If you want to improve the patient experience — and your patient satisfaction and HCAHPS scores — here’s a good place to start: Reconsider how your hospital or practice thinks about time. And get to work swapping a patient-centered approach to time for your provider-centered viewpoint.
To see this in action, try a quick phone call to Cleveland Clinic. Here’s precisely what you’ll hear, after just a bit of voice jail navigation:
“Thank you for calling Cleveland Clinic. Would you like to be seen today?”
And they mean it. They do “about a million” same-day appointments a year, according to James Merlino, MD, Cleveland Clinic’s Chief Experience Officer (CXO).
Now, doing a good job in healthcare does take time. Scans take time to read properly. Cultures take time to grow. Thoughtful diagnoses and effective discharges absolutely take time.
The last thing I want to do is turn your hospital or practice into the healthcare equivalent of a fast food joint.
But some of the wait times your patients suffer through don’t add anything to successful clinical outcomes. And the reason you’re making patients wait? Probably it’s partly because you’ve always done things this way, and everyone else in healthcare is making patients wait as well.
Well, you can’t use that last rationalization anymore. Not if you’ve been watching what Cleveland Clinic has been doing on the timeliness front.
Let’s go back to listening to Cleveland Clinic, and that mind-blowing greeting:
“Thank you for calling Cleveland Clinic. Would you like to be seen today?” (After 4PM the greeting rolls over to”Would you like to be seen tomorrow?”)
This is for real. According to Dr. Merlino,
“Anybody calling [Cleveland Clinic] for an appointment for any specialty can be seen today.”
Getting people in to see a doctor the same day they call is an extreme and extraordinary move by Cleveland Clinic to take patient satisfaction to a new level.
Which is something that’s come a long way since the bad old days, when their incoming CEO, Toby Cosgrove, would joke, “Patients come to us for high quality care– but they don’t like us very much. ” (Which wasn’t much of a joke, really. When Cosgrove took the reins at Cleveland Clinic in 2004, patient satisfaction was in the lowest 10 percent of the nation.)
An eye on the millennial generation of patients
While nobody of any age likes to wait, this commitment to speed comes partly from Cleveland Clinic’s eyes being trained specifically on the incoming millennial generation of patients. (Millennials are a crucial generation of customers for any business—including healthcare—to consider. They are 80 million strong in the U.S., making them larger than the baby boom, and much larger than Generation X, the generation that immediately preceded them. And their expectations are quite different, being the first generation to take the internet, and smartphones, entirely for granted. A historical reality which changes their perception of time, convenience, and more.)
A million same-day appointments
They pull this off… how? Well, the same-day appointment commitment required Cleveland Clinic to get through some operational hurdles. Actually, Dr. Merlino corrects me on this: “‘operational hurdles’ is an understatement.” An extraordinary amount of work has had to be put into “managing the flow and ensuring we have the capacity.”
The same-day appointment promise is also dependent on a sophisticated triage process.
In other words: I can’t just call up and say
“I have a headache. I want to see a neurosurgeon.”
Well, actually, I can call in and say that—and they’ll be ready to deal with it. Here’s what happens: I’m taken through a series of questions on the phone; depending on how I answer those questions, the Cleveland Clinic telephone agent will be able to determine whom I should see, and will ensure I get that appointment today.
“So, Micah, [in the example above] you may not see a neurosurgeon for your headache, but you may see somebody who is a headache specialist or you may need to talk to a nurse who can better triage what you need. But we will get you to the right provider at the right time.
“If you call and say, ‘Look, I was in the emergency department last night with a headache and they did a CAT scan and they say I have a brain tumor. I need to be seen by a neurosurgeon today,’ you will see that neurosurgeon today. If you call in with a headache [and] you say certain things which are warning signs—answering yes to ‘is this the worst headache you ever have in your life?’ is one — you will immediately be transferred to a nurse who will do a more assessment and then guide you to an emergency department.
If it’s just a garden variety headache, as determined by the agent’s triage questions, they’ll still “get you an appointment with somebody today who can help you with the headache.”
Speak the patients’ language, use the patients’ channels
The same-day appointment commitment isn’t the only time-bending patient satisfaction change Cleveland Clinic has introduced. Another one that struck me is their understanding that patients these days, especially but not only millennial patients, want to communicate with their healthcare providers through the same communication channels they use to run their social lives. Which is a theme I am seeing in every arena of business. Appointments via mobile, information via mobile, chat online, doctors (after HIPAA waivers) corresponding with patients via email. Using telepresence for followup care with homebound patients. and more.
All of which, if you think about it, are ways to stretch, bend, mitigate the effect of time on the patient experience. Emails are asynchronous: they don’t have to be read at the time the doctor wrote them, a fact that can make things more convenient for both parties. Online chat is immediate when you need it to be immediate, again reducing wait. Information on mobile apps (Mayo is another leader in this) is another time — and potentially life— saver as well.
So what’s next on the speed front? Chief Experience Officer Merlino, who is also a practicing colorectal surgeon, jokes it might be, “Thank you for calling Cleveland Clinic. We’ve already solved your medical issue; is there anything else we can help with?”
Micah Solomon is a customer experience and patient satisfaction consultant, customer service keynote speaker, and author.
by Dina Gerdeman
Women make up more than half of the labor force in the United States and earn almost 60 percent of advanced degrees, yet they bring home less pay and fill fewer seats in the C-suite than men, particularly in male-dominated professions like finance and technology.
This gender gap is due in part to “occupational sorting,” with men choosing careers that pay higher wages than women do, labor economists say. For example, women represent only 26 percent of US workers employed in computer and math jobs, according to the Department of Labor.
New research identifies one reason women might be shying away from certain professions: They lack confidence in their ability to compete in fields that men are stereotypically believed to perform more strongly in, such as science, math, and technology.
Women are also more reluctant to share their ideas in group discussions on these subjects. And even when they have talent—and are actually told they are high-achievers in these subjects—women are more likely than men to shrug off the praise and lowball their own abilities.
This weak self-confidence may hold some women back as they count themselves out of pursuing prestigious roles in professions they believe they won’t excel in, despite having the skills to succeed, says Harvard Business School Assistant Professor Katherine B. Coffman.
“Our beliefs about ourselves are important in shaping all kinds of important decisions, such as what colleges we apply to, which career paths we choose, and whether we are willing to contribute ideas in the workplace or try to compete for a promotion,” Coffman says. “If talented women in STEM aren’t confident, they might not even look at those fields in the first place. It’s all about how good we think we are, especially when we ask ourselves, ‘What does it make sense for me to pursue?’”
Coffman has recently co-written an article in the American Economic Review as well as two working papers, all aimed at studying men’s and women’s beliefs about their own abilities.
“Women are more likely than men to shrug off the praise and lowball their own abilities.”
What she found, in essence, is that gender stereotypes distort our views of both ourselves and others—and that may be especially troubling for women, since buying into those stereotypes could be creating a bleak self-image that is setting them back professionally.
Here’s a snapshot of findings from all three research studies:
Women are less confident than men in certain subjects, like math
In a study for the journal article Beliefs about Gender (pdf), Coffman and her colleagues asked participants to answer multiple-choice trivia questions in several categories that women are perceived to have a better handle on, like the Kardashians, Disney movies, cooking, art and literature, and verbal skills. Then they were quizzed in categories considered favorable for men, such as business, math, videogames, cars, and sports.
Respondents were asked to estimate how many questions they answered correctly on tests, and to guess the performance of a random partner whose gender was revealed. Both men and women exaggerated the actual gender performance gaps on average, overstating the male advantage in male-typed domains as well as overstating the female advantage in female-typed questions. And in predicting their own abilities, women had much less confidence in their scores on the tests they believed men had an advantage in.
“Gender stereotypes determine people’s beliefs about themselves and others,” Coffman says. “If I take a woman who has the exact same ability in two different categories—verbal and math—just the fact that there’s an average male advantage in math shapes her belief that her own ability in math is lower.”
Women discount positive feedback about their abilities
In an experiment for Coffman’s working paper Stereotypes and Belief Updating, participants completed a timed test of cognitive ability in five areas: general science, arithmetic reasoning, math knowledge, mechanical comprehension, and assembling objects. They were asked to guess their total number of correct answers, as well as how their performance compared to others. A woman who actually had the same score as a man estimated her score to be 0.58 points lower, a statistically significant gap. Even more surprising, even after participants were provided with feedback about how they performed, this gender gap in how well they perceived they did continued.
In a second study participants were asked to guess how they performed on a test in a randomly assigned subject matter and to predict their own rank relative to others completing the same test. The researchers then provided participants with feedback about their performance. They found that both men and women discounted good news about their scores in subjects that their gender was perceived to have more trouble with.
Stereotypes play on our minds so strongly that it becomes tougher to convince people of their talent in fields where they believe their gender is weak, Coffman says.
“A policy prescription to correct a confidence gap in women might be: Let’s find talented women and tell them, ‘Hey, you’re good at math. You got a really good score on this math test,'” she says. “But our results suggest that this feedback is less effective in closing the gender gap than we might hope. It’s harder than we thought to convince women in male-typed fields that they’ve performed well in these fields.”
It’s unclear whether women would feel better about their abilities if they received repeated rounds of positive feedback, rather than one piece of good news. “I’d be interested to find out if the gender bias gets smaller over time, once a woman has heard that she’s good at math over and over again,” Coffman says. “You might have to encourage women a few times if you want to close these gaps.”
“Our work suggests a need for structuring group decision-making in a way that assures the most talented members both volunteer and are recognized for their contributions, despite gender stereotypes.”
It’s important to note, Coffman says, that these studies also show that men have less confidence than women in their ability to shine in fields dominated by women. “It’s not that women are simply less confident; what we find consistently is that individuals are less confident in fields that are more stereotypically outside of their gender’s domain,” Coffman says.
Posted By Helen Riess, M.D.
We are facing a critical time of fear and uncertainty with the invasion of the novel Corona virus on the world stage, when healthcare organizations are scrambling to keep patients and workers safe, informed and calm. When fear takes hold, we can expect reactions to follow along a continuum from frank denial to full scale panic. Both of these extreme responses are not only unhelpful, but dangerous.
When people raid grocery stores or hospital shelves and stock up on more hand sanitizer, alcohol wipes or face masks than they could possibly need, they leave others vulnerable to infection and with even greater fear and loss of control. In a time of crisis, we need to worry about other people as much or even more than ourselves.
Many regard empathy as merely a soft emotion of feeling sorry for others. Empathy is a powerful tool in times of crisis (see more at TEDx The Power of Empathy.) Our hard-wired capacity for empathy involves both cognitive and emotional centers of the brain, and when effectively harnessed together, can help leaders provide truthful, caring, and helpful information while at the same time remain calm, steady, and decisive. Empathy is a crucial part of emotional intelligence that leaders need to employ in times of crisis.
How does empathy relate to emotional intelligence (EI)? EI is the ability to practice: (1) self-awareness (2) other awareness, (3) self-management, and (4) relationship management. Being alert to these practices and actually putting them into action through empathy can greatly impact overall health and well-being – of ourselves as well as others – during a healthcare crisis.
Self-awareness means recognizing your own emotions. Before springing into action, you must first assess your own mental states so you can manage them. Many empathetic people are better at perceiving the emotional needs of others than their own. Just as oncologists must steady themselves before delivering bad news so they don’t inflict their own stress onto their patients, you must recognize your own emotions. Self-awareness also involves understanding your own vulnerabilities and remembering what you need to do to remain calm and safe. In our current crisis, this means you must take into account how your decision-making may be influenced by your emotional state, and then adjust your choices accordingly.
Other-Awareness and Empathy
Every human being has a longing to be seen and understood, and this longing becomes much more acute in times of crisis. “I see you” is the meaning of the Zulu word for hello, “Sawubona”. It is also what opens the gate for other-awareness and empathy. It takes intention and openness to take in the emotional and physical expressions of others. Instead of looking at a waiting room as a sea of humanity, it’s important to see each person as an individual. Just a kind look in the eye or using the person’s name more than once in a conversation will help people know they matter.
Other-awareness involves not only appreciating the feelings of others but also understanding their perspectives and life circumstances. This capacity allows us to move beyond the chief complaints people have to valuing their chief concerns. Patients or co-workers who seem to be over-reacting to the current health crisis likely have some legitimate reasons for their fears. Genuine interest and careful listening will be necessary during this healthcare challenge to prevent dismissing concerns or labeling others. Showing empathy in this way will help calm fears and enable others to make rational choices for the care of themselves and others.
Self-Management and Self-Empathy
Implementing the tools that work best to calm your own fears requires knowing yourself and understanding your need for self-empathy. Contrary to popular belief, self-empathy is different from selfishness. It’s very hard to take good care of others if you neglect yourself. Self-empathy does not mean “I care more about myself more than you” but rather, “I need to take care of myself so I’m able to take care of you.” Every healthcare provider and staff member needs their own unique tool kit for self-management and know when to use it. And when we are asked to use social distancing and self-quarantine to avoid virus exposure, we do this to help both ourselves and others.
The secret to effective relationship management is empathic listening and seeking to understand others’ feelings, thoughts and circumstances. It is essential to finding common ground. In a crisis, we need to relay facts with empathy and clarity. False assurances are worthless and cause greater alarm when truth is revealed. In other words, spreading false hope is destructive. True empathy requires the ability to tune into the fears and concerns of others and provide the best recommendations, even if they are not what people want to hear. It is walking the fine line of perceiving and taking care of immediate emotions while not losing sight of what is the best medical care in the long term. No one wants to hear that his/her normal routines and practices are now curtailed, but when focused on the long-term health of our society, the short-term restrictions make sense.
The Power of Empathy: A Call to Action
At this time of international emergency, there’s an urgent need for global empathy. The current situation calls for us to empower ourselves and others to collectively come together, bringing our best selves to the forefront to overcome this global health crisis. Far from the notion of survival of the fittest, where the strongest individuals only take care of themselves, we need altruism, cooperation, and collaboration to save our society as a whole. It is time to think about our patients as individuals, as well as our neighbors, co-workers, friends and family, and do what we can to support one another and to ask for help when we need it ourselves.
Helping each other is what brings us together and enlivens our spirit and our communities, and it is needed now more than ever, locally, regionally, nationally, and globally.
Dr. Riess is a psychiatrist and Associate Professor of Psychiatry at Harvard Medical School. She directs the Empathy and Relational Science Program at Massachusetts General Hospital. She has devoted her career to the art and science of healing relationships. Her research has been published in leading medical journals and has won many awards. Dr Riess’s TEDx talk “The power of Empathy TEDX” has been viewed by more than 500,000 viewers. Her new book, The Empathy Effect has been licensed in nine foreign countries. In 2012, Dr. Riess co-founded Empathetics.com an organization that provides evidence-based empathy and communication skills training for healthcare and education. Dr. Riess and her teams are dedicated to transforming healthcare systems into compassionate care systems.
Richard M.J. Bohmer, M.B., Ch.B., M.P.H.
Governments and regulators influence the performance of health care organizations and practitioners primarily through positive and negative financial incentives, regulatory constraints on their licenses to practice, and support of performance-improvement activities through education, research, and measurement programs. The financial approaches aim to motivate change in the way organizations and practitioners configure their systems and deliver care, under the assumption that once they’re motivated to seek surplus or avoid sanction, they’ll be willing and able to make local operational changes to reduce cost and improve safety, patient experience, and outcomes. Unfortunately, experience shows that although a changed market may be a helpful precondition to local performance improvement, it hardly guarantees effective operational change.
Some organizations have successfully transformed themselves, however, substantially improving efficiency and quality. How have they done so? One popular approach is top-management–led structural and governance change — moving boxes on organizational charts of an individual entity or regional system. Services are merged or broken up, new roles defined, and new responsibilities assigned. This approach appeals to boards, CEOs, and consultants because big changes can be made rapidly. But such rearrangements may disappoint.1 Examination of organizations that have achieved and sustained substantial performance improvements reveals that lasting transformation requires the relentless hard work of local operational redesign.
Organizations’ delivery of care is ultimately governed by structures and processes at the ward, clinic, or practice level. These elements have usually accreted over time, often in response to regulations or technology and without subsequent performance review or deliberate updating. In contrast, successful “transformers,” from Seattle’s Virginia Mason Medical Center to the Salford Royal National Health Service Foundation Trust in England, constantly make small-scale changes to their structures and processes over long periods.2 Everything from communicating with patients to cleaning gastroscopes to ordering tests and choosing therapies has been subject to redesign. Major change emerges from aggregation of marginal gains.
These organizations’ experiences clarify that multidisciplinary teams must undertake this redesign work.3 The provision of modern health care integrates so many specialized skills — clinical and nonclinical — and patients routinely cross so many intra- and interorganizational boundaries that no single designer can create a highly functioning microsystem. Such teams often have diverse membership, including not only patients, referring doctors, corporate staff, and community service providers but also design engineers. When these teams redesign local structures and processes, they do more than write a “best practice protocol.” They also reconfigure the workflow, workforce, supporting technology, and even physical care delivery sites.
Other hard truths emerge from studying successful organizations. Teams often redesign local structures and processes despite the lack of senior support, adequate data, capital, or a reimbursement system that rewards their efforts. Although consultants routinely list support from senior leaders as a key prerequisite for change, initiation and early leadership of such teams often comes from the middle — committed clinicians and managers volunteering early mornings and late evenings to create better-functioning systems for their patients. Teams use whatever imperfect data are available, often collecting essential data by hand; they recognize that important organizational design decisions are often made with insufficient information. And few redesigns get it 100% right the first time. In practice, health care transformation is a long series of local experiments.
Transformation requires sustained change in individual behavior, team interactions, and operations design. Although consultants and information technology vendors can help, experience has shown that more than anything, change depends on internal redesign work.
If detailed, low-level, repetitive redesign of local operating systems one at a time is the reality of improving health care, how do successful transformers support their staff through that process? How do they change in a systematic way? And how can organizations seeking transformation make the process easier and faster than it was for the vanguard?
Examination of high-performing organizations suggests seven essential organizational elements that support orchestrated team-based redesign. First, these organizations deploy many redesign teams concurrently — some permanent, some temporary. Virginia Mason convenes small teams transiently to redesign key processes, whereas Intermountain Healthcare (Utah and Idaho) has a permanent team structure responsible for redesign and long-term oversight. Both organizations have developed expertise in managing multidisciplinary teams.
These redesign teams are typically led by clinicians, although managers are well represented. They aim to improve the quality and the efficiency of care simultaneously, and the organizations see no conflict between those goals. Because many clinicians don’t feel empowered or prepared to lead such efforts or feel comfortable with resource stewardship, transformers invest heavily in leadership development, usually creating their own leadership programs rather than outsourcing them, and they free leaders from some clinical duties to create sufficient time for this work.
Transforming organizations have a routinized process for change. The basis for their standardized approach to analysis, redesign, improvement, and management varies, but what’s most important is not which model — lean manufacturing, continuous improvement, six sigma — is chosen but that the process is internalized, repetitive, and consistent so that the same language is used throughout the organization and independent teams can undertake redesign autonomously.
In addition, these organizations have an internal support resource that includes skills in design, project management, data analysis, financial analysis, and organizational development. Organizations may be tempted to rely on management consultants for support, but the transformers have worked to develop these capabilities internally.
They also have well-developed measurement systems that include both a capability for developing or reviewing measures of clinical or financial performance and the capacity to collect, report, and act on internally generated data. Data are often an Achilles’ heel: few doctors believe they have adequate data for system redesign. Transformers, however, do the best they can with available information, recognizing that data will improve over time. They address clinicians’ need for evidence-based decision making by treating design change as a test of concept, rather than implementation of a known answer. Redesign becomes a process for testing new metrics and data sources, which can, over time, mitigate short-term data inadequacy.
Furthermore, a senior oversight group is responsible for establishing teams, setting their priorities, monitoring their progress, addressing institutional barriers to change, and integrating multiple teams’ work. This group ensures that teams remain focused on organizational priorities and have the necessary resources, and it resolves conflicts that arise when multiple groups make demands on shared resources. The teams thus become part of a broader structure for clinical governance and form the core of performance-management and improvement efforts. At Intermountain, the permanent teams both redesign and manage care systems.
Finally, because any model of team-based redesign devolves authority and accountability away from top executives, transformers have invested in creating a widely understood set of unifying values and norms. Whether expressed in value statements, compacts, or credos, these standards help align staff behavior both with the organization’s goals and among the professions working together to meet those goals, and they guide behavior when there’s no clear decision rule.
Many organizations find this approach challenging, and not only because it’s slow or requires investment. It also risks requiring job cuts, or at least job changes. Most challenging, however, is the fundamental change it represents in an enterprise’s governance. Clinician-led teams take control of patient-facing organizational subsystems and reform clinical protocols and operations, review performance data and make modifications, and may even have local financial control and responsibility. In effect, instead of taking their work context as a given, staff actively create the local system needed to provide the best possible care. This shift may be a bridge too far for some organizations, especially those facing reduced revenue or an urgent need for a turnaround.
Unfortunately, in the longer term, the prolonged hard work of repetitive, incremental, and often small-scale rebuilding of local operating systems probably cannot be avoided. Individual behavior change motivated by payment reform may be insufficient to generate the quality and efficiency gains needed in coming years. In their first year, the Pioneer Accountable Care Organizations have achieved only modest results.4 However, organizations seeking transformation can ease the process by building the support system described above. The short-term investments that are required can be surprisingly small, because most organizations already have many of the requisite human assets. The most substantial hurdle, it seems, is the change in mindset.
Robert M. Wachter, M.D., and Lee Goldman, M.D., M.P.H.
Twenty years ago, we described the emergence of a new type of specialist that we called a “hospitalist.”1 Since then, the number of hospitalists has grown from a few hundred to more than 50,000 (see graph) — making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades.
In the mid-1990s, the combination of managed care for privately insured patients and Medicare’s diagnosis-related-group–based payment system for inpatients pushed hospitals to manage care more efficiently without sacrificing quality or alienating patients. Hospitalists emerged as one potential solution. Within a few years, evidence showed that using hospitalists could result in reduced costs, shortened lengths of stay, and preserved or even enhanced quality of care and patient satisfaction2,3 — in essence improving the value of care. The field was off and running.
For hospital medicine to grow as quickly as it has, many stars had to align, including a viable financial framework, a pool of qualified physicians, and enough force to overcome resistance to change. Remarkably, those stars did align.
The first issue was economic. By the mid-1990s, elective medical admissions had all but disappeared, but emergency admissions were increasing. Acutely ill patients needed rapid attention on admission and often multiple daily visits during hospitalization, regardless of whether that disrupted the flow of physicians’ outpatient practices. Moreover, the remuneration for nonprocedural inpatient care, especially given its growing complexity, was not high enough to make physicians who had historically been responsible for such care (primary care physicians in community settings and specialist and researcher attendings in academia) feel strongly about retaining their hospital roles. So most such physicians willingly turned inpatient care over to hospitalists.
How could hospitalists, then, fashion careers out of a role that was economically unattractive to their colleagues? Once evidence of substantial cost savings had accumulated, health care organizations found it advantageous to have hospitalist programs, and most provided financial support to create appealing jobs with reasonable salaries. Thanks to the value proposition and new duty-hour limits for residents, hospitalists also increasingly became responsible for staffing nonteaching services in teaching hospitals.
The second facilitator of hospitalist growth was the very large pool of general internists in the United States, most of whom were trained predominantly in inpatient settings. Many internists, whether newly minted or experienced, found the hospitalist role attractive, particularly given growing dissatisfaction with primary care internal medicine. In contrast, the small reservoirs of general internists in countries such as Canada and Britain have hindered efforts to build inpatient programs staffed by generalists.
Third, the quality, patient-safety, and value movements and widespread implementation of electronic health records all emerged just as the hospitalist field came of age. Hospitalists’ early emphasis on improving systems of care4 bolstered the field’s credibility and fostered the development of a cadre of young physicians who would ultimately assume local and national leadership roles. For example, the U.S. Surgeon General and the chief medical officer of the Centers for Medicare and Medicaid Services are hospitalists — an impressive validation of such a young field.
As the specialty grew in size and stature, the model spawned variations on its central theme. One obvious extension was pediatric hospitalists, who now account for approximately 10% of hospitalists. More creative variations include “hyphenated hospitalists,” such as surgical hospitalists (also called acute care surgeons), neuro-hospitalists, and obstetrical hospitalists. Medical hospitalists also often comanage care with surgeons or medical subspecialists, thereby reducing costs and allowing those specialists to concentrate on procedural tasks.5 Finally, financial penalties for readmissions have led many hospitalists to staff post–acute care facilities to improve coordination with colleagues at acute care hospitals.
Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specialization and full-time hospital presence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing systems (e.g., handoff protocols and post-discharge phone calls to patients) to mitigate harm from discontinuity, it remains the model’s Achilles’ heel.
Many hospitalists have added value as local leaders in quality improvement, safety, and innovation, but some have functioned more as shift workers. For example, many community hospitalists have a 7-days-on, 7-days-off schedule that focuses mainly on high-volume clinical work and sends an unspoken but clear message that, at the end of an intensive clinical “on” stint, one is “off” and uninvolved. Our impression is that hospitalist programs provide more value when hospitalists’ inpatient assignments (clinical “systole”) are complemented by a systems-oriented “diastole,” during which clinical activity is limited but they contribute to key institutional programs. Productive diastole is more likely when hospitalists have strong leadership, a robust professional-development curriculum, and a mutual hospital–hospitalist commitment to adding value during specified and structured nonclinical time.
Another problematic, though not unanticipated, consequence of the use of hospitalists has been a diminished role for specialists and researchers on teaching services. Because specialists are far less likely than they once were to serve as inpatient attendings, trainees have less contact with them and less exposure to basic and translational science.
Finally, the few academic hospitalist groups that have developed substantial research programs generally emphasize the implementation of quality- and systems-related initiatives. Hospitalists have been slow to pursue substantial inquiry into discovery related to the common inpatient diseases they see or to lead multicenter trials of new diagnostic or therapeutic approaches. This deficiency limits hospitalists’ credibility in academia and the advancement of the field.
Although we continue to believe that the hospitalist model is the best guarantor of high-quality, efficient inpatient care, it’s clear that today’s pressures require innovative approaches around this core. In addition to following patients in post–acute care facilities, another modified approach is to have a subgroup of hospitalists function as “comprehensivist” physicians who care for a small panel of the highest-risk, most frequently admitted outpatients and remain involved when hospitalization is required. This model aims to blend the advantages of the hospitalist model for the vast majority (>95%) of inpatients with the potential advantages of continuity for a small group of patients who are admitted repeatedly.
Hospitalist programs are innovating in other ways as well. Many are developing early-warning protocols in which electronic health record data are used to identify patients who are at risk for problems such as sepsis or falls. Others are implementing bedside ultrasonography for procedures and diagnosis, pioneering methods of making rounds more patient- and family-centric, implementing unit-based leadership teams, or applying process-improvement approaches such as the Toyota Production System to inpatient care.
Many academic programs are also experimenting with new ways of reconnecting specialists and scientists with trainees. Some have begun offering focused basic-science training to hospitalists, others have developed molecular medicine consult services, and still others have instituted dual attending programs, with a consultative teaching specialist joining a more hands-on teaching hospitalist. Such innovations are welcome and should be studied. In fact, the field’s greatest risk may well be complacency — failing to embrace the kinds of transformation and disruption that led to its birth, or being slow to address the inevitable side effects of even the best innovation.
When we described the hospitalist concept 20 years ago, we argued that it would become an important part of the health care landscape. Yet we couldn’t have predicted the growth and influence it has achieved. Today, hospital medicine is a respected field whose greatest legacies may be improvement of care and efficiency, injection of systems thinking into physician practice, and the vivid demonstration of our health care system’s capacity for massive change under the right conditions.
More hospitals are meeting the surgical volume threshold, a key patient safety measure, although there is still room for growth.
– Adherence to key patient safety protocol during high-risk surgery may be getting better, but steps lay ahead for organizations delivering a slate of certain medical procedures, according to a new report from the Leapfrog Group.
The report, Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey, looked at how hospitals adhere to certain patient safety protocol when delivering one of eight common but high-risk surgeries.
Specifically, the report investigated how many hospitals deliver certain surgeries and meet what the Leapfrog Group calls its surgical volume threshold for those procedures. The surgical volume threshold refers to the minimum and maximum amount of times an organization administers a surgery.
When a hospital meets the minimum volume threshold, it is doing the surgery frequently enough to have experience in the area. But perform the procedure too often, the hospital runs the risk of spreading resources too thin.
The Leapfrog Group research team looked at how many hospitals meet the recommended volume thresholds for eight surgeries: bariatric surgery for weight loss, carotid endarterectomy, esophageal resection for cancer, lung resection for cancer, open aortic procedures, mitral valve repair and replacement, pancreatic resection for cancer, and rectal cancer surgery.
A higher percentage of hospitals met the surgical volume standard in 2019 than did in 2018, save for esophageal resection for cancer. In 2018, 2.6 percent of organizations hit the volume standard compared to 2.5 percent of hospitals that did in 2019.
However, the overall number of hospitals performing high-risk surgeries and hitting the volume thresholds is still less than ideal. The surgery type with the highest rate of organizations hitting the volume threshold was for bariatric surgery for weight loss, and even then, only 48 percent hit the threshold in 2019.
Next up was carotid endarterectomy, but only about 22 percent hit the threshold.
“The good news is we are seeing progress on surgical safety,” Leah Binder, the president and CEO of the Leapfrog Group, said in a statement. “The bad news is the vast majority of hospitals performing these high-risk procedures are not meeting clear volume standards for safety. This is very disturbing, as a mountain of studies show us that patient risk of complications or death is dramatically higher in low-volume operating rooms.”
“It’s time for hospitals and health systems to upgrade their surgical volume policies,” she added. “It will save lives.”
These figures differed slightly for rural hospitals, with rural hospitals being less likely to hit the volume threshold than urban ones. However, when viewed as a proportion of hospitals offering a high-risk procedure and hitting the volume threshold, rural facilities fared better.
“To the credit of rural hospitals, most choose not to perform elective procedures for which they have inadequate patient volume,” the researchers said. “Hospitals that cannot perform a safe volume of procedures should follow the lead of the vast majority of rural hospitals and refer patients to safer options.”
In other words, rural hospitals are aware of their low volume and make a judicious decision not to offer the procedure. The most common high-risk surgery a rural hospital will opt into is a rectal cancer surgery, and even then, 73.2 percent are opting not to offer that surgery and refer patients to safer options.
The report also looked at protocol to ensure organizations only conduct a certain surgery or procedure when it is absolutely necessary. For cancer surgeries, hospitals must convene a multidisciplinary group to review cases, or they must have national accreditation from the American College of Surgeons.
For other high-risk surgeries, organizations must report on hospital policy for reviewing surgical necessity and preventive measures geared at preventing surgery overuse.
Hospitals are very likely to have adequate procedures in place. Over 70 percent of hospitals had adequate appropriateness procedures in place for cancer surgeries.
Fewer had them in place for other high-risk surgeries. Only 32.1 percent of hospitals had appropriateness procedures in place for open aortic procedures, while 43.2 percent had them in place for Mitral valve repair and replacement. Up to about 60 percent had appropriateness procedures in place for bariatric surgery for weight loss.
When stratifying for hospitals that meet the volume standard, Leapfrog found that hospitals commonly had adequate appropriateness standards. The number of hospitals offering surgery for cancers with appropriateness standards reached up into the low 90 percent for various procedures. For other high-risk surgeries, those numbers crept up to between 55 and 70 percent, depending on the procedure.
“It is critical that hospitals do not perform surgery when the procedure is not appropriate for the patient,” said Binder. “In addition to the increased potential for harm to patients, unnecessary surgeries contribute to the burden of overuse and excess expense in the U.S. health care system.”
This information is key for patient decision-making, the researchers said.
“While progress has been made, far too many hospitals are performing surgeries too infrequently to be deemed safe for patients,” the research team wrote. “Abundant evidence suggests that for certain procedures, patients can save their lives by choosing a hospital and a surgeon with adequate, ongoing experience performing that surgery and as well as a hospital that protects against unnecessary surgery.”
Many hospitals do opt into sharing this kind of data with the Leapfrog Group, but currently there are not requirements for hospitals to do so. This means patients can miss out on important information that could help them make a care access decision based on safety.
“Hospitals should implement policies to ensure safe volumes,” the report authors concluded. “If they cannot achieve a minimum volume for safety, they should not electively perform that procedure. Physicians should be willing to have a conversation with their patients about facility or surgeon alternatives that will improve the patient’s odds of a better outcome.”
Driving nurse excellence and engagement will be essential to delivering on patient satisfaction and experience.
By Sara Heath
– When it comes to nurse engagement, efforts must go a lot further than just driving good job satisfaction. In fact, nurse excellence isn’t entirely about the nurses at all, although they are important. Instead, nurse engagement is an essential means to yield an overall positive patient experience, connecting all of the key elements of healthcare into one cohesive picture.
The call for good patient experiences is not something new. Healthcare has long valued the patient, striving for excellent bedside manner and good clinical quality outcomes. But in an age where healthcare consumerism reigns supreme and CMS reimbursements hinge on good satisfaction scores, driving that positive hospital experience has become even more crucial.
But building that experience is extremely nuanced, most industry experts can appreciate. A good patient experience requires a balance of certain hospitality elements, patient safety, and meaningful interactions between patients and staff.
And that’s hard, experts say. Hospitals only have so many resources to dedicate to facility amenities and clinicians are strapped for time, seriously hindering their ability to connect with patients on a personal level. Patient safety, although essential to clinical quality outcomes, can falter to human error in the most unfortunate cases, despite best efforts. Communicating those lapses then present a whole new challenge.
But those challenges aren’t insurmountable, especially when nurses are engaged. These clinicians are on the frontlines of everything ranging from patient interactions to medical care. So, when nurses thrive, everything else thrives, too, according to Christy Dempsey, DNP, MSN, MBA, CNOR, CENP, FAAN, the chief nursing officer at healthcare consulting firm, Press Ganey.
“A culture of nursing excellence really does impact everything,” Dempsey said in a recent interview with PatientEngagementHIT. “If you have a good culture of nursing excellence, then you’re more likely to have better physician engagement. You’re more likely to see that patient experience of their physicians, not just of the nurses, is better. Clinical quality is better. It’s the rising tide that lifts all boats in healthcare.”
As noted above, nursing excellence looks like a lot more than just good job perks and satisfaction, although those factors can be important. Instead, nursing excellence is about developing and advancing strong nurse leaders, who are then able to advocate for their patients and nurse peers.
“Nursing excellence requires a structure within the organization that supports shared governance so that nurses at every level are helping and involved in making decisions, measuring transparency of data, and establishing performance benchmarks and promoting autonomy for nurses inside that shared governance framework,” Dempsey explained.
Nurturing a culture of provider teamwork and implementing care frameworks that emphasize not just clinical quality, but safety and patient experience as well, is another key hallmark of nursing excellence.
But although the industry has a good model of what nursing excellence is – strong team-based care that gives all stakeholders the tools to succeed – it isn’t always happening.
“We are in an environment that is constantly changing. It’s complex in terms of the patients and the venues, the continuum of care,” Dempsey said. “There are a lot of pressures within healthcare today.”
But it’s those very factors that hamper efforts for nurse excellence that nurse engagement and empowerment can solve. When nurses are empowered, Dempsey maintained, the patient can thrive because the team can thrive.
“Even in today’s complex, constantly changing healthcare environment, that culture of nursing excellence can be fostered, promoted, and then impact everything else that happens in healthcare,” Dempsey asserted.
Healthcare organizations on a journey to nurse excellence need to start where they are today. Understanding their current competency in patient safety, nurse experience, and clinical quality and experience will be important for understanding the root causes of any underperformance they see in their facility, Dempsey instructed.
From there, organizations can design a path forward.
“Define what the nursing professional practice model in your practice is,” Dempsey said. “Once you have determined that, you’ve got to make sure that you have CEO and board support for that model and that the chief nursing officers and nursing leadership are involved in executive level decision making at the C suite and the board level.”
A nursing shared governance that included nurse managers and engages bedside nurses will help organizations build their accountability structure, leading nurses and other stakeholders to take ownership of the process. Stakeholders should also play a hand in writing out job descriptions, performance reviews, and standards for clinical practice.
After that, teams must scale that plan organization-wide.
“You need to establish a communication plan so that you are able to disseminate information and initiatives that help you drive towards nursing excellence,” Dempsey said. “You must have an organizational strategy for data transparency in how you talk about the data. You can’t just post it on the wall. How do you talk about the data and wrap stories around that data to make it come to life? Then, look at the specific work unit information and communication strategies.”
All of this must lead to an optimized work environment, Dempsey continued. Work environment, or the factors that make a job doable and even enjoyable, is even more important that staffing levels, Dempsey reported.
“Optimizing that nursing work environment is so important,” she said. “That includes the leadership development plan, how you are engaging nurses and fostering their development, and how you are providing incentives for professional development.”
Organizations must also assess how they are assuring they have the appropriate resources – both human and material – and emotional support for nurses. This will allow nurses to continue efforts for patient-centered care.
“Make sure that you’re optimizing staffing so that you have the right people taking care of the right patients in the right place at the right time,” Dempsey stated.
“Then, finally, track integrated metrics, so reducing silos both in terms of operations, but also in terms of the way we look at data,” she continued. “Integrate that data so that you can see things and how things move together — or don’t. This will help you draw insights from that integrated data and then build improvement plans, and accountability and ownership plans based on that integrated data.”
All of this will hinge on a culture of team-based care. The organizations that Dempsey sees fully committed to a culture of excellence are already deploying strong team-based care strategies, fostering collaboration, communication, and support across the team. This is a symbiotic relationship, she said, because the culture of excellence also draws on the whole hospital team.
And at the end of the day, that is what will help organizations push to the next level in value-based and patient-centered care.
“Driving nursing excellence is not just a good idea, it makes good fiscal sense,” Dempsey concluded. “It makes good sense to recruit and retain the best and the brightest. It is the rising tide that will help health care. We need to really promote that.”
Recognition is growing among healthcare leaders of the need for a culture change within their organizations. Moving from recognition to reality, however, is more difficult. The problem lies in the perception – or misperception – of what a culture change actually entails.
Culture change is not a program with a completion date, nor is it a quick fix. It is an ongoing journey – a journey that requires leaders to understand the current state of the organization, establish a clear vision, align behaviors and instill accountability.
Vision Versus Cultural Reality
Facing the need for a culture change, large corporations, not-for-profit institutions and faith-based organizations all say the same thing: “We’re different, we’re unique.” But actually, they share many common challenges and objectives. They all hire people with goals and ambitions, and with expectations as to how they will be treated, accepted, rewarded and promoted.
All too often, however, employee expectations and those of the organization are not fully aligned. This may be despite what the organization professes as its objectives. For employees, it is the culture of the organization that is the reality, not the mission statement that hangs on the wall.
Many senior executives are out of touch with the realities of their organization. Typically, leadership only discovers what is really going on when employee surveys come back with unexpected results. Such evidence dissolves complacency and compels action. In fact, this awareness is usually where the real journey toward culture change begins.
Achieving a culture change within an organization is an ongoing process involving deliberate, intentional steps that include:
- Knowledge and Awareness
- Honest assessment of the current culture
- Development of baseline data
- Vision of the desired state
- Recognition and Reward
- Demonstration of desired behaviors
- Encouragement and reward for desired behaviors and outcomes
- Determination of the decision-making process (who, what, when, how)
- Development of an organizational communication strategy
- Delivery of consistent messages throughout the organization
- Frank discussion of tough issues that are frequently avoided
- Systems, Structures and Linkage
- Alignment of top leadership and performance management with the organization’s core values and issues
- Determination of core competencies to support the desired culture
- Delineation of goals – including “stretch” goals – for leadership
- Linkage of behaviors, goals and achievements to compensation
Building a Framework for Change
Much can be learned from the successes and failures of organizations attempting to implement large-scale change initiatives. Such an examination reveals the value of using proven tools and techniques such as change acceleration process (for rapid decision-making), Work-Out (when the problem is known but the solution is not) and Lean Six Sigma (to streamline processes and reduce variation). These techniques can give employees a solid framework for addressing the issues they confront on a daily basis.
A simple equation to communicate this framework for sustainable change is Q x A = E, or the quality of the solution times the acceptance of that solution will equal the overall effectiveness. The individual components may be considered common sense, but they are not necessarily common practice.
In addition, it is important that this framework also include:
- Clear management and leadership systems with 360-degree feedback
- Skip-level meetings (meetings where leaders bypass their direct reports and speak to the next level of the organization)
- A consistent operating calendar
- A linkage between people, strategy and results.
The mere existence of an internal quality program cannot bring about a culture change. Leaders must focus on and balance all elements of the equation to begin the journey toward change and achieve sustainable results.
‘A’ Side of Equation Is Essential
Employee acceptance is essential. Many organizations have declared their mission, written goals, produced vision statements and embraced a philosophy or set of values that fits their organization. These affirmations often include such lofty themes as empowerment, boundarylessness, customer focus, passion for excellence, accountability, quality mindset, employees as partners and so on. They are conveyed to all employees, reinforced in communication and are used to measure performance.
However, often there is no structure to support the realization of these organizational objectives. The employees frequently lack a genuine commitment to their company’s stated goals, mission, value statements and general philosophies because:
- They feel they have no input into the process.
- The statements are long, vague and do not relate directly to employees’ work.
- Goals and values are only communicated once a year and then not mentioned again.
- The statements are constantly being changed or revised.
- The leadership team is inconsistent in its actions and behaviors in support of the goals and values.
The failure to support goals and values could stem from such management practices as giving individual rewards and recognition versus team projects and rewards; identifying and grooming individuals with high potential for selected management positions while ignoring others who contribute to the team’s success; relying on employee comparisons and rankings that may be subjective instead of objective; discriminating within training, development, salary and promotions; and talking to instead of with employees. Other problems could include leadership actions that fail to “walk the talk,” an unwillingness on the part of management to accept feedback, a lack of upper management diversity and high turnover.
Such organizational shortcomings are often a matter of focus. In an effort to reduce cost, raise quality, boost productivity and surpass the competition in the marketplace, management may neglect such issues without realizing the impact it can have on employees, and thus the entire organization. Further, when confronted with the problems of stressed, overworked and burned-out employees, management often dismisses the complaints as trivial. The employees are sometimes labeled as “not being team players” or “not the stuff leaders are made of.”
The general feeling is that “healthcare is a caring profession” – an environment in which it is difficult to discuss performance issues. Tough conversations about people and performance often do not take place in order to avoid difficult or confrontational situations. Action items, decisions and accountability may never be discussed in meetings, where behavior is polite and politically correct. In fact, some of the most important conversations and decisions take place in the hallways after meetings. The fact to remember is that, wherever they take place, face-to-face communication is critical to establishing an honest, open dialogue across the organization.
Conclusion: A Path Toward Culture Change
Healthcare faces many challenges today in the quest to deliver the best and most cost-effective services for patients. One important challenge is to institute a culture change that enables staff, clinicians and managers to feel empowered and adequately equipped to address the problems which can be resolved only by altering their work environment. They need to know they can propose and implement viable solutions to real problems. Visionary healthcare organizations that are seeking to transform the way they deliver care must begin by finding a path toward a culture change.
Physician burnout costs the United States health care industry $4.6 billion a year, a number that brings a new spotlight to an age-old problem.
In a paper published in the journal Annals of Internal Medicine this past June, a research team of seven co-authors, most of them doctors, concluded that the dollar losses were related to physician turnover and reduced clinical hours.
The research adds to previous work showing how physician stress generates negative clinical and organizational outcomes. No studies have previously been attempted to put a figure on burnout in the US on a national level. In part, that’s due to the difficulty of calculating the economic cost of all of the factors involved. For instance, some studies have associated burnout with an increase in medical errors, but calculating those costs are nearly impossible.
“Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians,” the study states.
“Essentially it’s this feeling of being overwhelmed. You don’t feel like what you are doing is meaningful anymore.”
It’s well understood that doctors are constantly asked to do more with less. In addition to a demand for physicians that outstrips the supply, new laws around electronic record-keeping have increased the administrative burden on doctors as well.
“Physicians don’t sign up for the job to stare at a screen. They are doing this to provide care for people,” says one of the study’s co-authors, Joel Goh, a visiting scholar in the Technology & Operations Management Unit at Harvard Business School. “It creates a high level of dissonance for them.”
According to one study, more than half of all doctors in the US report feeling at least one symptom of burnout: emotional exhaustion, a feeling of detachment, or a diminished sense of personal accomplishment—twice the rate of the general working population.
“Essentially it’s this feeling of being overwhelmed,” says Goh, who is also an assistant professor at the National University of Singapore (NUS) Business School. “You don’t feel like what you are doing is meaningful anymore.”
What’s the economic price of burnout?
Even though physician burnout is widespread, it’s difficult to put a price tag on the phenomenon in a way that medical institutions can understand. In past research, Goh focused on calculating the cost of workplace stress on medical costs in the US. That led Christine Sinsky, vice president of the American Medical Association, to contact Goh to ask if he could calculate the medical costs of stress experienced by doctors themselves. Sinsky is one of the authors of the latest paper.
“It was a great opportunity to explore this issue with thought leaders on the subject,” Goh says. “I could provide my technical skills on modeling, and they could provide their contextual knowledge.”
The researchers focused on one aspect of the problem they could measure: lost income due to reduced hours and turnover.
To do so, they used a 2014 survey of some 7,000 doctors that asked questions about burnout and short-term career plans to estimate the percentage of doctors planning to reduce their hours or leave their jobs due to burnout. They then correlated those numbers with the percentage of burnout experienced by doctors in different age groups and medical disciplines in order to estimate the overall effects of burnout on staffing nationwide.
They then created a formula to calculate the cost of lost hours—as well as the search, hiring, and training costs of filling vacant positions—to arrive at a total price tag for burnout from turnover.
A not insignificant number
Their final estimate, $4.6 billion annually, “is a decent amount that people should care about,” Goh says. Drilling down to an organization level, that number comes out to $7,600 per physician per year. Most of that cost, they determined, comes from turnover, which had five times the impact of reduced hours, due to all of the associated costs of filling a full-time equivalent position.
Of course, cost isn’t the only reason to deal with the issue of doctor burnout. “Organizations have an ethical imperative to take care of their employees,” Goh says. And doing so could help take care of patients as well by reducing medical errors.
Even so, the study shows that doing the right thing ethically can also make sense to the bottom line. “It’s not just going to be a waste of resources trying to deal with this problem,” Goh says. “Aside from all of the positive outcomes you generate, it’s probably a good financial return on investment as well.”
Goh and his colleagues further help organizations calculate that cost with a spreadsheet tool they developed that any organization can use to plug in their own figures and calculate their own potential costs of not dealing with burnout.
“In every other management decision, you try to have as complete a picture as possible,” he says. “This helps fill in some of those data points, not to supplant the ethical considerations, but to provide a more complete picture.”
For those ready to deal with the problem, says Goh, a range of interventions have been shown to be successful, including mindfulness exercises and stress-management training. To really make an impact, however, wider organizational changes are probably needed.
“One way to make a difference is by increasing the amount of administrative support doctors receive, so they are relieved of those burdens,” Goh says. “It may seem costly to hire that additional staff, but it will probably be beneficial in the long run.”