lot of uncertainty. We try to focus on things that are under our control and promote joy. We focus on things that go well and try to celebrate those things. As leaders, we are focusing on things that get in the way of providing good care.
The other challenge is engaging providers in operational efficiency work in a way that honors what they have been doing in the past while trying to push us forward and to be innovative. This work also involves focusing on value, quality, and safety.
I call myself the chief facilitating officer. When we are thinking about operational efficiency and making things better, I want to make sure that the medical staff has a voice in that effort. I have provider leaders designated by specialty, and I rely on them and their expertise to think about how to solve problems. I give them the “what” and rely on them to give me the “how.” I make it clear that as we go through and try to learn and innovate, and be more effective and efficient, that safety and quality must be at the forefront. They can't be compromised.
HL: You became CMO of Duke Regional Hospital during the first year of the pandemic. What have been your primary learnings as CMO during the pandemic?
Ross: I learned a lot about uncertainty and how it can lead to innovation and clarity of purpose. What I mean by that is when you have many things changing daily and you can't operate in the normal way you have operated in the past, it can cause a lot of internal angst. But you can work through that and say, "We may not be able to use our old bag of tricks, but we have the critical thinking skills, and we can figure out how to get through this." Even in the times of uncertainty, you can find clarity of purpose by working together and just putting one foot in front of the other.
Another thing I learned is how to be operationally flexible, while making sure that flexibility is based on sound principles. So, you need to focus on the problems you need to solve, then think about flexible ways to implement solutions.
Focusing on transparent communication is important. In times when things are changing, you want people to have access to you.
Adia Ross, MD, MHA, chief medical officer of Duke Regional Hospital. Photo courtesy of Duke Health.
HL: Now that the crisis phase of the pandemic has passed, what are the top clinical care issues at Duke Regional Hospital?
Ross: We are trying to cultivate a dual mindset of focusing on quality and efficiency. Managing patient flow and length of stay is a challenge for most health systems at this point—those are things we are trying to work on and get better at. It is important for our community to have timely access to care, and we are figuring out how to do that while focusing on quality and safety.
HL: Give examples of a care quality initiative you have been involved in at Duke Regional Hospital.
Ross: As the chief medical officer, my role is as a chief connector and sponsor of work. I see my role as helping to facilitate the work of frontline leaders and leveraging their expertise, so there have been many quality projects that I have been involved in. For example, I have worked with workplace violence initiatives to decrease events occurring with patients who are elderly and demented. We started a behavioral response team, and I helped make sure that we had a staffing model with nurses and providers, and I helped make sure that we had good outcomes and goals.
I sponsored and supported community-based research. We have done a lot of community-based research with COVID and other areas.
I continue to work on length of stay and serve as one of the physician champions helping to bring together hospitalists, specialists, critical care providers, and emergency department providers to work on ensuring that we can get patients in and out in a timely fashion.
HL: What advice would you offer to other female physicians who may be interested in serving in top administrative leadership positions such as CMO?
Ross: There are a lot of women entering the field, but as you go up the ladder, there are fewer and fewer women in leadership positions. When I think about my role and how I have gotten here, I had an understanding of the factors that allow people to accelerate their careers. I talk about developing a career map—where do you want to go? I did have aspirations to be a chief medical officer, so I tried to think about my career in different phases and five-year increments. I tried to think about the things that would be helpful to advance.
It's important to conduct informational interviews. If you see people in positions that you would like to be in, talking to a variety of them and understanding how they got there will help you develop the pathways to get there yourself.
Having mentors who understand what your goals are can help connect you with sponsors or sponsor you for work.
One thing that people underestimate is volunteering for assignments. One of the ways I have gotten to where I am is I always signed up for things that were outside of my comfort zone. If you are a clinical person, you must think about taking assignments that have nothing to do with your area of specialty and try to stretch yourself to gain knowledge of different operational areas than what you are familiar with.
I would just say be courageous.
HL: You provide leadership support for several clinical and operational departments, including medical staff services, pharmacy, nutrition services, emergency medicine, diabetes management, infection prevention, case management, and palliative care. How do you manage to juggle this broad area of responsibility?
Ross: First, I have wonderful leaders who work alongside me. They have clinical and operational expertise, and my role is to make sure they have the resources that they need. If there are barriers that their teams are facing, I work to eliminate those barriers.
It is really about the team that you have because they support you in doing the work.
Social determinants of health, which The Physicians Foundation calls drivers of health, include five primary factors: food security, housing stability, transportation access, utilities access, and interpersonal safety. About 80% of health outcomes are believed to be directly influenced by drivers of health.
Integrating drivers of health into a practice requires preparation, says Gary Price, MD, president of The Physicians Foundation. "It will require preparation because collecting this data in a sensitive way and in a way that works for the practice and for the patients is going to require buy-in by multiple members of the healthcare team. It is going to vary greatly by practice setting. In a hospital setting, the process will be somewhat different from what might work in a rural independent practice."
For the first time, physician practices will be able to report a drivers of health quality measure as part of the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS). For the 2023 reporting period, the quality measure is the percent of patients who are screened for drivers of health.
To address drivers of health, an individual practice needs to identify what they want to do, Price says. "A reasonable goal would be to begin collecting data in a way that is consistent with the MIPS quality reporting measure. It would also be important for the practice to identify ways that they might refer patients who identify as having social needs. The practice needs to identify which members of the team will be key leaders in implementing referrals and where the work is going to be done in the practice workflow."
Selecting a drivers of health screening method
An initial step to addressing drivers of health is selecting a screening method, he says. "After assessing the practice's needs and outlining the goals, the practice then needs to design a screening process. The good news here is that many templates for validated screening tools already exist. We have links to those on the Take 5 webpage, and the practice can look at those and choose the ones that are best for their practice and their patients. Many electronic medical record systems already have these screening tools built in."
Practices should assign someone to lead the screening process and follow best practices for asking patients questions about drivers of health, Price says. "Basically, the best practices involve making sure the questions are asked in an appropriate atmosphere—the patients should consider the setting private and safe. You need to build rapport with the patients as the questions are asked. You need to make sure the questioner employs empathy. You need to offer an immediate next step—some strategy for the patient to address drivers of health."
Designing a referral process
Once a practice has selected a drivers of health screening method, a key next step is designing a referral process, he says. "The referral process has to be efficient. It has to be integrated into the practice workflow, so it does not add much more time and effort. We regard the referral process as a time-saver, where the barriers for our patients attaining good health are surmounted."
Referral processes are going to vary by practice and the communities in which the work is done, Price says. "This is going to require the practice reaching out for resources that are already present in the community. The referral process step is a point where practices need to know that this work is not something they can do on their own—they are going to have to reach out and gain access to the various community resources. … This is a local and regional process, and practices can look to their local medical societies, to community social resources, and to their hospital systems that have already developed referral patterns."
Once a need has been identified, then the referral has to be made efficiently but it also has to be made to a resource that can actually follow through and connect the patients with the information and resources they need, he says. "Built into that process needs to be some feedback, so that if a referral is made, we can quickly ascertain whether it has been effective or not. In the future, you will see quality measures that ask about the effectiveness of the referrals—were they followed up on? More importantly, were they successful?"
Prospects for addressing drivers of health
Many healthcare organizations have years of experience in collecting drivers of health data, Price says. "We know that in a research study that was done before the onset of COVID in JAMA that a great number of hospitals and even smaller practices were already collecting this data. Over 90% of hospitals were collecting all five of the drivers of health measures before COVID, and about 16% of practices were collecting this data. When you look at how they are doing with measuring just one driver of health, the majority of hospitals and practices were measuring at least one. So, this process will not be completely new to most practices, but to those for whom it is new, we have the resources at The Physicians Foundation."
The Physicians Foundation played an active role in establishing the MIPS drivers of health quality measure, and the organization is committed to helping physician practices address drivers of health, he says. "The foundation has been involved in research about the importance of drivers of health for many years. Just introducing the simple metric of how many of your patients you are actually asking the questions of has started an intense amount of interest in looking for solutions for these problems that impact our nation's health so greatly. This is an inflection point in drawing attention to how drivers of health impact our health and our health outcomes."
Baptist Health is using technology tools such as voice recognition software that generates clinical notes to reduce administrative burden on physicians.
Technology can ease administrative burdens on physicians and improve physician satisfaction, says Brett Oliver, MD, chief medical information officer at Baptist Health.
The physician burnout level and other measures of physician distress increased dramatically during the coronavirus pandemic, survey research shows. The findings of the 2021 survey are troubling, with 62.8% of physicians reporting at least one symptom of burnout compared with 38.2% in 2020.
Medical technology is maturing and holds great promise for helping physicians, Oliver says. "For many years, technology has been seen to be a burden for physicians. I practiced family medicine for 25 years, so I remember the transition to electronic health records as well as other technologies, and we are at a tipping point in terms of technology where we can now make a positive difference for my colleagues."
A good example of technology that reduces administrative burden for physicians is Nuance's Dragon, which began as voice-recognition software that allowed physicians to dictate their clinical notes. he says.
"The difference in the technology now with what they call their Dragon Ambient eXperience is the physician does not dictate anything. The physician comes in the room. After getting permission from the patient, the physician hits the start button, and Dragon Ambient eXperience records the conversation. It records the whole interaction. It's not a transcript. The AI develops a summary note of that interaction with the patient. They have integrated ChatGPT4—generative AI—into the model, which generates the note in real time," Oliver says.
When the physician is done seeing the patient, the note is there for the physician to look at, he says. "The physician can make additions or corrections. Then the note can be filed away, and the physician is done. There is a huge lift of administrative burden."
Benefits of remote patient monitoring
Remote patient monitoring (RPM) can boost physician satisfaction, Oliver says.
Baptist Health has been using RPM technology developed by Current Health for about three years. Current Health has a device that the patient wears on their arm. It can either sit on the arm with a band or it has an adhesive that sticks on the arm. The device records multiple parameters such as heart rate and pulse oximetry. There is a scale that goes with the kit, so when patients weigh themselves on the scale, it is transmitted to the device. The technology is integrated into the Baptist Health EHR, so the data flows back to the health system, just like physicians would see other data on a patient. Clinicians do not have to go to another screen or another dashboard.
Initially, Baptist Health used the Current Health RPM technology for patients with chronic obstructive pulmonary disease and heart failure, but that pilot was disrupted in about six weeks when the coronavirus pandemic hit, Oliver says. "We were watching some hospitals getting overrun and we pivoted to use Current Health for our COVID patients to send them home with monitoring. We sent more than 350 COVID patients home with the Current Health device, and we did not have any of them readmitted."
Once the pandemic passed the crisis phase and Baptist Health realized it was not going to be overwhelmed, the health system went back to using Current Health RPM technology for heart failure patients, he says. "We had a heart failure clinic set up already, we just added remote monitoring to that clinic. In our Louisville market, we had about 55 patients over the course of nine months take the Current Health device home. This was a high-risk group of patients—you would predict a readmission rate in 30 days of 18% to 22%. For those 55 patients, we had nobody readmitted at 30 days. When you have those kind of successes as a clinician, it invigorates you. It is burnout-reducing."
Optimizing the EHR
Baptist Health has been focusing its EHR optimization efforts on the EHR in-basket messages to physicians, Oliver says.
"Since COVID hit, in-basket messages for physicians have gone through the roof. They are not a bad thing—we do not want to get rid of them. They are an efficient way of dealing with patient questions, but the volume has gotten crazy. We have some AI in place now so that if a physician has a back-and-forth with a patient, and the patient says, 'Thank you,' and there is no other clinical information, we are experimenting with AI that will close that conversation without the physician getting another in-basket message. These are not a lot of messages—about 5% of the total—but if you take one out of 20 messages out of the mix, it makes a difference."
Baptist Health is also using generative AI to come up with possible answers to patients' in-basket messages, he says. "The physician is alerted to a potential reply, and they are asked whether they want to modify it or just send it."
In addition, the health system is trying to limit the number of in-basket messages coming to physicians, Oliver says. "Number One, does a message even need to come to the physician? In the electronic world, it has made it so easy to send a message about anything to anybody. We are trying to filter messages that do not bring clinical value. It may still need to be in the chart, but does the physician have to address every message?"
Cultural competence has been embedded in One Medical, a primary care provider based in San Francisco.
One Medical has made culturally competent care a priority for the primary care provider.
Cultural competence is critical in decreasing healthcare disparities through culturally sensitive care, according to the Agency for Healthcare Research and Quality. "Culturally competent care is defined as care that respects diversity in the patient population and cultural factors that can affect health and healthcare, such as language, communication styles, beliefs, attitudes, and behaviors," AHRQ says.
One Medical has a similar definition of culturally competent care, says Hemalee Patel, DO, senior medical director for chronic care management. "Culturally competent care is the ability to deliver effective healthcare that meets the social, cultural, and language needs of a patient. You need to understand that for any given patient coming in the door, they may have a different experience from a provider, and they come with their own norms that may be different from a provider's. You need to understand and meet folks where they are at and be able to deliver effective care with empathy."
Culturally competent care is essential to provide high quality care, she says. "As the nation is becoming more diverse, it is important to be culturally competent. You need to build trust and a relationship in order to help patients from a preventative standpoint but also from an acute standpoint. You want folks to understand that they can come into a healthcare setting and feel that they are being heard, and they have a trusted source of care."
One Medical has embraced cultural competence as an organization, Patel says. "One Medical is a very diverse place. I came from a traditional health system. I feel that even in the interview process it was extremely important that they took my values into account and that everyone's values were heard. That is part of the culture here."
One Medical clinicians receive training and feedback about culturally competent care, she says. "In terms of providers, we have a lot of training opportunities and resources. We have training courses that we have providers go through. We are constantly giving feedback to providers. We are sharing information about their patients that they might not necessarily have seen. Our clinical learning team develops modules and workshops for providers to get the training when they need it."
At One Medical, culturally competent care is helping to achieve positive health outcomes, Patel says. "In my program, we are proud to say that outcomes of improvement in areas such as cholesterol and weight are equal across all races and ethnicities. That is data that we continue to look at, continue to gather, and continue to learn from."
She gave an example of a patient who required culturally competent care. "I had a patient who came in who had diabetes, and she was of Filipino background. In her entire family, everyone has diabetes, including her mom and her sister, who were on insulin. She was scared. When I asked her about her understanding of someone having diabetes, it was insulin and a short lifespan. For her, it was very important that family meals are traditional. She didn't understand how she could turn her diabetes around."
Understanding that traditional meals were important to the patient was an important element of providing culturally competent care, Patel says. "We could still do a lot in terms of mitigating her disease state. In the course of about six months, she was able to see her glucose levels coming down. She was still able to enjoy family meals. By improving her own metrics and her family observing this achievement, her mom and her sister also become One Medical patients, and they have also been able to shift the way they think about food without compromising their values."
Aimee Becker, MD, MBA, chief medical officer of UW Health. Photo courtesy of UW Health.
Sam Banks, chief procurement officer and vice president of supply chain at IU Health. Photo courtesy of IU Health.
Adia Ross, MD, MHA, chief medical officer of Duke Regional Hospital. Photo courtesy of Duke Health.
