Cruz, an emergency medicine physician and president of a 609-bed hospital, says continuing to see patients weekly helps him "gain understanding outside of the patient interaction, about everything that is required to be in place to make that work successfully and effectively."

This is the first in an ongoing series of conversations with physicians who also lead hospitals, health systems, and other healthcare provider organizations.

When OSF HealthCare, the large nonprofit, faith-based system needed a new president for OSF Saint Francis Medical Center, its flagship hospital in Peoria, Illinois, leadership decided to appoint a physician for the first time in the hospital's history.

Michael Cruz, MD, rose from being a resident in the hospital's emergency medicine program in 1987 to hold various physician leadership positions, including associate chief medical officer and vice president of quality & safety, a position he began in 2007. OSF has nine hospitals, more than 600 employed physicians, home health sites, and two colleges of nursing.

He recently spoke with me about how his training as a physician helps him lead, and why he still sees patients.

HealthLeaders: OSF Saint Francis Medical Center is a 609-bed acute care facility with more than 900 clinical staff, why did you decide to continue seeing patients?

Cruz: I see patients in the ED once a week on Thursdays. I can't guarantee this will continue. It's tricky, but I was trained to be an emergency physician and I think seeing patients is important. The reason Thursday is interesting is because the medical students, rotating residents, and our residents don't work in the ED. That's their conference day. So we staff the ED quite differently on Thursdays, and as a result, I get to work in one of the busier areas seeing patients.

I do that for several reasons. I still want to maintain my skillset, and I enjoy seeing patients. When a conversation comes up [about clinical care], I can speak to it very clearly. When you live it and breathe it, you can bring a personal component to solving a problem.

For example, hospital administration might think something happens in a particular way. I can say, 'No, that's not how it happens, it really happens this way because I just did that last week.' It's one slice I can bring to this position as president that keeps clinical agenda fresh in my mind.

HLM: What factored into your decision to move into more administrative roles at OSF Saint Francis?

Cruz: It's been gradual. I've had some administrative positions within our emergency department group, which is a hospital group, so since 1990, I've had some administrative duties. Those duties, which were within quality and safety made it easy to transfer to hospital quality and safety work, which was an administrative position, in part. I was vice president of that position for 7 or 8 years, and spoke right to the CEO.

I've had a transition to this [leadership position] but there's still a quantum leap, I would say. I was trained to be a physician, not a president, or vice president, or administrator. There's been a lot of learning and growing. Sometimes I was a little shortsighted [as a physician], thinking,"I'll bring a fair amount to this administrative position," but really, it made me an even better physician.

HealthLeaders: How did being in an administrative position make you a better physician?

Cruz: I wish that physicians had more [leadership] opportunities because of what it brings to the bedside. You gain understanding outside of the patient interaction, about everything that is required to be in place to make that work successfully and effectively.

That understanding improves our ability to work within the group. In the emergency department, it may be a little easier because so many clinicians have to work in such a tight environment, and teamwork is a critical piece to that.

But I think understanding the bigger picture brings a lot of understanding to physicians as to why an electronic record works the way it does, why it is important to be integrated, and why it is important to do this or that before we do an admission or transfer a patient.

HealthLeaders: How can you deliver information about the broader strategy of OSF Saint Francis to physicians so that they aren't overwhelmed?

Cruz: The delivery of information can be inundating. Emails, texts, portals, departmental meetings, town hall meetings, that's how information gets across, but I think even more important than that is how do we engage clinicians in the same agenda? How closely in parallel can the clinicians work with the CFOs and the administrative team?

We have to engage the clinicians in administrative work. They don't all have to become administrators because we don't need 900 administrators. But the fact of the matter is that when there are decisions about the electronic health record system, how engaged are they? How engaged are they about modeling bundled payments, integrating care post-operatively for orthopedic patients, for example?

They [doctors] have to be an integral player in that movement. They have to understand how that is going to affect them in the long run. If they don't start having that language and hearing about it and playing with us in the sandbox together, then we're not going to be able to get where we need to be.

HealthLeaders: Now that you're at the helm what sorts of things are you doing or hope to put into place that bring the clinician closer to understanding the role they have in ensuring OSF Saint Francis achieves its goals of improved outcomes, quality, and cost?

Cruz: I think we're at the beginning. We look to benchmark and learn from other organizations. Our size makes it tricky. When you have 900, APNs, CRNAs, residency programs, etc. it's definitely a big change, but there's work around the graduate medical education and engaging the residents earlier on.

There's work within succession planning and talent management, performance improvement, and engaging physicians within dyad structures in certain service lines. Today, as opposed to 10 or 20 years ago, we have a lot more physicians that have formal training in patient safety, performance improvement, have gone through leadership academies, and from a physician standpoint, that's very different.

Going forward, we need to have them engaged at these levels of discussions so that when we have meaningful conversations about bed utilization and length of stay metrics, it's not just about what they see that day with a patient. It's about how that group of intensivists works with the residents and the APNs to affect change. That's how we're going to start moving that dot.

CDC data shows the numbers of uninsured are at their lowest point in 15 years. But research reveals that efforts to improve access to healthcare to a key portion of the Latino population have failed.

As the Patient Protection and Affordable Care Act turns five years old, federal health officials have been keen to point out the sweeping law's impact on the uninsured. Earlier this week the CDC released figures showing uninsured numbers are at their lowest point in 15 years, but a new survey reveals that efforts to improve access to a key portion of the Latino population have failed.

The Latino population is one of the country's largest ethnic minority groups; however, it remains one of the groups with the highest uninsured rates. The PPACA is helping make a dent in that rate, but a new survey shows there is still considerable work to do to reach this growing group of patients.

The Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico recently a poll of more than 1,400 Latino adults to assess, in part, the impact of the PPACA. The interviews were long, on average they lasted more than 20 minutes, and were conducted in English and Spanish. The questions also aimed to measure Latinos' attitudes toward immigration policies and community connections.

The poll found that 82% of those polled reported having insurance. Gabriel Sanchez, PhD, executive director of the RWJF Center for Health Policy at UNM and director of Research at Latino Decisions, a research firm focused on Latino opinion polling, says that is the highest percentage of insured Latinos since polling of this population began in 2008.

"The ACA, in terms of expanding access to the Latino population, is clearly working," says Sanchez.
 
The survey results also pointed to more Latinos having insurance without interruption. Sanchez says 64% reported being insured for 12 consecutive months, which is also an improvement over previous years.

Getting Left Behind
There are many similarities between the RWJF findings and other populations in the data collected. For example, most Latinos are insured through their employers (38%). Medicare was the second most common source of insurance coverage (19%) followed by Medicaid (12%).

However, the newest insurance coverage option—health insurance exchanges—accounts for covering only 8% of those polled. The main reason that number is so low among Latinos is because the respondents had not heard of the exchanges.

"One in four Latinos, or 25% indicate that they literally heard nothing at all about the exchanges or [health insurance] marketplaces," says Sanchez. "That's an important number because although the ACA is clearly working and increasing access… there's still a pretty large segment of the Latino population that is not being touched by that outreach effort."

Sanchez says he wanted to dig deeper into the exchange data for this population, and found that a key age group the federal government was aiming for to help stabilize the exchanges reported the least amount of awareness. The survey found that 67% of Latinos in the 18–34 age group reported limited or zero knowledge about the exchanges. It is, ironically, this group that the administration needs the most.

"A lot of emphasis was placed on trying to reach out to young Latinos primarily because they are a healthier segment of the population… there needs to be outreach," says Sanchez.

Dwindling Numbers of Physicians
It likely needs to be real outreach rather than a simple brochure printed in Spanish. Physicians play an important role. Although the most recent poll results do not examine Latino patients' relationships with physicians, Sanchez says he has explored the option in the past.

"In our 2013 survey, we asked Latinos, 'Where do you prefer to acquire information about the Affordable Care Act?' And doctors were the most trusted messenger."

Among those most trusted messengers are Latino physicians, who understand the cultural needs and norms that exist with this population. The numbers of Latino doctors are declining, however, which, when coupled with the increasing demand and need for them, means a potentially looming health crisis.

A recent study from the UCLA's Center for the Study of Latino Health and Culture showed a significant drop in Latino physicians from 1980 to 2010. The rate of non-Hispanic white physicians grew from 211 per 100,000 people to 315. The rate of Latino physicians went from 135 per 100,000 people to 105 over the same time frame. The authors of the study used census data from California, Texas, Florida, Illinois, and New York because of the high Latino populations.

While the numbers of Latino physicians declined over the 30-year period, the number of Latinos in the U.S. increased, growing from 7% of the population in 1980 to 16% in 2010. By 2060, the numbers are projected to almost triple.

When the study was published in Academic Medicine, the lead author, Gloria Sanchez, MD, [no relation to Gabriel Sanchez] associate clinical professor at UCLA's David Geffen School of Medicine, and family medicine associate residency program director, Los Angeles County Harbor–UCLA Medical Center, said that dwindling numbers of Latino physicians could adversely affect patients because as physicians' numbers decline, they take with them valuable language skills and cultural familiarity that allows effective communication, and Sanchez says the need for more Hispanic physicians is urgent.

"It's not just about having Latino providers, but having more providers serving the Latino population," she says.

A Way Forward
There are organizations trying to bridge the current and projected gap. The Hispanic-Serving Health Professions School (HSHPS) is a nonprofit organization that is made up of schools and/or colleges of various medical programs, such as medicine, pharmacy, nursing, and others, that aims to increase the Hispanic health workforce by providing academic and career assistance to up and coming health professionals. HSHPS has trained more than 500 health professionals, but it's clear that more are needed.

There are several things providers can do to communicate with their Latino patients. First, learn from patients by doing a community-based assessment.

"It doesn't take a lot of money, it is not hi-tech research," says Sanchez. "It's getting a patient advocacy group in your clinic to learn what the barriers to care are and what is working."

Sanchez also says having a Spanish-speaking provider in the office is "huge," because the inability to communicate with a patient allows for gaps in cultural empathy and patient care.

"We have a crisis," says Sanchez. "We aren't communicating well, and not with just Spanish-speakers, but with all patients. I advocate for people willing to be bilingual, and not just MDs, but ancillary providers, too. The [RWJF] survey shows that this issue is about having a public policy and public health approach to this population."

Meticulously cleaning duodenoscopes linked to several cases of antibiotic-resistant CRE infection "should reduce the risk of transmitting infection, but may not entirely eliminate it," says the FDA.

In the latest superbug outbreak, which is associated with contaminated duodenoscopes used in a gastroenterology procedure, the only consensus is that the device is hard to clean.

Hundreds of patients have been exposed to antibiotic-resistant CRE, (carbapenem-resistant Enterobacteriaceae) because of the contaminated scopes, but the FDA has not halted their sale, nor has it suggested that physicians stop using them.

In an update issued last week, however, the FDA said there may not be a way to totally rid the device of bacteria. "Meticulously cleaning duodenoscopes prior to high-level disinfection should reduce the risk of transmitting infection, but may not entirely eliminate it," says the FDA's safety communication.

Duodenoscopes are primarily used in an ERCP, (endoscopic retrograde cholangiopancreatography) a procedure used to treat bile duct and pancreatic problems. The FDA estimates that 500,000 ERCPs are performed annually in the U.S.

But its recent guidance puts physicians in a precarious position: They don't have complete confidence in the disinfection instructions from the three primary manufacturers of these scopes, but they can't stop seeing patients who need the procedure that uses the scopes in question.

"There's no consensus as to what is the best reprocessing, sterilization, cleaning procedure, so everybody is essentially going by their own protocol," says Yousif A-Rahim, MD, PhD, chief medical officer for Covenant Surgical Partners, the Nashville-based owner and operator of 28 ambulatory surgery centers.

Rahim is also a practicing gastroenterologist who performs ERCPs at the West Roxbury Campus of Boston's VA Healthcare System and at the Pali Momi Medical Center in Hawaii. He says the superbug contamination on the scopes caught him by surprise.

"I am very shocked," he says. "People have been doing this procedure [ERCP] for probably well over 30 years. It exposed a potential fault in the scope, but it's interesting that it took 30 years for that [superbug] to be exposed."

A Design-Related Problem
The dominant manufacturer of the duodenoscope used in ERCPs is Olympus (yes, the same Olympus name on your camera). The company issued a two-page patient safety information letter on February 19th, notifying physicians to pay special attention to an elevator on the scope that has small crevices that need to be cleaned manually. The letter from Olympus pre-dates the FDA's statement that the scope might not be able to be completely free of infection.

"The infection in question has really only been reported in the duodenum scope because it has this elevator, which is connected to a channel… and apparently nothing can really get into that channel to clean it," says A-Rahim.

Although none of Covenant's ASCs perform ERCPs, A-Rahim says the heightened awareness of infection risk was enough to prompt the centers to randomly test its scopes for infection.

"We implemented this a few weeks ago," he says. We were getting cultures from all scopes and looking to see that our processes are adequate."

The results from the random sample?

"All negative," he says. "Our facilities are completely bug-free because we don't do those procedures, and we follow the recommended reprocessing and disinfection procedures. But we know this [CRE outbreak] happened despite those protocols."

Without clear guidance on the best way to disinfect the duodenoscopes, A-Rahim says he knows colleagues who are "gassing" them, a procedure that takes much longer and impacts patient volume.

"The scope processing used to take 30 minutes, now people are basically gassing the scopes (with bleach or hydrogen sulfide) for somewhere between 24–48 hours," he says. "Some of my colleagues won't do [the procedures] anymore because of the liability. I could do seven procedures in the morning; there's no way I could do seven procedures now."

Two patients have died from the CRE superbug linked to duodenoscopes used in ERCP procedures and five other patients have been infected. Those patients were treated at Ronald Reagan UCLA Medical Center in Los Angeles, but CRE has also been found at Cedars-Sinai Medical Center, also in Los Angeles.

According to the FDA, 75 medical device reports were filed between January 2013 and December 2014 relating to infections as a result of the duodenum. The reports indicate 135 affected patients, and now Bloomberg News is reporting the FDA's struggle to get Olympus to improve its disinfection guidelines for the scope.

A-Rahim says the various gastroenterological societies, the FDA, and the manufacturers are working to come up with a consensus on protocol.

"We don't know the best method to sterilize the scopes. The manufacturer doesn't know. We don't know, but it's taken on a contagion-like pitch."

Hospitals and health systems are already containing costs and improving outcomes for other patient populations with specific needs. Stratifying emergent care for seniors is another opportunity to do the same.

Hospital emergency departments are crowded, noisy places. When patients come in, either via ambulance or on their own, there is some expectation that the ED environment is going to be uncomfortably bustling. This busy, congested atmosphere could be contributing to poor patient outcomes in seniors, a growing population with multiple needs.

"Ten thousand people turn 65 every day," says Teresita Hogan, MD, director of geriatric emergency medicine, and associate professor for geriatric and palliative care medicine at the University of Chicago Medicine, the 568-bed academic medical center on the campus of the university with the same name.

Hogan, who helped write new geriatric ED guidelines that came out in 2014, is passionate about making sure that seniors in the ED get quality care.

"I became a crusader when I looked around and saw things we could fix that were so simple," says Hogan.
 
In 2013, Hogan's study on the number of geriatric EDs in the U.S. and their characteristics was published in Academic Emergency Medicine. She found 24 hospitals had an existing geriatric ED, and six were planning on building one. Most of the of the hospitals with a geriatric ED reported making the simple changes Hogan refers to, including Holy Cross Hospital, a 443-bed nonprofit hospital that is part of Holy Cross Health, which is part of Livonia, Michigan–based Trinity Health, one of the largest health systems in the country.

1. Seniors' Basic Comfort Needs are Unique
In 2008, Holy Cross opened a seven-bed Senior ED. The investment was just $150,000 because hospital executives focused on senior patients' needs, which were, and are, fairly straightforward.

"It's changing the lighting, the paint on the wall, [and] the floor color so it would be easier for seniors to navigate," says Blair Eig, chief medical officer at Holy Cross. "We put walls between bays, so that it cuts down on noise. The mattresses are much thicker. We installed a blanket warmer, simple things like that."

In Hogan's research, those were among the most common changes hospitals made to help seniors navigate their EDs. Visual aids and direct follow-up with senior patients post-discharge are also two common characteristics of existing geriatric EDs. The Holy Cross SEC uses both of those, too, and Eig says the follow-up with patients has been one of its most effective changes.

"We have a geriatric social worker in that SEC and they follow up with most of patients a day or two later… now, six and a half years later, it's been successful and it was so obvious, 'Why didn't we do this before?' "

2. An Opportunity to Reduce Readmissions
Hospitals and health systems without the space to build a new ED dedicated to seniors can still do a better job taking care of seniors that present in their existing EDs.

Last year, the American College of Emergency Physicians, the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine released its Geriatric Emergency Department Guidelines, a multi-year collaboration on senior care in the ED that laid out specific guidelines and recommendations for common issues in the ED.

From medication management to appropriate use of urinary catheters in the senior population, the guidelines are an important step in improving the care of this population, says Hogan.

The medication interactions in the senior population are a big issue. Because seniors typically have comorbidities, they may be taking five or more medications before they even get to the ED. Managing their pain from a fall becomes more complicated, and ED physicians need to realize the differences in this patient population.

"When the frail elderly woman falls down and breaks her arm, and you put her arm in a two pound cast and sling, she can't balance… And if you give her a bottle of Vicodin, she's going to fall and break a hip," says Hogan. "Geriatric ED care is very different, and the awareness level is low."
Incorporated into the guidelines for ED care for seniors is a sample dashboard, which includes measuring readmissions within 24 and 72 hours. At Holy Cross, the 72-hour readmission rate among its seniors was reduced after it built its SEC.

3. ED-CAHPS Scores are Coming
Measuring patient satisfaction via HCAHPS may be a sore point among hospital leadership because the survey isn't an accurate representation of everything a hospital does well, but it's a tool that CMS is expanding.

ED-CAHPS was supposed to begin this year, but it's been delayed and now the survey is expected to begin in 2016. Still, with a good chunk of hospital admissions originating through the ED, it's prudent to improve care now in the ED for populations that frequently use it.

"Seldom will a patient wait 12 hours in a waiting room and give a glowing report on HCAHPS," says Christina Dempsey, RN, chief nursing officer for Press Ganey, a large healthcare consultancy.

Dempsey is a former vice president for emergency and surgical services at a level 1 trauma center. She's familiar with the common bottlenecks that occur in an ED, which can leave patients who get admitted, and thus, get HCAHPS surveys to fill out, primed to complain.

Hospitals and health systems are already tailoring care for other patient populations in order to get costs down and improve outcomes. Stratifying the senior population is another opportunity to do the same.