The burnout rates for Allegheny Health Network physicians and nurses are below national averages. Here's how its CMO did it.
At Allegheny Health Network(AHN), a six-year journey to improve the well-being of physicians, advance practice providers, and other staff is generating positive results.
There are three primary reasons why CMOs should be concerned about clinician well-being, says Donald Whiting, MD, CMO at AHN and president of Allegheny Clinic. Promoting well-being is essential for retention of clinicians, clinician well-being has been linked to the overall quality of patient care, and well-balanced clinicians perform their jobs better than clinicians who are struggling with well-being, Whiting says.
"As the CMO, you want your clinicians to come to work and put all of their energy toward taking care of their patients," Whiting says. "To do that, you need to address both the basic and advanced needs of your clinicians."
About six years ago, Thomas Campbell, MD, MPH, proposed creating a physician wellness program to Whiting. At the time, Campbell was serving as chairman of emergency medicine at AHN. He is now vice president of wellness at the Pittsburgh-based health system.
"I wanted to launch a physician wellness program because I had been doing research on burnout," Campbell says. "Dr. Whiting wanted to include more than just physicians, so our decision was to create a program for physicians, residents, advanced practice providers, and nurses. The intent was to grow the program to include all employees."
After launching dozens of wellness initiatives, AHN has made significant progress in boosting staff well-being. In recent years, physician burnout has trended 10 percentage points lower than the national average. In 2023, AHN earned recognition from the American Medical Association for demonstrating a commitment to promoting clinician well-being through proven efforts to address work-related stress and burnout.
"For our physicians as well as our nurses, we have been below the national averages for burnout," Campbell says. "In national surveys, there has been physician burnout as high as 62%. Our highest burnout rate for physicians has been about 52%."
To promote clinician well-being, CMOs and other leaders need to start with understanding the environment clinicians are in and the stressors that they are facing, Whiting says. "When we launched our well-being program, we started by surveying our physicians and advanced practice providers in several categories around the components of Maslow's Hierarchy of Needs. There were specific questions about safety at work, hours of work, the ability to take time for meals, and the respect of peers."
Well-being interventions
AHN began its efforts to promote clinician and nurse well-being by focusing on "low-hanging fruit," Campbell says.
The health system's first annual wellness survey indicated that many clinicians and nurses were not aware that they could reach out for behavioral health help. Leaders publicized the fact that behavioral health services were available to all employees through AHN's Employee Assistance Program, which also was made available to non-employed independent clinicians.
AHN's internal behavioral health group created a 24/7 help line for employees. "That was a great success, and it has continued since the beginning of our wellness program," Campbell says. "It is a foundational program."
The early annual wellness surveys found that some basic needs were not being met. Staff members were not taking meal breaks and they were getting dehydrated from not taking a break to drink water. "We made a big push among physicians, residents, and the nursing staff to get people focused on meal breaks," Campbell says. "Our parent organization, Highmark, gave us a grant to create water stations in our hospitals at convenient locations."
The annual wellness survey found female clinicians had higher burnout scores than male clinicians, which matched national data. There were cultural responsibilities impacting female clinicians such as the need to get children to school in the morning, so the health system implemented flexibility for start times and job-sharing capabilities.
Over time, after the low-hanging fruit had been grabbed, AHN began tackling more challenging aspects of promoting well-being, Campbell says. "We are working on initiatives that are much more difficult such as creating a caring culture to care for each other. We are trying to find ways for people to still take their breaks despite staffing shortages. We are trying to make sure physicians can take their vacations without checking patient messages in their electronic in-boxes."
Some AHN well-being initiatives launched during the coronavirus pandemic have become permanent.
"We now have 'decompression rooms' that people can go to when they are stressed out. These are quiet rooms with massage chairs and resources for people to reach out if they need help," Campbell says. "We also created another 24/7 help line for people in the emergency department and critical care. In addition, we started a peer support program for physicians and nurses so they could get help when they were at the end of their rope—if they were hesitant to reach out to a clinical professional, they could reach out to a peer."
In recent years, AHN has launched several new and innovative well-being initiatives.
The health system hired a wellness officer for each institute on the medical staff, Campbell says. "These wellness officers are my panel of experts for fields including surgery, obstetrics-gynecology, family medicine, and internal medicine. Almost all of these wellness officers have gone to programs on burnout and completed Stanford Medicine courses on well-being."
Last year's AHN wellness survey found improvement in the burnout scores related to electronic health record work, Campbell says. "We asked specific questions about the in-box because we knew that was a driver of burnout. What we found was that burnout from the EHR in-box got better for our physicians but a little worse for our advanced practice providers. What I think happened is that some of the work got pushed to the APPs, and now they need help."
For the clinician resident group, AHN has posted a couple of recent successes, Campbell says. "For example, the residents have complained that they have a lot of administrative tasks and other things that make their life difficult such as interruptions in their workday. Instead of equipping them with pagers, we got them cellphones, so they could be reached by text, which is less disruptive than a page, especially when they are at home. We also have provided healthy food in the resident lounges."
For the APPs, AHN has launched several initiatives because they are critical to getting work done, Campbell says. "We created an APP council, so their voices would be heard. In addition, every hospital medical staff executive committee has an APP representative, so their voice is heard in those forums. They have become more integrated with the leadership of the institutes."
The Wisconsin-based health system is using Stanford Medicine's well-being survey and following the Stanford Medicine Model of Professional Fulfillment.
UW Health is following clinician well-being best practices established by Stanford Medicine, the chief clinical officer of the Madison, Wisconsin-based health system says.
With a nation-wide shortage of physicians worsening, physician well-being programs are essential for retention and recruitment. In addition, physician burnout remains a concern across the country, and it spiked during the coronavirus pandemic. In a 2021 survey of physicians conducted by the American Medical Association, Mayo Clinic, and Stanford Medicine, 62.8% of physicians reported experiencing burnout symptoms, which was up from 38% the previous year.
When a physician's well-being is compromised, there are several negative effects, says Aimee Becker, MD, chief clinical officer at UW Health.
"When we look deeply at physicians in particular, certainly we know there is a financial impact to a lack of well-being and the presence of burnout," Becker says. "There is fluidity with physicians leaving the organization as well as recruitment and retention issues. There is also a lost opportunity when physicians are not well or burned out—their work is impacted. For example, there can be productivity and quality issues."
UW Health stepped up efforts to promote physician and advanced practice provider well-being in 2017, when the health system conducted its first physician and APP well-being survey as part of Stanford Medicine's Physician Wellness Academic Consortium. UW Health has repeated the survey every two years since 2017, Becker says. "It is challenging to make meaningful change without having data and metrics."
The Stanford Medicine well-being survey includes annual benchmarks for burnout and professional fulfillment. "The benchmark for burnout has risen since before the pandemic, and the benchmark for professional fulfillment is slightly lower than since before the pandemic," Becker says.
UW Health is using the well-being survey to monitor well-being trends in its physician and APP workforce.
"In our most recent survey, which was conducted in 2022, we rated at approximately the benchmark for the country," Becker says. "In general, our female physicians experience slightly more burnout than our male physicians, and female physicians experience slightly lower professional fulfillment than male physicians. In our APP group, those findings have been reversed, with our male APPs experiencing slightly more burnout and slightly lower professional fulfillment."
Programs that support physician and APP well-being
After UW Health started conducting the well-being survey, the health system committed to not only measuring wellness among physicians and APPs but also to acting on the measurements. UW Health developed a well-being committee that included physician and APP representation from all clinical departments. "They were tasked with helping us as an organization to identify initiatives to improve physician and APP well-being," Becker says.
Most of UW Health's well-being improvement initiatives for physicians and APPs have been consistent with the Stanford Medicine Model of Professional Fulfillment, Becker says. The model has three domains: culture of wellness, efficiency of practice, and personal resilience.
An example of promoting a culture of wellness in recent years is the health system's revamping of its Physician Leadership Development Program, which had been in place for more than a decade. UW Health partnered with the American Association for Physician Leadership to have a robust curriculum that offered a Certified Physician Executive pathway and credits for a Master's in Medical Management. The revamped Physician Leadership Development Program was implemented in 2020.
Examples of the leadership program's curriculum include conflict negotiations, constructive feedback, healthcare finance, emotional intelligence, and leading by influence.
"On average, we have had 25 physician leaders in each Physician Leadership Development Program cohort," Becker says. "As physicians have graduated from the program, they have advanced in the organization, whether that is in their clinical department or stepping into new roles at the health system."
Another example of promoting a culture of wellness at UW Health is an organization-wide peer support program that is a holdover initiative from the pandemic.
"We have physicians and APPs trained to provide peer support," Becker says. "The people who provide peer support are activated when there is a challenging work situation or when there is individual stressor burnout. There is comfort in being able to reach out to a peer to have a conversation when you are struggling with something."
An example of efficiency of practice initiatives at UW Health includes addressing burdens associated with the health system's electronic health record such as documentation and extra regulatory clicks in the EHR, which is Epic.
"This is a pain point for physicians and APPs," Becker says. "So, we have had some initiatives aimed at these burdens. One was implementing a remote scribe program for clinic-based physicians to ease documentation burdens, which improve efficiency of practice for these physicians."
To educate care teams about Epic and get feedback from care teams about using Epic, UW Health expanded the health system's physician informatics team to ensure that each clinical department had representation. "That was a big addition to support efficiency of practice," Becker says.
In the domain of personal resilience, UW Health is supporting staff members individually and helping them grow and develop.
"Emotional well-being resources are foundational for personal resilience," Becker says. "We are not relying on individuals to solve our well-being stressors and things that make healthcare challenging. For physicians, APPs, and other staff members, there is access to financial counseling. There are well-being initiatives for physical well-being. We are also supporting initiatives to promote connectedness and having fun. We also shine a light on mental health, including destigmatizing mental health challenges."
Successful healthcare organizations can distinguish between the patient experience and the customer experience.
Healthcare organizations need to focus on both the patient experience and the customer experience. And yes, there are important differences.
The contrast between patient experience and customer experience is largely a difference in perspective, says Sarah Way, MD, JD, chief quality and medical officer at Texas Health Dallas, a hospital operated by Texas Health Resources.
Patient experience is related to when someone receives medical care in the moment, says Way, an emergency medicine physician. For example, receiving treatment from an emergency room clinician is a patient experience.
"A customer experience is when you look at an interaction more broadly, when somebody is engaging with the healthcare system, but it is not the provision of medical care in the moment," Way says. "In the emergency department, customer experience includes how somebody is checked in at the front desk and how they are discharged. The customer experience also includes family members and how they perceive a patient's visit to a care setting."
Patient experience and customer experience are different engagements with the healthcare system, and one person can be both a patient and a customer, says Amy Goad, managing director at Sendero Consulting.
While someone is a patient when they receive care directly from a provider, that person is a consumer when dealing with other aspects of the healthcare system outside of direct medical care.
"You are a customer when you are trying to schedule an appointment, when you are trying to coordinate insurance, when you are trying to find lab results while navigating a patient portal, and when you are conducting research on who you want to be your provider," Goad says.
Identifying different strategies for different forms of engagement
One difference between the patient experience and the customer experience is that patients are much more vulnerable and want to spend time with their healthcare providers, Goad says.
"That vulnerability creates a different bond with your care provider than the situation when you are trying to order a prescription or schedule an appointment," Goad says. "When my health is in question and it feels risky, the patient relationship becomes a bigger priority than the customer components."
On the other hand, Goad says, a health system's customer experience strategy should focus on convenience and ease of use.
"As customers, people do not want the heavy engagement that they need when they are patients—they want to be bothered as little as possible," Goad says. "Customers are convenience-focused and transactional. You want convenience in your interactions, which you want to be quick and simple."
A health system that fails to distinguish between patient experience and customer experience will see the effect in negative satisfaction scores, Goad says.
"When I'm wearing the hat of the customer and somebody tries to treat me like a patient, it is going to wear me out—you are trying to take up too much of my time, and I am going to go somewhere else where it is easier," Goad says.
"When I'm wearing my patient hat and I'm feeling anxious about my pregnancy and want to spend more time with my doctor, if I get treated as a customer such as quickly getting in and out of an appointment, I am going to feel frustrated," Goad says. "I am going to feel that I am not a known entity and that there is no one investing the time to make sure I am OK."
Conversely, Way says, a CMO must understand that the healthcare experience is about the whole person, both the patient and the customer. Failing to recognize and address both types of engagement, Way says, could lead to fractured care or a feeling of disconnection with the health system.
"You need to provide the right medical care in the moment, but you also need to recognize that if you do not address the customer experience you are not going to get the best result for the person you are serving," Way says.
Serving both the patient and the customer
Key components of the customer experience in healthcare involve taking steps beyond the provision of medical care, such as providing resources for follow-up care or health and wellness services, Way says.
"We need to recognize that there is more to serving people than providing medical care in the moment," Way says. "For example, if you write a prescription, you need to consider whether the pharmacy is open, whether your patient has transportation to get to the pharmacy, and whether your patient can afford the medication."
For the customer experience, healthcare organizations need to recognize the resources people need to build their overall health even when they are not sick, Way says.
"One of the big initiatives across the country is to look at social determinants of health," Way says. "We need to be gathering information about what our patients are struggling with such as food insecurity and housing. If a patient is struggling with food insecurity, healthcare organizations need to help patients find resources in the community such as food pantries and connect patients to those resources."
Ensuring patients have transportation is another element of generating a good customer experience, Way says.
"If a patient is discharged from the hospital and there is a high likelihood that the patient is going to need outpatient care or come back to the hospital, you need to ask the patient how they are going to get to their appointments," Way says. "If transportation is an issue, the next question you need to ask is what can we do to help you get transportation. There are community resources that provide transportation."
If transportation is problematic, healthcare organizations also should be able to provide appointments via telemedicine, Way says.
Navigating between patient experience and customer experience
Healthcare providers need to understand the full health journey and be able to differentiate between the patient experience and the customer experience, Goad says.
"When a care provider is sitting in an exam room with someone, they need to recognize they are dealing with a patient," Goad says. "When someone is at the front desk, they are likely to want more of a customer experience versus a patient experience."
When health systems are looking to invest and innovate, if they are trying to innovate on a patient experience but focus more on consumer-centric factors such as billing and scheduling, they are missing the mark, Goad says.
"Examples of investing in patient experience include having more clinical trials and hiring more clinical staff so clinicians can have more time with patients," Goad says. "Health systems need to understand how they are investing in these separate experiences to get better efficiencies and outcomes."
Healthcare organizations need to know that patient experience and customer experience are equally important, and they cannot be disconnected, Way says.
"We are having to shift as physicians and providers from the idea that providing medical care is enough for the people we serve," Way says. "We also have a responsibility to ensure that the medical care we provide is received and accessed in the right way. It is not enough to be great physicians in the technical sense—we also must be good communicators, we have to work in a system that reaches out and provides good access, and we have to address needs beyond the provision of medical care."
Historically, clinicians have focused on the people they serve as patients, but that focus is too narrow, Way says.
"We must expand that zone to also think about the people we serve as customers," Way says. "This is not a skill set we are taught in medical school—healthcare organizations need to build the skill set of their providers to include dealing with people as patients and customers. We want the care we provide to be recognized as good because it is received well."
Zero-tolerance policies and the promotion of reporting incidents of mistreatment such as sexual harassment are essential, CMO says.
A recent JAMA Network Openarticlefound sexual harassment and other forms of mistreatment are common in the obstetrics-gynecology field. CMOs and other healthcare leaders need to address the problem, a CMO says.
The recently published research article conducted a systematic review of 10 studies on harassment and 12 studies on interventions. One study that examined harassment rates in several medical specialties found that OB-GYN was second only to general surgery in specialties linked to the highest rates of sexual harassment.
"This systematic review found that 28% to 71% of participants reported sexual harassment, sexual coercion, or unwanted sexual advances within the field of OB-GYN in surveys," the research article's co-authors wrote. "These events were often not reported to institutional leadership, however, given that individuals experiencing these forms of mistreatment feared retaliation and did not feel that their experiences would be taken seriously. There were also high rates of bullying, gender bias, and microaggressions among trainees and practicing physicians."
The research article has several key findings:
Workplace discrimination among female gynecologic oncologists ranged from 57.0% to 67.2%
Bullying was reported by 52.8% of female gynecologic oncologists
Sexual harassment such as gender harassment, unwanted sexual attention, and sexual coercion was reported by 69.1% of OB-GYN trainees
The primary perpetrators of harassment were identified as physicians (30.1%), trainees (13.1%), and operating room staff (7.7%)
In a survey of 250 female gynecologic oncologists, 83.2% reported experiencing microaggressions such as being told to smile more, dress in certain ways, and to act more female or motherly
In gynecologic surgery, gender discrimination was the most common form of discrimination for male clinicians (72.3%) and female clinicians (90.1%)
"These findings suggest that there is high prevalence of harassment in OB-GYN," the research article's co-authors wrote.
CMO perspective
The data in the research article reflects the problem of workplace mistreatment and sexual harassment in American society, says Mark Simon, MD, MMM, CMO of Ob Hospitalist Group.
"Unfortunately, gender harassment and sexual harassment is too common in American society in general," Simon says. "The field of medicine is made up of people from society, so you see a continuation in what you see in society at large inside medicine in general and OB-GYN in particular."
OB-GYN has the highest percentage of female clinicians such as physicians and midwives, which underlies the data in the research article, Simon says. "With a large percentage of female clinicians and as is the case in society at large, women are on the receiving end of sexual harassment, which makes OB-GYN prone to sexual harassment."
The finding that nearly three-quarters of OB-GYN trainees experience sexual harassment is disturbing but not surprising, Simon says. "Especially when you are talking about OB-GYN trainees, there is a power dynamic between people who are teachers or other individuals who are responsible for the trainees. This power imbalance can set up a dynamic for a harassment situation. In addition, the data shows that vast majority of trainees and young OB-GYN clinicians are women, which is a component of this problem."
When perpetrators are senior staff members, CMOs need to hold them to the same standards as other staff members, Simon says. "Even if the alleged perpetrator is a powerful individual within an organization, staff members need to see that the alleged perpetrator will be subject to an investigation the same as anybody else and will be held accountable the same as anybody else."
CMOs and other healthcare organization leaders can take actions to reduce mistreatment such as sexual harassment, Simon says.
"It is important for CMOs and other healthcare leaders to take the opportunity to set expectations and have zero tolerance for sexual harassment and other mistreatment," Simon says. "That requires codes of conduct, education, an internal recognition that harassment is occurring, a willingness to hear and be open to any complaints that are lodged, and a commitment to investigate complaints thoroughly and fairly. Then healthcare leaders must hold perpetrators accountable to the expectations."
CMOs must be intentional to alleviate fear of retaliation when mistreatment is reported and to address the concern that complaints will not be taken seriously, Simon says. "The best thing CMOs can do is have an open and transparent process for the lodging of complaints. CMOs should have zero tolerance for harassment when it is identified. CMOs should have clear and transparent policies for retaliation, which is illegal."
The CMO of Northwell Health is developing a specific care strategy for the fastest growing segment of the nation's population.
With seniors comprising the fastest growing segment of the American population, Northwell Health is developing an "age-friendly" strategy aimed at improving clinical outcomes.
According to thePopulation Reference Bureau, the number of Americans who are 65 or older is expected to rise 47% over the next three decades, increasingfrom 58 million in 2022 to 82 million by 2050. During this period, the share of the total population of Americans who are 65 or older is expected to increase from 17% to 23%.
Healthcare providers need to step up efforts to serve that population, says Jill Kalman, MD, CMO, deputy physician-in-chief and executive vice president at Northwell Health.
"They are complex with multiple chronic conditions," Kalman says. "We need to take care of this growing part of our population. Both the 65-and-older and 80-and-older patient populations are growing."
Northwell has joined 29 other health systems in launching the Institute for Healthcare Improvement's Age-Friendly System-Wide Spread Collaborative. The collaborative is designed to accelerate and spread evidence-based care for older adults. A primary goal of the collaborative is to push adoption of four evidence-based elements of high-quality care, known as the 4Ms: medication, mobility, mentation, and what matters most to older patients and their families.
Kalman says Northwell has embraced the 4Ms at the health system's 21 hospitals and 900 ambulatory practices:
For medication, Northwell is focused on how an older adult metabolizes certain medications, which can be significantly different with younger patients, especially if there is kidney disease, liver disease, or heart disease. Clinicians take great care with medications that can be harmful for older adults such as benzodiazepines and opioids. Those medications are used when necessary, but doses are adjusted and clinicians are intentional about the medications they choose.
Mobility is of the utmost importance in the inpatient and outpatient setting. For example, clinicians need to be aware of a patient's mobility for risk of falls. In the outpatient setting, Northwell is encouraging physical therapy and mobility activities that can be specifically tailored to an older patient's co-morbidities.
Mentation and cognition may decline naturally over time, and there are diseases that impact mentation such as Alzheimer's. Northwell is focusing on how patients can improve their mentation with specific activities such as games or social interactions.
Northwell is focusing intently on what matters most to the health system's older adult patients and their families. For example, patients are asked about what matters to them as they advance in an illness and about their goals in care.
Age-friendly care delivery and CMOs
Kalman says CMOs have an obligation to address quality of care, and the delivery of age-friendly care is part of that mission.
"It is important to deliver on quality metrics for older patients," she says. "I am focused on making sure evidence-based forms of care are used and making sure we are minimizing harm in everything that we do. I understand that older adults often have multiple chronic conditions that need to come into play when we are looking at the complexity of care for these patients."
The primary quality metrics in the care of older adults include the 4Ms, length of stay, and hospital readmissions, Kalman says.
"I monitor dashboards for our age-friendly health system that look at multiple metrics across our hospitals and ambulatory practices, so we can continue to understand how well we are doing in the evidence-based delivery of care," she says.
A CMO must recognize that older adult patients also have different needs and risks when it comes to surgery, Kalman says.
"Someone coming into a hospital for an appendectomy at the age of 80 is going to have different needs than someone coming in for an appendectomy at the age of 25," Kalman says. "It can be extremely different. Even the least complex surgery can be complex in an older adult, particularly in the recovery phase."
CMOs who are committed to age-friendly care delivery should make sure their health systems pay attention to medication management, delirium screening, and the goals of care, Kalman says.
"These factors need to be put together to drive the best outcomes," she says. "If we can drive the best outcomes in the outpatient and inpatient settings, we also work toward preventing some of the frailty in the older adult [and supporting] a better health span. We can also reduce length of stay and reduce hospital readmissions."
Value of age-friendly care delivery
The benefits of age-friendly care delivery are considerable, Kalman says.
"It is all about the quality of life and quantity of life, if that is what the older patient desires," she says. "The combination of health span and life span is extremely important. The benefits of age-friendly care include driving good clinical outcomes."
"The drawbacks of not providing age-friendly care delivery are poorer outcomes," Kalman says. "For health systems, there are financial drawbacks from not providing age-friendly care delivery. If you provide the best care and achieve the best outcomes, it will drive the financial health of your organization as well."
MaineGeneral Medical Center's CMO also says the noncompete ban will make healthcare organizations face higher physician recruitment costs.
A Federal Trade Commission (FTC) ruling last week that bans noncompete agreements will likely raise healthcare costs, the CMO of MaineGeneral Medical Center says.
The FTC estimates that about 18% of the nation's workforce—roughly 30 million people—are subjected to noncompete clauses. The American Hospital Association and other healthcare stakeholders claim the FTC overstepped its authority to approve what the AHA calls "a bad law, bad policy, and a clear sign of an agency run amok."
The noncompete agreement ban, which will take effect 120 days after it is published in the Federal Registry, will be challenging for healthcare organizations that employ physicians, says Dana "Dan" Vick, CMO of MaineGeneral Medical Center.
Vick does not agree with the FTC's assessment that the noncompete agreement ban will reduce healthcare costs by $194 billion over the next decade.
"I can see an increase in worker earnings," Vick says. "Without a noncompete agreement, a physician can easily move from one practice to another depending on who is the higher bidder, so I do not see how the ban will reduce healthcare costs. Banning noncompete clauses is going to force healthcare organizations to compete on price point for physicians. It also costs thousands of dollars to recruit physicians."
The noncompete agreement ban will spur bidding wars for physicians, Vick says. "If a physician who is employed gets a better offer across the street and decides to take that offer, then the initial employing organization may make a counter offer to keep that physician. If the counter offer is successful, the initial employing organization will have a higher cost for keeping that physician."
Dana "Dan" Vick is CMO of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.
Vick, who has been a physician in private practice subject to a noncompete agreement and works at an organization where noncompete clauses are part of employment agreements, sees both sides of the issue.
"From the employee standpoint, if a job does not work out, the employee may want to move to another position and noncompete clauses can prevent them from doing so in a certain geographic area, which is typically how noncompete clauses are set up," Vick says. "These clauses can have a time limit that forces employees to wait to work in another part of the designated geographic area."
"From an organizational standpoint, noncompete agreements are a way to protect a business by reducing the risk of business loss," Vick says. "These agreements prevent clinicians from taking patients, staff, and organizational information with them if they go somewhere else. These agreements increase employers' incentives to provide training to healthcare workers that could be costly versus opting not to provide training if employers think workers are going to jump ship and go somewhere else. These agreements also help to decrease labor turnover."
About 40% of physicians are bound by noncompete agreements, according to the American Medical Association. That level of noncompete agreements among physicians is probably reasonable in terms of where the noncompete agreements are in effect, Vick says.
"In large metropolitan areas, where you have competitors overlapping with each other, you would tend to see noncompete agreements more prevalent than in rural areas where competitors are not located close to each other," Vick says.
Vick says the noncompete agreement ban will likely have a negative impact on MaineGeneral Health, which uses noncompete clauses in employment contracts with physicians. "It is going to increase the cost of employing physicians as well as increase the cost of recruiting physicians if people do leave."
It remains to be seen whether the noncompete agreement ban will be upheld in the courts, Vick says. "There are going to be some significant legal challenges to the ban. The U.S. Chamber of Commerce has already said that it plans to file suit to block the ban. We'll have to see exactly what happens."
WellSpan Health is set to open three small-format hospitals by the end of 2025.
WellSpan Health is opening small-format hospitals to increase access to emergency care and inpatient care in three communities.
The small-format hospitals, which are being sited in New Freedom, Carlisle, and Newberry Township, Penn., feature emergency rooms with 10 beds and 10 inpatient rooms. The hospitals, which do not have operating rooms, will offer X-ray, CT scanners, and ultrasound as well as diagnostic laboratory studies. The hospitals will be open 24/7 year-round.
The three hospitals are expected to open by the end of 2025.
"We are locating the hospitals in convenient areas for our patients, particularly in areas that are underserved in relation to inpatient care," says David Vega, MD, MBA, senior vice president and CMO at WellSpan.
One of the big benefits of the small-format hospital model is that they tend to have short wait times compared to traditional hospitals and emergency departments, Vega says. "Typically, the wait time in the emergency department is 10 minutes to care, and for patients who are discharged from the emergency department, it takes about 90 minutes from the time patients check in to the time when patients go home."
The small-format hospitals are based on a streamlined model of care that allows caregivers to see patients faster and to expedite services without any reduction in the patient experience, Vega says. "In fact, it is a better patient experience than what most hospitals in the country can achieve."
The streamlined model of care includes use of standardized protocols and standardized ways of seeing patients that will help the small-format hospitals to gain efficiency, Vega says, adding the scope of care is more narrowly focused than at WellSpan's traditional hospitals.
"The scope of what is going to happen in the emergency departments at the small-format hospitals is not the same as we experience at York Hospital, which is a Level 1 trauma center," Vega says. "At York Hospital, there can be several trauma patients and stroke patients in the emergency department. At the small-format hospitals, the scope of care and the volume of patients is going to be lower than what you see at traditional hospitals, which will make us more efficient in the care that we provide."
The small-format hospitals will also be designed to provide efficient access to specialists through virtual connections, Vega says.
"This is a different model than traditional hospitals," Vega says. "Instead of having to wait for a specialist to become available and come physically to a location, a lot of our specialists will be available immediately at the bedside through a virtual connection. For example, if you need a cardiologist, they will work with the nursing team at the small-format hospital to be able to examine the patient remotely such as hearing the heartbeat."
From a CMO perspective, the small-format hospitals will allow WellSpan to have a more focused and efficient approach to care within the scope of services that will be offered, Vega says.
"The services that are offered are a little different than traditional hospitals," Vega says. "For example, there are no operating rooms or surgical procedures performed at small-format hospitals. However, the emergency department is fully licensed by the state and available 24/7. The inpatient side of the hospitals is also available to our patients."
As WellSpan's CMO, it also is important to have the small-format hospitals integrated into the health system's electronic medical record, Vega says. "If a patient needs a higher level of care than what the small-format hospital can offer, we will make it smooth and easy for patients to be transferred to a higher level of care at one of our traditional hospitals."
Providence is expanding the health system's Co-Caring Model at inpatient units and working to improve patient care progression in the inpatient setting.
The chief clinical officer of the Providence health system is shepherding a pair of inpatient care initiatives aimed at improving the patient's journey.
Hoda Asmar, MD, MBA, is supporting a quality improvement initiative called the Co-Caring Model. Under the Co-Caring Model, bedside teams in the inpatient setting are supported by a team of nurses, social workers, case managers, and other staff members who work in a virtual role 24/7.
The Co-Caring Model was launched as a pilot last year on one acute-care unit. By the end of 2024, Providence will have 33 acute-care units using the Co-Caring Model.
Staff satisfaction with the Co-Caring Model has been high and it has the potential to help address workforce shortages, Asmar says. In the first seven months of the pilot for the Co-Caring Model, there was 100% retention of staff on the inpatient unit that adopted the model.
Patients have also been receptive to the Co-Caring Model, says Asmar, who has been executive vice president and chief clinical officer of Providence since October 2021. Previously, she served as executive vice president and chief clinical officer of Adventist Health and chief medical officer of system clinical improvement at Baptist Memorial Health Care.
"We tell the patient there will be a virtual team supporting the bedside team that they interact with in-person," she says. "None of our patients have opted out of the Co-Caring Model. When we looked at patient satisfaction and experience scores for patients and their families who were engaged in the Co-Caring Model, there were great results."
The Co-Caring Model gives the patients and staff more choices, which supports growth, Asmar says.
"In healthcare right now, there is a challenge in having enough caregivers joining the workforce," she says. "By creating choices, efficiency, and a positive culture, the Co-Caring Model is helping us to recruit and retain staff members, which is helping us to serve more patients."
Providence considers the Co-Caring Model to be a learning opportunity, Asmar says.
"As we are implementing the model at acute-care units, we customize elements for the local context, and we keep refining the model as we go based on the results and what we are learning," she says.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer of Providence. Photo courtesy of Providence.
Improving patient care progression
Asmar is also involved in efforts to improve patient care progression. Patient care progression is measured by operational efficiencies in the acute-care space and hospital length of stay, she says.
Providence started working on patient care progression about three years ago to address some of the challenges that occurred during the pandemic—long lengths of stay, difficulty in discharging patients, and lack of access to enough post-acute care.The work began with the goal that every patient deserves a safe and timely discharge from acute care, Asmar says.
"We created a multidisciplinary team from across the organization and implemented a back-to-basics approach," she says. "We adopted more than a dozen basics that hardwired and established critical processes and workflows. We also worked on the connection to post-acute care such as home care and skilled nursing facilities in addition to access to primary care after discharge."
The work is paying off. In the first quarter of 2024, the health system is seeing a trend in the right direction for length of stay in acute care.
What happens before and after an acute-care stay is part of the patient care progression work, Asmar says.
"We are looking at hard-wiring standardized workflows, promoting automation, having safe and timely discharge from an acute-care stay, and addressing some of the chronic and repetitive issues with access to primary care as well as access to post-acute care," she says.
As is the case with the Co-Caring Model, patient care progression work is supporting growth at the health system, Asmar says.
"The ability to create operational efficiencies, reduce length of stay, and improve access in primary care gives us more capacity to serve patients in our emergency departments and have the beds ready for patients who need acute care," she says.
The South Carolina-based health system's ACO is working in collaboration with CVS Accountable Care.
Prisma Health has established a collaboration between its accountable care organization, InVio Health Network, and CVS Accountable Care to participate in the ACO REACH model.
ACO Realizing Equity, Access, and Community Health (REACH) is an accountable care model developed by the Centers for Medicare & Medicaid Services that features upside and downside risk for healthcare providers serving traditional Medicare beneficiaries. Clinicians participating in ACO REACH include primary care physicians and specialists. ACO REACH participants must have a plan to meet the needs of people in underserved communities and to address health disparities.
The ACO REACH collaboration between InVio Health Network and CVS Accountable Care will have both organizations capitalizing on their strengths, says Drew Albano, DO, MBA, chief medical officer of population health management at Prisma Health.
"They can look at ways to provide additional clinical programs or expand on existing programs," he says. "They can also work together to harness data—there are increasing volumes of data in the healthcare space, and these partners will be able to manage data and use it in a meaningful way. This collaboration also will supplement InVio Health Network's population health programs."
InVio Health Network's strengths include robust connections locally with Prisma Health's employed physician practices and the health system's medical group, Albano says, adding InVio Health Network has strong relationships with independent physician practices in Prisma Health's geographic footprint in South Carolina. That local presence will be complemented by CVS Accountable Care's national presence and CVS Health's MinuteClinics in South Carolina, he says.
InVio Health Network also has staff tackling population health and value-based care initiatives from different angles, Albano says.
"Some of those angles include addressing care gaps such as cancer screening, scheduling of wellness visits, and getting patients in for chronic disease management for conditions such as diabetes and hypertension," he says.
CVS Accountable Care also has extensive experience with longitudinal care and care coordination, Albano says. "This will help us do well in managing populations of patients as they transition from acute care such as hospitalizations back into their communities."
Navigating upside and downside risk
Prisma Health has been serving Medicare beneficiaries since 2015, including downside risk arrangements such as Medicare Advantage health plans. Prisma Health is confident that InVio Health Network can achieve shared savings in the ACO REACH model, Albano says.
"We feel it is important to equip our clinicians with resources that are going to help them better address the holistic aspects of a patient's care," he says. "We think about not only medical management but also helping the patient to align with their optimal health trajectory and care pathways. So, we think about how we get patients in for preventative visits, chronic care management, and medication adherence."
Providing access
To be successful in ACO REACH, InVio Health Network is thinking beyond traditional methods of providing access such as getting patients into ambulatory settings for evaluation, Albano says.
"What we have seen since the coronavirus pandemic is that there are novel models for access that we can start to leverage," he says. "Virtual visits are certainly an opportunity, particularly in behavioral health. CVS Accountable Care has sought to provide access through their MinuteClinics. We are thinking about chronic disease management using remote patient monitoring for conditions such as hypertension and heart failure."
InVio Health Network and CVS Accountable Care want to provide access through the traditional model of providing in-person office visits for patients, but they also want to decentralize that model by taking care of patients in their homes, Albano says.
"So, there are many avenues to provide access," he says. "Partnerships such as this one help us to showcase which avenue is best to pursue with each patient. We know that the one-size-fits-all model is not going to work. We must take a tailored approach knowing that we are going to meet the patient where they are at and address the needs that they have using the right access pathway."
Promoting health equity
InVio Health Network's plan to boost health equity in ACO REACH includes addressing social determinants of health, Albano says.
"We have implemented a process to screen patients for social determinants risk factors," he says. "We have a tool that not only helps identify social determinants of health but also connects patients to community resources. We close the loop—it is not just providing an available resource for an identified social determinant but also making sure the patient is able to have their social determinant addressed."
CVS Accountable Care has a robust care management capability, which will also promote health equity, Albano says.
"We are going to be able to scale up what we have done historically from a care management standpoint," he says. "For example, we are looking at how the CVS Accountable Care transitional care management team can do more acute-care transitions such as patients who have a hospitalization for surgery then are transitioned back into the community."
David Battinelli says the health system must offer a range of approaches to boost the well-being of employees.
The top priority for the physician-in-chief of Northwell Health is the well-being of physicians and other staff members.
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell. He is also dean and Betsey Whitney Cushing Professor of Medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Prior to taking on his current roles, Battinelli served as senior vice president and chief medical officer at Northwell.
1. Physician and staff member well-being
"I need my providers and staff members to be as well as possible," Battinelli says.
Addressing the well-being of a clinical staff requires "an entire menu of approaches," he says. "The concept of well-being is not a one-size-fits-all. We are going to have to engage a variety of different strategies for a variety of different people."
For some people, the adoption of a hybrid work environment at Northwell has been a big improvement, but for others, it does not work, Battinelli says. "You can't just say a hybrid work environment is going to solve well-being problems."
A crucial element of addressing workforce well-being is engaging staff members, he says. "If you are not aware of the things that people are struggling with regarding maintaining their well-being, then you are going to offer programs that have nothing to do with their real problems."
For clinicians, Northwell wants to work on reconstituting relationships that were formed in the past, Battinelli says.
"Years ago, ambulatory providers would round at the hospitals. They would congregate in a doctor's office or lounge, and they helped each other maintain their balance," he says. "Doctors used to support each other quite a bit, which helped them maintain balance. Now, ambulatory doctors don't go to the hospitals anymore."
The health system has two programs to foster physician get-together events. "The Doctors Lounge" is a regional dinner program initiated by practice leadership. "Connect the Docs" is a smaller local program initiated by individual physicians.
"These programs are a way for physicians to get together and relax," Battinelli says. "These programs have been remarkably successful—it is a way to ensure that doctors can support each other when they are feeling unbalanced."
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell Health. Photo courtesy of Northwell Health.
2. Patient access
Battinelli is also focused on an organizational goal to improve access for patients.
"There are many ways that our people are working at providing access," he says. "Getting in to see a provider for an appointment is important, but it is not the primary issue when people talk about access. The primary issue is that the only way to speak to a provider is with an appointment. Often, a provider cannot see a patient for two months."
Battinelli says Northwell has learned a lesson from the banking industry, which expanded access with online banking rather than hiring more tellers or expanding hours.
"We need to embrace 'connected care,' which is what they use in Great Britain, or embrace virtual care," he says. "Patients want to be connected first, then achieve access through an appointment later. They do not want to feel like they are being left 'out there' on their own."
To promote access, Northwell has two primary initiatives: offering a nurse navigation program and launching a virtual patient engagement program.
"Our nurse navigation program is centered on cancer services because of the emotional context of cancer and making sure that patients are connected immediately with anybody that they need," Battinelli says. "Our nurses can connect with patients 24/7 and make sure they understand everything that is going on with their care."
"The virtual patient engagement program is triggered the moment a patient calls in," he says. "The patient gets a virtual connection with a member of our staff, even if it is not the doctor with whom they get an appointment. This virtual connection assures the patient that waiting for an appointment for two weeks or two months is the best time if that is appropriate. The virtual connection also assures the patient that they are going to meet with the right doctor."
3. Technological transformation
Battinelli is also involved in efforts to establish the mindset at Northwell that artificial intelligence and other new technologies will help the staff to do work in the future.
"Many of these technologies are not mature yet, but it is clearly a good idea to be thinking about adopting these technologies," he says. "The number of things that can be done with AI is mindboggling."
For example, the patient-provider interface of the future will not involve a mouse and a keyboard, Battinelli says. At Northwell, the right interface is going to be new digital technology such as AI. The health system is looking at technology that will record the entire patient-physician interaction, then AI will generate the clinical note and documentation for the encounter.
"This will free up the physician, who can interact better with the patient," he says.
4. Becoming an age-friendly organization
Battinelli says he wants to be at the forefront of efforts at Northwell to better serve the health system's aging patient population.
"The healthcare industry has delayed addressing the aging population for as long as theoretically possible," he says. "If we do not start thinking about how to engage our aging population, the Silver Tsunami is going to hit us, and we are going to be overwhelmed."
Leaders and care teams at Northwell must think about all the things the health system should do beyond just giving expert medical care to be perceived as age friendly, Battinelli says.
"We must be able to provide things that aging patients might need," he says. "This does not necessarily commit us to something specific, but as things come along, we are thinking about how we can position ourselves to be age-friendly because we want our aging population to understand that we want to partner with them to learn how to take care of them."
Northwell is challenging care providers and other employees to identify potential programs that are going to be age friendly, Battinelli says. "For example, as an organization, we have more than 85,000 employees. We are considering creating a program that will allow employees to take time off to care for aging family members. We want to provide an employee environment that is age friendly."
The health system is also reaching out to older patients to find out about their needs, he says. "We are not going to solve the aging problem. But we can engage the aging population to find out what it is that they want from us."
Dana "Dan" Vick is CMO of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer of Providence. Photo courtesy of Providence.
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell Health. Photo courtesy of Northwell Health.