Forum Focus – AONE Toolkit and Guiding Principles on Mitigating Violence in the Workplace

Workplace violence is an increasingly recognized safety issue in the health care community. In 2010, the Bureau of Labor Statistics data reported health care and social assistance workers were the victims of approximately 11,370 assaults by persons. While workplace violence against health care professionals can and does happen everywhere, the hospital emergency department is among the most vulnerable settings. According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported.

Concerned about the issue, members of the American Organization of Nurse Executives (AONE) and ENA met to discuss how incidents of violence are currently addressed in hospitals and the need to create an environment where health care professionals, patients and families feel safe. A culture change is also needed so violence against health care professionals is no longer viewed as “part of the job.”

The outcome of the meeting was the development of guiding principles and a tool kit to assist nurse leaders in systematically addressing measures to manage and reduce violence against health care professionals in hospitals.

Guiding Principles and Priorities

The guiding principles are steps to systematically reduce lateral, as well as patient and family violence in the work place. These include recognizing that violence can and does happen everywhere, requiring an interdisciplinary team, which includes patients and families, to address workplace violence, and that addressing workplace violence may increase the effectiveness of nursing practice and patient care.

The priority areas delve deeper into the guiding principles, focusing on five areas critical to a successful workplace violence prevention program. They challenge organizations to take a closer look at their social environments, figure out how hazards can be addressed and what training may be required to mitigate them, and devise a way to measure success.


The toolkit provides step-by-step procedures for customizing a violence prevention plan for organizations, as well as templates to document progress. It begins with defining what constitutes workplace violence and providing resources for organizations to develop a zero-tolerance policy. It next shows organizations how to assess the risk factors in their facilities and develop a workplace violence prevention plan. It also offers a number of resources organizations can utilize to train and deploy staff to recognize what isn’t acceptable and what to do if they witness workplace violence. Lastly, it provides resources organizations can use to evaluate the changes and identify next steps in the process.

To download the toolkit and guiding principles, visit

Forum Focus – The skills doctors and nurses need to be effective executives

This article originally appeared on the Harvard Business Review ( on April 7, 2015.

By Sachin H. Jain, MD

We are witnessing an unprecedented transformation of the health care industry. There has been a rapid growth in jobs and an explosion in the number of start-ups. There are new types of insurance companies such as Oscar; novel provider organizations such as OneMedical, IoraHealth, and ChenMed; and new health information technology companies such as Castlight, Vital, and WellFrame that aim to use technology to improve care and value. Physicians and nurses are being called upon to lead these new health care enterprises — and are assuming a higher level of influence in the business of health care than ever before.

Maximizing the effectiveness of physicians and nurses in these new positions, however, will require different skills than the ones they developed during their clinical training. Having managed or worked with clinical leaders in care-delivery organizations, the pharmaceutical industry, and government, I have observed three skills that are critical to the success of doctors and nurses as they make the transition to management:

Operations management and execution. Many physicians and nurses excel at operations management because it requires the same kind of detail and complexity that is required to effectively manage a large clinical load.  In clinical work, we must constantly triage patients and parse significant amounts of low and high-level detail. Many clinicians manage a small operation in the form of their own clinical practice or ward before shifting to leading larger operations.

Still, many clinicians struggle with operations management because they fail to appropriately distinguish between urgent tasks and important, non-urgent tasks — often letting the latter fall by the wayside in favor of the former. Just as a first-year resident physician or a fresh nursing graduate must learn to manage his or her own workflows and develop a plan of attack to manage a patient’s issues, so too must a new clinician executive learn to act with urgency and ownership to build an organization’s workflows and address its problems. Clinician leaders should recognize this potential gap in perspective and work actively to make sure that tasks are appropriately triaged by priority level.

People leadership. When thrust into a management or leadership position, many clinicians have never hired or fired anyone in their life. The instincts crucial to deciding whom to hire and how to hire them managing others’ performance are often underdeveloped in clinical leaders. For example, many clinicians, by nature and by training, are kind and compassionate. While these qualities help engender loyalty, they often make some of the difficult conversations associated with managing people especially challenging.

To accelerate the development of their people-management skills, clinicians should partner closely with fellow business leaders and HR professionals. These colleagues can be instrumental in helping them surface their needs and identify tactics to build and manage high-performance teams. These colleagues can also serve as sounding boards when they must make hard decisions and hold inevitable hard conversations.

Setting and defining strategy. Many clinician leaders are drawn to roles in which they can actively work to define organizational structure and strategy. While strategy roles often tap the strengths and deep frontline knowledge of clinicians, executives with clinician backgrounds often forget that creating a strategy involves making trade-offs. The decision to pursue one set of activities is often a decision not to pursue another. Strategy guru and Michael Porter of Harvard Business School elegantly articulated this when he wrote that strategy is both what we choose to do — and what we choose not to do. Clinicians must work to develop organizational strategies with this simple and important maxim constantly in mind.

One CEO with whom I have worked remarked that physicians and nurses run the risk of losing their clinical identities as they develop into executives. It would be a shame if they did. As they transition to careers in the business of health care, clinicians must hold on to the heart and practice of medicine as they continuously develop the core executive skills required to effectively lead and shape their organizations. Health care will be markedly better for it.

Sachin H. Jain, MD, is chief medical officer of the CareMore Health System, a division of Anthem, Inc., and a lecturer in health care policy at Harvard Medical School. Follow him on Twitter at @sacjai.

Forum Focus – Recognizing and Addressing Physician Stress and Burnout to Improve Satisfaction and Patient Care

By Alan H. Rosenstein MD, MBA, Michael R. Privitera MD, MS

There are a growing number of surveys and reports attesting to the increasing amount of stress and burnout impacting physicians in today’s health care environment, affecting nearly 80% of practicing physicians.1 The downstream impact of protracted stress and burnout can lead to a number of problems ranging from dissatisfaction, frustration, and anger, to more serious physical and emotional states that affect behavior and can compromise work relationships and patient care.2,3 While many organizations are beginning to recognize the impact of stress and burnout on satisfaction, productivity, care coordination, and clinical performance, there are still a number of barriers that need to be resolved.

First is the issue of perception. Many physicians are working at full capacity but may not recognize that their mind and body are working under stress. The cultural norm in pre-med, medical school, and residency is to push oneself beyond usual human abilities. Usual human feedback systems are often suppressed, and even when physicians realize stress may be taking a toll, many choose to handle it themselves and are often reluctant to seek outside help because of self- ego, stoicism, questions about competency, or concerns about confidentiality. Often problems related to stress are only addressed after a career-changing decision or disruptive event occurs where intervention may be focused more on damage control than emotional support.

The second issue is that of organizational response. With the changing priorities and incentives in today’s health care market many organizations are faced with increasing demands on physicians and supporting staff to meet the evolving challenges of health care delivery. Providers have their own concerns and at times feel that changes are being made without an opportunity for their input or discussion. Organizations need to be mindful of physician and staff concerns and take a leadership role in educating, involving, and engaging clinical staff in organizational decisions.

The third issue is socio-political perception. Patient safety initiatives and the Triple Aim efforts of improving the experience of care, improving the health of populations, and reducing per capita costs of health care may have unintentionally overlooked supporting the clinicians providing the care. Hospitals and health systems have had to rapidly adjust to uncoordinated mandates from multiple sources. Until recently, the trickle down incremental, cumulative effect on physicians and staff had been unrecognized as a major source of occupational stress. Reduction and prevention of physician occupational stress and burnout is beginning to be recognized as a patient safety concern and included in patient advocacy efforts.4 Recently, organizations such as The Joint Commission, National Patient Safety Foundation, and the American Hospital Association published recognition of the need to reduce stress and burnout.5-7

We have several recommendations. First is that the health care organizations recognize the need to support clinical staff to meet regulatory requirements while reducing occupational stress and sustaining wellbeing. The next step is to assess the current status of physician morale. Provide opportunities for physician input and involvement focused on ways to help them succeed. Surveys can help gather needed site-specific information. Inquiry should invite candid feedback about the positives and stressors of the work environment as well as actionable solutions. Results should be shared in aggregate form with management, physicians, and staff in a timely way to enhance trust through transparency. Using the results in future meetings can develop dialogue needed to encourage creative solutions. Using these dialogues as a basis, organizations can begin to provide education about the changing priorities and accountabilities in care delivery and work collaboratively with clinicians to pursue the mutual goal of providing appropriate, effective, high quality, safe, and satisfying patient care.

Maybe what’s most important is to provide the physician with emotional support. At one end is the issue of educating them about the dynamics surrounding health care delivery. Increasing awareness will increase understanding, which will lead to improved compliance and more satisfactory and effective hospital- physician- staff- patient relationships. Another level is to provide them with the skill sets to be more effective communicators and collaborators to enhance staff and patient relationships and satisfaction. Providing additional programs that focus on diversity management, cultural competency, Emotional Intelligence, stress, anger, or conflict management are helpful in improving behavioral compliance. In some cases individual coaching and counseling may be necessary which might be offered internally through Human Resources, Wellness Committees, a Physician EAP (Employee Assistance Program), or outsourced to a specialty vendor. In some cases, disciplinary action must be taken to address behaviors that could compromise patient care.8

We are all in this together. Physicians and all clinical staff are a precious resource whose focus is to deliver the best care. Hence, it is essential that the healthcare system administration, clinicians, and staff be seen as a team that through collaboration and aligned goals provides the best care possible to their community.

  1. Physician Stress and Burnout Survey 2015 Cejka Search and VITAL WorkLife Report
  2. Danielson, D., Ketterling, R., Rosenstein, A. “M.D Physician Stress and Burnout: Causes, Effects, and Impact on Performance and Behavior AMGA Group Practice Journal Vol.62 No.3 March 2013 p.38-41.
  3. Rosenstein, A. “Physician Stress and Burnout: What Can We Do?” American College of Physician Executives Vol.38 No.6 November/ December 2012 p.22-30.
  4. Privitera, M., Rosenstein, A., Plessow, F., LoCastro, T. “Physician Burnout and Occupational Stress: An Inconvenient Truth with Unintended Consequences” Journal of Hospital Administration Vol.4 No.1 December 2014 p.27-35.
  5. National Patient Safety Foundation, “Patient Safety News and Resources”
  6. The Joint Commission, “Physician Leader Monthly”
  7. American Hospital Association, “Physician Leadership Forum”
  8. Rosenstein, A. “Bad Medicine: Managing the Risks of Disruptive Behaviors in Health Care Settings” Risk Management Vol.60 No.10 December 2013 p.38-42.

For more information, contact Alan H. Rosenstein MD, MBA, at

Forum Focus – Back in the saddle again: The value of reentry physicians to hospital systems

By Bill O’Neill, Director of Outreach & Communications, Reentry to Clinical Practice Program, CPEP – The Center for Personalized Education for Physicians


“When a patient is newly covered by Medicaid, that doesn’t guarantee a primary care doctor will take them on – and they often end up coming to us. Our ER traffic increased 10% between 2013 and 2014.”

Greg D’Argonne
Chief Financial Officer of HCA-HealthONE and the HCA Continental Division


By now, the growing shortage of physicians in the United States has become common knowledge. “Geographic maldistribution” issues compound the problem. Some fortunate regions have an abundance of physicians, while others fall far short. HCA’s D’Argonne adds “The supply of physicians varies a lot depending upon the community. Lots of people want to move to Denver for the climate and lifestyle, so there really isn’t a noticeable shortage here. On the flip side, smaller cities without those advantages can face a very different situation.”

Changing Models, Changing Needs

The historical model of reimbursement in which incentives are aligned with increasing volume of procedures and services is fading fast. David Watson, Chief Medical Officer of the Centura Health Physician Group, comments, “Health systems are moving to managing population health in an ever increasing manner. Population health is best served at the primary care level and the supply of PCPs is insufficient to meet demand. The need to increase the number of providers, especially in the primary care field, is likely not going to stabilize for well over a decade.”

So what to do about these issues? Expanding the number of physicians by increasing the number of Medicare-supported residency programs may be an option, but federal budget scenarios are tight and developing new slots could take years. Working to grow the number of allied healthcare providers – PAs and NPs – can also help, but those providers are limited in the types of cases they manage.

Reentry Physicians as a Partial Solution

“Reentry physicians are like a ‘rapid deployment force’ – a relatively quick way to expand the number of practicing physicians when compared to expanding the medical school-residency-fellowship pipeline.”

Steven Summer
President and CEO of the Colorado Hospital Association

“Reentry” applies only to clinicians who left practice voluntarily for two years or more due to a variety of reasons, such as family obligations, personal health reasons, alternate careers, or retirement, and wish to return to the workforce to practice in the same specialty. The term does not apply to those who left practice for disciplinary reasons.

A lot can happen in a physicians’ life – and in the medical world – while he or she is away from patient care. Physicians may be required to demonstrate competence in order to obtain a medical license or join a practice. The clinician may choose to participate in a formal reentry training program, such as the program offered by CPEP, or engage in a self-managed reentry process.

“The literature indicates there is often a gap between a physician’s opinion of his or her competence vs. the results of an objective, third-party assessment. Working with an established, structured assessment and education program may result in the best outcomes for reentry physicians their prospective employers, and most importantly their patients.”

Scott Kirby, M.D.
Medical Director, North Carolina Medical Board

There are a handful of formal reentry programs across the country providing evaluation and education services. The length, activities, and cost of these programs vary. Established in 2003, CPEP’s Reentry to Clinical Practice (RCP) program is one of the original programs in the field. Through the RCP Program, participants complete an educational needs assessment in clinical skills and medical knowledge and an educational plan is developed. These structured plans include focused study, precepted education, and resumption of clinical activities under gradually decreasing levels of oversight. Once the clinician successfully completes the Reentry Plan, they receive documentation from CPEP summarizing their reentry efforts and their preparation for independent practice.


While physician shortages are major problems that lack easy solutions, hospital systems and group practices should explore the potential benefits of hosting reentry physicians in a preceptor setting. These candidates are experienced, highly motivated clinicians who can provide significant economic benefit to their hosts while bringing much-needed services to the communities in which they live.

Additional Resources

To download a copy of “The Roadmap to Reentry” developed by CPEP and the American Academy of Pediatrics, click here.

To access directories of structured reentry programs, visit the Physician Reentry to the Workforce Project website.

About CPEP and RCP

CPEP is a 501 (c)(3) organization that works to promote 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’s RCP program has had a broad impact since its inception, with over 150 physicians from states enrolled in the Clinical Practice Reentry Program since 2003.

Forum Focus – Creating exceptional physician-nurse partnerships: Using collaborative partnerships to raise the standard of care and improve the overall patient experience

By Alan J. Conrad, MD, MMM, CPE, FACHE, Medical Director of Palomar Health ( and Tracy Duberman, PhD, FACHE, CEO & Founder of The Leadership Development Group (


To lead today, health care organizations require a fundamentally different approach to care giving, one that is patient-centric with a strong focus on the patient experience, quality and safety, clinical integration, care coordination and waste reduction. In order to be best positioned for the future of value-based care, health care organizations must develop their clinical (physician and nurse) leaders as partners in team-based care delivery. Leaders in health care must work under an interdependent, rather than an independent, leadership model.

To that end, physician and nurse leaders must work collaboratively with open communication and trust in order to achieve common goals. Successful partnerships work together to set goals, create operating and capital budget, implement initiatives, and oversee operating and clinical performance. The focus of the partnership is shared responsibility, and equal accountability. In our recent webinar, we shared a case study of a health care system that has successfully developed its clinical leaders toward effective partnership.

Palomar Health’s Approach

Palomar Health, a 3-hospital system based in San Diego, California, recognized the need to develop physician leaders as partners to meet system, operational and clinical performance goals. Prior to intervention, Palomar lacked formal physician leadership (CMO) on their senior management executive team, and lagged on HCAHPS scores. Palomar sought a partnership with The Leadership Development Group (TLD Group), a recognized leader in physician leadership development, to design and deliver their Academy for Applied Physician Leadership (AAPL) based on TLD Group’s Applied Physician Leadership Academy (APLA©), a multi-faceted physician leadership development program entirely customized to deliver high value and high impact to health care and life sciences clients. The customized physician leadership development model addresses the need for collaborative partnerships between physicians and nurses for enhanced patient satisfaction, engagement and outcomes. The program utilizes multiple learning strategies including 1:1 assessment and coaching, learning and application modules, and action learning projects.

A key component of Palomar Health’s AAPL was, a Partnership Activation Process, an action learning-based experiential learning platform to enable clinical partners to enhance their collaborative leadership skills while tackling issues on their unit. The process enabled partnerships to identify solutions to problems that provide immediate, measurable impact and organizational results. Participants were broken into Partnership Activation groups consisting of physicians and nurses from both inpatient hospital units and outpatient clinics. Groups were facilitated by an Action Learning Coach and were asked to pick a project that would impact their units in a positive way. Groups met on a monthly basis over a 4-month period to work on their projects.

Participants were led through a project planning approach where they identified the problem to be solved, considered potential obstacles or challenges to implementing a solution, formulated a vision of success and desired state to be achieved, and determined the best solutions and actions to achieve success. Projects included: enhancing the physician/nurse rounding process, expansion of acute rehabilitation services, improving the mother-baby discharge process, and several others. The Partnership Activation Process also included a peer coaching/action learning Model, which led participants through reflective listening, active questioning, challenging assumptions, and giving/receiving feedback while taking their projects from concept through to solution and implementation.


Palomar Health’s AAPL program led to significant results that surpassed the desired goals. Press Ganey scores increased considerably. Overall physician ratings increased from the 30th to the 66th percentile, overall nursing ratings jumped from the 33rd to the 82nd percentile, and overall system ratings from 14th to 76th percentile. There was also an increase in HCAHPS scores for the question item entitled “My physician listens carefully to me” suggesting that patients recognized an improvement in physicians’ listening communication skills.

Participants of the AAPL program also developed learning competencies including an understanding of how their emotional intelligence impacts others, knowledge of their role as a clinical leader, identification of a clear purpose for their partnership relationship, and the ability to drive patient satisfaction and physician engagement.


Palomar Health’s customized Academy for Applied Physician Leadership was designed for physician leaders, nurse leaders, and administrators to drive alignment on the system’s goals, build leadership competencies, and facilitate a team-based approach to care giving. The Partnership Activation Process helped to strengthen trust, build relationships, and enhance communication between the physician and their nursing partner to establish collaborative partnerships which raise the standard of care and improve the overall patient experience.

To view the webinar, please visit

Forum Focus – Developing a workforce for health

By Dan Paloski, Communications Specialist, AHA’s Physician Leadership Forum

In 2011, the American Hospital Association (AHA) and a roundtable of clinical and health system experts crafted a model for a redesigned primary care system, one that encompasses the birth to end-of-life continuum and defines primary care workforce roles. Two years later, the AHA convened another roundtable, this time to discuss reconfiguring the bedside care team in order to meet the demands of health care reform. Below are some key findings from the reports.

In “Workforce Roles in a Redesigned Primary Care Model,” the roundtable’s most important recommendation was the creation of a hub-and-spoke model where patients, their families and the healthy community are at the center of everything. Radiating out are the different health care professionals, charged with delivering care in a team-based setting and to the full scope of their practice. Communication is essential for this model to work, not only among those charged with providing care to the patient, but also with patients and families. Clinicians need to engage patients actively in discussions and decisions regarding their own care and develop strategies to help them effectively manage that care.

One of the greatest challenges highlighted by the roundtable was re-educating the workforce to work in a team-based model of care. In order for teams to function at their highest ability, a fundamental shift in how people are trained needs to take place. Medical schools, colleges, and centers of professional education need to redesign curricula to meet today’s current clinical needs. At the time of the report, roundtable members were concerned with the slow progress on the part of schools and universities in preparing their students for team-based care. In the three years since, some progress has been made. For example, two schools, Brown University and the University of Michigan, have incorporated inter-professional education into their curricula. Both universities are piloting workshops and programs that bring together students from different clinical disciplines and have them work together to solve different issues.[1]

The report also emphasizes the need for a stronger partnership between the community and hospitals. Essentially, hospitals need to evolve into “health systems,” with hospitals as the drivers of community-based population health management. This issue is particularly important for rural areas where primary care access can be limited. Innovative ways to deliver care, including utilizing information technology, telehealth, after-hours access, and non-traditional settings will be vital. The focus should be on wellness that spans the full continuum, and not just on treating illnesses and chronic conditions. In a recent article for USA Today, Rich Umbdenstock, president and CEO of the American Hospital Association, said, “Hospitals are undergoing a major shift, building collaborative teams that are improving the coordination of health care. They’re partnering with other health care providers and experimenting with new ways to provide care where people live and work — not just at the local hospital.”[2] Ultimately, this evolution of hospitals into “health systems” will not be successful without the establishment of a true and balanced partnership with the community.

In “Reconfiguring the Bedside Care Team of the Future,” the authors call for a paradigm shift in how the traditional bedside care team is defined. The report touches on a few of the same themes as the “Workforce Roles” report, namely making sure patients and their families are seen as essential members of the care team, as well as the use of information technology in facilitating and complementing the clinical judgment of the care team. The report identifies four other principles to guide this change in the bedside care team. First, bedside care team members must be fully engaged, working at the full scope of their practice. Second, the care team should be localized to a unit and should be limited to only those patients/families located within that unit. Team members must also be vigilant in coordinating communication with the patient/family. Third, the team should be balanced in regard to meeting patient needs. Evidence-based guidelines that improve care should be developed and followed by all team members. Fourth, no matter where they are in the continuum of care, patients needing acute care should be able to safely move through it.

In response to the shifting and evolving health care system, new models of care are needed, specifically concerning primary care and the bedside care team. With more patients coming into the system and a projected clinical workforce shortage, a team-based care approach with clinicians working to the full scope of their practice is critical. Care must revolve around the patient and family and must be available at any access point along the continuum. In 2015, the AHA Workforce Center plans on developing additional resources to assist hospitals with redesigning and reconfiguring their workforce to meet new care model demands. Copies of both white papers discussed above, along with other workforce resources, can be found at the AHA Workforce Center website,


[1] AMA Wire, 4/24/14,

[2] USA Today, 12/8/14,

Forum Focus – AHA unveils toolkit to help hospitals hire veterans

The American Hospital Association (AHA) is excited to share with hospitals and health systems a new hiring resource, “Hospital Careers: An Opportunity to Hire Veterans.” Part of AHA’s continued efforts in support of the federal Joining Forces initiative, the toolkit was developed with input from nearly 20 groups representing hospitals, nurses, physician assistants, community health centers, the federal government, veterans and military members. It’s designed to help hospitals recruit and hire veterans with clinical and leadership skills into nursing, physician assistant and other hospital careers, and includes examples of organizations doing as such, for example the Scottsdale Lincoln Physician Network.

Excerpted from “Hospital Careers: An Opportunity to Hire Veterans,” American Hospital Association, November 2014, pg. 11.

HOSPITAL HIRE: From Active Duty to Patient “Coach”

Scottsdale Lincoln Physician Network, part of the John C. Lincoln Accountable Care Organization in Arizona, has begun a program to hire veterans as patient transition coaches in order to lower readmissions.

The health system connected with local veteran organizations and asked that former hospital corpsmen and/or combat medics participate in the program. In September 2012, they started with two veterans and, after the initial success, spent time refining and building out the program, raising $780,000 to date from community groups to fund it. Within months, their readmission rate went from 21 percent to six percent. Currently, there are 14 transition coaches who work from a list of Medicare patients as well as hospitalist/nurse orders for visits. Visits are conducted early in the admission so the transition coach gets to know the patient and helps them get ready for their transition needs. The day after discharge, they visit the patient at home and do a variety of services from health checks to scheduling home health visits, to doing the dishes and moving or rearranging furniture to minimize falls. Furthermore, they do a social work assessment for additional services that might be needed. A transition services record in the electronic health record enables all clinicians to see their notes.

The coaches are highly motivated and have initiated programs with the pharmacy assistants to ensure patients can read their medication bottles (enlarging text as needed). As part of the program, all coaches are enrolled in college degree programs and most are pursuing clinical/health care positions. The program is co-led by a physician leader who reviews cases and provides focused supervision and a retired Air Force colonel administrator who provides an understanding of the specialists’ military background. Click here to view a video of their program:

Forum Focus — It’s not just a numbers game: Implementing a patient blood management program

Patient blood management (PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. According to the AABB, an international, not-for-profit association representing individuals and institutions involved in transfusion medicine and cellular therapies, PBM can reduce complications, save lives, and reduce expenditures.[1] AABB recently issued a list of five recommendations to decrease overuse of blood and improve patient care as part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.

Hospitals, as part of their mission to serve as good stewards of limited resources, have begun to develop PBM programs and protocols for efficient and consistent practice across the organization. The American Hospital Association, under the direction of its Committee on Clinical Leadership, developed “Appropriate Use of Medical Resources,” a white paper released in November 2013 that identifies five areas where hospitals, in partnership with their clinical staff and patients, should look to reduce non-beneficial care. To help hospitals and their communities address these recommended areas, the AHA will release toolkits throughout the year targeting each of the five procedures/interventions. The first, appropriate blood management in inpatient services was developed with AABB and released in April.[2]

One of the members of the Committee on Clinical Leadership, Dr. David Perlstein, Chief Medical Officer and Senior Vice President of SBH Health System in the Bronx, New York, shared his hospital’s experience in developing a patient blood management program. Joining him was the PBM physician champion, Dr. Robert Karpinos, Chair of Anesthesiology, and the Medical Director of Perioperative Services. SBH Health System includes a 461-bed community teaching hospital and Level I Trauma Center serving a diverse population in an economically disadvantaged area, with a payer mix largely skewed to Medicaid. With nearly 100,000 emergency room visits and nearly 3,000 staff, SBH Health System has been a cornerstone of their community for over a century, incorporated in April 1866 as America’s first chronic disease hospital and the inspiration for many to follow.

Getting Started

The SBH Health System PBM program grew from a strong patient-centered culture that focuses on putting the patient first and empowering every employee to take an active role in making patient care better. In looking for ways to provide better care and improve the patient experience while remaining good stewards of their limited resources, blood management seemed a worthwhile pursuit. Patient blood management allowed SBH Health to decrease patient risk, improve quality of care and outcomes, respect patient autonomy, and involve patients in the care process. In addition, if done right, the PBM program had the potential to reduce blood use and save resources.

According to Dr. Perlstein, education was the major driver for PBM adoption. Dr. Karpinos agreed that physician buy-in was a matter of education and awareness. The initial development rested largely in the hands of the PBM physician champion, Dr. Karpinos. He began the journey by reaching out to the Society for the Advancement of Blood Management (SABM) to learn more about becoming a certified center of excellence. Dr. Karpinos then met with critical stakeholders and department chairs to make the case for PBM. Using that feedback and enthusiasm to develop a steering committee, Drs. Perlstein and Karpinos brought the concept to the hospital leadership committee. The combination of a patient-centered culture and largely clinically-trained leadership team supporting the effort created a place for the steering committee within the transfusion committee. Deliberate in their choices, Drs. Perlstein and Karpinos brought leaders from Informatics, Care Transitions, Internal Medicine, Outpatient medicine, and other key departments to the steering committee early on to help champion the PBM effort. In addition, support from the nursing community was essential.

As an initial task, the steering committee looked at blood usage patterns across the hospital and armed with a clear call for reducing unnecessary utilization, launched an educational program with nationally recognized guest speakers sharing the clinical evidence for PBM, the advantages and disadvantages of using blood and blood products, and the potential risks for patients. While in hindsight Dr. Karpinos would have brought the steering committee together sooner to speed the transition, he is pleased with the response across the organization. As they move toward full implementation following the year-long groundwork and education efforts, SBH Health System expects they will need additional resources for data analysis to track results and staff to coordinate the program.

PBM is a comprehensive blood management program, so moving beyond transfusion rates was important to SBH. As part of their comprehensive approach, SBH Health System is making changes to their anemia management protocols; changing standards from two units of blood to one unit, for example. The anemia and transfusion protocol revisions are being reviewed for approval by the medical staff in preparation for full PBM program implementation. By including the directors of medicine and medical informatics on the steering committee, there is broad support to drive the changes.


Dr. Perlstein was most surprised by the rapidity with which the clinicians and staff accepted and were excited about a PBM program. Neither Dr, Perlstein nor Dr. Karpinos expected the multi-disciplinary support across the hospital as well as the buy-in from more senior physicians who would be changing lifelong practice patterns to new protocols. Both credit the clinical evidence and educational campaign for making the PBM case clear and compelling to the full spectrum of clinical staff.

Additionally, although it was not the intent, a PBM program also allows them to provide services to a sizeable population in their community sensitive to the use of blood and blood products. While PBM was undertaken as a quality improvement to the delivery of care, once the program is fully implemented, SBH will be able to address the needs of this population as well.

Lessons Learned

Dr. Perlstein says the biggest lesson he learned is to look for opportunities and not shy away from them because of concerns over culture. Building cultural change takes time, but that shouldn’t preclude efforts like PBM which can help enhance the patient-centered approach. He also cautioned that creating a program like PBM is not a destination, it is a journey and it is important to do your homework before starting out. The key, he says, is to have a plan, approach it slowly and methodically. He also advises gauging the challenges early to address potential pitfalls.

Dr. Karpinos agrees with the slow, methodical approach noting there are many resources available for beginning a PBM program. The Joint Commission has proposed guidelines for transfusion therapy, and their home state of New York has issued transfusion therapy guidelines. He advises those interested in PBM to learn as much as possible from these resources, such as the toolkit available from AHA[3], and build a system that enhances your organization’s strengths and mitigates its weaknesses.

Finally, Dr. Karpinos advises those looking to start a program to “just do it:” get educated, do the research, do the background work, and don’t be afraid of changing the culture. Although it will take time, the results thus far are very rewarding.


[1] Patient Blood Management. AABB. Accessed 6/1/14 at

[2] Appropriate Use of Medical Resources. Physician Leadership Forum. Accessed 6/1/14 at


Forum Focus – A new alternative to clinical practice guidelines

Physicians at Boston Children’s Hospital have created a new alternative to clinical practice guidelines that allow for more flexibility, narrow practice variability, all the while letting clinicians tailor treatments to an individual patient’s needs. Called Standardized Clinical Assessment and Management Plans (SCAMPs), they also aim to optimize resources, improve patient care, reduce costs and keep pace with changing medical knowledge. An article (abstract only) published in the May 2013 issue of Health Affairs provides more details about SCAMPs. A summary of the article follows.

The need for change

Although clinical practice guidelines are intended to reduce variation and improve care, one of their main shortcomings is they do not account for individual and personal preferences among patients. The following of ridged guidelines may also reduce the autonomy of physician practice. Other shortcomings include the limitations clinical studies have in forming the foundation for the guidelines, and medical evidence used to form the basis of the guidelines usually has a short shelf life. Physicians at Boston Children’s Hospital thought there had to be a better way. This is how they came up with SCAMPs.

Creating a SCAMP

Developing and modifying a SCAMP involves eight steps and is led by a multidisciplinary group of clinicians.

  1. A group formulates a background paper on a particular disorder, examining the medical literature and relevant professional society guidelines in order to establish a foundation for sound clinical practice.
  2. Modeled on the processes/standards used to create practice guidelines, the group reaches a consensus on which patients to include in the SCAMP, what clinical assessments to include and how to structure the treatment methods.
  3. The group identifies what data will be collected to inform knowledge gaps that may exist.
  4. Electronic forms/tools are created to collect the data.
  5. The SCAMP is then piloted at a few sites before being deployed on a larger scale. A data coordinator helps with patient enrollment. Clinicians see and treat patients, in general, according to the appropriate SCAMP protocol, but are free to vary from the protocol for any reason, as long as he or she documents why they diverted from the protocol. The clinician makes sure to collect and record data on the patient, including the reason for diversions.
  6. A data coordinator gathers the information collected by the clinicians, as well as additional relevant information from the patient’s electronic health record. All of this information is stored in a database.
  7. After a period of six to 12 months, or a minimum of 200 patients have been enrolled, a statistician analyzes the data. The report is reviewed by the clinical group, as well as all of the clinicians participating in the SCAMP.
  8. Using data from the report, including the diversions, and new medical literature, the SCAMP is then modified for future use.


From early 2009 until the publishing of the Health Affairs article, more than 12,000 patients were enrolled in 49 SCAMPs in nine states and Washington, D.C. One study found clinician adherence to SCAMP protocols has exceeded 80 percent. Another analysis found that revising the SCAMP criteria for a genetic specialist referral on pediatric patients with a dilated aorta rose from 19.6 percent to 75 percent. Boston Children’s own analysis on six episodes of care where a SCAMP was implemented showed an 11-51 percent decrease in total medical expenses.


SCAMPs have shown to be a viable alternative to clinical practice guidelines. Because of their design, SCAMPs allow for a more flexible approach when it comes to patient care and clinician adherence, as diversions are permitted. They are routinely examined and modified to stay current with the growth of medical knowledge, thus ensuring high quality care is delivered using the appropriate amount of resources.

“SCAMPs have proved to be a very useful tool for many clinical scenarios, where there is insufficient information to inform medical decisions,” said Kathy Jenkins, MD, MPH, Senior Associate in Cardiology, Senior Vice President, Chief Safety and Quality Officer, Boston Children’s Hospital, and Professor of Pediatrics, Harvard Medical School. “SCAMPs allow rapid progress to reduce unnecessary resource utilization, while improving care delivery.”  

For more information on SCAMPs, contact Kathy Jenkins at Kathy.Jenkins@CARDIO.CHBOSTON.ORG.

Forum Focus – AIAMC National Initiative IV: Mastering the Clinical Learning Environment


By Dan Paloski, Communications Specialist, AHA’s Physician Leadership Forum

In 2007, the Alliance of Independent Academic Medical Centers (AIAMC), a national membership organization of major independent academic medical centers and health systems, was searching for opportunities to provide greater resident involvement in hospital safety and quality efforts. As part of their mission to help members integrate medical education and research into the organizational clinical mission, AIAMC felt focusing on resident quality improvement efforts had the potential to improve safety and quality quickly and with the greatest impact. To test this hypothesis, AIAMC created National Initiative I with the goal of improving patient care through graduate medical education (GME). Nineteen member academic teaching centers participated, integrating residents and GME into quality and patient safety initiatives. Participants found that integrating residents into existing efforts greatly increased the strategic value of their academic programs to the organization. The December 2009 issue of Academic Medicine featured five articles regarding the results of National Initiative I.

Two years later, AIAMC launched National Initiative II, this time focusing on residents and their involvement in five specific quality improvement areas: effective communication, hand-offs, infection control, readmissions, and transitions of care. Thirty-five institutions participated with results shared in a variety of publications including the May/June 2012 special supplement issue of the American Journal of Medical Quality, which recapped the June 2011 “Integrating Quality” meeting sponsored by the American Association of Medical Colleges. Thirteen AIAMC members that participated in National Initiative II and their project results were featured at this meeting.

In 2011, National Initiative III involving 35 teams was launched. It built on the strength of the first two phases and addressed the development of medical education faculty and teaching leadership. One of the main outcomes of National Initiative III was the development of a national network for improvement and sharing of best practices across the United States. Participants were also able to show how GME and continuing medical education (CME) play a central role in quality improvement, and how GME and CME can align with hospital leadership to improve quality of care. The proceedings of National Initiative III were published in the spring 2014 issue of The Ochsner Journal.

Last year, AIAMC launched National Initiative IV, which focuses on navigating the Accreditation Council for Graduate Medical Education’s (ACGME) new Clinical Learning Environment (CLE) review program. Created in 2012, CLE provides residency sponsoring institutions feedback on resident and fellow engagement in the following six areas:

  1. Patient safety
  2. Quality improvement
  3. Transitions in care
  4. Supervision
  5. Duty hours oversight, fatigue management, and mitigation
  6. Professionalism[1]

Each CLE site visit provides an opportunity for feedback and evaluation of how the institution addresses each of the six areas and begins and ends with a meeting with the senior leadership of the institution and the residency programs. Feedback is viewed as formative and the aggregate results of the CLE visits will help inform the ACGME’s next accreditation system, which emphasizes resident outcomes and learnings indicating they’re on the right path toward individual practice. The goal of CLE is for sponsoring institutions to use the feedback to continually improve in the six areas. In addition, ACGME hopes to learn how to best engage and involve residents and fellows in hospital efforts regarding patient safety and quality in the clinical environment.[2]

AIAMC’s current effort, National Initiative IV, began last October with 34 teams. Each team consists of a resident, faculty member, quality improvement professional and additional staff as needed. To begin, each of the teams completed a self-assessment survey against the six areas of CLE to determine which area would be their focus. The teams were subdivided by area for monthly teleconferences and discussions to share progress. As with the other initiatives, the groups convene for monthly conference calls, as well as attend four live meetings throughout the 18 months of the initiative. The four in-person meetings allow the six subgroups to collaborate and share best practices across the spectrum.

According to AIAMC, National Initiative IV is providing teams the training and guidance to:

  1. Identify strengths and weaknesses across the six areas
  2. Prioritize areas for improvement
  3. Outline, streamline and implement improvement strategies
  4. Significantly and measurably advance the institutional level of preparedness for addressing the CLE focus areas[3]

The next group meeting will be in Fort Worth, Texas in October 2014 with the final one taking place in March 2015. Led by AIAMC’s steering group, the Committee on the Integration of Academics and Quality, three scholarship teams have been formed to disseminate findings in the form of research, resource materials, and program descriptions at the conclusion of the initiative.

Overall participation has increased over the life of the National Initiatives and yielded results that have echoed throughout the organizations that have participated. “Ochsner Health System’s participation in all four AIAMC National Initiatives (NIs) has yielded far more than just finalized projects and presentations,” said Ronald Amedee, MD, Designated Institutional Official and Chairman, Otolaryngology, Ochsner Health System, and President, AIAMC Board of Directors. “In addition to substantial patient safety improvements, the NIs have provided us with the ability to submit manuscripts, create a robust Resident Quality Council and be recognized by our C-Suite for the value of GME and its integration in quality improvement efforts.”

For National Initiative V, AIAMC plans to involve residents and fellows in addressing health care disparities from the front line. National Initiative V participants will be selected in the summer of 2015 with the first meeting in October 2015.

For more information on the AIAMC and their National Initiatives, contact Kimberly Pierce-Boggs, Executive Director, at or visit



[1] Weiss KB, Wagner R, Bagian JP, et al. Advances in the ACGME Clinical Learning Environment Review (CLER) Program. Journal of Graduate Medical Education. Dec. 2013; 718-21.

[2] Ibid.

[3]Background of the AIAMC National Initiative. The Alliance of Independent Academic Medical Centers. Accessed 7/11/14 at