Yale New Haven Health is stepping up efforts to be a high-reliability organization.
For 2024, a top priority for the chief clinical officer of Yale New Haven Health is improving patient safety and care quality.
Thomas Balcezak, MD, MPH, has served as chief clinical officer of the health system since 2020. He previously held several positions at Yale New Haven Hospital, including chief medical officer, chief quality officer, director of performance management, and medical chief resident.
This year, Balcezak is focused on re-evaluating and retooling patient safety and care quality programs. Yale New Haven Health is doubling down on efforts to be a high-reliability organization that began a decade ago, he says.
"During the coronavirus pandemic and with the influx of new staff, we have seen an opportunity to recommit to the principles of high reliability," Balcezak says.
The effort involves the aspiration if not the actual achievement of zero harm for patients, he says. "It involves education. It involves making sure that we do a thorough evaluation of every serious safety event and near-miss event. It involves engaging staff members who can re-engineer processes and practices given the recognition that very few safety events are the fault of an individual. It is more often the fault of the system."
In the area of care quality, the health system has launched an initiative called Care Signature. The foundation of Care Signature is that patients should have the expectation that no matter where they go in the health system, they are given the same care based on their clinical condition, Balcezak says.
"You get the same therapeutic evaluation, the same access to cutting-edge therapeutics, and achieve the same outcomes no matter where you go," he says.
Care Signature involves operational standardization, according to Balcezak. For example, each hospital in the health system has the same radiologic protocols, the same laboratory protocols, and the same pharmaceutical formulary.
The initiative also seeks to influence physician behavior, he says.
"We want to reduce to the lowest possible denominator physician variation and how they approach diagnostic workups and therapeutic plan development," Balcezak says. "We are creating clinical care pathways, which include links to order sets within our electronic medical record for what tests should be ordered, what tests should be avoided, and what is the correct approach therapeutically for a patient with a given clinical condition."
Thomas Balcezak, MD, MPH, is chief clinical officer of Yale New Haven Health. Photo courtesy of Yale New Haven Health.
Financial turnaround
Balcezak is also focused on helping Yale New Haven Health improve its financial standing.
"Like many institutions, we had negative operating margins during and immediately after the pandemic for a variety of reasons such as inflation, labor tightness, and a lack of elective procedures," he says. "This will be the first year in which we break even on operations or even turn a small profit since the pandemic."
Clinical care efforts tied to financial performance at the health system include managing hospital length of stay and patient throughput as well as clinical stewardship, Balcezak says. Yale New Haven Health saw an increase in length of stay during the pandemic, and returning to a pre-pandemic length of stay has been a multifaceted body of work, he says.
These efforts include key drivers on hospital units such as setting an anticipated date of discharge, working with the patients and the care management team to get the patient ready for discharge, bringing the family into the discussion with the expectation about date of discharge, then holding all members of the care team accountable to hitting goals, Balcezak says. "For example, the physicians, the nurses, the care management team, and the social workers have to be held accountable."
Managing hospital length of stay and patient throughput is a top concern for clinical officers because it not only impacts cost of care but also is tied to the quality of patient experience and bed capacity.
Embracing clinical stewardship makes care delivery more efficient and cost effective, he says.
"In clinical stewardship, there was a time several years ago when we had an open pharmacy formulary, and you could get virtually any drug at the hospital. You could also order virtually any test," Balcezak says. "That was a time when physician autonomy as well as a lack of clear clinical guidance ruled. Clinical care guidance has become much clearer. How we do utilization review on the inpatient and the outpatient services has changed. Determining appropriate workups, appropriate testing strategies, and appropriate therapeutic regimens has become much clearer."
Clinical stewardship achieves more efficient medical care, which gets patients treatment faster, so it is more efficient financially and timewise for the patient, he says.
"We use the literature to help us guide us on care pathways, which gets us to better outcomes in a more efficient way," Balcezak says.
Coping with growth
Another priority for Balcezak this year is dealing with population growth in Connecticut.
"In the past, both outpatient and inpatient growth stalled. In our Connecticut communities in the late twenty-teens, growth in our population stalled," he says. "There was a net out-migration in Connecticut for at least a couple of years. The pandemic changed that trend. Since the pandemic, we have seen a net increase of particularly younger people seeking to live in Connecticut. We also have seen a growing elderly population."
Growth in the patient population over 65 is a concern for clinical officers nationwide.
Yale New Haven Health is experiencing growth in outpatient and inpatient services, Balcezak says.
"We have had growth across virtually all service lines," he says. "The growth has been between 2% and 4%."
Part of the health system's response to growth has been to launch a healthcare access initiative, Balcezak says. "The access initiative is in conjunction with the Yale School of Medicine to try to improve outpatient access for workups, diagnostics, and therapeutic treatments," he says.
On the inpatient side, Yale New Haven Health has been operating at record capacity, which makes length of stay work and throughput important beyond their impact on cost of care, Balcezak says.
"We cannot create new beds in an instant and we do not have any shuttered units that we can open and operate," he says. "So, the most important things we can do to accommodate inpatient growth is to lower length of stay and improve patient throughput."
The United States has the highest maternal mortality rate among high-income countries.
For chief medical officers seeking to boost maternal care, a top priority should be care coordination between the inpatient and outpatient settings, the CMO of Ob Hospitalist Group says.
The United States has the highest maternal mortality rate among high-income countries, according to statistics from the National Center for Health Statistics and the Organization for Economic Co-operation and Development. U.S. maternal mortality rates have been rising, with the rate pegged at 32.9 deaths per 100,000 live births in 2021, compared with a rate of 23.8 in 2020 and 20.1 in 2019, according to the Centers for Disease Control and Prevention.
CMOs should be focused on care coordination to achieve good maternal health outcomes, says Mark Simon, MD, CMO at Greenville, South Carolina-based Ob Hospitalist Group.
"Chief medical officers should focus on the continuum of obstetrical care from conception into the postpartum period," he says. "Especially at health systems, CMOs should be focused on how the outpatient setting is connecting to the inpatient experience that the patient has as well as care in the outpatient setting after the patient leaves the hospital. CMOs need to focus on how the outpatient setting and the inpatient setting are working together to ensure that the care is consistent across those locations. Good maternal care is about ensuring that connections are happening in the outpatient and inpatient settings, and those connections are happening consistently across a health system."
Good communication between care teams in the inpatient and outpatient settings is crucial, Simon says.
"Even if there is not a true admission, does the information that is gathered in the hospital setting such as an emergency room visit or an OB triage visit connect to the outpatient setting, where the patient is going to follow-up?" he says. "Is there a process by which that patient can have follow-up in a timely manner for whatever condition was seen in the hospital? Good communication is also required when patients are seen in the outpatient setting. Does the information that the patient has created during their visits in the prenatal experience get to the hospital? Does the physician and the team that is going to take care of the patient in the hospital know what has happened in the pregnancy before hospital admission? They should not be starting with a 'blank canvas.'"
In the hospital setting, care providers need to know where their patients are coming from and have relationships with community-based care providers, Simon says.
"Most patients we see at Ob Hospitalist Group have prenatal care to some extent," he says. "So, you must build relationships with the people providing the care, whether it is community physicians who are obstetricians, or it is midwives in the community. If hospitalists do not have relationships with these other care providers, it can create a very difficult situation."
Evidence-based care
CMOs should be involved in ensuring that maternal health patients receive evidence-based care, Simon says.
"There is evidence on clinical pathways and protocols that should be followed and adhered to," he says. "There are protocols on conditions that affect pregnancy. The key is to make sure those best practices are implemented in your clinical settings, whether they are outpatient settings or inpatient settings. With best practices, you need to implement them, you need to measure them, you need to analyze the data to see how you are performing, and you need to implement changes if things are not going as well as you want them to."
Simon says two key protocols in maternal health are a patient care bundle on hemorrhage and the management of hemorrhage in pregnancy as well as a protocol for hypertensive pregnancies. "Making sure patients are on the path with these protocols is the right thing to do because they can prevent poor outcomes," he says.
There are several maternal health metrics that CMOs should ensure are followed at health systems, hospitals, and outpatient clinics, Simon says.
Mode of delivery such as C-section rate
Hemorrhage metrics such as blood product use
Hypertensive management such as how quickly anti-hypertensive medications are given to a patient after an abnormal blood pressure reading
How quickly patients receive follow-up care for adverse conditions
Screening for mental health disorders such as postpartum depression
Addressing workforce shortages
CMOs are well-positioned to address workforce shortages in maternal care such as a dearth of physician obstetricians, Simon says.
"What a CMO should be doing is thinking about how they are utilizing their obstetrical clinicians to the best of their ability," he says. "The CMO should be thinking about how they can have their physician obstetricians doing top-of-license work such as caring for high-risk patients and doing C-sections. These physicians should be involved in care pathways that require the highest level of medical support for patients. Then the CMO should be thinking about how they can supplement physician obstetricians with other clinicians such as certified nurse midwives and women's health nurse practitioners, who can manage the low- and moderate-risk patients."
CMOs should work on team building in maternal care, Simon says.
"If you think in siloes, with separate obstetrician practices and separate midwife practices, you will run out of clinicians," he says. "CMOs need to re-think how we do obstetrical care in this country. Most prenatal care does not need a physician obstetrician. Most prenatal care is relatively low risk or moderate risk, which is well-suited to the skill sets of certified nurse midwives or women's health nurse practitioners. CMOs should want physicians seeing high-risk patients or working in the hospital setting."
With prior authorizations disrupted, Davis Health System is performing fewer elective surgeries after the cyberattack.
The chief medical officer of Davis Health System says the Change Healthcare cyberattack has affected patient care and revenue cycle at the health system.
According to an American Hospital Association survey, 94% of hospitals have experienced a financial impact from the Change Healthcare cyberattack, with more than half of hospitals reporting a significant or serious impact. The survey found the cyberattack has impacted the cash flow at 80% of hospitals, with 60% of those hospitals reporting an impact on revenue of at least $1 million per day. The survey also found that 74% of hospitals reported direct patient care being affected.
"Across the country, this cyberattack has been very disruptive," says Catherine "Mindy" Chua, DO, CMO of Elkins, West Virginia–based Davis Health System. "A couple of the big things are providers not being able to take credit card payments so patients who are trying to pay their hospital bills can't pay them and some pharmacies cannot take credit card payments. A lot of the coupons that patients use to take money off of their copays for their pharmaceuticals are not able to be used because they cannot be verified."
The cyberattack has impacted patient care at Davis, Chua says.
"We can't do many prior authorizations, and most insurance companies require prior authorizations for certain tests," she says. "We cannot schedule those tests without the prior authorization because the patient may end up being responsible for the cost of the test. So, tests are being put off, which affects patients and revenue cycle."
The cyberattack is also affecting elective surgeries at the health system, Chua says.
"Without being able to get prior authorization and insurance verification, many patients do not want to take the risk of having their insurance not cover the procedure," she says. "We are doing less elective surgeries."
The Change Healthcare disruption has also had a financial impact on Davis, Chua says.
"We have experienced the same thing as other health systems," she says. "We are not getting payments from insurers, so the cyberattack has significantly affected cash on-hand. We have had to move to almost completely manual claims processing. Whereas before we used to move claims from the electronic health record to another computer system, where they would be scrubbed and sent to the insurance companies, our entire revenue cycle team is hand-keying every one of our claims."
Even when claims are submitted to insurance companies, some of them cannot be processed, Chua says.
"The claims get sent to the insurance companies, but any of the insurance companies that were engaged with Change Healthcare are not necessarily able to process the claims on their end," she says. "So, even if we can get claims to the insurers, that does not mean that the insurers can process the claims and get us the reimbursement."
Schaal has three strategies for addressing the high-profile issues of physician burnout and well-being.
"We want to create a culture of wellness for physicians at Houston Methodist," she says. "We do not want a culture where physicians feel pressured to see as many patients as possible as fast as they can."
“The second thing we are focusing on for physician well-being is the efficiency of practice," she says. "There are many things in the modern practice of medicine that take up a physician's time, and we want to redesign our processes to make sure our physicians are practicing at the top of their licenses, and they have support to do things such as coding, billing, and answering messages."
"The third thing is personal resilience," Schaal adds. "We know there are ways that we can help physicians increase their personal resilience, which is related to a culture of wellness and efficiency of practice."
Schaal, who also serves as president and CEO of Houston Methodist Physician Organization, is leading a Joy in Medicine Initiative (JIMI) as well as reaching out to Houston Methodist physicians to see how they define a culture of wellness.
"I have to ask physicians, 'What does a culture of wellness mean for you?'" she says. "The idea behind JIMI is not to do a top-down assessment, then have me say, 'I think that a culture of wellness is defined by four elements, and here they are.' We are going to physicians and asking them about a culture of wellness."
Developing leaders
Schaal is also focused on leadership development this year.
Houston Methodist, which features an academic medical center and six community hospitals, has three leadership development programs: The Chair Academy, which serves the physician leaders who run the health system's clinical departments; the Administrator Academy, which mainly serves the administrative dyad leaders who are paired with clinical department chiefs; and a Physician Leadership Development Program.
"I truly believe that our leaders are the prime people who affect the efficiency, the morale, and the capabilities of their teams," Schaal says. "I want Houston Methodist to have the best leaders possible."
This year, the Chair Academy and the Administrator Academy are focused on three areas:
Leadership: Program participants will find out about the key components of leadership, including the qualities of a good leader, how leaders influence people, and team building.
Philanthropy: Program participants will learn about how to be well-versed in philanthropy to work with people who would like to donate to Houston Methodist or support an initiative that the health system believes is important. "Philanthropy is important because in medicine you need philanthropic help in order to go above and beyond for your patients," Schaal says.
Communications: Program participants find out about how good leaders communicate verbally, inspire people through communication, communicate with a team, and relay bad news.
The Physician Leadership Development Program is taught collaboratively with Houston Methodist executives and Rice University professors. The program is designed for physician leaders who are not department chairs, and it lasts for six months.
It's basically a condensed version of an MBA program, Schaal says.
"We have several modules that physicians learn, including strategy, organizational behavior, finance, and operational management," she says.
Quality and patient safety
Schaal is also focused on advancing quality and patient safety.
"In my role as chief physician executive, quality and patient safety is part of my responsibility," she says. "We deliver high-quality care at Houston Methodist as measured by organizations such as U.S. News & World Report, the Centers for Medicare & Medicaid Services, Leapfrog, and Vizient. All of our hospitals are top performers in these external rankings. When I came here in April 2023, a big part of my role was to take quality and patient safety one step forward."
Last year, Schaal conducted a listening and learning tour of Houston Methodist facilities to see how the health system could improve quality and patient safety. During this tour, she learned that Houston Methodist did not have a communications strategy for quality and patient safety.
"We devised a communications strategy to communicate all the great things we are doing," she says. "Now, we have a website for quality and patient safety. We have a newsletter called Quality Time and a podcast called Quality Time. This is a way for us to share everything that we are doing with each other and with the world."
Schaal also found a lot of variation in how quality teams were built at Houston Methodist. So the health system devised a "diamond structure” at each facility, comprised of the CEO, chief quality officer, chief nursing officer, and quality director to lead quality efforts.
"In the diamond structure, all four of these executives work together to lead quality at their facility," she says. "This standardization has been helpful because we have also built communities around our CEOs, chief quality officers, quality directors, and CNOs. They can share knowledge with each other, with the spirit that a rising tide lifts all boats. If we share with each other, we can solve problems together rather than acting in siloes."
Schaal says the health system wants to "capitalize" on quality and patient safety academically, rather than financially.
"We want to highlight our process improvement efforts and all of our ideas and innovations at Houston Methodist at academic conferences," she says. "We want to share the success of our quality and patient safety efforts with our colleagues in Texas, the nation, and the world. We want people in other health systems to learn from us, so they can also improve."
Photo: Shlomit Schaal, MD, PhD, MHCM, is executive vice president and chief physician executive at Houston Methodist. Photo courtesy of Houston Methodist.
Most behavioral health patients do not need to receive care in hospital emergency departments, the chief physician executive of WellSpan Health says.
By offering a wide spectrum of mental health services, WellSpan Health has been able to reduce the number of behavioral health patients seeking care in the health system's emergency rooms.
Crowding at emergency rooms has become a national problem. According to CMS data, the median wait time for patients in emergency rooms has increased from 2 hours, 18 minutes in 2014 to 2 hours, 40 minutes in 2022. The average overall length of stay for emergency room patients increased from 184 minutes in 2019 to 205 minutes in 2022, according to the Emergency Department Benchmarking Alliance.
WellSpan has embraced providing behavioral health services as a core element of the health system's mission, says Anthony Aquilina, DO, executive vice president and chief physician executive.
Pictured: Anthony Aquilina, DO, executive vice president and chief physician executive at WellSpan Health. Photo courtesy of WellSpan.
"WellSpan is the 13th largest provider of behavioral health services as a health system in the United States," he says. "It is a significant part of what we do. We certainly provide more behavioral health services to the people of south-central Pennsylvania than any other health system around us."
WellSpan offers a range of behavioral health services, including inpatient services, intensive outpatient programs, partial hospitalization programs, telemedicine, behavioral health specialists embedded in emergency departments, and residential care. In the spring of 2021, the health system launched an innovative behavioral health clinic, the Specialized Treatment and Recovery Team (START).
Offering a plethora of behavioral health services has helped reduce the number of behavioral health patients seeking care in WellSpan's emergency rooms. From January 2023 to January 2024, the number of patients seeking behavioral health care in the health system's emergency departments decreased 50%.
Most behavioral health patients do not need to be in emergency rooms, Aquilina says.
"Traditionally, these patients have gone to an ER or have waited months to see a behavioral health provider," he says. "There must be access to services somewhere in between those extremes. That is why we have things like our START program and other options as well. As a chief physician executive, I know our health system thrives when we deliver great care. The best care is delivered to patients at the right place at the right time."
In addition to contributing to emergency department crowding, there are negative consequences for behavioral health patients seeking care in emergency rooms, including a suboptimal patient experience, Aquilina says.
"The main drawback is if you go to an emergency room there is a triage process, and if you are not as sick as someone else you have to wait for care," he says.
Increasing access to behavioral health services
The START program at WellSpan has increased access to multidisciplinary behavioral health services.
The START clinic offers same-day and next-day appointments for people who need behavioral health services. The clinic is open 8 a.m. to 8 p.m. Monday through Thursday and 8 a.m. to 4 p.m. on Fridays. There are plans to have the clinic open on Saturdays.
The START clinic is focused on providing rapid access and stabilization, says Mitchell Crawford, DO, medical director of addiction services at WellSpan and medical director of the START program.
"It is not the long-term home for everyone, and it is not everything for everyone, but it is a place for patients who need immediate help and a place where patients can get stabilized until they can get to a setting that is more appropriate for longer-term care," he says.
The START clinic has a team-based approach to care, Crawford says.
"I serve as the medical director of the clinic, and we have two nurses, clinical leadership, social service specialists, crisis management specialists, peer specialists, and therapists for mental health and treatment of addiction," he says.
START has purposely designed care not to be paternalistic, Crawford says.
"We do not want to say, 'I'm the doctor. I know what is best for you. Here is your treatment plan for the diagnosis I gave you. Take this medicine, and I'll see you in two weeks,'" he says. "With that kind of approach, you do not hear the participant. You do not establish an alliance with the participant. They would take their treatment plan and prescription, then put them in a trash can on their way out the door. Then we would not see them again, and they would decompensate and end up in one of our emergency departments."
Crawford says START staff members ask program participants—they are not called patients—a key question: What is most important to you right now and how can we help? START clinicians provide participants with medical care, but if a social need is most important to a participant that gets addressed as well.
A program participant may be going through a divorce and have worries about eviction and putting food on the table, Crawford says.
"They have a hierarchy of needs beyond their mental health condition, which I offer a treatment plan for. But I also pull in our social services specialist, who is really the caregiver that the participant needs to talk to in that moment," he says.
Matthew Ewend is focused on patient and caregiver experience as well as balancing academic and community medicine.
The leading 2024 priorities for the chief clinical officer at UNC Health include improving the experience of patients and care providers.
"We want to make the experience of delivering healthcare and receiving healthcare better," says Matthew Ewend, MD, chief clinical officer of UNC Health and president of UNC Physicians. "Right now, it is not much fun to deliver healthcare and for many of our patients it is challenging to enter into the system and to get healthcare."
1. Supporting caregivers
Ewend says his number one priority is supporting his clinical care team.
"I want to use the position I have to ease barriers for my staff," he says. "I use the analogy of football, where the pulling guard is out blocking. I want to clear the path and break down barriers, so that the people on my team can work on things such as quality, high-value care, improving our clinic functions, and getting services to patients in rural areas who do not have access to care."
Technology such as artificial intelligence can improve the caregiver experience, Ewend says.
"For example, when I am in my clinic, I put my phone down on the desk, then I ask my patient's permission to use ambient listening," he says. "It listens to the conversation with the patient, and it generates a note. By the time I get back to my work station, I have an AI-generated note about the patient encounter. It is organized with the patient history, what I found during the physical exam, what tests such as X-rays showed, and the plan of care. It is not perfect, but it is better than me typing a note. This is an example of making it easier for providers to deliver care."
Managing messaging on the health system's patient portal is another way Ewend wants to support clinicians.
"When we created the patient portal, people thought we were creating a means to send messages to providers like they were messaging a friend. Patients felt they should be able to message anything at any time and get an answer back right away," he says. "So, we have set expectations for our patients. You can expect an answer within three business days, and you should ask questions that are a continuation of care that you have received. Some of the answers might be that the patient needs a virtual appointment, a phone call, or an in-person visit. So, we set expectations with our patients, and we set expectations with our doctors. We want our doctors to answer these questions, but we understand they cannot answer patient portal questions within 10 minutes."
By setting expectations and using technology and support staff to screen messages, UNC Health has been able to reduce the number of patient portal messages being sent to clinicians and decrease the amount of time clinicians are spending tackling messages, Ewend says.
"More importantly, we have made it so when a message reaches our doctors, it is only something the doctor can answer," he says. "They do not get messages about a patient expecting to be 15 minutes late for an appointment. That may be good to know, but it does not need to come to the doctor—it should go to someone else on the team."
Matthew Ewend, MD, chief clinical officer of UNC Health and president of UNC Physicians. Photo courtesy of UNC Health.
2. Patient experience
From the patient standpoint, Ewend wants it to be easier for patients to find their way to the right provider, at the right place, with the right expertise.
"The analogy we use is air travel. You can go online and book a flight to China on your phone, but it can be difficult to book an appointment with your primary care doctor," he says. "The problem is we are comparing receiving healthcare to a single, episodic event. It is easy to order protein powder from Amazon, but that is a much simpler thing to deliver than a kidney transplant."
To apply the consumer expectation that healthcare is going to be instantaneously available and at the patient's fingertips is very complicated, Ewend says.
"We want to offer online scheduling," he says. "We want patients to able to access their providers in a thoughtful way and to be able to get information about their care through patient messaging, but we know when that is done badly it overwhelms our providers."
3. Balancing academic and community health priorities
Ewend plays a role in balancing UNC Health's academic mission with its commitment to serve communities across the state of North Carolina.
"We want to be at the forefront of academic discovery, research, training the next generation of healthcare providers, and providing complex subspecialty care. But we also have the mission of serving the entire state of North Carolina and improving the health of the people of North Carolina," he says. "So, our health system is trying simultaneously to serve all the people of North Carolina and also to be at the forefront of developing new knowledge, new technology, and new research breakthroughs, as well as training the next generation of care providers."
Harnessing the collective power of the health system's academic and community physicians is among Ewend's top priorities.
"I want to clear the path so that our community physicians, who are a crucial part of our mission, are able to do the work that they do, which is providing high-quality care close to patients in their hometowns. At the same time, I want to support our academic group in doing groundbreaking research, training, and providing the quaternary care that they do."
Using technology to make things easier for clinicians is one of four top priorities on J.P. Valin's schedule this year.
With stress and burnout at high levels this year, Intermountain Health's chief clinical officer wants to make things simpler.
"When I think about simplification for our physicians and APPs, with whom I work most closely, we need to look at some of the emerging technologies and to deploy emerging technologies that are going to reduce some of the tasks that they do and free up time for direct patient care," James P. Valin, MD, says.
"On the physician and APP side, I am really interested in some of the ambient listening tools. We are looking at a couple of different tools that will listen to a doctor-patient interaction to transcribe that and turn it into a note, which will simplify work for our physicians and APPs."
Here are four of Valin's priorities for Intermountain and how he plans to make it simple.
1. Simplicity
Valin, who was named CCO of the eight-state, 33-hospital health system in 2022 after its merger with SCL Health, lists simplicity as one of his four top priorities this year.
He says initial piloting of ambient listening technology at Intermountain has been promising in terms of freeing up time for physicians and APPs, reducing documentation time by as much as two hours a day.
"This can be life-changing for our providers," he says.
He's also looking forward to the enterprise-wide deployment of a single electronic medical record.
"We currently have a mix of electronic medical records across our footprint, and we are working to be on one platform—Epic," he says. "We will be spending a lot of this year planning for that transformation and doing the build for deployment in 2025. Enterprise-wide, we will be on a single longitudinal electronic health record. This is an opportunity to simplify our work and streamline a lot of our care processes."
J.P. Valin, MD, chief clinical officer of Intermountain Health. Photo courtesy of Intermountain Health.
2. Improving access to care
Another priority for Valin is improving healthcare access for patients. This includes opening new clinics, recruiting new physicians and APPs, and creating space within existing clinics to be able to accommodate more patients.
"We are in three of the fastest growing metropolitan areas of the country—Salt Lake City, Denver, and Las Vegas," he says. "There is a tremendous need for care in the population we serve, and we are focused on meeting that need."
Intermountain is facing the challenge of recruiting more physicians and APPs in a tight clinician labor market, Valin says.
"Our goal is to make Intermountain the best place to work and provide care," he says. "Some of that is giving our physicians and APPs the right tools such as ambient listening—we think that will be a differentiator. We have focused a lot on physician and APP well-being. We have put a lot of support tools around our physicians and APPs. In 2023, we were able to recruit more than 900 physicians and APPs to our organization."
Other efforts include building a talent pipeline. The health system is partnering with medical schools, graduate medical education programs, and APP schools as well as creating learning experiences across the organization for student learners.
To boost physician and APP well-being, Valin says Intermountain's leaders have spent a lot of time understanding the clinician experience.
"That has led to targeted efforts around simplification and making it easier to practice medicine," he says. "We also have a dedicated focus on keeping clear lines of communication open across our organization between our physicians and APPs and their leaders in the enterprise. Those efforts have helped people to feel connected and have a sense of belonging."
3. Value-based care
Valin is also at the forefront of moving the health system from fee-for-service to value-based care.
"As an organization, this is an enterprise-wide priority for us," he says. "We absolutely believe that the future for healthcare is in the value-based care arena, where we are taking full clinical and financial accountability for more patients."
Intermountain has a broad footprint across eight states, and each market is in a different place in its value-based care journey. The health system's goal, Valin says, is to identify and meet those markets where they are and increase partnerships with payers to advance value-based care.
Intermountain's primary value-based care strategies include increasing preventative services and embracing early interventions for illnesses, both of which can improve the overall health of the population.
The health system is also pursuing value-based care arrangements with commercial payers and participating in the Medicare Shared Savings Program and accountable care arrangements in Medicare Advantage.
4. Post-merger integration
Valin is also continuing integration efforts tied to Intermountain's merger with SCL Health.
"We are continuing to move and advance our clinical integration; as part of that, we are doing a lot of work with clinical best practice implementation at scale," he says. "Intermountain has had a long history of identifying clinical best practices and deploying them across a broad footprint, so that we have a high degree of reliability and consistency in care delivery. We can spread that even further across the legacy SCL Health footprint."
Valin says he wants to create a consistent clinical experience for patients regardless of where they interact with Intermountain.
"It starts with what it feels like when you walk into a clinic or a hospital," he says. "The feel and the interaction should be the same at all of our facilities. It is also about how people interact digitally and how they interact in terms of care processes. We want to ensure that our care processes are aligned and feel the same at our clinics and hospitals."
Urgent care centers can treat many conditions commonly treated in emergency rooms, including sprains, fractures, lacerations, and urinary infections.
More than two dozen members of the U.S. House of Representatives have written a letter to the Centers for Medicare and Medicaid Services (CMS) asking the agency to pursue policies that would encourage patients with non-emergent needs to visit urgent care centers rather than emergency rooms.
Crowding at emergency rooms has become a national problem. According to CMS data, the median wait time for patients in emergency rooms has increased from 2 hours, 18 minutes in 2014 to 2 hours, 40 minutes in 2022. The average overall length of stay for emergency room patients increased from 184 minutes in 2019 to 205 minutes in 2022, according to the Emergency Department Benchmarking Alliance.
Daniel Roth, MD, executive vice president and chief clinical and community division operations officer at Trinity Health, says the health system is experiencing widespread crowding at its emergency rooms.
"Across Trinity Health, we are seeing crowding in our emergency rooms," he says. "It has a negative impact on care and our caregivers, and it leads to long wait times for our patients."
Emergency room crowding results in several negative consequences, Roth says.
"First and foremost, it is not a good patient experience—patients wait a long time in emergency rooms," he says. "Emergency room crowding can have a negative impact on care—care processes get slowed down. Emergency room crowding creates strain on caregivers—it is creating a strain on an already stressed group of nurses, technicians, and physicians, who are working harder than ever."
Solution for ER crowding
Urgent care centers represent a solution to the problem, the members of Congress said in their letter to CMS.
"Despite growing acknowledgment of the challenges caused by overcrowding in emergency rooms, few efforts to mitigate this problem have been successful. Resolving these issues will require significant public and private investment, and we believe that urgent care centers are an easily accessible resource that can reduce crowding by providing treatment to non-emergency patients in a more appropriate setting."
The lawmakers cited two 2019 studies that indicate urgent care centers can ease crowding at emergency rooms and reduce costs. A National Bureau of Economic Research study found that up to half of the annual 137 million emergency room visits could be treated at a less emergent facility. A Medicare Payment Advisory Committee report found that one-third of nonurgent emergency room claims could be appropriately treated in an urgent care center at a third of the cost.
Kevin DiBenedetto, MD, chief medical officer of Premier Health, which specializes in urgent care center joint ventures with health systems and hospitals, says urgent care centers can help ease emergency room crowding across the country.
"There are more than 14,000 urgent care centers in the country, so there are many of them in every state and Washington, DC," he says. "We think there is still room for more urgent care centers, but they are spread across every region of the United States."
DiBenedetto says many conditions that are commonly treated in emergency rooms can be treated at urgent care centers.
"Many conditions treated in hospital emergency departments can be treated at urgent care centers," he says "These conditions include sprains, fractures, lacerations, musculoskeletal injuries, respiratory illnesses, and urinary infections. Urgent care centers also can perform X-rays and diagnostic lab tests."
Urgent care centers are a key element of Trinity Health's care delivery strategy, Roth says.
"We are continuing to work in our partnership with Premier Health and with other urgent care centers across Trinity Health to try to improve access and to make sure patients know they have access to high-quality care in our urgent care centers when they need it and when they want it," he says. "We are committed to growing our urgent care centers, which serve our communities by providing access to healthcare at a low cost with high quality."
What CMS can do to promote urgent care centers
CMS should pursue policies in the Fiscal Year 2025 Physician Fee Schedule to encourage Medicare beneficiaries and Medicaid enrollees to use urgent care centers for non-emergent care needs, the lawmakers said in their letter.
Roth and DiBenedetto say CMS can help raise awareness about the benefits of treating nonemergent patients at urgent care centers rather than emergency rooms.
"Across Trinity Health, we provide communications, marketing, and patient information about what care is appropriate for seeing a primary care physician, urgent care centers, and emergency rooms," Roth says. "We are working in all of our communities to make sure patients have information about where they should go for certain conditions to help them be empowered consumers."
"It is a matter of awareness and getting primary care physicians to refer patients to urgent care centers," DiBenedetto says. "Urgent care centers are open seven days a week and, most of the time, 365 days a year. We are open more hours than a primary care doctor. Patients need to be made aware that no appointment is needed—it is on-demand care."
Miscommunication in the hospital setting is a major driver of medical errors and malpractice claims.
Appalachian Regional Healthcare (ARH), which operates 14 hospitals in Kentucky and West Virginia, is adopting a structured communications program for clinical care transitions that has been shown to reduce medical errors.
Miscommunication during clinical care transitions is a major factor in medical errors and malpractice claims. A study published in the Journal of Patient Safety showed that during a 10-year period nearly half of all medical malpractice claims involved communication failures, 77% of which could have been prevented with an effective patient handoff tool.
With financial support from the Kentucky Hospital Association, ARH is implementing I-PASS, a communications bundle for clinical care transitions developed by the I-PASS Patient Safety Institute. I-PASS has been adopted by more than 100 healthcare institutions.
I-PASS is a bundle of interventions to try to improve patient handoffs and communication in hospitals.
"The primary element is to get caregivers to speak with each other in a consistent way about patients as they are passing off patients at the change of a shift or a change of location," says Christopher Landrigan, MD, MPH, co-founder and executive council member at the I-PASS Patient Safety Institute.
The I in I-PASS stands for illness severity, so caregivers have a solid understanding of a patient's medical status.
The P in I-PASS stands for the patient summary, which summarizes the condition of the patient, why they are in the hospital, and what care has been provided since the patient was admitted to the hospital.
The A in I-PASS stands for action list, which is a list of things that are expected to happen in a patient's care.
The first S in I-PASS is situational awareness, which includes telling caregivers what is special about a patient.
The final S in I-PASS is synthesis by receiver, which is designed to make sure that when there is a handoff of a patient that the caregivers are on the same page.
I-PASS includes infrastructure that supports improved communication, Landrigan says.
"We think a lot about how we train people, how we implement I-PASS in a way that is going to stick, how we build tools into the electronic health record, and how we use devices in a hospital to push the program forward," he says. "We want to pass along patient information in a reliable manner every day."
Research has shown that I-PASS significantly reduces medical errors and adverse patient events.
A study on I-PASS published by the New England Journal of Medicine found a 23% reduction in medical-error rate and 30% reduction in the rate of preventable adverse events after the implementation of I-PASS. The researchers reviewed 10,740 patient admissions (5,516 preintervention and 5,224 postintervention).
I-PASS is a better framework for communication, says Anthony Stumbo, MD, regional chief medical officer at ARH.
"If a patient comes in with pneumonia, you may think they are going to get better, but you may get a call in the middle of the night that the patient cannot breathe and must be placed on a ventilator," he says. "Communication is key. I-PASS standardizes communication."
Stumbo expects ARH will generate several benefits for the health systems and its patients once I-PASS is implemented at the 12 ARH hospitals in Kentucky. "I expect better communication. I expect better clinical outcomes. I expect better quality. I expect less medical errors. I expect decreased malpractice claims. I expect better care transitions. The handoff of a patient from one nurse to another or one clinician to another is critical—there must be a flow of information," he says.
Investment and ROI
The implementation of I-PASS is going to require limited investment by ARH, Landrigan says.
"The good news for ARH is that the Kentucky Hospital Association has committed to the adoption of I-PASS at ARH," he says. "The hospital association has put up most of the funding to make this program happen. Certainly, the leaders and care teams at ARH are going to have to invest time and energy."
The return on investment from I-PASS includes lower malpractice claims and efficiency gains, which can generate a 3-to-1 ROI, Landrigan says.
"We have found that nursing overtime and the amount of time it takes nurses to do a patient handoff has decreased significantly," he says. "That has benefits in overtime costs and the quality of life for nurses, who can get out of the hospital when they are scheduled to get out of the hospital. With the nursing shortage across the country, anything we can do to improve the work-life balance of nurses is beneficial."
Anne Zink, credited for life-saving work during the pandemic, is leaving her CMO role in seach of work in healthcare data.
Anne Zink, MD, is stepping down from her role as chief medical officer of Alaska effective in April.
Alaska's CMO is a position within the state Department of Health that reports to the commissioner of health. It is a position that is appointed by the governor, but it does not have to be confirmed by the legislature. The primary responsibilities of the role include providing clinical advice to the governor and the Alaska Department of Health.
Zink's successor has not been named.
U.S. Sen. Lisa Murkowski (R-Alaska) has credited Zink with saving many lives during the coronavirus pandemic.
"The big thing that I credit for the successes during the pandemic in Alaska was our partnership with communities, including tribal leaders, municipalities, and local individuals at community healthcare organizations," Zink says. "I also was inspired by the ingenuity, creativity, and problem-solving attitude of Alaskans. Despite the fact that we had no commercial testing for the virus in Alaska when the pandemic began, we were the most tested state in the nation in the first year of the crisis. When the vaccines rolled out, we were able to get vaccines out and were the fastest vaccinated state in the country despite being bigger than Texas, California, and Montana combined."
Zink says she was involved in "countless initiatives" during the coronavirus pandemic.
"I participated in daily news briefings with the governor to make sure that communities were aware of what was happening and were able to make the best decisions they possibly could," she says. "Alaska repatriated the first flight from Wuhan, China, so we were very involved with the federal government's response to the virus from early on. We stood up our emergency response system in January 2020, so we were involved in the pandemic response early on. In testing, we manufactured our own swabs, we created our own testing platform that we got FDA-approved, and our public health labs did most of the testing in the first year of the pandemic. We were the first state to offer monoclonal antibodies in a community-based setting as a treatment option. We set up the first airport testing site."
Anne Zink, MD, is chief medical officer of the state of Alaska. Photo courtesy of the Alaska Department of Health.
Zink has been involved in several initiatives beyond her work during the pandemic.
"I have been focused on how we can make systems work better for patients, instead of asking patients to take on the burden of our complex and broken systems," she says. "I have also been focused on how we can have a healthcare system focused on health instead of a healthcare system responding to illness."
Since Zink started as the state's CMO in July 2019, she has been focused on complex care to serve patients with multiple behavioral health and physical medical needs as well as focused on data.
"I have worked to make sure that we have secure data that is patient-centric, so that a patient has access to their own information—what I call data democratization," she says. "I have tried to make sure that public policy officials such as the governor have the information that they need in terms of healthcare data and public health data to make decisions. I have tried to simplify data so that healthcare providers on the frontline have the information they need to care for their patients in real time."
A practicing emergency medicine physician, Zink says working in an emergency room has provided a solid foundation for serving as Alaska's CMO.
"In emergency medicine, you have a frontline view of all the ways that the system does not work. I have been able to work in the emergency department and see problems, then go back to my day job and find ways to make the system better," she says. "There were about four months when I didn't see patients during the peak of the pandemic because of the demands of the CMO job. I quickly realized that I needed to see patients to stay grounded in the purpose of what I was doing. It has been an amazing opportunity to do both jobs simultaneously. I can serve patients and work on high-level policy issues."
After she leaves the Alaska CMO role, Zink says she plans to find a position working in healthcare data.
"For both healthcare and public health to do their mission of improving the health and well-being of populations, data is at the core," she says. "Data is going to be one of the key ways we provide insight to understand the challenges, solutions, and how we move things forward. If you do not have the data, you cannot tell the story in healthcare. I have had the honor to work in the CMO role for nearly five years, and I have seen many times that the data element has been lacking."
Physicians should seize on opportunities to work in the CMO role, Zink says.
"For a hospital or health system CMO, many hospitals and health systems are really doing public health. They are starting to think about and are being financially rewarded for population health efforts," she says. "There is a real need in hospital leadership as well as in larger health system leadership to have a clinical voice to say, 'What makes sense for the patient? What makes sense for the clinicians who are practicing?' As a hospital or health system CMO, you can play a major role in finding solutions."
Thomas Balcezak, MD, MPH, is chief clinical officer of Yale New Haven Health. Photo courtesy of Yale New Haven Health.
Matthew Ewend, MD, chief clinical officer of UNC Health and president of UNC Physicians. Photo courtesy of UNC Health.
J.P. Valin, MD, chief clinical officer of Intermountain Health. Photo courtesy of Intermountain Health.
Anne Zink, MD, is chief medical officer of the state of Alaska. Photo courtesy of the Alaska Department of Health.