Career development is essential for job seekers. Learn how the CMO of Northeast Georgia Health System uses it as a selling point.
Key elements of healthcare worker recruitment include investing in culture and educational programs, says Vikram "Vik" Reddy, MD, chief medical officer of the Northeast Georgia Health System.
Reddy became CMO of the Gainesville, Georgia-based health system in July. His previous leadership experience includes serving as CMO of two hospitals at the Wellstar Health System in Georgia.
HealthLeaders recently talked with Reddy about the many challenges he faces, including promoting quality in the hospital setting, clinical integration, and population health. Reddy says his biggest challenge is course correcting and dealing with the "new normal" following the crisis stage of the coronavirus pandemic.
"There are challenges in recruitment for nursing," he says. "There is an increasing challenge with regard to reimbursement. There is also an issue with wage inflation. It all adds up to being more mindful with resources. While you are trying to focus on quality and safety, you must acknowledge that we are not going back to the pre-COVID times."
To address the workforce challenge, Reddy is focusing on strategies to draw nurses, physicians, and other team members to Northeast Georgia. The health system needs to recruit healthcare workers in a way that makes joining the organization attractive, he says. This involves investing in the health system's culture and offering educational programs.
"For example, we have a program where someone starts off as a medical assistant and can advance to becoming a nurse," he says. "You are not just coming to us for a job. You are coming to us for a career."
In physician recruitment, the health system is looking for candidates who are willing to make a commitment to the communities they serve and the region's medical community, Reddy says.
"We want to find people who are going to make an investment in both the broader community and the medical community in the area," he says. "We want to make sure our physicians feel they are making a difference—it is not just a job where they show up and move on."
Reddy says he also needs to be mindful that there are not unlimited resources at the health system.
"If there is already a service being provided by other health systems or other healthcare providers in the area, we do not want to duplicate services just because we can," he points out. "We want to be selective in what the community needs."
Vikram "Vik" Reddy, MD, chief medical officer of Northeast Georgia Health System. Photo courtesy of Northeast Georgia Health System.
Serving as a hospital CMO vs. a health system CMO
Having previously served as CMO of two hospitals, Reddy says overseeing five hospitals in the Northeast Georgia Health System requires him to be cognizant of the individual hospitals and their differences.
"For example, our flagship hospital, Northeast Georgia Medical Center Gainesville, has nearly 600 beds," he says. "It is a Level 1 trauma center. The hospital offers several quaternary care services. Whereas our smallest hospital, Northeast Georgia Medical Center Habersham, is much more rural and we do not have as many services there. What you want to do is ensure that the patients at Habersham and the patients at Gainesville have the same level of quality of care."
One of the biggest challenges in serving rural populations is ensuring access to primary care, Reddy says.
"One of the reasons I was attracted to Northeast Georgia Health System is that unlike several other health systems in the Georgia market, we have alignment with 70% of the primary care practices—whether it is employment or agreements—in our primary service area," he says. "With Habersham, we are going to be investing in more primary care in that area. Primary care drives quality."
He says the health system is taking a three-pronged approach to boosting primary care services in rural areas: Opening new primary care practices, opening new urgent care centers, and expanding virtual care.
Succeeding in clinical integration
The key to success in clinical integration is partnerships outside the four walls of the hospital, says Reddy, who previously served as chief clinical integration officer at Henry Ford Health's Macomb Hospital. Clinical integration requires having partnerships with other nonprofits and government agencies as well as having a tight relationship between the inpatient and outpatient settings, he says.
"For example, with hospital readmissions, our goal is to try to avoid readmissions if they can be avoided, and that requires an exchange of information with the ambulatory practices to know what changes have occurred, what medications were prescribed, and what tests occurred," he says. "There needs to be a bidirectional feed of information so that we can make sure when the patient is discharged there is a smooth transition to the outpatient setting."
Driving clinical quality
The health system uses lean management and daily huddles to drive clinical quality, Reddy says.
"For example, during our huddles, we look at any kind of immediate safety issues, and we try to manage them right away," he says. "If there is an issue, we determine how we are going to solve it and identify who is going to own it. If there are any barriers, the issue can be escalated to someone in the C-suite. It is key to have line of sight into quality and safety."
Hospital-acquired conditions are a primary concern at the health system. For example, catheter infections can lead to prolonged hospital stays, prolonged morbidity, and even mortality if the infection is severe. Reddy says the health system is using technology such as the electronic health record to reduce catheter infections.
"What we do with technology is we identify the patients in the hospital who have catheters, and we have physicians and nurses try to figure out which lines can be removed, and who is at risk of getting an infection," he says. "As we get increasingly wired, we want to see how we can leverage technology and move away from manual processes of writing down who has catheters. We want to use technology to generate reports and streamline workflows to prevent harm."
Prevailing in population health
Reddy, who also previously served as associate medical director of population health for Henry Ford Health, says partnerships and risk assessment are essential for population health initiatives.
"At Henry Ford, we had a large population of patients who did not have access to things like primary care," he says. "So we partnered with another group, which looked at patients' medications and reviewed them to see whether there were any kinds of gaps that could be referred to our primary care practices."
There are several approaches to risk assessment, he says: "Some of it is doing community needs assessments, but you also need to do interviews with patients and analyze why patients are readmitted. You need to analyze why individuals are showing up at your hospitals and ambulatory clinics. You can use technology to investigate, but you also must get into the weeds with individuals to find out about gaps."
A pair of chief clinical officers share their strategies for managing length of stay.
Managing length of stay in hospitals is a primary concern for chief medical officers and chief clinical officers.
Reducing length of stay cuts costs by decreasing the labor associated with caring for patients. Reducing length of stay also decreases the risk of a patient suffering an adverse event in the hospital such as a hospital-acquired infection or fall. In addition, length of stay reflects the efficiency of processes and clinical care in the hospital setting.
Length of stay is ultimately a key metric for how well hospitals care for patients, says Marjorie Bessel, MD, chief clinical officer of Banner Health. "When your length of stay is appropriate, it means that everything that sits under that—how well you take care of patients, how well you work them up, how well you treat patients once you understand what disease process they have, and how well you anticipate the patient's needs post-discharge—is functioning well. From a chief clinical officer's perspective, having the hospital function well is ultimately our responsibility."
Weak management of length of stay is a driver of emergency department boarding of patients, says Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market. Bon Secours is part of Bon Secours Mercy Health, and the Bon Secours Richmond market features seven hospitals.
"Oftentimes, we find that some of the initial testing and treatment for patients may not be started when they are boarded in the ED. Boarding can also overwhelm an ED. As we discharge patients appropriately out of the hospital, we can free up inpatient beds and pull patients from the EDs to start their inpatient care," he says.
Reducing length of stay
Bessel and Charvat say there are six primary strategies for reducing length of stay.
1. Preventive care: Health systems should encourage their patients to receive preventive care. During the coronavirus pandemic and in the post-pandemic period, many patients did not receive routine preventive care, which has led to sicker patients in hospitals and longer lengths of stay. "During the pandemic, there was concern that people were not getting preventive care and in the post-pandemic era people would have late presentation of disease. We are seeing some of this effect," Bessel says.
2. Operational efficiency: Hospitals need to focus on the efficiency of their internal operations, Bessel says. "How fast can you get things moving? How fast can you get a patient worked up to get a diagnosis? How fast can you get the right treatment for the patient? And how quickly can you help the patient recuperate so they are stable enough to be discharged to the next level of care?" she says.
3. Manage transitions to post-acute care: Sometimes, length of stay is extended because of limited access to post-acute care services such as skilled nursing or home health. "Post-acute placement such as with skilled nursing, inpatient rehab, and home health care can be problematic if our post-acute partners are not able to provide services on a timely basis," Charvat says. Hospitals need to start their discharge planning early and hold conversations with post-acute care partners as soon as possible, he says.
4. Managing high-demand services: Hospitals need to coordinate high-demand services such as MRI exams or move high-demand services to the outpatient setting when possible after a patient is discharged, Charvat says. "Is there an evidence-based best practice for determining which patients need to be admitted and which patients need testing such as high-tech imaging? If you can standardize your approach, you may be able to decrease the demand for some inpatient services. The other consideration is looking for opportunities to shift to outpatient services. So, if a patient does not need a test during the inpatient stay, you can schedule that test in the outpatient setting after discharge," he says.
5. Embrace a team approach to discharge: Hospitals can use daily rounding on patients in the morning to identify barriers to discharge and work through those barriers, Charvat says. "We have the hospitalists, nurses, care management team, and other members of the care team going through each patient every day. The team looks at the goals for discharge, the expected discharge date, how the patient is tracking toward discharge, the tests and treatment needed, and successfully transitioning the patient from the inpatient setting. We work through the barriers and often follow-up with an afternoon huddle to go through any last-minute issues," he says.
6. Establish mobility: One of the more recent efforts to reduce length of stay at Bon Secours has been to establish early mobility of patients, Charvat says. "The sooner that a patient who is admitted can get up and start having mobility, we can identify a safe disposition for the patient and whether the patient needs any ongoing therapy or special services at home or in the post-acute setting."
Chief medical officers and other top clinical officers are playing an active role with financial teams.
Chief medical officers and other top clinical officers are more closely involved in financial affairs than in the past.
One of the most salient observations at this summer's HealthLeaders Chief Medical Officer Exchange was that top clinical officers are being encouraged to engage with chief financial officers and their staffs to help address financial challenges at health systems and hospitals. This cooperation is essential as health systems and hospitals face tighter financial margins.
Aimee Becker, MD, CMO of UW Health, says she works closely with the Madison, Wisconsin-based health system's chief financial officer. "All of our leaders are expected to possess a business acumen, including our physician leaders. That business lens has to be part of how we care for patients. Our physician leadership structure includes triads and dyads, where our physician leaders work in partnership with our administrative colleagues. Through these partnerships, we are executing on the right patient care in financially responsible ways."
UW Health sees financial opportunities in providing value in care, she says. "One specific example is inpatient flow optimization work. When you think about patient navigation, whether it is through our emergency departments, through elective admissions, or through surgical processes, patient flow is key. From a process improvement standpoint, by being more efficient and providing the patient with the right care when they need it, there is a financial benefit that comes with that."
Value-based care requires cooperation between clinical leaders and financial leaders, says Daniel Durand, MD, chief clinical officer and chair of radiology at Baltimore-based LifeBridge Health.
"We are looking at the current value-based contracts that we have and the different terms of the contracts. We look at which contract terms that we like, which contract terms that we want to do more of in the future, and which contract terms that we want to do less of in the future. On an annual basis during the budgeting cycle in combination with others such as the chief operating officer of the medical group, we look at the value-based contracts that we are in and think about the new budgetary items we need to focus on—we look at the capabilities that we don't have today that we need to excel in value-based care such as actuarial analytics, physician-facing reporting, contract alignment at the physician level, access solutions, and patient navigation hubs," he says.
Durand and LifeBridge's physician leaders are also focused on cost-cutting, he says. "In cost cutting, we are getting rid of unused space in our bricks-and-mortar facilities, minimizing inventories, getting rid of high-cost supplies that have acceptable alternatives, and limiting premium labor. These are great ways for a health system to focus resources on where they are needed most and get rid of waste."
Optimizing clinical documentation
A primary area where clinical activity has financial implications is clinical documentation.
Accurate and timely clinical documentation is a top priority at UW Health, Becker says. "We are trying to make it easier for physicians and advanced practice providers to do accurate and timely documentation. That work has a host of secondary benefits, including improved risk adjustment, meeting quality metrics, and coding integrity. It makes sure we get paid, but it is really about doing the right thing for patient care, and it is part of our professional obligation as physicians and advanced practice providers."
At UW Health, there are coding reviews that occur behind the scenes to ensure the integrity of clinical documentation, she says. "The clinical documentation integrity team is fact based and data driven. We have a physician medical director who is involved with this work, too. They work to leverage the functionality of our electronic medical record, Epic, using standard, templated note documentation to improve both the integrity of the documentation in real time as well as to make it easier for busy physicians on the front-end."
The coding team works closely with clinicians, Becker says. "Our coding team conducts coding reviews and, sometimes, they seek clarification through coding inquiries with our physicians. As we have done this documentation integrity work at the clinical service level, we have seen that the coding inquiries have decreased considerably. It has been a big satisfier for our physicians who have been part of this work on template review and optimization."
Technology plays a key role in clinical documentation, Durand says. "Whenever you have some kind of documentation solution, usually they are electronically oriented. No one is using paper charts or paper billing anymore. All of this is now digital, meaning that it all can benefit from tools such as natural language processing and artificial intelligence as well as electronic workflows. Every one of these solutions that we put in play gets vetted by both compliance and information technology staff."
There are multiple paths to good clinical documentation, he says. "One is a delayed loop, where you have coders looking for key patterns to generate insights for physicians, so that when they document in the future, they include certain key information. There is obviously a lag in this pathway, and there are people who will say that you get your biggest bang for your buck when you present clinicians with information in real time in their workflow. We have a variety of different pilots and operational programs that fit that description, where people are prompted with an algorithm that is doing natural language processing. When clinicians use certain words, it has reimbursement implications and sometimes it has penalty implications, too. Often, penalties arise unnecessarily when clinicians do not use clinical terms thoughtfully. That can result in miscoding."
Clinical documentation is a primary responsibility of clinicians, Durand says. "The future of clinical documentation will be more and more digital. The physician will be focused on a process to make sure that they have done a truthful and complete documentation. We want to be truthful because we do not want to ever over-document, but we want to be comprehensive because we do not want to under-document and either underrepresent the patient's medical risk or underrepresent the services that were provided."
"RVU was supposed to solve compensation problems, but I believe it has now become the problem because people are defining it in too many ways," says Northwell Health's EVP and Physician-in-Chief David Battinelli.
A physician compensation model "must be tailored to what you want physicians to do," says David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
Prior to his current role, Battinelli served as Northwell's senior vice president and CMO. While working as CMO, he also served as the chief operating officer for the Feinstein Institutes for Medical Research. Other leadership positions he has held at the health system include chief academic officer and senior vice president of academic affairs.
HealthLeaders recently talked with Battinelli about a range of issues, including physician compensation models, his challenges as physician-in-chief, how physicians are involved in administrative leadership at Northwell, and physician engagement. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the physician-in-chief of Northwell?
David Battinelli: Obviously, the size and complexity of the organization is a challenge. The additional complexity that most people don't know is that the physician-in-chief is also the dean of the health system's school of medicine. It is structured that way because the school of medicine is co-owned and operated by Hofstra University, which grants the degree, and Northwell, which executes most of the clinical and research enterprises of the school. So, at least half of my job is running the school.
To lead as the physician-in-chief at Northwell requires that I have a team of people at Northwell who help in all the domains that a physician-in-chief has at the health system, which includes the clinical enterprise, quality issues, and related issues that a chief medical officer would have in their responsibilities. The advantage is that I have experience in various roles such as academics and research, and as chief medical officer, which gives me a line of sight into who would be best to put into various positions so that things run as smoothly as possible for me as physician-in-chief and I can align the medical school and the health system in the clinical and research enterprise.
HL: You mentioned that the size and complexity of the health system is a challenge. How are you rising to that challenge?
Battinelli: The role of the physician-in-chief is oversight of the clinical and research activities in a 90,000-person organization. No amount of leadership at the top can compensate for the lack of local leadership. So an enormous responsibility of the physician-in-chief is to ensure strong local leadership. Talent acquisition, alignment, and selecting the right leaders at the various locations of the organization is critical.
Someone might ask how we run the health system's 23 hospitals. The answer is you have 23 good people leading those hospitals. Coping with the size and complexity of the health system requires scaling talent acquisition, alignment, and staff development across the enterprise.
HL: What are the main elements of Northwell's physician compensation model?
Battinelli: With 5,000 employed physicians, the good news is that we do not have 5,000 compensation models, but we do have a lot of them. The compensation model needs to be tailored to what you want people to do. So, our compensation model is variable, but there are some commonalities. Part of the commonality is the compensation models have a clinical component, there is a teaching component, and for somebody who is a primary researcher there is a research component.
Most of the compensation models are geared primarily toward the physician's primary job—whether it is clinical, education, or research. For those jobs that are blended, we blend the qualities of the compensation models into a single piece.
Where we are headed is moving away from primary incentives to models that make more sense for individual physicians. You can chase money and chase relative value units, or you can focus on how physicians are spending their time. This is opposed to grinding out the work and logging as many relative value units as you can until you burn yourself out. Having a stable job description and alignment is handled much better than chasing after a relative value unit model. Physicians are hesitant to align themselves with RVUs these days. Twenty-five years ago, the RVU was supposed to solve compensation problems, but I believe it has now become the problem because people are defining it in too many ways.
HL: How are physicians seeking to define RVUs in different ways?
Battinelli: Some physicians say they need academic RVUs. Others say they need research RVUs. Others say they need clinical RVUs. If it is a relative value unit, the clinical value has been pretty much worked out—you get a certain amount of money for a certain amount of work. But if a physician is doing research or academic work, it is more difficult to set an RVU—what would that value be?
David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Photo courtesy of Northwell Health.
HL: How are physicians involved in administrative leadership at Northwell?
Battinelli: We have our Physician Leadership Development Program, which is an executive leadership program. We take physicians we have targeted as leaders and are likely to take jumps in their positions from six to 18 months. We firmly believe in physician leadership.
We have several physicians leading our hospitals. We have about 40 chief medical officers who are all physicians. Given the size, scope, and complexity of the organization, you need people with a clinical perspective as a physician to help non-physician leaders understand what is important to our physicians. It is not just money—money is important to everybody, but it is not more important than some of the other aspects of a physician's work.
HL: In addition to yourself, are there other physicians in the C-suite and at the vice president level?
Battinelli: There are other physicians at the executive vice president level, senior vice president level, and vice president level. In the C-suite, there is a substantial number of physicians. When I first joined Northwell in 2006, there were only two physicians in the C-suite, but there are many now.
HL: What are the benefits of having physicians serving in administrative leadership roles?
Battinelli: For better or worse, physicians are not the easiest group to communicate with. They are more likely to listen to physicians than non-physicians. It is similar to patients—patients from certain ethnic and racial backgrounds prefer a physician from a similar background because the patients feel these physicians understand them better. With physicians, they will take the same message from a respected physician leader better than they will take the message from a respected non-physician leader.
It is easier to promote alignment and engagement physician-to-physician.
HL: What are the primary elements of physician engagement?
Battinelli: I explain effective physician engagement and leadership in a few ways. One is you want people who are respected clinicians to engage physicians. Physicians are a tough group—they do not like to listen to non-physicians. They will listen to a doctor if they think that person is a good doctor.
Second, you need to have a certain amount of selflessness, meaning that the physicians you are communicating with have to believe that this is about them succeeding, not you succeeding. They are not against you succeeding, but they are against you succeeding without them.
Third, effective physician engagement requires good governing skills, meaning you must be fair, equitable, trustworthy, and possess integrity. Trust is probably the most important word—the decisions you are making as you are helping to align physicians must be in their best interest.
HL: In addition to serving as dean of the medical school, you have served in several other academic roles. What are the primary qualities of a good medical educator?
Battinelli: There are some people who believe your role as a teacher is to get students to do what you want them to do. The educators that I believe are most effective are the ones who are interested in inspiring people and helping people achieve what they want to achieve. With medical school students, you are dealing with adults. In that setting, a good educator supports and inspires rather than motivates and directs.
Phoenix Children's Hospital has added a new emergency department and will open two free-standing hospitals in 2024.
Balancing growth with operational excellence is the primary clinical challenge at Phoenix Children's Hospital, says Jared Muenzer, MD, MBA, chief physician executive for the pediatric health system and chief operating officer of Phoenix Children's Medical Group.
Muenzer was named chief physician executive in August and has been chief operating officer of Phoenix Children's Medical Group since 2016. His prior leadership roles at the pediatric health system include physician-in-chief, associate director of the emergency department, and vice president of the medical staff.
HealthLeaders recently talked with Muenzer about a range of issues, including physician leadership, physician engagement, and the keys to success in managing service lines. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges you’ve seen as chief physician executive of Phoenix Children's?
Jared Muenzer: The biggest challenge for me is balance. We have set out on a massive growth campaign—we have added an emergency department in the West Valley, we are adding 40 beds on the main campus, and we are adding two free-standing hospitals in 2024. Balancing that growth with operational excellence, a strategic plan for operational improvement, workforce development, and workforce growth, and putting it all in one package and getting it to function and flow are the biggest challenges.
The beauty for us is that the team within the medical group and the hospital both from a physician leader standpoint and an administrative leader standpoint are definitely up to the task. They are the ones who drive the improvement and the change.
The other challenge I would add is technological advancement. We need to slide technological advancements into our changes. We need to make sure that technological advancements fit and drive improvements for our patients and our families.
HL: How do you address those challenges?
Muenzer: We have tremendous physician leaders in this organization. In Phoenix Children's Medical Group, we have 34 division chiefs, and we are helping them understand their book of business and working with them to understand what their needs are. We are partnering them with administrative leaders.
When I took over as chief operating officer of the medical group in 2016, I had two directors and about two dozen managers, and that has grown to four vice presidents, a dozen directors, plus about 30 managers. The partnership of the physician leadership and the administrative leadership allows us to develop the cadence and the projects as well as tie in the technology so that all of the challenges I have talked about get addressed.
HL: What are the keys to success in physician engagement?
Muenzer: With the growth, we were at 300 providers in 2016 and we are at more than 800 today. We had 26 divisions and now we have 34. Physician engagement is really about the development of the leaders. My goal for them is to say, "You own your book of business—you run it." I want to empower them to do that and find out about their needs and resources.
Then I want people at the executive level to say, "We still are a children's hospital with limited resources, but how can we maximize those resources to give all of our physician leaders and all of our books of business the attention they need to drive world-class healthcare for our patients and their families?"
Jared Muenzer, MD, MBA, chief physician executive for Phoenix Children's Hospital and chief operating officer of Phoenix Children's Medical Group. Photo courtesy of Phoenix Children's Hospital.
HL: How have you managed growth strategies and process improvement for the medical group?
Muenzer: It is all about the data. We need to understand our patients and families, our community, our state, and the Southwest in terms of what the needs are in pediatric healthcare. We need to utilize the data. What are the wait lists in our divisions? Where are patients coming from in the state? What procedures do they need? For the things that encompass healthcare, understanding the data behind it allows us to focus not only on areas of growth but also what pace we need to grow at. We determine what growth needs to be then develop individual strategies to do that.
One of the big areas of growth has been our residency program and our fellowships. We are now up to 30 fellowships across this health system, which helps serve growth from a provider standpoint.
We also have a large contingent of advanced practice providers in this organization, and we have relationships with numerous colleges that produce nurse practitioners and physician assistants. Those relationships drive advanced practice providers here for rotations, which helps them fall in love with pediatric healthcare and drives workforce development.
HL: What are the primary elements of physician leadership?
Muenzer: Servant leadership is important. Accountability is important. One of the things that I love about our physician leaders goes back to the book of business and the dyad model of leadership. When our physician leaders take accountability for their book of business, their growth, and their strategic plan, it helps me and the organization drive change and the growth that we need. It also helps them because when they hold themselves accountable, it helps their groups to be accountable.
The other big piece of physician leadership is effective communication. When my physician leaders effectively communicate not only with their physicians and staff but also with me and the organization, it is a game changer to drive necessary change.
HL: How do you define servant leadership?
Muenzer: It involves accountability; support; open communication; listening to the people around you; engaging the people around you; putting together the needs, wants, and asks of the people around you; and being willing to translate growth and cadence of growth. A servant leader makes sure the people around them feel that their voices have been heard.
HL: How are physicians involved in administrative leadership at Phoenix Children's?
Muenzer: Physicians play an important role as division chiefs.
We also have developed numerous channels and avenues for our physicians to have a voice and to engage in leadership. We have committees in the medical group, which involve understanding operations, understanding strategic growth, and understanding patient safety and quality. We have aligned physician leaders in the medical group with physician leaders in the hospital, so that the medical group and the hospital are aligned. That applies to patient safety and quality, so we have patient safety and quality leadership as well as medical directorships on most of the floors in our hospital, in our emergency department, and in ambulatory clinics that align with nursing quality leadership and quality office leadership. So we are all aligned.
We also have alignment across operations as well as across compliance and the regulatory function, so we have a system that drives partnerships that support the goals of the whole institution.
HL: You have helped to add or expand several divisions at Phoenix Children's, including nephrology, infectious diseases, anesthesiology, and neonatology. What are the keys to success in managing service lines?
Muenzer: With our growth, one of biggest challenges is that when you bring new groups in, or when you are growing a group from scratch or growing a group fast, is to make sure you understand culture and you understand the best avenues for communication. In the growth stage or the onboarding stage, you set the tone for the future. We have tried to make sure that everyone feels like they are part of the Phoenix Children's family and part of our culture, which is striving to provide the highest quality of care possible. We have supported our new or expanded groups to meet that goal.
Healthcare organizations need to develop a plan to promote professionalism among their staff members, according to an expert at Vanderbilt University School of Medicine.
About 3% to 5% of physicians, nurses, and other healthcare workers have a pattern of unprofessional conduct, says Gerald Hickson, MD, Joseph C. Ross chair of medical education and administration as well as professor of pediatrics at Vanderbilt University School of Medicine, and founding director of the Vanderbilt Health Center for Patient and Professional Advocacy (CPPA). Unprofessionalism is any behavior that "gets in the way" of healthcare teams or effective care for patients, he says.
Unprofessionalism in the healthcare setting can come in many forms, Hickson says. "Traditionally in medicine when we have thought about unprofessional or disrespectful behavior, it has been the notion of aggressive behavior. In our research, it is clear that passive and passive-aggressive behaviors are more common and can be just as interfering with our intent for good outcomes."
Examples of unprofessional behavior include throwing equipment, yelling at colleagues, and willful disregard of hand hygiene, he says. "These behaviors get in the way, and 3% to 5% of physicians, nurses, and other medical professionals have patterns of these behaviors that can have an extraordinary impact on healthcare teams and the patients we serve."
Unprofessional behavior has several negative impacts on healthcare teams and their patients, Hickson says. "We know that if physicians or nurses are disrespectful of the patients they are serving, it decreases the willingness of the patient to come back for care, to share their concerns, and to follow care plans. As you escalate unprofessionalism into a larger health system or a hospital, physicians, nursing professionals at the bedside, pharmacists, and other professionals need to play as a team. If a healthcare professional is disrespectful of colleagues, if they belittle questions from colleagues, or if they fail to perform a professional duty, it decreases the willingness to ask the healthcare professional for help and it decreases willingness to share information about a patient, so team function falls, and bad outcomes occur."
For surgeons who engage in unprofessional conduct, research has shown that patient outcomes are impacted, he says. "If you see one of those surgeons and you have a surgical procedure, you are 20% to 30% more likely to get a surgical site infection, you are 20% to 30% more likely to have to be readmitted to an intensive care unit, and you are more likely to experience a host of avoidable complications because the team is not functioning well."
Unprofessionalism can drive healthcare workers from the field, Hickson says. "When we interview nurses who leave their positions, 20% to 40% of them cite having to work with a problematic physician as the reason they leave. When you look at the cost of replacing a nurse, that is a problem. Unprofessionalism is a huge driver of the retention problem we are seeing in medicine now."
Rising to the unprofessionalism challenge
Healthcare organizations can effectively address unprofessionalism, Hickson says. "No. 1, leaders such as chief medical officers need to model professionalism themselves. If leaders are committed as professionals, the first thing they do is look at and self-assess their own performance."
Health systems, hospitals, and physician practices need to have a plan that promotes professionalism, he says. "The plan is built on the observations of patients, families, and healthcare team members. They see and experience unprofessional conduct, and individuals need to be able to address those behaviors in the moment. Reports and stories of unprofessionalism can be funneled into an office of patient relations or reported in a safety event system by coworkers. If those reports are mined or looked at routinely, you can identify at-risk individuals."
Plans to promote professionalism have several elements, Hickson says. "The plan for promoting professionalism begins with the onboarding of new hires to be sure they understand their roles and their importance in the organization. It involves wellness resources because some of the individuals who get identified as unprofessional have personal, family, or illness-related issues that need to be addressed. You need to have mental health and physical health resources because you just can't tell someone, 'Go get better.' There also needs to be a commitment to terminate the rare number of employees who refuse to respond."
To address instances of unprofessional conduct, healthcare organizations should provide feedback to problematic employees early and often, Hickson says. "In organizations that are committed to professionalism, they have trained peers who take the stories and reports that have come in, and they address the problematic professionals within a day. They sit down with their colleagues, and say, 'Here at this institution, we are committed to do everything we can to maximize outcomes for patients. We have a story of an event, and we want you to review this event, and if there is anything you can think of to do differently, we know you will do the right thing in the future.'"
Healthcare organizations need to promulgate standards for professionalism, he says. "You must have general communication, so people know the expectations for professionalism. Everyone in the organization must know that issues of professionalism are taken seriously."
The best practice for addressing unprofessionalism in individual healthcare workers is direct communication, Hickson says. "There is no more effective way educate and share professional standards than one-on-one communication in a private setting. When a peer comes and knocks on your door, you are not being called to the principal's office. The peer comes in and shares an observation. The peer shares all of the events that have arisen. The peer is not going to diagnose the situation, they are going to say, 'I know there are two sides to the story, and I just want you to reflect on the events.' The other issue in engaging people who have been unprofessional is letting them know that they are trusted to do the right thing. If there are ongoing reports of unprofessionalism, the problematic employee must be told that they are going to get another knock on their door. The good news is that in the majority of cases, the unprofessionalism does not happen again."
Among physicians, healthcare organizations can address unprofessionalism whether physicians are employed or practicing independently, he says. "Every physician who walks into a hospital must have privileges. You may be employed or a physician in your own practice; but in both circumstances, you must have privileges to practice care. If you have a health system, hospital, or physician practice where everyone is employed, all physicians operate under the same rules. If on the other hand, a physician has a separate practice, to work with patients that physician has to agree to certain standards and be held to those standards."
CMOs must work collaboratively with organizational partners to address unprofessionalism among physicians, Hickson says. "We have learned that HR is a critical partner in delivering safe care. CMOs need to recognize and understand that they have an important role in moving a health system, hospital, or medical group forward. To do that successfully, they must understand and respect the roles of HR, legal departments, safety departments, and risk management. They need to see them as partners."
The Vanderbilt Health CPPA is holding a two-day course on addressing unprofessionalism in December. To register, click on this link.
In 2023, the primary concerns for CMOs include clinical staffing trends, financial challenges, and a nurturing environment for patients and the workforce.
Cathcart has been CMO of Newark Beth Israel since 2022, and he has been chairman of radiation oncology at the hospital since 2010. Prior to taking on the CMO role, he was vice president of medical affairs at the hospital for seven years. Newark Beth Israel is part of RWJBarnabas Health, the largest academic health system in New Jersey.
Newark Beth Israel and Children's Hospital of New Jersey is a comprehensive medical center that delivers care to some of the most critically ill patients in its region, including heart failure patients, patients with advanced pulmonary disease, infants born with congenital heart conditions, and cancer patients at all stages of the disease. Earlier this year, Newark Beth Israel opened a new outpatient geriatric center, the James and Sharon Maida Geriatric Institute, to offer seniors increased access to the specialists and education they need to manage their care.
HealthLeaders recently talked with Cathcart about a range of issues, including how to remain financially viable with many Medicare and Medicaid patients, how academic medicine impacts hospitals, and the primary concerns of hospital CMOs in 2023. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Newark Beth Israel Medical Center?
Charles Cathcart: The physicians and staff at Newark Beth Israel are truly my colleagues and I consider myself a servant leader, essentially a player-coach. I meet with my division chairs and chiefs regularly to discuss the challenges they are facing and to ensure that we are all working in alignment to reach our hospital goals and deliver the highest level of care to our patients.
As the CMO, I must ensure that our physicians and our medical practices are meeting the needs of all our patients, from chronic disease management to complex advanced cutting-edge medical care.
Charles Cathcart, MD, chief medical officer of Newark Beth Israel Medical Center. Photo courtesy of RWJBarnabas Health.
HL: In 2023, what do you think are the primary concerns for hospital CMOs?
Cathcart: The healthcare industry continues to feel the effects of the COVID-19 pandemic. Across the country, we have experienced a great shift in employment trends from The Great Resignation to new expectations of a new generation of employees. Physicians are in high demand but, increasingly, they are a limited resource, and we need to expand our clinical teams to include more advanced practice nurses and physician assistants. Hospitals across the country are also facing increased financial challenges. As a CMO, my primary concern is creating an environment where our patients receive the highest level of care in a safe environment by a team that feels supported by their colleagues and leaders.
HL: A large percentage of your payer mix is Medicare and Medicaid. How do you remain financially viable with so many Medicare and Medicaid patients?
Cathcart: At Newark Beth Israel and Children's Hospital of New Jersey, we are committed to providing excellent care to all the communities that we serve. Although we have a high government payer mix, we also provide tertiary and quaternary care to a wider range of patients, inclusive of more commercial payers, which mitigates government payer shortfalls.
HL: You were previously a faculty member at the University of Medicine & Dentistry of New Jersey. How does academic medicine impact hospitals?
Cathcart: I spent the first half of my career, 18 years, as a faculty member at the University of Medicine & Dentistry of New Jersey. That experience helped me to understand the importance of medical education and the role that research plays in delivering quality patient care.
The origin of the word "doctor" is teacher. As we teach our patients and their families about their illnesses, we can teach one another both at the bedside and in formal peer review meetings. Peer review is one of the most important aspects of improving our clinical outcomes.
At Newark Beth Israel, I work with my chairpersons to help them develop practices that incorporate and optimize our partnership with Rutgers Health and our robust residency program—Newark Beth Israel has 23 residencies and fellowships—to deliver the best, most advanced, and evidence-based care to our patients.
HL: How are physicians involved in administrative leadership at Newark Beth Israel?
Cathcart: As the CMO at Newark Beth Israel, I have a seat at the senior management table alongside our chief academic officer and our medical staff president. Our job is to represent the medical staff in many administrative decisions where patient care is involved. I strongly believe in the dyad model, where a physician leader and administrative leader work hand in hand to develop clinical programs.
In addition, Newark Beth Israel and our entire health system is on a high reliability organization journey toward reaching zero preventable harm events. Our physician leaders are actively engaged in that journey, providing leadership at safety and quality meetings with our administrative leaders, engaging in weekly patient-centered rounds, and helping our hospital prepare for federal and state safety and quality surveys.
HL: You have a clinical background in oncology. How has this clinical background helped prepare you to serve in administrative roles such as CMO?
Cathcart: As an oncology physician, I was trained to practice medicine in a collaborative manner. I have been an oncology physician for 31 years. We rely on our fellow oncology clinicians to help us make critical decisions about how to treat our patients. I am very comfortable pulling together teams of stakeholders to discuss issues, review cases, and decide on the best course of action for my patients. I am a CMO who still wears a white coat to work every day, and this means that I often need to venture into clinical areas that are unfamiliar to me. It is my job to ensure that the correct clinical expertise is in the room that includes physicians, nurses, and social workers. I must pull together the appropriate resources to address clinical issues throughout the hospital, and at the same time I must be a resource for my clinical leaders.
I have an acute understanding of the challenges that clinical leaders face, when they are asked to split their time between the practice of medicine and the administrative duties that are equally important for the effective operations of a 665-bed regional care teaching hospital, such as ours. As CMO, I've made it my mission to help my colleagues bridge that gap, by creating an escalation system that enables our clinical teams to access our chiefs and chairs 24/7, and by placing leaders at the center of critical patient care decisions. We have also developed a weekly patient-centered rounding tool that connects clinical and administrative leaders to the frontline staff on our units to ensure that we all stay connected to our patients and their loved ones.
The Camden Coalition's care management model has a return on investment because it reduces hospital readmissions, emergency department utilization, and overall healthcare spending.
The Camden Coalition's care management model reduces hospital readmissions and has a strong return on investment.
The Camden Coalition is a nonprofit that supports the work of healthcare providers in Camden, New Jersey. The coalition's members include health systems, primary care providers, academic institutions, and community organizations.
A recent research article found patients with complex medical and social needs that were engaged in the Camden Coalition's care management model had significantly lower hospital readmissions than similar patients who were not engaged in the care management model. The research article, which was published by JAMA Network Open, features clinical trial data collected from 782 patients. The intervention group was engaged in the coalition's care management model for about 120 days and the control group received usual post-discharge care.
The research article includes two key findings:
Among patients who were most likely to engage in care management, the relative 30-day readmission risk for intervention participants was 48% lower than the control group.
The relative 90-day readmission risk was 52% lower.
The Camden Coalition's care management model features a multidisciplinary team, says Kathleen Noonan, JD, president and CEO of the nonprofit. "Our care management program has always been a nurse and community health worker team, with a social worker who is connected to each team. We basically enroll a patient in the hospital—we use data from our health information exchange to identify complex patients with complex medical issues and complex social needs. Our local hospital, Cooper University Health Care, let's our enrollment managers work on the inpatient floors, and we try to enroll people in our program."
The care management team conducts community-based work with patients, she says. "They are the ones who are doing the care planning, working with the patients to see what they think their needs are, and working with patients around the health issues that brought them into the hospital. If you are enrolled in our care management program, you have been in the hospital for at least two times in the past six months. So, these patients have a lot of interaction with the healthcare system."
The Camden Coalition's care management model benefits healthcare providers and their complex patients, says Louis Bezich, MPP, senior vice president and chief administrative officer at Cooper University Health Care, which is a member of the coalition.
"It plays a supportive role that leverages and coordinates the partners to maximize the value of their work such as my hospital or a federally qualified health center. The Camden Coalition connects the dots. Early on, the Camden Coalition focused on care coordination and meeting patients at the bedside to make sure they had follow-up visits scheduled. It has focused on the social determinants of health—the identification and documentation of social determinants of health and how that is a critical gap that needs to be filled in order for patients to maximize the value of the healthcare they receive," he says.
Resources, costs, and ROI
In addition to staffing, resources applied to the Camden Coalition's care management model include housing and legal assistance, Noonan says. "Because of the barriers that we see for our patients, we created a housing program called Housing First, in which we enroll some of our patients. We also created a Medical Legal Partnership (MLP) program, where we have an attorney who works with people who have complex social needs because those needs sometimes involve the courts. So, we created new resources where we saw gaps."
The Housing First program costs about $15,000 per person annually, and the MLP costs under $5,000 per client, she says. The care management model has a high return on investment because it can avoid multiple hospital readmissions for patients, with each hospital readmission costing at least $10,000, Noonan and Bezich say. "The return on investment is also lower recidivism in the use of the emergency department and less healthcare spending overall because patients get well," Bezich says.
Replicating the care management model
Healthcare providers across the country can implement the Camden Coalition's care management model at their organizations, Noonan and Bezich say.
"This care management model can absolutely be replicated at other healthcare providers. We train people on our approach to patient care. We train people on how to work with community partners. We also have protocols for how we conduct care management. Our model and the tools we use are written down," Noonan says.
"What the Camden Coalition has done successfully is take this model and share it across the nation. We have an annual conference and last year it was in Sacramento, California—we had about 600 people from across the country attending the conference to learn more about complex care. For a small, nonprofit in Camden, New Jersey, to hold an annual conference and attract a healthy number of attendees nationwide, speaks to the need as well as the quality and acceptance of the coalition's model. It is real, it works, and it is relevant to the challenges that we all face in urban areas and some rural areas," Bezich says.
At MaineGeneral Medical Center, clinical staff recruitment is boosted by an attractive organizational culture, an earnest approach to healthcare, and a state-of-the-art physical plant, the hospital's CMO says.
The CMO of MaineGeneral Medical Center says he has three primary challenges at the community hospital: clinician recruitment, financial sustainability, and mental health and addiction medicine resources.
Dana "Dan" Vick, MD, MBA, has been CMO of MaineGeneral Medical Center since 2022. MaineGeneral Medical Center, which is located in Augusta, Maine, is a 198-bed community hospital that is part of MaineGeneral Health. The hospital is considered a rural referral center, with Augusta a modestly sized city with only about 20,000 residents. His prior healthcare leadership experience includes serving as vice president of medical affairs for two Ascension health system hospitals: St. Vincent Evansville in Evansville, Indiana, and St. Vincent Warrick in Boonville, Indiana.
HealthLeaders recently talked with Vick about a range of issues, including how physicians are involved in administrative leadership at MaineGeneral Medical Center, patient safety at the hospital, and patient experience. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of MaineGeneral Medical Center?
Dana "Dan" Vick: There are three things that are challenging.
One is staff recruitment. We are constantly recruiting for various specialties. About 85% of our medical staff are employed, which puts the onus on us as an organization to recruit clinicians. Fortunately, one of the things that makes us attractive is we have a great organizational culture, which runs from the top down. We have a lot of longevity throughout our organization in many employment levels.
We are taking care of patients who are members of our community—sometimes they are family members and sometimes they are neighbors of people who work here. There is a sense of earnestness in how we approach healthcare, which helps with our recruitment. We also have an excellent physical plant—the hospital was built about 10 years ago with input from people who work throughout the organization. The hospital is a place that is convenient for patients and user-friendly for those who work here. When you step inside the hospital, it looks like it opened just last week. When we have recruits who come to the hospital, they are impressed by the facility.
The second challenge is financial. Like every healthcare organization, we are struggling with decreasing reimbursement while trying to figure out how to increase access for patients. We are trying to reduce length of stay to be a more financially adept organization, while providing the care that patients need in as timely a manner as possible.
The third challenge is mental health and addiction medicine resources. In Maine, we struggle to have enough resources to address the issues that occur in those realms. In many states, mental health and addiction medicine has become a crisis.
HL: How are you rising to the financial challenge?
Vick: We look at the ways we can improve upon the services that we offer to increase access and deliver those services in a cost-effective manner. We also try to limit length of stay for patients. Additionally, we try to make sure that we capture appropriately the services that we provide to boost reimbursement.
HL: How are you rising to the mental health and addiction medicine resources challenges?
Vick: We continue to recruit adult and pediatric behavioral health staff. We are also working with telehealth providers to help provide some of the care that we are not able to provide on-site.
HL: What is the physician compensation model at MaineGeneral Medical Center?
Vick: All physicians are on a base salary to guarantee them a base compensation. Most of the service lines can pay physicians additionally based on productivity. We used to have payment based on value, but we have folded that component into the base salaries because we found that we had to compete with other hospitals for recruitment, and that has made us more competitive.
Dana "Dan" Vick, MD, MBA, chief medical officer of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.
HL: What is the approach to patient safety at MaineGeneral Medical Center?
Vick: We have a multipronged approach. We have a daily report prepared by risk management staff showing anything that may rise to the occasion of being a miss or a near miss. We have a peer review process with the medical staff that looks at cases that may rise to serious patient-safety criteria.
We also have a Speak Up Award—employees are encouraged to speak up if they see something that may have the potential to cause a problem. So, employees receive an award when they have found an issue and potentially avoided a patient safety event from happening. We also conduct rounds on staff and patients from the senior administrative director levels.
We try to promote a culture of safety. We have worked on flattening the hierarchy, so employees on the frontlines know they can bring their concerns forward quickly. We also have a process design department, and they do a lot of lean process work. We are doing everything we can to reduce errors and to improve patient safety.
HL: Is there a process in place when medical errors occur?
Vick: When a medical error occurs, we determine whether it represents a sentinel event or significant event. Then we implement our medical staff peer review process to look at the case.
HL: What are the keys to success in patient experience in the inpatient setting?
Vick: Two things that are important are teamwork and communication.
Healthcare is not an individual endeavor. It takes the work and input of everyone on the healthcare team. So, we have promoted teamwork and have built teamwork into our culture. We conduct interdisciplinary team rounding every day on our medical and surgical wards.
We also promote the value of communication. You can never communicate a message too frequently—that is very important. We want our patients to understand what is occurring with their healthcare. We want to hear from them if they have any concerns. So, we survey patients frequently.
HL: How are physicians involved in administrative leadership at MaineGeneral Medical Center?
Vick: They are involved in several manners. We have employed medical directors for our service lines. We have our medical executive committee, which consists of our department chairs. We have medical staff and hospital committees, where physicians serve in leadership roles. And we have medical staff members who are on the board of directors.
We have worked to build a leadership development program for our medical directors, assistant medical directors, and lead advanced practice providers. This consists of quarterly half-day retreats that we hold at an off-site facility. We cover several topics such as leading through a team-driven approach, how to overcome dysfunctions in a team, and understanding physician compensation. So far, this leadership development program has been well received, and it is helping us grow the next generation of leaders and helping current leaders grow in their roles.
HL: What are the benefits of having physicians involved in administrative leadership?
Vick: It helps because otherwise you can get engrained and focused on components of healthcare without understanding why we must do some of the things that we do in running a healthcare organization. When physicians have an opportunity to be involved in administrative leadership, it gives them a better sense of the other side of the equation beyond patient care, and it allows them to convey that message to their medical staff group or department.
'You basically cannot have patient safety without health equity,' says Yale New Haven Health executive.
Yale New Haven Health is striving to address the health equity elements of patient safety.
Health equity has become a top priority for healthcare providers nationwide. Last year, health equity was added as the Quintuple Aim for healthcare providers. In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
Linda Fan, MD, assistant professor of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine, and GME director of quality and safety at Yale School of Medicine and Yale New Haven Health, says health equity plays a significant role in patient safety.
"You basically cannot have patient safety without health equity. It is a glaring hole in how we have not been able to adequately address patient safety. In the past, we have believed that patient safety is an issue because the patient is not compliant—they did not listen to the directions or there is something intrinsically flawed with them. When you get to the root cause of a patient safety issue, it is possible that the patient did not understand directions, there could be language issues, or there could be issues with access," she says.
There are several elements of health equity that impact patient safety, Fan says. "There can be different domains of social factors, including language barriers. There are conventional ways that we look at patient safety—we look at the patient, we look at the caregivers, and we look at processes. In the past, there has not been the language to include health equity elements such as access to care, language barriers, transportation issues, and social supports. Those kinds of things do not fall into the normal ways we have looked at patient safety."
Pairing health equity with patient safety is a healthcare trend, she says. "We are not used to looking at patient safety through the equity lens. Health equity is a different way of looking at patient safety. Once you start looking at patient safety through an equity lens, you cannot unsee it. We are at the beginning of incorporating health equity in patient safety."
There are two primary approaches to addressing health equity issues in patient safety, Fan says. "When you are looking at quality and safety and health equity, one approach is to understand disparity indexes, where you might take something such as mortality related to myocardial infarction or how patients are treated for chest pain, and you compare how men and women are treated or how Blacks and Whites are treated. If there is a difference, then we should be trying to hone in on it and improve it. You need to be looking at information transparently and making sure that the data reflects disparities. Another approach is when you identify a safety event such as a medical error leading to a sentinel event, then you ask all the reasons why the error occurred, including health equity elements as part of the framework of looking at safety events."
Visualizing the data
Health systems, hospitals, and physician practices should follow four steps to develop a systemwide process for equity data visualization of quality and safety measures, says Lou Hart, MD, medical director of health equity at Yale New Haven Health.
With a multi-stakeholder, transdisciplinary team, launch a We Ask Because We Care education and training campaign directed to both patients and staff around the importance of sharing and collecting high fidelity patient self-reported demographic information to eliminate unwanted variation in care and patient outcomes. Start with REALD SOGI and social determinants of health data such as race, ethnicity, language, disability, sexual orientation, and gender identity. Co-create and update field values and selections after conducting focus groups with staff, patients, community advisors, neighboring health systems, state government agencies, and other stakeholders.
Agree upon and ratify standardized mapping and reporting guidelines to ensure the health information technology system uses one single source of truth for assigning demographic categorization to patients that persist across encounters in their legal electronic medical record.
Leverage existing or create formal quality and safety reports and dashboards, then calculate demographic subgroup-specific characteristics such as income, Zip code, language, disability, and race as process and outcome measures for the quality and safety metrics in question. For example, examine 30-day readmissions with subgroup readmissions and subgroup index admissions. Examine the Medicaid readmission rate by looking at patients with Medicaid experiencing 30-day readmissions and patients with Medicaid who had an index admission. Compare the Medicaid readmission rate to the commercial insurance rate by looking at patients with commercial insurance who experienced 30-day readmission and patients with commercial insurance who had an index admission. Start with metrics that are institutional priorities such as corporate objectives, risk-based contracted measures, and those that impact the most patients.
With the group-specific outcome rates stratified, create an equity index showing relative risk or risk ratios across the subgroups. This should be viewed in a bar chart for ease of understanding. The control group should be dynamic and the group with the best outcome rate.
Health equity and patient safety outcome
A recent example highlights collaborative change management led by Yale New Haven Health Pediatrics in partnership with Women's Health, Hart says.
There was a case of a child welfare report being filed for positive urine toxicology during pregnancy and a desire to test the baby. The former hospital procedure often involved testing the newborn at birth despite already having information from the parental test. This resulted in a child welfare investigation process that was traumatic, which led to a patient safety incident report being filed on behalf of the family.
During the investigation, it was found that Black and Hispanic parents were disproportionately tested for substance use during pregnancy compared to White patients. Black and Hispanic parents were also less likely to be positive when tested than were White parents. Given this clinical disparity and the potential for bias-driven healthcare inequity leading to disproportionate child welfare system involvement with racially minoritized families, a partnership was formed with the regional child welfare system—the Connecticut Department of Children and Families (DCF)—to address the concern locally and structurally.
Yale New Haven Health partnered with patient advocates and multiple clinical departments and quality improvement experts. The health system also created a partnership with DCF to educate on the lack of medical necessity for routine newborn toxicology testing because it was redundant to parental testing, often did not change clinical management, and could lead to bias in future care.
These efforts led to two key changes, Hart says, noting the changes not only decreased the racial disparity in newborn toxicology testing but also decreased unnecessary testing in all racial groups for newborn toxicology testing.
There was policy clarification and procedural change to limit use of newborn toxicology to cases where it was purely clinically necessary and not used for social risk stratification or confirmation of parental testing. The health system created an electronic medical record clinical design support tool to guide clinicians in real time to highlight the need for informed parental consent being required to perform newborn toxicology.
There was broad internal messaging at the health system regarding the clinical disparity and to raise collective awareness among key stakeholders. There was internal and external training with hospital staff and DCF staff as well as re-evaluation of the statewide drug exposure reporting system to distinguish between mandated anonymous fetal substance exposure versus formal child welfare referrals for in utero substance exposure.
David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Photo courtesy of Northwell Health.
Jared Muenzer, MD, MBA, chief physician executive for Phoenix Children's Hospital and chief operating officer of Phoenix Children's Medical Group. Photo courtesy of Phoenix Children's Hospital.
Charles Cathcart, MD, chief medical officer of Newark Beth Israel Medical Center. Photo courtesy of RWJBarnabas Health.
Dana "Dan" Vick, MD, MBA, chief medical officer of MaineGeneral Medical Center. Photo courtesy of MaineGeneral Health.