Once the pandemic hit, patients might be admitted in one hospital and have their vital information recorded, only to be transported across town once they were diagnosed with COVID-19.
This article was originally published May 20, 2021 on PSQH.
As COVID-19 infections spread across Minnesota in March 2020, M Health Fairview—a healthcare company made up of the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services—made the decision to dedicate its M Health Fairview Bethesda Hospital in Saint Paul, Minnesota, to serving COVID-19 patients. However, providing the rapid care needed for these patients became complicated when individuals were transferred to Bethesda from one of the 11 other hospitals in the health system.
Like many health systems developed through mergers and acquisitions, M Health Fairview sported consistent branding across what had previously been the Fairview Health and HealthEast Care systems, but it had a disparate array of back-end medical record systems behind the scenes.
“In the normal day-to-day kind of interaction with the patient, that’s really invisible to the patient. Most patients get their treatment within one hospital or you continue to see your same specialists, or if you move across systems over a period of time, we can make that really invisible to you behind the scenes,” says Eric Murray, director of IT data solutions and technology at M Health Fairview. “Then along came COVID.”
Once the pandemic hit, patients might be admitted in one hospital and have their vital information recorded, only to be transported across town once they were diagnosed with COVID-19. The health system struggled with slow diagnoses and was wasting time on tracking down and reentering vital information.
“We had a problem around how we could best treat these patients from a system perspective,” Murray explains. “There really was this need for this ability to have a longitudinal view of a patient record regardless of where that patient came from.”
An effective patient matching solution
One of the challenges with patient matching, Murray explains, is creating effective rules for matching records. “The fact that the name and address and birthday are the same doesn’t necessarily mean that they’re the same patients,” Murray says. “We found out we were either undermatching or overmatching based on the information that we had.”
The IT team worked with technology provider Verato to improve its patient data algorithms. Verato relies upon referential matching, a technology that matches patient records to a comprehensive reference database rather than simply comparing the data within two patient records. This approach, according to Verato, better overcomes the challenges of working with records that are outdated or contain errors.
“It really allowed us to get much better and much more accurate how we matched and merged the patients,” Murray says.
This optimized patient matching technology addressed two challenges that tend to come up with patient matching. First, it removed the need for time-consuming human interventions to match data. Second, it removed the risk of undermatching that comes from applying rudimentary matching rules. As Murray puts it, “If you’re undermatching patients, you’re not providing them the best possible treatment because they’re showing up at another hospital and their vitals aren’t there.”
How patient matching drives faster diagnoses
Murray’s team was already working toward streamlining medical record access across the health system when the pandemic accelerated the need for improved connectivity. Within two weeks of converting Bethesda Hospital for COVID-19 response, M Health Fairview had accordingly shifted the objectives for its patient matching technology.
Speedy diagnosis and treatment were essential. As the IT team worked to support faster record sharing, University of Minnesota researchers were focusing on making more rapid COVID-19 diagnoses. “Back when the COVID pandemic was just starting, waiting for bloodwork and things took a long time—often more than a week,” Murray says. “That made it really difficult for us to treat patients.”
However, university researchers were beginning to develop an artificial intelligence algorithm that could identify patterns in the chest x-rays taken from patients presenting with COVID-19 symptoms. The algorithm could thereby rapidly predict the patient’s likelihood of having COVID-19. Within seconds, the health system’s Cognitive Computing platform could pull an x-ray, run the algorithm, and enter a predictive diagnosis into the EHR software that was, by this point, integrated across all its hospital locations.
“The reason that we were able to do that was because we could create this longitudinal view of a patient regardless of where their data came from,” Murray explains. “It could come from one of our EHR systems, imaging system, our lab system, or the telehealth systems we were setting up.”
Building on a data-based foundation
The game-changing success of the COVID-19 diagnosis tool helped demonstrate the usefulness of the patient matching system and has driven the health system to explore additional use cases.
For example, the technology now supports Fairview’s goal of improving its Net Promoter Score, which measures patient satisfaction. When a patient calls to book an appointment, receptionists can access patient records across the health system’s 32 locations, giving visibility into where that patient has been seen in the past and what their treatment preferences are. The result is a streamlined process that works to boost patient satisfaction from the first interaction.
The technology is also proving useful in business operations. Based upon the COVID-19 use case, where hospitals were linked with labs to speed the transmission of test results, the IT team is expanding this connectivity across facility types. For example, by using patient matching to support prescription drug monitoring, a Fairview clinician can rapidly verify whether an existing prescription holder is the same person as the patient they’re currently seeing.
“That typically would have gone into a work queue that would cost the company money to work down, and also potentially delay getting that prescription to the patient. Our ability to put this technology in the middle has reduced that workflow,” Murray explains.
The work done in diagnosing COVID-19 patients has also built a strong foundation for using patient matching technology to identify patterns in other conditions.
“We’re able to use this foundation and apply the same methodology, including the patient matching, across multiple systems to several different disease states,” Murray says. “So when we look at sepsis, for example, we utilize this success story and these lessons learned to build this concept of a learning health system where you take data, test and validate models, put them into practice, and then continue to monitor to make them better and smarter and faster.”
Over the years, physicians have been frequently accused of resisting change. In the face of tremendous new pressures—ranging from explosive levels of new technology and data to changing regulatory burdens and expectations—it is understandable that care providers may struggle to keep up. Now, Thomas H. Lee, MD, chief medical officer for Press Ganey and a physician at Brigham and Women’s Hospital in Boston, finds that this reluctance to change may itself be changing.
In recent years, Lee says, there’s been a promising “changing of the guard” that he believes may better support the new demands of leadership in healthcare’s future. “They’re different,” Lee says of the physicians coming out of medical school today. “They’re wired more to be part of teams as opposed to individuals raging about change.”
That’s a necessary evolution, as Lee sees the demands facing future leaders steadily increasing. The trends against which physicians have pushed back are not, as he puts it in a June article for NEJM Catalyst, “trends that can be ignored or reversed … physicians need leadership guidance to help them plunge into these trends.”
The changing of the guard
Lee’s article, “Six Tests for Physicians and Their Leaders for the Decade Ahead,” written with Toby Cosgrove, MD, executive advisor and former president and CEO of the Cleveland Clinic, highlights the traits needed of tomorrow’s physician leaders. However, it also notes a change in how this leadership is organized. Citing the AMA’s 2019 Physician Practice Benchmark Survey, the pair point out that 2018 was the first year in the survey’s history that there were fewer physician practice owners (45.9%) than employees (47.4%). Only 26% of physicians under age 40 had an ownership stake in their practice in 2018, hinting at the greater shift to come as physicians consolidate beneath the umbrellas of large practices or health systems.
This consolidation is a trend that supports the need for greater economies of scale, effectively meeting new consumer expectations and preventing physician burnout. As Lee and Cosgrove write, “Problems are emerging that can only be addressed through scale. For example, small groups and hospitals are simply unable to take on emerging cybersecurity challenges.”
The consolidation trend will demand strong leadership from physicians at the helm of these evolving models—as well as physician employees who want to drive their practice toward best practices for navigating future challenges.
As Lee and Cosgrove put it, there’s no retreating from challenges, which include:
An explosion in knowledge due to research advances—and increasing complexity that threatens to overwhelm physicians
Greater pressures to improve in order to meet regulatory burdens of the Affordable Care Act
A loss of autonomy for physicians, who are increasingly driven to work in groups
The need to improve interactions between physicians and their electronic medical records
Lee and Cosgrove have identified a set of six “tests” for physicians and their leaders that they predict will define effective healthcare leadership in the future.
Emphasizing transparency in all aspects of care
According to the NEJM article, “The idea that good care is good business seems obvious, but the notion that meeting patients’ needs should be the focus for every decision remains disruptive.”
Patient care may be the mission, but Lee finds that “distractions” keep physicians from focusing foremost on patient care. Reprioritizing patients is the first test for leaders, and this may mean rethinking payment and compensation.
By organizing around the fee-for-service system, the authors suggest, physicians prioritize performing procedures, tests, and operations rather than taking care of patients. “The organizational structure and the fee for service incentives behind it don’t incentivize bad care, but they don’t directly reward us for being at our best,” they write. The practice of coupling compensation with volume of services also gets in the way of excellent care.
Transparency, Lee suggests, can help drive these needed shifts. It’s already underway for some practices with online reviews. “Transparency tends to have its most dramatic effects on the parties who are being measured, even more than on the patients/consumers who might seem the targets for the information,” the authors write in the NEJM article. “Physicians want what is said about them on the Internet to be consistent with how they see themselves. And the most reliable way to make that happen is to be their best selves consistently.”
This shift toward prioritizing patients will continue with greater transparency around cost, a critical, if often overlooked, piece of the patient experience. As Lee and Cosgrove point out, many health systems are beginning to take steps in this direction. While groups such as Mayo Clinic, Cleveland Clinic, and Geisinger Health System see most of their revenue flow through fee-for-service contracts, they pay their physicians straight salary, without financial incentives for performing more services.
“The trend is in this direction, but we need to accelerate it,” Lee elaborates. He suggests that the groups that provide greater transparency and are more reliable in meeting these patient needs will prosper.
Embracing collaboration and competition
Physicians are becoming more collaborative, both with their peers in these growing practices as well as with colleagues across other areas of care. But Lee and Cosgrove encourage the creation of super-teams, with members who remain focused on the goal of excellent patient care above all else.
“The team members don’t worry about job descriptions; they do what it takes to help the team achieve its goal, and they know they can count on their colleagues to do the same. They are resilient individually and collectively, which enables them to deal with unexpected crises with effective aplomb.”
It’s a tricky demand at a time when physician burnout remains on the rise, but this push toward super-teams can actually help physicians work more efficiently. Super-teams proactively address complaints from both patients and physicians. They are made up of high-performing partners across care delivery: administrators, schedulers, scribes, and others who work to simplify the burdens that distract from patient care.
“Scheduling turns out to be one of the biggest causes of dissatisfaction,” Lee says by way of example. “So, in a really good team, the scheduler is sitting right there with the clinicians to make things work.”
With a focus on collaboration, it may seem counterintuitive to also focus on competition, but Lee and Cosgrove say actively thinking about—and ultimately embracing—competition is another critical test of leadership.
“Most physicians don’t think positively about the effects of competition in the health care marketplace,” the pair write. Physicians are often glad when their organization deflects competition through mergers with potential competitors. But this may not be the best strategy for improving patient care. Healthy competition can drive the lower prices, better care, and increased transparency that patients truly desire.
One such step, Lee says, is checking your online ratings and embracing the competition with other practices. You may already be the best, but it’s critical to ensure consumers see this. “Knowing that every patient can comment on my work, and anyone can see the comments, makes me want to be wonderful. That’s the way I want to be seen,” Lee says. “Creating an environment where people are trying to be at their best all the time is kind of stressful, but it’s necessary for plunging into competition.”
Driving change and innovation
As Lee mentions, change is coming more easily to many physicians, but the next step is to embrace innovation—pushing to introduce something new.
“The desire to be perfect creates a culture that has a way of smothering innovation,” Lee and Cosgrove write. “Physicians are afraid of failing. They and their colleagues get paralyzed by exceptions. They say something shouldn’t be tried unless there is evidence that it will make things better—and, as a result, it never gets tried.”
A strong first step toward embracing innovation, Lee suggests, is to start looking beyond the healthcare industry. “Healthcare is a decade or two behind other businesses,” he points out. “The idea of using balanced scorecards and having a clear strategy that helps you focus on what it is you’re trying to do so that you can be reliable about doing those things, that is 1990s insights for the rest of the business world, but it’s relatively new to healthcare.”
This is becoming somewhat easier as other industries begin to move into healthcare, particularly the technology industry. As new names offer entirely new service delivery concepts that compete with traditional models, innovation will become increasingly necessary for physician practices to survive.
And, with technology tackling diagnostics and other challenges, Lee says soft skills may become a more critical edge for leaders in the years ahead. Leadership training will need to support this and other shifts. Training more managers in the needs for physician leadership will encourage the collaborative, innovative processes that will help drive organizational success.
“When Toby and I started having this conversation, we could see that the decade ahead we were going to have to change. But we didn’t know how the new physician workforce would respond,” Lee says. Now? “We’re optimistic.”
Building clinician awareness of potential cyberattacks on medical devices could save patient lives.
Editor's note: This article originally appearedMay 6, 2019, on the PSQHwebsite. It has been edited for brevity.
HIPAA may require safeguards for protecting the privacy of personal health information, but it doesn't lay out a specific plan for how healthcare organizations are to protect patients from the threat of cyberattacks.
And these types of attacks aren't slowing down. The Department of Health and Human Services Office for Civil Rights is investigating 22 instances of healthcare provider or health plan data breaches from January 2019 alone.
While data breaches are hugely problematic, healthcare systems worry that hackers may be thinking bigger. For nearly a decade, healthcare professionals and medical device manufacturers have been aware that medical devices, including insulin pumps and pacemakers, can be hacked.
A 2017 Frost & Sullivan forecast on the Internet of Medical Things (IoMT) reports "an estimated 4.5 billion IoMT devices existed in 2015, accounting for 30.3% of all IoT devices globally. This number is expected to grow to $20–$30 billion IoMT devices by 2020." There is an entire spectrum of IoMT-enabled devices, including smart implants communicating information about patients, smart hospital rooms and clinical tools, devices supporting telehealth, and even drone-based emergency response. As this interconnectivity grows, new threats to device security are constantly revealed—but not always resolved.
While IT departments and manufacturers are pushing for patches and security upgrades, the ongoing threat is leading to new demands to build clinician awareness of this problem. If hackers turn from data to deadly consequences, physicians and nursing staff need to be aware that a life-saving medical device could actually be what puts a patient's life in jeopardy.
The need for cybersecurity training for clinicians
The FDA defines a medical device broadly as an instrument, machine, implant, or similar item that is used in diagnosis, prevention, or treatment of a disease, or that affects the structure or function of a body in a way other than chemical action. Should such a device fail to work or become unpredictable in its performance—through a malware attack, for example—there is the potential for life-threatening consequences.
The CHIME report, conducted in collaboration with KLAS Research, surveyed 148 healthcare IT executives and "found that 18% of provider organizations had medical devices impacted by malware or ransomware in the last 18 months." While few of these incidents reportedly compromised protected health information, they did seem to shake providers' confidence in these devices. The survey found that only 39% of respondents were "very confident or confident that their current strategy protects patient safety and prevents disruptions in care."
The FDA is aiming to fill in some of those gaps. In October 2018, Scott Gottlieb, MD, the FDA Commissioner at that time, released a statement outlining new resources from the administration aimed at strengthening its medical device cybersecurity program.
"Even when medical devices are not being deliberately targeted, if these products are connected to a hospital network, such as radiologic imaging equipment, they may be impacted," Gottlieb commented in the statement.
While these devices haven't been directly targeted yet, there is potential they will be. As Gottlieb explained, "Cybersecurity researchers, often referred to as 'white hat hackers,' have identified device vulnerabilities in nonclinical, research-based settings. They've shown how bad actors could gain the capability to exploit these same weaknesses, thereby acquiring access and control of medical devices."
The goal, obviously, is to prevent any such attack from ever occurring. Therefore, in coordination with the MITRE Corporation, the FDA has released acybersecurity "playbook" for healthcare delivery organizations focused on promoting cybersecurity readiness.
The Medical Device Cybersecurity: Regional Incident Preparedness and Response Playbook describes the types of readiness activities that can assist healthcare organizations in preventing a cybersecurity incident involving medical devices. These include steps such as developing a medical device inventory and conducting training exercises.
What clinician cybersecurity training might look like
A team of physicians and computer scientists with the University of California (UC) San Diego, UC Davis, and Maricopa Medical Center in Phoenix demonstrated the need for clinician awareness of cybersecurity risks at the August 2018 Black Hat conference. Christian Dameff, MD, and James Killeen, MD, of the Department of Emergency Medicine for UC San Diego; Jordan Selzer, MD, and Jonathan Fisher, MD, of Maricopa Medical Center's Department of Emergency Medicine; and Jeffrey Tully, MD of UC Davis' Department of Anesthesia and Pain Medicine simulated a simple way to exploit the connection between laboratory devices and medical record systems to modify medical test results.
The team demonstrated a "man-in-the-middle attack," where a computer inserts itself between the laboratory machine and the records system, on a test system they created. The team was able to remotely modify blood test results to indicate that the "patient" was suffering from diabetic ketoacidosis. In the real world, prescribing an insulin drip to a falsely diagnosed patient could lead to coma or death. The researchers also modified the blood test results to indicate that the patient had low potassium, knowing that starting a potassium IV on a healthy patient could cause a heart attack.
Following the demonstration, the researchers provided details to physicians on how to simulate these types of exercises in their own facilities. In an article in the February 2019 issue of The Journal of Emergency Medicine, the researchers lay out their development and execution of three clinical simulations designed to teach clinicians to recognize, treat, and prevent patient harm from vulnerable medical devices.
The team compiled data and conducted interviews with medical device manufacturers to identify three devices with known vulnerabilities: bedside infusion pumps, automated internal cardioverter-defibrillators, and insulin pumps.
Next, they crafted patient scenarios around each of these devices, based on vulnerabilities highlighted either in the media or through security conferences. Simulations were conducted using these scenarios at the University of Arizona College of Medicine-Phoenix, with teams made up of an emergency physician, med students, simulation-trained nurses, paramedics, and patient actors trained in simulation, later supported by high-fidelity simulation mannequins.
In each scenario, the physicians succeeded in reaching the appropriate treatment. Yet in each case, they failed to identify the medical device as a source for the patient's presentation. During the debriefing, the physicians admitted to being completely unaware that a compromised device could be a source of patient harm. Worse, as one physician commented to the researchers during the debriefing, "I would have gone into the next room and grabbed the same pump for the next patient." By not considering that a medical device could be compromised, the physicians also ignored the possibility that all such similar devices could be compromised.
While the researchers admit to the study's limitations, they note that their chief goal is to build awareness that medical devices might not always be reliable. In addition, by recognizing the frailty of the existing medical infrastructure, physicians can push their healthcare organizations to devote greater funding to security spending, or back such efforts if they're already underway.
The researchers are now using their findings to develop medical cybersecurity training for physicians, and the CyberMed 2018 Summit hosted by the University of Arizona College of Medicine-Phoenix provided some insight into how this training might look. Tully, Dameff, and event co-organizers invited fellow physicians to participate in clinical simulations that placed them in simulated emergency situations where they ultimately learned that the systems upon which they depended to care for sick patients were not reliable. The summit also included tabletop exercises, where attendees mapped out responses to a simulated cybercrisis impacting local hospitals.
New responsibility for devices
In a 2015 article from Medical Devices, researchers Patricia A.H. Williams, of the School of Computer and Security Science at Edith Cowan University in Australia, and Andrew J. Woodward, of the university's eHealth Research Group and Security Research Institute, write about smart medical devices, "It is important to note that vulnerabilities were always inherent in these devices, and that it is the exposure to a greater threat landscape, through these network connections, that is responsible for the increased risk. Thus, the responsibility for maintaining device functionality, integrity and confidentiality of information, patient privacy, device and information availability, to prevent adverse effect on patient safety is now shared by manufacturers, healthcare providers, and patients."
Certainly, healthcare organizations must invest in security to protect their patients. But clinicians may also need to shoulder new responsibilities. By considering the possibility that a medical device may be prone to error or worse, clinicians can better fill their roles as frontline responders.
See something, say something
The FDA's medical device reporting program relies on reports of medical device malfunctions to drive safety improvements. Should you notice a safety concern or be involved in a device-related adverse event, the FDA advises taking these steps:
Recognize when a device malfunctions and stop using it to
prevent possible harm.
Remove the device immediately and tag it with a label describing the problem.
Report the incident through the appropriate channels per your facility's policy. If the facility does not have a policy, you can submit voluntary reports about adverse events that may be associated with a medical device, as well as use errors, quality issues, and therapeutic failures, directly through the FDA's MedWatcher mobile app or www.accessdata.fda.gov/scripts/medwatch.
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com
Here's how healthcare providers can work with private patient care advocates to improve patient care and outcomes.
For patients with chronic conditions, navigating the healthcare labyrinth can be a challenge. Sorting out payment, deciding among specialists, understanding differing second opinions—all of these and more can be major hurdles for patients already overwhelmed by a diagnosis. The issues are compounded by adding in age and conditions such as dementia, which deepen the cloud of confusion around care complexities. When patients stop taking their medications or don't schedule necessary follow-up exams, a deterioration in condition and higher use of emergency services can occur.
A growing solution to this struggle is the use of private patient advocates. The Institute for Healthcare Improvement defines a patient advocate as a "supporter, believer, sponsor, promoter, campaigner, backer, or spokesperson." This can be a family member or close friend, but it's increasingly an independent professional who specializes in helping patients and families make sense of their healthcare options.
In fact, the Patient Advocate Certification Board's multiyear effort to develop board certification paid off in March 2018 when it held its first test, certifying approximately 150 patient advocates.
"The patient advocacy movement is growing," says Debby Deutsch, founder and principal advocate of Patient Care Partners LLC in Madison, Wisconsin, and among the first round of Board Certified Patient Advocates (BCPS). As Deutsch adds, "There is such a need for this."
Empowered Patients Report Higher Satisfaction with Care Teams
Private patient advocates first and foremost serve patients, but they also see themselves as partners in the healthcare team. They share clinicians' goals of doing what's right for the patient, but they have the added benefits of time and a holistic view of an individual's health.
"The biggest benefit is enhanced patient-provider communication, which also enhances patient safety and clinical outcomes," explains Jessica Tulloss, MPH, RN, CPPS, CLNC, owner and patient advocate for TrueCourse Healthcare Consulting LLC in Roswell, Georgia.
"Offering this type of individualized support has a way of helping the efficiency of the healthcare system," Deutsch says. "And it increases my clients' levels of satisfaction with their healthcare."
When patient advocates help their clients work through healthcare challenges, they find patients become more engaged in their care and more satisfied with their providers. Patients also typically become more compliant with medication and follow-up appointments.
Take, for example, a client of Kim Mcilnay, a former physician who now owns Together Patient Advocates LLC in Sacramento, California. "The client was supposed to start a medication that he would take once a week and then a supplement that he needed to take daily to help the medication," Mcilnay says. "When we finished the appointment and I asked the client to share back what he understood, he understood he was supposed to take the medication every day."
"Advocates can also help to ensure patients understand the plan of care, follow through on the plan of care, and ask questions if needed," Tulloss elaborates. "This is especially important after appointments and discharges. Depending on the situation, the client may not be in a state of mind to process all the information that's been given to them, let alone think of the right questions to ask. While nurses and doctors can provide instructions and orders, if a patient does not follow through because they missed something or misunderstood, it can affect the desired outcome, to the point of even an adverse outcome."
Creating a Full Picture
A private patient advocate can also help organize information to present a full picture to healthcare providers.
"Providers depend on the patient's ability to provide complete and accurate information regarding their medications and health history. Some patients see multiple providers over the course of several years. Private advocates can be instrumental in assisting clients to gather and organize key information and have it readily available for providers," Tulloss says.
During her time as a resident, Mcilnay recalls, she began asking a patient with multiple issues to write problems out prior to her appointment. "Her number one issue was her toenail fungus, and her 20th issue was her chest pain," Mcilnay says. "By having that written in a list, we could each pick our most important issues, and she picked the toenail fungus and I picked chest pain. We would have never gotten to chest pain if she had been going down her list in order."
More challenging are patients who can't speak to their own struggles, such as those suffering from dementia.
"A lot of times patients get confused by the questions," Mcilnay says. "So I've got that whole picture in my mind. For example, I went to an appointment with a patient and the neurologist asked if he was having any difficulty with urinary incontinence. The patient's response was no because it wasn't a problem for him—he wears diapers and it was okay. Yet the disease that the clinician was looking for causes dementia and urinary incontinence. This client was having some cognitive difficulties, so the clinician wouldn't have known to look further for that condition without knowing that he was actually having the incontinence."
In each of these instances, patient advocates become a channel for improving communication. And as Teri Dreher, RN, CCRN, iRNPA, owner and founder of NShore Patient Advocates in Chicago, points out, "Really, medical error is due in large part to miscommunication."
What to Expect From a Private Patient
Many patient advocates come from the healthcare industry and have backgrounds as RNs or physicians. They're well aware of the time constraints present in the healthcare system and strive to balance patient needs with the limitations providers face.
"I coach my clients on the fact that the practitioners we're going to see are ordered by the system to move patients through," Deutsch says. "I brace them for the fact that the national standard is eight to 15 minutes for a patient visit. We have to prepare for the fact that we're likely only going to be seen for 10 to 15 minutes and oh, by the way, while we're there the physician will be documenting and on the computer; there's a lot going on during that time. So I make sure we're very well-organized, we've got the questions all mapped out, and I've got the patient prepped."
Tulloss counsels preparing practitioners for the patient advocate's arrival ahead of time. "To avoid potential challenges, I always recommend clients inform their providers early on of their intent to work with a private advocate," she says. "I also make sure that if I'm attending appointments or hospital visits, either myself or the client informs the healthcare team beforehand. HIPAA forms are submitted in advance, and I keep a copy on hand. This helps to ensure there are no surprises."
Mcilnay works closely with clients before an appointment to outline and prepare any questions they might have, as well as assemble a high-level view of the client's issues. "I usually do a summary sheet before the appointment that lists our issues, and if it's a client with multiple issues, usually there's an acknowledgment that we realize there may not be time to address all of these different problems," she says.
For patients with complex medical needs, Mcilnay may give a copy of the summary to the medical assistant, who will give it to the clinician to look at while the patient is being checked in. "My goal there is that they can scan over it and make sure there aren't issues that they feel are higher-priority," she says.
During the appointment, Deutsch finds that the simple act of notetaking can add a level of accountability that gives more detail to the process. "I take notes the whole time, making sure the questions are answered and understood," she explains.
While patient advocates work to ensure their patients feel understood, many are also able to fall back on their professional background to better address providers' first concerns.
"I was a critical care nurse. I know what doctors want to hear first, second, and third. Patients want to go into a story and physicians stop listening," points out Barbara Abruzzo, founder and president of Livingwell Health Advisory in New York.
"If there's a patient advocate on board, [physicians] can communicate much more efficiently with a colleague rather than listening to a family member talk for 45 minutes," Dreher agrees. "We can come in, hand you a two-page professionally prepared medical profile or care plan that says who this patient is, what happened today, what we're concerned about, etc. If you have a professional that knows how doctors think and knows what information they need, you just cut down on the amount of time that they have to spend, and then they can quickly, accurately diagnose the patient to get them treated instead of standing around scratching their heads because the patient's too sick to give an accurate history."
Your Relationship With the Patient
Given the newness of the patient advocate accreditation program offered by the Patient Advocacy Certification Board, it's easy to appreciate why many professionals in the field are relatively new to their role—and why many providers might be confused about what this role entails.
"Once they understand we're not there for any legal reasons, they really calm down," Dreher finds. "We don't really get involved with any kind of legal things. Rarely will we see something that just isn't quite right in the hospital, and then we'll go straight to the hospital management department or a supervisor and try to sort it out so it doesn't lead to something worse. We actually help prevent medical error and lawsuits."
If you haven't worked with a private patient advocate yet, it's becoming more likely you will. The Patient Advocacy Certification Board held its second test in September, with double the number of individuals sitting for the BCPS certification. And as physicians begin working with patient advocates, many are encouraging other patients to seek out these problem solvers.
"I have had clinicians ask if they can refer clients to me," Mcilnay says. "They're definitely seeing a benefit to my clients in having me there."
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com.
Nurses must create a culture that encourages family caregivers to speak up about patient safety issues.
Editor's note: This article originally appeared on PSQH.
During her early research on patient safety over a decade ago, focusing on medical error disclosure and ways to improve communication with patients and families after harmful events, Sigall K. Bell, MD, director of patient safety and quality initiatives for the Raskin Fellow in Medical Education at Beth Israel Deaconess Medical Center, began to notice a pattern.
"I started noticing that some of the stories of harmed patients and families shared a common narrative: 'I knew something was wrong, but I couldn't say anything' or, 'I didn't know how or who to tell' or, 'I tried to say something, but it didn't work.' This resonated with themes we heard from interviewed patients and families who experienced medical error, which included a sense of guilt: 'If only I had been there,' or, 'If only I had said something,'" Bell recalls.
As it turns out, clinicians may be overlooking, if not actively discouraging, input from a significant patient safety resource: patient caregivers.
In an article published July 2018 in BMJ Quality and Safety, Bell and her colleagues present numbers to back up these anecdotes. The team found that in a survey of family members of ICU patients, significantly more than half were hesitant to speak up about possible mistakes, mismatched care goals, confusing or conflicting information, or even inadequate hand hygiene.
Among the ICU families, 50%–70% expressed hesitancy to voice concerns around surveyed areas. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns. Most commonly, they did not want to be seen as a "troublemaker." In other cases, they felt the team was too busy or they simply didn't know how to express these concerns.
The researchers concluded in the paper, "Patient/family education about how to speak up and assurance that raising concerns will not create 'trouble' may help promote open discussions about care concerns and possible errors in the ICU."
Hesitation from family members is a real problem for clinicians, who could be losing a valuable partner when caregivers are reluctant to speak up.
"Engaging caregivers in conversations what's going on with the patient and their treatment options, and answering their questions about the treatment plan is really important because it can help guide you as a provider," says Hanan J. Aboumatar, MD, MPH, director of the Johns Hopkins Armstrong Institute Center for Engagement and Patient-Centered Innovations and Core Faculty.
For starters, those conversations provide clinicians an opportunity to prepare a caregiver on providing necessary treatment to the patient and emphasizing the importance of sticking with the treatment plan.
"Caregivers need to buy in to a treatment regimen just as much as the patients do," says Caitlin Donovan, director of outreach and public affairs for the National Patient Advocate Foundation. "Often much of a treatment regimen relies on the family as a caregiver, who have to monitor medicine, drive to appointments, and stay on top of a diet. If they have any concerns, or don't let a provider know of their inability to adhere to the treatment, the patient may not get the best possible care."
In addition, caregivers who are present across multiple hospital stays may become familiar with treatment routines and notice changes that could signify an error. "Potentially the caregiver could recognize certain problems in care that others might not," Aboumatar says. "That may be a very good way to identify problems early on and prevent any harm from occurring to their loved one."
Barriers to better interaction with caregivers
In her research on communication, Bell has also explored the "speaking up climate," or the degree to which the environment enables clinicians to speak up about patient safety threats. "Here we found that the medical hierarchy can be problematic and that residents, nurses, and even faculty physicians can have trouble raising concerns with other clinicians."
This research set forth the idea that in an era of emphasizing patients as part of the safety team, safety culture should include a focus on creating an environment that allows patients and families to speak up about care concerns. "Anyone should be able to 'stop the line' when they see a possible safety problem—including patients and families. While we haven't yet developed a 'speaking up climate' scale for patients and families, this study was a first step in that direction," Bell says.
Programs that encourage physicians to speak up when something is wrong are becoming more common for healthcare organizations, particularly related to the problems that physicians and nurses face as a result of traumatic second victim situations. But this encouragement to speak up doesn't always extend to families.
"We rely on caregivers to take care of patients in the outpatient setting as soon. But as the patient comes into the hospital, we take over all care activities for the patient," Aboumatar notes.
And it's easy to see why. For starters, Aboumatar points out, not all patients have caregivers, so the system is set up to handle all patient needs regardless of the presence or absence of a caregiver.
That's just the beginning of the barriers that must be overcome. In the ICU in particular, there's a risk of a caregiver inadvertently harming the patient unless he or she is properly trained in how to provide care. That training demands time and resources that may not be available.
"You have to answer their questions, there may be some tasks you need to supervise, so if you don't have systems in place and tools available that will make it easier for you to engage the caregivers, then time and concern for how the caregivers may perform may be barriers to engaging them, particularly in the hospital," Aboumatar adds.
Aboumatar points to one more barrier that is within the power of today's doctors to change. "Healthcare professionals learn by example," she says. "If you don't have enough role models around you where you're seeing healthcare professionals engaging in behaviors that will support caregiver engagement, you may not do that."
Awareness of this oversight—and the benefits patients are losing by not engaging caregivers—is likely to be the most powerful trigger to change.
"Healthcare professionals are used to not relying on caregivers for any patient care services in the acute care setting," Aboumatar says. "So, for us to start engaging patients more and more in their own care while in the hospital, and for caregivers to become more engaged as well, you really need to become very aware of that and do this more as part of your practice. It doesn't happen naturally. You have to think about how this can be integrated into your own practice as a provider and how the practice approaches engaging caregivers in the hospital."
Resources to encourage caregiver engagement
More healthcare organizations are looking to encourage patients and families to speak up.
The MedStar Institute for Quality and Safety has a "We Want to Know" program to improve two-way communication capabilities. It aims to help patients report problems and concerns as they happen or after discharge.
Through its Roadmap project, the National Patient Advocate Foundation is working to encourage communication between patients and providers, particularly on care conversations. "We suggest that in the very first appointment with a provider, both the patient and their caregiver have the opportunity to evaluate the process and outcomes of the appointment, including treatment options," Donovan says.
And The Joint Commission relaunched its Speak Up program in May 2018 to help patients and their advocates become more active in their care. The program includesvideos to engage the general public.
"Recognizing that patients can potentially play a role in preventing catastrophic medication overdoses, cancer centers also encourage patients to speak up, and state the importance of doing so on patient-related materials," Bell adds. "Organizations across the country are interested in patient engagement and strong safety partnerships with patients and families—speaking up will be an important component."
Skills for starting the conversation
While these programs offer plenty of value to healthcare organizations looking for resources to make caregivers more comfortable in voicing patient safety concerns, there may be some simpler strategies clinicians can try first.
"We know that it can be intimidating for patients to speak up to doctors, authority figures, or other experts," Donovan says.
She finds assessments to be an important tool for encouraging open communication. "Not only is the first appointment critical in establishing the treatment and protocol, but there should be assessments at every key decision point to ensure that goals are still being met and to evaluate if those goals have changed," she says.
While Bell notes that it will take further research to guide the next steps, she suggests, "Patient education programs should help patients to develop the language of speaking up in healthcare. But organizational support systems need to lead the way."
Based on the paper's findings, Bell offers six steps that organizations can begin to consider:
Underscore as part of ICU orientation or other patient participation programs that families hold unique information about the patient. Develop patient education programs that enable interested patients and family members to identify patient safety hazards.
Reinforce that the clinical team wants to know about caregivers' concerns. This may help offset concerns about being viewed as "troublemakers."
Provide at the outset (before they are needed) clear instructions about how to raise concerns, such as who to speak to and how to notify clinicians about urgent issues.
Identify language for how patients and families can most effectively raise their concerns, through research and pilot programs. Patient education about speaking up should ensure a clear way to describe the concern and to make a clear "ask" statement—what do patients and families need that clinicians can act upon? This might include adaptation of the SBAR approach for communication, AHRQ's TeamSTEPPS, or the CUS model:
I am Concerned
I am Uncomfortable
I am worried this is a Safety issue
Prepare clinicians to respond effectively when patients speak up. This will require faculty development and strengthening of transparency culture, ensuring that patients feel heard and respected.
Recognize patients and families that speak up, and celebrate their role as part of the healthcare team and safety culture. This can help reinforce organizational commitment to partnering with patients, increase the visibility of this leadership and frontline commitment, and encourage other patients and families to voice their own concerns.
Aboumatar offers several additional strategies to help clinicians gain support and feedback from caregivers:
Encourage all providers to communicate verbally and nonverbally in a way that allows caregivers and patients to feel comfortable and able to approach them with questions, she says. This may include basic things, such as introducing yourself with a smile and explaining your role, both of which acknowledge the caregiver in the room.
Try sitting next to caregivers, rather than talking with them from the hallway, so they feel you are giving them the time and attention that they need.
Ask questions and give caregivers the time, without interruption, to speak up with any concerns.
Put yourself in their shoes. That means "thinking about yourself in that position and how you would want to be treated," Aboumatar says.
But making these changes depends on leadership willing to drive this organizational focus. For clinicians to change, leadership needs to emphasize the value of caregiver input.
"Bottom line, it has to do with creating that organizational culture that provides permission and encourages basic engagement for caregivers and allows them the support and education they may need to become more active participants in the care of their loved one," Aboumatar says.
By tackling small problems first, healthcare organizations can create a problem-solving culture that leads to continuous improvement.
A version of this article appeared in July on PSQH.
In an ideal world, healthcare providers would be constantly studying patient satisfaction scores for even the smallest suggestions that could help them improve the patient experience. They'd be regularly searching for even minor insights on how to improve surgical processes or strengthen communication among caregivers or with patients.
In a more realistic setting, though, healthcare providers are struggling to implement improvements and rarely have time for meaningful engagements with patients that could translate to even the smallest advances in patient care.
Yet there is room for improvement, even in the real world. And often it's the simplest changes that can have a big impact.
Change in Language Can Change Your Outlook
Jennifer Lenoci-Edwards, RN, MPH, CPPS, executive director of patient safety for the Institute for Healthcare Improvement, shares a story that IHI CEO Derek Feeley likes to tell: "There was an elderly woman who was always getting out of bed, even though she was a fall risk. It turns out that the reason she kept getting out of bed was because staff kept putting her rosary beads away in the drawer across the room. They had to figure out what mattered to her, which was having those rosary beads. Having those with her in bed minimized her risk of falls."
Introduced in 2012, IHI's "What Matters to You?" program is one example of how the smallest changes can have a huge impact on patient care.
"Our previous CEO Maureen Bisognano reframed the question 'What's the matter with you?' to instead ask 'What matters to you?' " Lenoci-Edwards explains. "It has a huge applicability from a patient standpoint in terms of really defining the critical aspects of care that a patient needs in order to be happy and healthy."
The question highlights the discrepancy between patients and caregivers that can crop up when creating an optimal care plan. "Think about when the patient comes in and you're talking to them about cholesterol medications, when the truth is all they really care about is whether they can ambulate to the door to talk to the mailman every day," Lenoci-Edwards points out.
Getting on the same page, by reframing the initial question, can help create a care plan to which the patient will adhere—and that's important. "We're spending a lot of time overmedicating patients when really at the heart there are adherence issues because that was never really something that mattered to the patient," Lenoci-Edwards adds.
Asking the Right First Question
Asking the right question is often the biggest impetus for change, as questions create clarity and inspire people to think in unpredictable ways. But to get value from this process, you have to be willing to act on the answers.
As Australian anesthesiologist Dr. Rob Hackett recently blogged, "Because Evidence Based Medicine places all of the emphasis on clinical trials, it forgets to ask the first, most basic question of all: does the idea make sense? Through this, EBM can be used inappropriately as a tool to maintain the status quo … Certainly, lack of evidence must not be used inappropriately to stoically defend the status quo—for in the end it is our patients who suffer."
Hackett would know. He rose to worldwide social media fame when the hashtag #TheatreCapChallenge highlighted his decision to write his name and position on his reusable cotton surgical cap.
The idea behind this was simple. The World Health Organization's Surgical Safety Checklist advises that all staff in the operating room introduce themselves by name and role prior to beginning surgery. This doesn't always happen. And while not performing introductions might seem like a simple oversight, Hackett had seen firsthand that working with a cast of ever-changing nameless colleagues was potentially putting patients in danger.
One of the more compelling parts of this story is that, when Hackett approached senior hospital staff about adopting his surgical cap strategy, he met with resistance—even though the simple step has since been found to reduce staff member mix-ups, facilitate patient handovers, and improve camaraderie during surgery.
As Hackett later wrote on his PatientSafe Network: "Perhaps administrators view a label on one's head as a message of imperfection. If we forget people's names what else might we forget? Unfortunately, this is how hospitals are invariably designed—on the premise that as doctors and nurses we shouldn't make mistakes … We need to develop systems which reduce mistakes and minimize them from causing harm when they inevitably occur. For this to happen, we need to let everyone know we're human."
Prioritize to not be overrun by data
Being human, healthcare staff often find it overwhelming to simply maintain the status quo, much less drive improvements in care. Even in healthcare organizations that are open to process changes, there's simply no time to identify and act on even the simplest improvements.
"If you think about patient data, staff satisfaction data, safety culture data—all of that information has these little nuggets of things that could be improved, ways to make a very small change in the acute care setting or in ambulatory care," Lenoci-Edwards points out. "But we don't necessarily have the ability to turn on a dime on prioritizing these nuggets or turning them into improvement. A really well-oiled machine has some type of structure that helps you to look at all these individual data pieces and triangulate on which one of these ideas could help address a particular problem and then actually using improvement teams to take action.
"But I think this is really hard. There's a lot of data, and it takes a lot of manpower to turn this into improvement," Lenoci-Edwards adds.
Commit to Simple Changes
Simple changes aren't always going to make a massive impact, but they can consistently drive performance forward—which is an improvement over refusing to change at all.
In fact, research from the Harvard Business School revealed that when healthcare organizations move the focus from "big bang" priorities to low-hanging fruit, their employee-suggestion programs are more likely to succeed. By acting on and fixing small problems first, organizations make strides in developing a problem-solving culture that ultimately can smooth the way for larger-scale solutions.
More hospitals and health systems are creating second victim support programs to help clinicians cope after adverse events.
Editor's note:
COVID-19 has a grip on the nation. Since the first known case of COVID-19hit Washington state in January, the number of cases, and subsequent deaths, continue to steadily rise. While many states have issued stay-at-home orders, as essential workers, most nurses do not have the option to stay home. In addition to being on the frontlines in the battle against COVID-19, there have been very public struggles regarding the availability of personal protective equipment.
For example, on March 27, the Association for Professionals in Infection Control and Epidemiologyreleased data that 48% of U.S. healthcare facilities surveyed were already out of or almost out of respirators. The data was collected via a national survey of 1,140 infection preventionists in all 50 states and the District of Columbia.
Not only does lack of proper PPE put nurses' health at risk, it also jeopardizes the health of their patients, their families, and their communities.
For nurses, causing harm to patients can be devastating and a trigger for the development of second victim distress.
The article below, which appeared in the May/June 2018 issue of PSQH, offers insights on how healthcare leaders can assist nurses who may be struggling with worry and guilt of second victim syndrome during this pandemic.
Second victim distress—a phenomenon that can happen to clinicians involved in errors or adverse events—is getting more attention, and support options are slowly growing.
It's becoming more understood by health system administrators and safety and risk officers that physicians, nurses, and specialists directly involved in an adverse patient event or traumatic episode are likely to suffer an emotional response that might lead to difficulty sleeping, guilt, anxiety, or reduced job satisfaction.
More hospitals and health systems are launching second-victim support programs so healthcare staff can have the support they need.
The culture shift
Nationwide Children's Hospital in Columbus, Ohio, began the pilot phase of its YOU Matter program in 2013, rolling out peer support training to eight members of its pharmacy department.
Jenna Merandi, PharmD, MS, CPPS, medication safety coordinator at NCH, worked on a safety team with other service nurses and physicians. They were troubled watching the ongoing emotional struggle of individuals involved in errors, adverse events, or traumatic situations.
This confluence of events sparked a grassroots effort at the hospital to create an interdisciplinary peer support program.
But Merandi emphasizes that the program might never have launched if it was not for the culture of support already in place at the institution.
"I think our culture here, from a safety standpoint, was where it needed to be," Merandi says. "We have a very robust event reporting system at our hospital. People really feel comfortable reporting events and know that we look at things from a system's perspective."
In Merandi's view, health systems do need a culture of accountability, but it must be balanced with an environment where staff feel safe in reporting problems or issues that are occurring and knowing their reports will be handled "not in a punitive environment but in an environment that really allows us to hold individuals accountable whether at the individual or system level," as Merandi puts it.
While the NCH support program was grassroots-driven, its success was largely dependent on executive leadership's support.
"We felt it was very important to have an executive sponsor to help advocate for the program, and work closely with our senior leadership at the hospital," Merandi says.
What the development of the YOU Matter program revealed to the NCH team is that healthcare professionals often want support from their peers, managers, or supervisors—those people around them who really understand the work that they do and who may have gone through similar situations in the past.
The peer support program also offers immediacy, versus setting up an appointment some weeks distant through the EAP. "That's why we thought it was really important to build a program that encompassed that peer level support and then has more levels of support in place all the way through professional levels of support when needed," Merandi adds.
Granting full access
Effective second victim programs also recognize that physicians and nursing staff are not the only ones impacted by adverse events.
"These are things that are outside the normal realm of your day," Wilmarth adds.
What qualifies as "outside of normal" differs for every department. For ambulatory care offices, a critical incident could be that somebody coded. In other words, it has to be taken into account that traumatic events can happen beyond the operating room or emergency department.
"The other piece we focus on beyond critical incidents are areas that have recurring or repetitive stress—ICU, OR, or ED—where every day might be high volume. In those areas, it may not be a particular incident, but just that things might be tough lately and they need a 'debriefing,' " Wilmarth adds.
URMC developed its YoUR Support program around the "Demobilization, Defusing, and Debriefing" model that comes from trauma care.
As described by Muriel Prince Warren in Trauma: Treatment and Transformation, demobilization involves removing the individual from the scene and provided with coping techniques.
Defusing happens within 12 hours of the event and is built around group discussions designed to reduce acute stress and get staff back to their normal functioning. Debriefing should come two to 10 days later, to help give some sense of closure following the event.
URMC also recognized the wide-ranging need in setting up its critical incident response program. It's for this reason the organization opted to partner with its existing EAP to create a complementary program.
"We already have the phone system in place where you can phone 24 hours a day if you need EAP support for yourself, and they partnered with us to triage team support needs," explains Julie Colvin, MS, RN-BC, associate director of nursing practice at URMC's Psychiatric Mental Health Nursing Service.
The EAP program provides individualized staff support for challenges including work-life balance and general stressors. The YoUR Support program adds a team-based emotional support element to help staff get through difficult times.
Lessons learned
Support programs aren't rolled out overnight, and it's not without trial and error. But at the heart of these peer support programs is an emphasis on collaboration and sharing successes and failures to help other hospitals succeed. These professionals offer some findings that they've encountered along the way:
Timing is important. Colvin found that the excitement about the new support program meant that many staff members wanted to pull in extra support before they even needed it. As she explains it, the demobilization is meant to get staff back on track and recovering from the neurobiological effects of the stress. The defusing keeps people safe and able to go home.
"They were wanting to do a full-on debriefing a little bit too soon. You do need a little bit of time for your brain and body to filter the neurobiological sensations and effects," Colvin says.
Maintain the focus on emotional, not clinical, support. The URMC team notes that it sometimes takes effort to pull clinicians into a mindset that allows them to focus purely on their emotional state.
"Everybody in healthcare is a bunch of problem solvers and want to steer the conversation to the clinical debriefing—we need to steer it right back towards truly an emotional support conversation for staff," Wilmarth says. These conversations should not be about reviewing a timeline of what has happened and what will happen next.
Keep driving engagement. All too often the attention given new programs quickly falls off. It's for this reason that NCH built strategies into its program to keep that momentum going forward.
The organization holds an annual celebration featuring prizes, food, and continuing education opportunities for peer supporters.
NCH hosts quarterly lunches with leads in different areas to help disseminate information to the peer supporters. It also created YOU Matter Awareness Week with the encouragement of senior leaders, which provides an opportunity to talk about the different support systems available to staff.
"Our senior leaders were really the ones who wanted to partner with us on that week," Merandi shares. "They volunteer their time to go around and deliver cookies and information and resources to share what supports we have available. The CEO of our hospital was with us this year volunteering his time to do this. It really sends a powerful message when you have that level of buy-in at all levels of the organization and they show up."
Capturing success
The success of these programs is still being measured, but evidence points to the effectiveness of peer support programs in their mission to help staff cope with the challenging emotions that can follow a critical incident.
NCH, for example, is in the process of publishing its research on the success of the YOU Matter program.
Merandi and her team surveyed approximately 1,000 employees at NICUs across the hospital, off-site NICUs, and other hospitals across the city that NCH operates.
Some of these units had a peer support program in place, while the others received it six months later.
"We utilized tools such as our Professional Quality of Life Scale, looking at compassion, satisfaction, burnout, secondary traumatic stress; as well as things such as the Hospital Anxiety and Depression Scale; and different perceived desires for support," Merandi says.
The researchers utilized the Second Victim Experience and Support Tool to examine how supported staff felt with and without peer support programs in place, regardless of whether they'd been involved in a traumatic or adverse event of some type.
"We've shown statistical significance, in terms of employees who have experienced an adverse event having statistically significant higher levels of burnout and secondary traumatic stress—anxiety, depression—and showing the benefit of peer support as well," Merandi says.
URMC is watching the data too. In the first 15 months after YoUR Support went live, URMC increased the number of debriefings done by 258% compared to the same time frame before going live. But for this type of problem, the anecdotes are a more compelling story of effectiveness.
"We do have data on how many of the formal debriefing sessions that we have, and as this becomes more engrained in the culture here, we certainly know that we're not capturing all of those—but that's OK," Wilmarth says.
"If people are reaching out to their natural resources and relationships that they have with their established debriefing team in real time, then they're getting the support that they need and it's OK that we're not capturing every single one in data," she says.
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com.
Editor's note: This story was updated on April 2, 2020.
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