Forum Focus – The impact of emotional intelligence and resiliency on health care performance

By Larry McEvoy, MD, and Tracy Duberman, PhD, MPH, FACHE

Today’s health care climate can feel like a tumult of accelerated and disruptive change and continuous stress – one of volatility, uncertainty, complexity, and ambiguity (VUCA). Amid this is an incessant tension to lower cost and improve quality in an effort to move toward value while still in fee-for-service payment.  It is no wonder that exhaustion and cynicism have become the new normal. With expectations to be adaptable and agile, yet stable and predictable, health care providers are inundated with conflicting and compounding requirements that heighten vulnerability toward burn-out, depression, and exhaustion for clinicians and compromised clinical quality for patients. If VUCA were an occasional event, we could steel ourselves for occasional stressful times. However, with the constant challenges of complexity defining “the way things are,” health care organizations must create adaptability and resilience at every level and capacitate their people. Resilience has become a strategic requisite skill.

So What Can Be Done?

Health care organizations can grow their capacity for navigating VUCA by strengthening emotional intelligence (EI) and resiliency, thereby creating an antidote to burn-out and a bridge toward positive, open work environments.

Organizations that have high levels of EI and resiliency tend to:

• Actively question the reality and the norms that underlie their behaviors
• Hold focused conversations with open questions
• Uncover root causes of problems
• Create new ways for people to work together
• Create systems that sustain emotionally intelligent practices
• Integrate operational learning (“How did this go well, and how do we get a bit better?”) and relational learning (“How were we healthy, and how do we get a bit better?”)

EI is defined as: “the capacity for individuals to recognize their own, and other people’s emotions, to discriminate between different feelings and label them appropriately, and to use emotional information to guide thinking and behavior.” ¹ EI consists of a set of skills that can be learned by individuals (i.e., self-awareness, self-regulation, motivation, empathy, and social skills), who, in turn, can capacitate the rest of their team and their organization to do the same. Similarly, resiliency is the ability to absorb the bad moment, learn from it and accept it, and then mobilize it forward into positive emotional, behavioral, and process effect while remaining in the environment. Resiliency enables one to roll with the punches without having to leave the negative environment.

Strengthening emotional intelligence and resiliency is even more critical when one considers the three primary challenges that currently place health care providers at risk for burnout or “anti-resiliency”: ²

1. Cognitive scarcity. When there is not enough time or enough clarity on what to do
2. Rewards asymmetry. A constant search for what is wrong and needs fixing, rather than for what is right and needs multiplying
3. Loss of autonomy. A lack of room for choice.

Implications and Next Steps

At the heart of this issue is the patient. Patients want kindness and timeliness, hope, certainty, continuity and coordination. Providers want fulfillment, meaningful work, connection to colleagues and patients, and clear feedback. Health care organizations want to provide high quality care at low cost. The good news is that these respective ‘wants’ are harmonious, congruent, and in alignment with the outcomes desired by patients, providers, and organizations. The key, of course, lies in building the capacity for EI and resilience.

Health care organizations can improve their capacity to adapt and operate by committing resources to strengthening EI and resiliency at the individual, team, and system level. Resiliency reduces the negative impact of provider burn-out on organizational efficacy, quality, and vitality. By investing in emotional intelligence as a shared practice tied to native and existing organizational work processes, health care organizations will create more effective leadership and a culture motivated by, and dedicated to, continuous improvement and innovation. This can be done by crafting leadership and team development around EI, embedding resilience practices in training, development, and care delivery, and designing an exponential diffusion strategy for both EI and resilience. In a world where health care personnel are already task-saturated, adding “resiliency training,” no matter how well-intended, raises the risk of adding another “to-do” to already taxed clinicians. The key to personal and systemic resilience is to incorporate new technique and practice into current actions and structures, de-weighting daily duress while learning new practices. Resilience and EI emerge, then, from a different “how” rather than an additional “what.”

To learn more about approaches for improving resilience and emotional intelligence in your clinical microsystems, please join us for the upcoming AHA Physician Leadership Forum Webinar on Monday, Nov. 7 at 2:00 p.m. ET. To register, click here.

References

1. Goleman, D., & Boyatzis, R. (2008). Social intelligence and the biology of leadership. Harvard Business Review, 86(9), 74-81.
2. Ariely, D., & Lanier, W. L. (2015, December). Disturbing trends in physician burnout and satisfaction with work-life balance. In Mayo Clinic Proceedings, 90(12), 1593-1596. Elsevier.

Larry McEvoy, MD, is co-founder of PracticingExcellence.com.

 

 

 

Tracy Duberman, PhD, MPH, FACHE, is president & CEO of The Leadership Development Group.

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Putting the puzzle pieces together

This article first appeared on LinkedIn on July 26, 2016.

By Jerry Penso, MD, MBA, Chief Medical and Quality Officer at AMGA

During a recent meeting of the AMGA-AHA Learning Fellowship focused on Clinical Integration in San Diego, Dr. Craig Samitt, EVP and Chief Clinical Officer of Anthem, presented a visual image that resonated with the group of physician and administrative leaders present. Each part of an integrated system―medical group, hospital, and health plan―was represented as a piece of a puzzle, all fitting together to create a complete picture. It was a perspective that challenged those in attendance to find ways to create a more organized, coherent system of care that provides value to patients.

A clinically integrated system has been defined by the AMA as “the means to facilitate the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused.” This means all stakeholders―hospitals, physicians, and health systems―coordinate and align care for patients regardless of the setting where they receive care―inpatient, ambulatory, or community. Clinical integration also must result in the desired goal of improving patient care, meaning better quality of care and patient experience, reduced cost of care, and increased access to care.

Successfully creating a level of integration that achieves this goal is hard. Those attending the Fellowship agreed that physician and administrative leadership working as a team is essential to navigate the myriad of issues that come up when aligning different organizations.  As one leader expressed, technical and adaptive changes will be required.

Technical challenges are those that can be solved by applying existing knowledge or systems. They might include creating care information and measurement systems, meeting legal and regulatory requirements, successfully negotiating contracts, and redesigning care processes. Though complicated, these challenges are usually solvable.

The adaptive challenges—or people issues—loom much larger. The different parts of the integrated system will need to agree who makes key decisions, how to divide responsibility for specific processes, and what changes in clinical practice need to be accomplished. It requires trust on all sides. Adjusting to these changes may provoke fear or even a backlash, and leaders must be capable of helping those affected adjust to the new ways of providing care. One participant described that her role in leading providers through change initiatives sometimes feels like being a “grief counselor.”

The puzzle metaphor is particularly apt because a puzzle is incomplete without each piece, and no piece is more important than the other. Over the next year, participants in the AMGA-AHA Fellowship will be working to achieve true clinical integration where every piece has a place. I am confident that they will find a way, piece by piece, to put their puzzles together.

MACRA News: When is an APM not an APM?

While it is clear that Congress intended to nudge physicians toward participation in alternative payment models (APMs) when it enacted the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), it is less clear which particular models Congress had in mind. Much will depend on how the Centers for Medicare and Medicaid Services (CMS) interprets the law in upcoming regulations – and specifically, how much financial risk CMS will require providers to accept to earn APM incentives.

The MACRA includes strong incentives for physicians who provide a significant amount of care through APMs – a bonus of five percent of their Medicare professional services payments in 2019 through 2024, exemption from the performance reporting requirements and payment adjustments under the Merit-based Incentive Payment System (MIPS) and beginning in 2026, a slightly higher annual increase to base Medicare rates than physicians paid through the MIPS. These incentives, plus the potential to share in savings realized under APM models, likely will result in increased interest in APM participation among physicians.

However, not all APMs are created equal under the terms of the MACRA. Eligible APMs under Medicare are limited to models tested by the Center for Medicare and Medicaid Innovation (CMMI); Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs); and certain other demonstrations under federal law.  A physician participates in the APM by working through an “APM entity” – such as a hospital, physician group practice or ACO – to provide care in accordance with the APM’s requirements.  Congress included certain requirements that an APM entity must meet before a physician’s participation “counts” for purposes of earning the MACRA APM incentives: the APM entity must participate in an APM that 1) requires participants to use certified electronic health record technology and 2) ties payment for professional services to quality measures comparable to those in MIPS; and the APM entity must bear more than nominal financial risk for monetary losses under the APM (or be a medical home expanded under CMMI authority).

These statutory requirements lead to many questions that CMS will need to address through rulemaking – for example, how will the agency assess whether an APM’s quality measures are comparable to those in the MIPS? And will CMS find a way to capture payments made by Medicare Advantage plans, even though Congress did not include those plans among its listed Medicare APMs? However, it is likely that the key question that will distinguish APMs that “count” from those that do not is what constitutes “more than nominal financial risk.” The AHA and other associations, including the American Medical Association, have pushed CMS to define this term broadly, so that it is not limited to models that require providers to accept downside risk but instead recognizes the significant financial investment providers undertake to implement APMs. However, CMS has signaled publicly that models with upside-only risk (such as MSSP Track 1 ACOs) may not meet the statutory threshold. It is expected that CMS will address the issue in proposed regulations anticipated this spring; stay tuned to our website (www.aha.org/MACRA) for additional information on this and other issues related to the new physician payment system.

Forum Focus – Founding participant of ASA Perioperative Surgical Home Learning Collaborative 1.0 shares experiences on evolving model of care

Sonya Pease, MD, second from left, with members of her TeamHealth PSH team.

In November 2015, 44 leading health care organizations wrapped up a year and a half-long Learning Collaborative designed to evaluate the viability of the Perioperative Surgical Home (PSH) model of care. Developed by the American Society of Anesthesiologists (ASA), the PSH is a patient-centered, team-based practice model of coordinated care that guides patients through the entire surgical experience, from the decision to undergo surgery to discharge and beyond.

One of the 44 participants, TeamHealth, a multispecialty physician group based in Palm Beach Gardens, Florida, ended its run with the first Learning Collaborative determined to help expand the PSH model across its facilities nationwide.

TeamHealth Chief Medical Officer Sonya Pease, MD, talked about her group’s challenges and successes with their PSH:

What prompted you to incorporate a PSH in your institution? 

Our organization is a multispecialty physician group, so strategically the goals of improving integration across service lines aligned perfectly with the goals of coordinated care in the Perioperative Surgical Home. So for us it was a no brainer, an opportunity to get smarter faster with added resources and infrastructure. It was also a way of engaging our hospital C-suites and post-acute care partners in a joint effort by becoming a part of their organizations’ value stream as well. So being a part of this collaborative not only improved our internal integration efforts, it helped us integrate better with our health care organization partners.

What kind of reaction did you get from your group? From the C-suite? 

Most of our medical directors were very wary of the added work. Leadership is work and requires time and requires support, so we hired a full-time project manager and decompressed some clinical time so our leaders could be engaged. Our C-Suites have been very engaged and supportive. In fact, all of our innovation sites have a C-suite executive sponsor, and all of our sites have actively participated in the collaborative quarterly meetings.

How successful has your PSH been so far?

On a scale from 1-10, I’d say overall we’re about a 7. Some of our sites started at a 1, some of our sites started at a 7, so those struggling at the bottom learned quicker and had a lot of tools and resources to use. Those who started on the higher end of the bell curve still showed significant improvement in the overall standardization and process improvement steps, but probably didn’t show as much growth simply because they were already great performers.

What have you learned through the process?

I look at the PSH initiative as a portfolio of work, everything from leadership alignment, clinical standardization, to quality management and improvement. There are definitely some steps and processes that have to be in place to do the next foundational elements, so having been a part of this at multiple sites representing community hospitals, academic hospitals, for-profit, non-profit, unions and non-unions, has given us a huge portfolio of tactics and strategies to make this possible in any environment.

What are your next steps?

Continue to hardwire what we have learned and continue to build out our portfolio of implementation tools so we can make this model of care the standard across all of our practices nationwide.

How has the learning collaborative helped you in your PSH journey?

It has helped enormously by doing the hard work of circling the wagons, hiring an excellent conveyor and putting the resources and tools into our hands to actually get out there and make something happen. We’re all competitive, and when you see what other organizations are doing first-hand, it’s impossible to stand there and do nothing. Being a part of the collaborative has created a lot of momentum within our organization.

The above piece was reproduced in part from an article previously published in the February 2016 ASA Monitor.

Learning Collaborative 2.0 Applications Due March 15!

ASA has partnered with Premier, Inc., a leading health care improvement company, to launch the second iteration of the PSH Learning Collaborative, which will run from Apr. 1, 2016 to Mar. 31, 2018.

Please visit asahq.org/psh and click on “Learning Collaborative,” where you will find detailed information on the PSH, the goals of the Learning Collaborative, and a toolkit to help get you started on your own PSH model.

Last year, the American Hospital Association’s Physician Leadership Forum and the ASA partnered on a half-day complimentary program at the Health Forum/AHA Leadership Summit exploring two care models that ease transitions across the continuum of care: the perioperative surgical home and the Hospital at Home®. A report of the proceedings can be downloaded by clicking here.

 

Forum Focus – Appropriate Use of Medical Resources: Toolkits to Improve Care

In November 2013, the American Hospital Association’s Physician Leadership Forum (PLF) released “Appropriate Use of Medical Resources,” a white paper that identifies some of the drivers of health care utilization and its contributing factors. More importantly, the paper recommends a way to move forward that will place hospitals at the forefront of innovative change for reducing non-beneficial services while improving health care overall. The paper focuses on a “top five” list of hospital-based procedures or interventions that should be reviewed and discussed by a patient and physician prior to proceeding.

To support hospitals’ efforts in the appropriate use of medical resources, the PLF produced toolkits on each of these five recommended areas. Each toolkit contains dedicated sections for hospital and health system management, clinicians, and patients. Materials are available at www.aha.org/appropriateuse. Below is a brief look at the five topics targeted.

 

Patient Blood Management

Clinical research has shown that restrictive transfusion practices are generally associated with better patient outcomes as well as reduced health care resource utilization. A growing number of clinicians who order blood products are turning to patient blood management (PBM) as an important component of their care planning decisions. PBM comprises a variety of methods, such as the use of evidence-based transfusion guidelines as well as anemia and coagulation management.

The Patient Blood Management toolkit is composed of three sections:

• Hospital and Health System Resources – Includes a readiness assessment tool, the starting point in developing a successful PBM model, as well as resources supporting the benefits of appropriate use of PBM, and frequently asked questions.
• Clinician Resources – Includes a webinar, clinical evidence supporting appropriate use, implementation instructions, and an iPhone application.
• Patient Resources – Includes a guide on how patients can best engage in their care.

Antimicrobial Stewardship

Antibiotics are one of the great discoveries in medicine and the most important weapon in fighting bacterial diseases. Infections that were once deadly can now be cured, and antibiotics have made many life-saving treatments possible. However, overuse and unnecessary use of antibiotics can lead to deadly antibiotic-resistant strains of bacteria and cause serious side effects. The Centers for Disease Control & Prevention reports that approximately half of all antibiotic prescriptions written are either unnecessary or used inappropriately.

The Antimicrobial Stewardship toolkit is composed of three sections:

• Hospital and Health System Resources – Includes a readiness assessment tool, the starting point in developing or enhancing a successful Antimicrobial Stewardship Program (ASP). For ease of use, the tool is divided into two sections, one for those just beginning a program, the other for those who wish to enhance an existing program.
• Clinician Resources – Includes webinars, clinical evidence supporting appropriate use of antibiotics, implementation guides and related articles.
• Patient Resources – Includes frequently asked questions, pamphlets and handouts on how patients can best engage in their care and resources on appropriate use of antibiotics.

Ambulatory Care Sensitive Conditions

As resource-intensive settings, emergency department and inpatient hospital care need to be carefully monitored to ensure the most appropriate use. Significant research has shown that for several Ambulatory Care Sensitive Conditions (ACSCs) – low back pain, asthma, uncomplicated pneumonia – access to primary care, urgent care clinics, outpatient services, and other sub-acute settings can improve patient outcomes, reduce hospital admissions and readmissions, and lower costs. Reducing ACSC admissions requires understanding of the problem and a commitment to making change.

The ACSC toolkit is composed of three sections:

• Hospital and Health System Resources – Includes guides, fact sheets, and resources supporting treatment of ambulatory care sensitive conditions.
• Clinician Resources – Includes clinical evidence for management of specific ACSCs, frequently asked questions and a report on the impact of integrated care on preventing hospitalization.
• Patient Resources – Includes action plans, frequently asked questions and resources for patients on how to best engage in their care and prevent hospitalizations for ACSCs.

Elective Percutaneous Coronary Intervention

According to the American College of Cardiology, American Heart Association, the Society for Cardiovascular Angiography and Interventions and other experts, immediate coronary angiography with percutaneous coronary intervention (PCI) is recommended for patients with ST elevation myocardial infarction (STEMI). Research has shown, though, for patients with non-acute coronary artery disease, PCI has little to no effect on outcomes. Appropriate use of PCI with the right patient at the right time can improve outcomes, reduce hospital admissions and readmissions and lower costs.

The Elective PCI toolkit is composed of three sections:

• Hospital and Health System Resources – Includes quality improvement resources and links to the National Cardiovascular Data Registry®.
• Clinician Resources – Includes mobile applications, guidelines and clinical evidence supporting the appropriate use of elective percutaneous coronary interventions.
• Patient Resources – Includes resources to understand the best use of angioplasty and how to obtain the right tests and treatments.

Aligning Treatment with Patient Priorities in the Context of Progressive Disease for Use of the ICU

The most appropriate use of the intensive care unit (ICU) can improve outcomes, improve the care experience and lower costs. Hospital and health care systems should encourage early intervention and discussion about priorities for medical care in the context of progressive disease and robust communication between patients and their providers to understand patients’ preferences and goals. These discussions should address the likelihood of acceptable (to the patient) recovery, the risks, the options for palliative care co-management at the same time as disease-directed treatment and the benefits of hospice care, all in the framework of the patient’s priorities.

The ICU toolkit is composed of three sections:

• Hospital and Health System Resources – Includes assessment guides, PowerPoint presentations, key statistics and findings, position statements and resources supporting the appropriate use of the ICU for patients near the end of their lives.
• Clinician Resources – Includes fact sheets, a palliative care screen, tip sheets, communication guides, articles, a webcast and recommendations regarding end-of-life care in the ICU.
• Patient Resources – Includes two overview pieces and resources regarding palliative care, advance care directives, and ICU/treatment-specific concerns for patients, their families and caregivers.

Forum Focus – ICD-10 implementation: We’ve only just begun

By Nelly Leon-Chisen, RHIA, American Hospital Association Director, Coding and Classification

On Oct. 1, 2015, the United States turned the switch on the long-awaited (and several times delayed) implementation of the ICD-10 clinical coding system. This was no small feat as this was the biggest change in the coding field in 30 years. Hospitals, physicians, payers and practically everyone involved with the health care field had planned, trained, tested, and in general worked very, very hard to make the transition. At press time, all signs are positive that all that hard work has paid off. Physicians have continued to see their patients. Hospitals have kept their doors open. And the world as we know it did not end. Payers are beginning to report successful processing of claims with low rejection rates and no major issues in the early days of ICD-10. “Cautious optimism” is a phrase that has been repeated by many during the first two weeks of ICD-10 as we wait for the volume of submitted claims to increase.

The one-year delay has been touted by some as having been beneficial to allow the field to conduct more thorough testing of provider and payer systems. Others had feared that the delay would make it more difficult to continue the momentum that had been steadily building up early 2014. And hopefully no one was left behind believing that another delay would “save” them. One thing is clear–hospitals and physicians have had the closest collaboration ever on coding and documentation, admittedly a not very exciting topic for most physicians. Hospitals feared significant cash flow problems if coders would need to stop and ask every physician for clarification on vague documentation. Instead, hospitals proactively identified documentation gaps and steadily worked with medical staffs on specialty-specific issues rather than broad ICD-10 codes that would never be used. “Documentation, documentation, documentation” (or rather the lack thereof) has been the perennial challenge for coding professionals working in any coding system.

“What’s in it for the physicians” was a recurrent theme of many such conversations. After all, physicians’ payment was never meant to be directly affected by the conversion to ICD-10. While ICD-10-CM (diagnosis) codes provide justification for the need to provide a particular service, physician fees are not calculated on the basis of the diagnosis code. On the other hand, hospital payments can vary significantly based on the ICD diagnosis and procedure codes, to the point where even whether a code is listed in the first position (principal diagnosis) or a secondary position can make a great deal of difference in the payment the hospital would receive. The preparations for ICD-10 implementation were an excellent opportunity to improve coding and documentation that will provide a solid foundation for information that can be used towards implementing shared physician and hospital goals to advance excellence in patient care and improving health and health care in our communities. The more detailed ICD-10 codes coupled with improved documentation will help paint a more complete and accurate picture of the patients we jointly serve. As the field moves from the current volume-based fee-for-service (FFS) payment system to a value-based system that pays for patient outcomes rather than individual services, good documentation resulting in specific coding can provide better data to help identify best practices to deliver value-based care. Physicians have become increasingly familiar with broad sets of performance-based payment strategies that attempt to use financial incentives to influence provider performance. More specific coding can also help explain and justify the perennial “my patients are sicker” with solid facts rather than generic-sounding excuses. Describing a patient as having “type 2 diabetes on insulin with peripheral neuropathy, diabetic ketoacidosis and diabetic renal disease” can provide a different clinical picture from just saying that the patient is diabetic.

What will still remain a challenge ahead? ICD-10-PCS, the procedure classification system to be used by hospitals reporting inpatient procedures, will continue to be challenging for hospital coding professionals. The coding system requires a level of detail and clinical understanding much beyond what ICD-9-CM ever required. That detail is not only about the specific veins, arteries, muscles, or nerves operated on, but also an understanding of the objective of the procedure in order to select the appropriate code. It’s important that coding professionals have access to physician resources – surgeons for example – who can answer questions about surgical procedures when assigning ICD-10-PCS codes for those difficult or unusual surgical cases. Perhaps this will be a new area for physician advisors to provide assistance. It’s now the physicians’ turn to educate the coders on the most common procedures they perform.

According to the ICD-10-PCS Official Coding Guidelines physicians are not expected to use the terms used in the ICD-10-PCS code description, nor is the coder required to query the physician when the correlation between the documentation and the defined ICD-10-PCS term is clear. Nevertheless, information that is abundantly clear to a surgeon may not be so clear to a professional coder. For example, a stent insertion is no longer only about inserting a device as the correct code will depend on the intent of the procedure. Is it done to dilate an occluded vessel, to relieve a ureteral obstruction, to provide assistance to drain a ureteral stone, or to restrict the lumen of an aneurysm? Physicians and hospital coding professionals will need to continue to collaborate as both learn the nuances and terminology associated with the ICD-10-PCS codes.

While a lot of progress has been made in improving physician documentation to meet the needs of a future that involves an increasing reliance on claims data to represent clinical differences between patients and the services provided to them, a lot still remains to be done. This is only the beginning as there are still a number of areas where a close collaboration between hospitals and physicians will continue to be an essential component of every hospital’s strategic plan. In fact, it’s more like the beginning of a hopefully long lasting collaboration as the 1970’s hit single “We’ve Only Just Begun” that became popular for weddings reminds us.

Forum Focus – Take the pledge to eliminate health care disparities

As the U.S. continues moving toward a majority-minority population, the need to identify, ad­dress and eliminate health care disparities is increasing. Although the role of the physician will be critical for this effort to work, we know it will take everyone’s focus to make meaningful progress. That’s why the American Hospital Asso­ciation (AHA) in 2011 joined the Associa­tion of American Medical Colleges, Ameri­can College of Healthcare Executives, Catholic Health Association of the United States and America’s Essential Hospitals in a national call to action to eliminate health care disparities.

To meet the changing needs of our communities, hospitals and health systems are working hard to make sure that every individual receives the highest quality of care. To achieve that goal as our nation becomes increasingly diverse, we must redouble our efforts to identify and eliminate disparities in care. We are focused on three core areas: increasing collection and use of race, ethnicity and language prefer­ence data; increasing cultural competency training; and increasing diversity in health care governance and leadership. Areas we believe provide the greatest opportunities for hospitals and health systems to increase the equity of the care they provide to patients. We have also publicly set goals and milestones in each area to further cement our commitment and hone are focus collectively.

The AHA recently launched the #123forEquity Pledge to Act Campaign. The campaign builds on the National Call to Action to Eliminate Health Care Disparities. The AHA first announced the #123forEquity Pledge to Act Campaign this summer at the Health Forum Leadership Summit, and more than 700 hospitals have signed the pledge already. In addition, a number of partner organizations have endorsed the campaign. We are asking you to:

• TAKE THE PLEDGE – Pledge to achieve the three areas of the Call to Action within the next 12 months.
• TAKE ACTION – Implement strategies that are reflected in your strategic plan and supported by your board and leadership. Provide quarterly updates on progress to AHA and your board in order to track progress nationally.
• TELL OTHERS – Achieve the goals and be recognized. Tell your story and share your learnings with others in conference calls and other educational venues including social media to accelerate progress collectively.

Is your hospital on the list? You can check at www.equityofcare.org/pledge/pledging.shtml, where hospitals that have made the pledge are listed by state.

If your hospital is not on the list, talk to your CEO and board about your equity initiatives and taking the pledge. Addressing disparities is no longer just about morality, ethics and social justice: It is essential for performance excellence and improved community health. As we endeavor to resolve the social, economic and environmental determinants that affect health and their correlations with specific health outcomes, a focus on equity in care will be vital. We are also keenly aware that addressing the needs of the lesbian, gay, bisexual and transgender (LGBT) commu­nity and people with disabilities, including individuals experiencing mental health and substance abuse disorders, is equally important. Hospitals as a field have made progress, but more needs to be done, quickly. Equity of care is central to quality improvement and the business imperative of your work.

We’ll continue rolling out the campaign to all hospitals over the next several months. Our goal is to have 1,000 hospitals sign the pledge by the end of the year. Add your health care organization to a growing list of leaders taking action today by visiting www.equityofcare.org/pledge.

Paramount to the campaign will be demonstrating the link between quality, equity and collaboration, with diversity and inclusion as the cornerstone to accelerate progress. These are pillars that the Institute has championed and continues to promote in all of its work.

To help the field with these renewed efforts to eliminate health care disparities the Institute for Diversity in Health Management as an affiliate of the AHA has developed a number of resources, including a toolkit that offers a user-friendly “how-to” guide to help accelerate the elimination of health care disparities and ensure hospital leader­ship and governance reflect the communi­ties they serve. The toolkit contains best practices and resources that can assist all hospitals – whether you are just beginning this work or are far along on your journey.

The time is right for action and we stand ready to support you! Add your organization today and join a growing list of leaders across the country committed to achieve high quality, equitable care for all patients served.

Tomás León, MBA
President & CEO
Institute for Diversity in Health Management
institute@aha.org
(312) 422-2630

Forum Focus – Communication, collegiality, and care (part two of a two-part series)

By Bill O’Neill, Director of Outreach and Communications for the Center for Personalized Education for Physicians

Pitfalls and Perils on Medical Teams

In recent years, changes to the structure of medical teams, intended to improve communication, sometimes have the opposite effect. As medicine becomes more team-based and less hierarchical, some physicians may feel threatened. According to Matt Steinkamp, M.S.W., lead faculty for CPEP’s “Improving Inter-Professional Communications” seminar, “Physicians often tell me they have feelings of loss: loss of their role as a leader, loss of respect and prestige, and perceived loss of influence. These feelings can manifest as anger and frustration with their colleagues.”

By definition, the practice of medicine is a stressful endeavor, and stress can lead to friction on a medical team. Dr. Michael Yochelson, Chief Medical Officer at MedStar National Rehabilitation Hospital, notes, “As a physician leader, this is something you have to deal with perpetually, and it occurs with both attending physicians as well as residents. Sometimes the friction can be peer to peer, but other times it occurs between a physician and a nurse or even a patient. Unfortunately, physicians may be able to get away with behavior that other team members cannot. Many are highly trained in very specific sub-specialties and are difficult to replace.”

According to Steven Defossez, M.D., Vice President of Clinical Integration at the Massachusetts Hospital Association, “A busy work day or environment just accentuates a ‘head’s down’ focus on the task at hand and can heighten tensions with others. If you’re constantly in a hurry, you’re already set up for failure when it comes to inter-professional communication.”

Mr. Steinkamp agrees that time management, along with other factors, can complicate team dynamics. These include stylistic challenges, training issues and changes to the ways medical teams are structured. “Many physicians tend to be black and white, task-oriented, and can be perceived as ‘too direct,’ while nurses are often more process and relationship oriented. These styles can grate against one another,” Steinkamp reports.

Training issues, and the competitive nature of medical school and residency programs, may foster this “direct” style. Competitiveness, hard work and self-reliance are both required and rewarded, while teamwork may have been given a lower priority. When tempers flare, the words “I’m sorry” may be in short supply. Says CPEP’s Steinkamp, “Some physicians report apologizing is very difficult for them, and to some extent, have been trained not to as an admission of wrong-doing and an opening to liability.”

The Power of Relationships

In the face of these structural changes, Steinkamp suggests focusing on the “power of relationships” rather than on direct lines of authority. “Physicians can take steps to humanize themselves, bond with colleagues, educate vs. dictate, ask for input, and thus increase influence through ‘soft power.’”

Dr. Defossez adds, “You have to take the time to show you care about the people around you, and that can require trade-offs and motivation. Some individuals need to be convinced that by becoming more empathetic, effective communicators, they will in turn become more effective leaders. Interpersonal skills then become a useful tool, not just a ‘nice to have.’”

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, notes that embracing a team-based approach can lead to direct benefits for physicians. “Data shows that approximately 40% of physicians nationally report symptoms of burnout. An internal research group led by both physicians and nurses found that Mayo care groups that had a stronger team ethic reported reduced feelings of burnout, and thus greater job satisfaction.”

Strategies that Foster a Culture of Collegiality

Steinkamp encourages the use of team huddles as a way of assuring all hear the same thing at the same time and have an opportunity to get clarification. “You can’t just paper it over with a memo from the top. You need to lead by example and build these huddles into the daily schedule of medical teams – and then show up and engage. Scheduling huddles and then not attending can be more detrimental than not having a huddle to begin with.”

Dr. Defossez points to the Mayo Clinic’s primary value of “The needs of the patient always come first” as an example of a culture that promotes inter-professional teamwork. Dr. Wald agrees: “The Clinic was founded not only by the Mayo brothers, but also by the Sisters of St. Francis, who provided nursing and related care. The culture of mutual respect and partnership between physicians and staff was present from day one, and is still stressed today in every meeting at every level of the organization.”

Asked about team huddles, Dr. Wald notes, “These types of interactions are very common throughout the organization; some are formal, some informal. Pre-procedural/surgical huddles are a clinical requirement before any type of procedure, and all team members are encouraged to ask questions and make suggestions.”

Ed Eckenhoff, founder and president emeritus of the MedStar National Rehabilitation Hospital, maintains that the culture of teamwork is particularly strong in the rehabilitation hospital community: “We incorporate the team approach, where the entire clinical team meets together several times per week to discuss the patients’ successes and needs. It becomes this summary that assists communication between attending physicians, nurses and therapists. They all become quickly up–to-date with all aspects of patient care and appreciate each other as patient-centered team members.”

MedStar NRH’s Yochelson adds, “Health care in general is moving towards a model that rehabilitation hospitals have embraced since the 1940s. Our patients have unique needs. They require a team approach to care, and that close-knit, interdisciplinary approach is built into our training in residency. In other environments, physicians often talk to nurses, not with nurses. In the rehabilitation setting, that communication is more of a dialog and a two-way street. Nurses learn from physicians and vice-versa.”

The Challenge of Leadership

Dr. Yochelson continues: “These issues can be a real challenge to manage as a leader – nobody really likes, or wants, to deal with them. However, physician leaders have to resist the temptation to sweep these problems under the rug – they have to be dealt with in a serious manner. Leadership needs to sit down with the physician in question and be very candid; a physician may not have any idea how they come across, and that has to be made clear to them. Hopefully they will have the ability to change, although it may not happen overnight. These conversations may lead to education, coaching, or, if problems continue, discipline.”

“At MedStar NRH, we make it clear that regardless of title, all physicians are leaders and role models and are expected to act accordingly.”

About CPEP

CPEP (www.cpepdoc.org) is a 501 (c)(3) organization that promotes quality patient care and safety by enhancing the competence of physicians and other healthcare professionals in all 50 states from its offices in Denver, Colorado and Raleigh, North Carolina. CPEP offers focused courses on communication in the clinical environment, prescribing controlled drugs, and professional ethics as well as comprehensive clinical competence assessments.

Forum Focus – Bridging the gaps in effective communication (part one of a two-part series)

By Bill O’Neill, Director of Outreach and Communications for  the Center for Personalized Education for Physicians

The Physician Leadership Forum’s white paper, Lifelong Learning: Physician Competency Development, examines the ACGME/ABMS core competencies and identifies gaps between the perceived importance of each competency and the evidence that each is put to work in the hospital. The gap between importance and evidence was particularly apparent in one area: Interpersonal and Communications skills.

Everyone can agree on the importance of effective information exchange and the ability to work cooperatively in a health care team, but is everyone willing, or able, to devote the time and effort required for success in those areas? Evidence suggests there is still work to do. This article is the first of a two-part series, and will deal with the effective exchange of information on medical teams. While common pitfalls will be described, the real focus will be on improvement approaches for individuals, as well as strategies leaders can employ to create cultures of meaningful communication.

Effective Information Exchange via Effective Documentation

For the most part, effective information exchange in the hospital setting is accomplished through appropriate charting and record keeping. “Done well, documentation should serve multiple purposes: improving quality of care, patient safety, and institutional finances all at the same time,” said Dr. Joel Dickerman, Chief Medical Officer at Community Care in Colorado Springs, Colo. According to Dr. Dickerman, positive financial outcomes and effective documentation often go hand in hand. “Effective documentation contributes to effective transition of care, which in turn leads to reduced readmission rates and increased patient satisfaction – both metrics that improve patient care and reduce non-beneficial care,” he said.

Have Electronic Medical Records (EMR) Helped?

According to Dr. Dickerman, EMR systems do not always live up to their promise. If these systems are simply used to improve legibility and capture procedures and charges, they are not being utilized to their full potential. “EMR systems are tools, not solutions by themselves. Documentation should be viewed as a form of communication, not just a means of capturing charges and minimizing liability,” he said.

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, feels the structure of some EMR systems may contribute to this problem. “EMR systems do a good job capturing charges and documenting that various quality measures are being implemented (asking about smoking status, blood sugar control, etc.). Unfortunately, this can make a smooth narrative of patient care hard to find – and that can be problematic when there is a transition of care,” he said. As a result, he adds, “the architecture of these systems needs to evolve, making sure that clear, intuitive provider-to-provider communication is front and center in these systems.”

Never Enough Time…

Participants in CPEP’s Medical Record Keeping Seminar report that the biggest roadblock they face in improving documentation is time – a precious commodity in short supply. In addition to proactively building documentation time into the clinical schedule, Dr. Dickerman, the seminar’s program director, suggests hiring medical scribes as an effective approach. “The additional patients you see will more than pay for the service and allow you to be a doctor – not a typist,” he said. The American Health Information Management Association has a resource page devoted to medical scribes at http://bit.ly/145Gs36.

Strategies for Hospital Leaders – How to Improve Documentation at the System Level

Dr. Dickerman hypothesizes that the advent of value-based reimbursement may change the picture with its greater emphasis on quality of care, highlighting the value of effective documentation. He notes, however, “Some physicians may need to relearn lessons in professionalism and communication in such an environment.”

One way to encourage a new outlook on these issues is to put systems in place in which hospital and physician incentives are well aligned. While some hospitals are now reimbursed on a population health management basis, the physicians within those organizations may still be reimbursed on a volume-based, fee-for-service model. Improving the alignment of hospital and physician incentives will encourage physicians to view medical record keeping as an opportunity for ensuring and improving patient care rather than as a series of check boxes and drop-down menus that document individual procedures.

Dr. Katie Richardson, Director of Physician Experience at the Colorado Permanente Medical Group, notes, “At Kaiser Permanente, we’re incentivized to do what’s right for the patient, and our success is measured by the quality of our care, not by our productivity. We have medical informatics and communications teams that work closely together on training in oral and written communication/documentation, and the training is done almost exclusively by physicians. What’s more, our documentation skills are reviewed annually by our local physician leaders to ensure that each of us is communicating clearly with colleagues as well as patients in the After Care Summary – a Core Measure of meaningful use requirements.”

The Road Ahead: Transparency for Patients

In separate interviews, Kaiser Permanente’s Richardson and Mayo Clinic’s Wald independently noted the new reality of patients’ access to their data, and the subsequent demand for clear and cogent documentation. Dr. Wald notes, “Traditionally, the ultimate goal of EMR systems was clear communication with colleagues, ensuring smooth transition of care. More and more, however, patients demand greater access to their information and so clear documentation needs to speak to them as well.” Dr. Richardson concurs, “Full transparency of medical records with our patients is coming. As patients gain full access to their information, the responsibility for creating clear and meaningful stories of care will only grow more acute.”

Conclusion

The effective exchange of information through appropriate record keeping is a challenge for individuals and institutions alike. However, access to available educational resources, combined with innovative strategies driven by committed physician leadership can improve quality of care, reduce the risk of medical error and make measurable improvements to the financial health of health care institutions.

About the Author

Bill O’Neill is Director of Outreach and Communications for CPEP, the Center for Personalized Education for Physicians (www.cpepdoc.org). CPEP is a 501 (c)(3) organization offering comprehensive clinical competence assessments, customized education plans for physicians, and focused educational programs including Medical Record Keeping, Improving Interprofessional Communication, Prescribing Controlled Drugs, and ProBE (Problem-Based Professional Ethics).

Forum Focus – Physician payment reform and the SGR fix

After 18 years and 17 “temporary” patches, Congress finally passed legislation – the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – earlier this spring to permanently repeal and replace the Medicare physician sustainable growth rate (SGR). The SGR fix and its implications for physician payment were the subject of a recent Physician Leadership Forum webinar.

The SGR formula was replaced with specified payment updates. For the next four years, Centers for Medicare & Medicaid Services (CMS) will apply an annual update of 0.5 percent to the physician fee schedule. Beginning in 2019, payment rates will remain flat, and physicians and providers paid under the physician fee schedule must choose whether to be paid under a merit-based incentive payment system (MIPS) or through alternative payment models (APMs).

The MIPS will tie physician payment directly to performance measurement. MACRA sunsets the current-law physician quality reporting system, meaningful use and value-based modifier programs and incorporates the measures and processes for these programs into the MIPS. Professionals’ performance will be assessed in four specific areas: quality, resource use, clinical practice improvement activities and meaningful use of electronic health records (EHRs). That performance will then be used to determine a payment adjustment. The payment adjustment – in the form of bonuses for high performer and penalties for poor performers – will be assessed on a sliding scale and capped at +/- 4 percent in 2019; +/- 5 percent in 2020; +/- 7 percent in 2021; and +/- 9 percent in 2022 and subsequent years.

As an alternative, physicians and other professionals who receive a significant proportion of their payments through an entity that participates in a qualifying APM, such as the Medicare Shared Savings Program, will earn an additional 5 percent payment each year from 2019 through 2024. In addition, beginning in 2019, qualifying APM participants are exempt from the MIPS, as well as most EHR meaningful use requirements. A qualifying APM entity must require use of a certified EHR, bear more than nominal risk for financial loss, and tie payments to APM participants based on quality measures comparable to those used in the MIPs.

Bryan Gamble, MD, MS, FACS, president and CEO of the Florida Hospital Medical Group, discussed the work his medical group has done to manage the clinical and financial risk in alternative payment models. He discussed the different categories of payment and how a larger percentage of Medicare fee-for-service payments will be linked to quality and APMs. He said his group is focusing on the way they deliver care, following the Triple Aim of improving the health of the population, improving the quality of care they receive all while reducing costs.

Gamble described other factors driving change and dollars in the marketplace such as value-based payments and a movement from inpatient to ambulatory space. He especially underscored the increasing role of consumerism in health care. He said patients are looking for convenience in handling their health care needs. They’re interested in technology and connectivity. In the near term, he said compensation will be determined on a number of issues such as coding accuracy/audits, as well as Stark Law implications, fair market value, commercial reasonableness, and designated health services.

For more on this issue, see our webinar SGR Fix: Implications for Physician Payment.