The Exec: 7 Questions With Yale New Haven Health's Chief Clinical Officer Thomas Balcezak

Balcezak says that at Yale New Haven Health "nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers."

Thomas Balcezak, MD, MPH, chief clinical officer of Yale New Haven Health, recently talked with HealthLeaders on a range of issues, focusing primarily on physician burnout and workforce shortage issues, while expressing how the  organization is moving healthcare forward in the communities it serves with patient safety initiatives and hospital acquisition goals to provide higher-quality care.  

The transcript below has been edited for clarity and brevity.

HealthLeaders: Yale New Haven Health is in the process of acquiring three hospitals in Connecticut. What are you plans for clinical care at these hospitals?

Thomas Balcezak: We have acquired other hospitals and integrated them into the health system. For example, in 2012, we acquired the Hospital of Saint Raphael. In 2016, we acquired Lawrence and Memorial Hospital and Westerly Hospital. And in 2019, we acquired Milford Hospital. In each one of those transactions, our goals were straightforward. Connecticut is a parochial state—we like our healthcare local, and we like access to high-quality services. In these transactions and the proposed transactions for the three other hospitals, our goals are to broaden access to high-quality clinical services, to keep care to whatever extent possible local, to improve the quality of care, and to reduce the cost of care.

It comes down to cost, quality, and access. If all goes well as in the previous transactions, we believe we have an opportunity to do all three.

HL: How do you lower the cost of care in these transactions?

Balcezak: There are a couple of different ways. One is to take advantage of being a relatively large organization—we are almost $6 billion in revenue. That gives us good power in negotiation for products. It gives us access to competitive pricing on things such as drugs and supplies. So, we have some opportunities in supply chain savings.

The other way we can lower cost of care is in economies of scale for back-office services. Healthcare in general and hospitals in particular are human capital—intensive. We do not believe there is an opportunity to reduce direct caregivers—we have enhanced the staffing on the clinical side at the institutions we have acquired and integrated into the health system. There is opportunity in management structure, span of control, and back-office services.

HL: What is the status of physician burnout at Yale New Haven Health?

Balcezak: We are in a similar position as other health systems and hospitals across the country. Burnout is an issue beyond physicians—it is all of our clinical caregivers such as nurses, respiratory therapists, and pharmacists. We are seeing an epidemic of burnout in U.S. healthcare. It is something we are taking a lot of steps to address, but we do not have all of the answers.

The steps are relatively simple, but they are nuanced with a lot of efforts that are bolstering those steps. One step is making sure that we have adequate staffing, which has been a challenge. We have staffing shortages in virtually every area of our institution; just like you are seeing in other industries, we have seen growth in open positions.

Addressing staffing shortages goes well beyond salary and benefits. People want to work where they feel they are doing important work that is contributory to society. That is where healthcare has an advantage over many other industries. People go into healthcare because they want to help people—they want to help communities. It is important to be grounded in that as a health system. We need to spend more time focusing on what we are doing to improve the lives of the patients we serve and the communities we serve.

Another step is supporting the caregivers—giving them the tools that they need to deliver good care as well as reducing the barriers and the excess work that they do such as difficulties with documentation or use of the electronic medical record. There is a whole stream of work that we have been engaged in to improve day-to-day work effort, while providing employee and health resources support, so that staff have opportunity to express where their concerns are.

Pictured: Thomas Balcezak, MD, MPH, is the chief clinical officer at Yale New Haven Health. Photo courtesy of Yale New Haven Health.

HL: Give an example of an initiative you have put in place to address physician burnout.

Balcezak: One of the initiatives that we have is spearheaded by our chief medical information officer, and it is called Building Against Burnout. This initiative is specifically looking at how much time physicians are spending using the electronic medical record, particularly the "pajama time" outside of standard work hours. We have had a reduction in pajama time that can be tied directly to what our CMIO and his team has been doing to make the electronic medical record more streamlined and easier for physicians to use.

The electronic medical record is a big complaint by physicians, and it is appropriate that they are complaining about it. Technology is supposed to make lives at work easier, but what we often hear from physicians is that technology has made their work more onerous. In healthcare, we need to make documentation easier and use things such as virtual scribes to make the amount of time that physicians are spending on the electronic medical record go down.

HL: What have been your primary efforts to address workforce shortages?

Balcezak: We have made a multi-pronged effort. One of the efforts has been to make sure that we can offer a competitive salary and benefit package. We need to be competitive with more than other hospitals. We need to be competitive with other industries because it is not just healthcare that has a workforce shortage. We find ourselves competing with Amazon, retail outlets, and manufacturing organizations—we are competing at all levels of the workforce.

Right now, we have about 3,000 open FTEs that we are trying to recruit, and they are everything from pharmacists to respiratory therapists, nurses, environmental services, biomedical engineering, and clinical technicians. Virtually every position in our organization has open positions.

If you are a young person, and you are looking for a career in healthcare, the good news is there are lots of openings. There are openings at all levels, from physical therapists to occupational therapists, to all kinds of technicians, radiology, and the operating room. Every one of those positions has opportunities.

We have partnered with our local colleges to provide more educational opportunity such as scholarships for people to join the workforce. Some of our positions call for a high school diploma, and we are hiring people who do not have a high school diploma and allowing them to get a GED on the job. We have pathways for folks to get nursing degrees, and we are offering that with some tuition assistance at local colleges.

HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?

Balcezak: In many ways, it is getting back to basics. We have had growth in our length of stay. If you are not able to take care of patients in the acute phase of their illness in the most efficient way, and get their workup completed and their therapy completed in a timely way, that is a quality issue. So, we are attacking length of stay. We want to make sure that patients are not seeing delays in either diagnostics or therapeutics—that is a big deal for us now.

We are also still clearing the backlog of patients who had delays in care because of COVID. We have a backlog in screening exams—in colonoscopies. Those are burdens for population health that we are focusing on now. We are coming out of the other end of these backlogs, but we have not seen them completely cleared.

HL: Give an example of patient safety initiatives you have launched at Yale New Haven Health.

Balcezak: One of our most groundbreaking patient safety initiatives has been our work around becoming a high-reliability organization. We started this work about a decade ago—we were a relatively early adopter. The Connecticut Hospital Association created an initiative for hospitals, and we fully embraced it.

It was a galvanizing moment for our health system to get everybody involved in safety. Applying the principles of high reliability such as a deference to expertise has been permeating our organization. Rather than one initiative around falls, or one initiative around surgical-site infection reduction, we have implemented checklists and we have implemented technology for safety events. We have been addressing the most flawed part of our safety environment, which is the propensity of humans to make mistakes. The high-reliability work that we have done has taken direct aim at the frailty of humans and the fact that we are not perfect creatures.

We can talk about what we have done with technology and what we have done with human-factors engineering—those have been great individual efforts in individual error prevention. But nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers.

Related: The Way Forward: 'Staffing is the Biggest Challenge'