Millie offers midwife-led care to patients with low-risk or moderate-risk pregnancies.
Millie, a maternal care clinic based in Berkeley, Calif., features a midwife-led care model with doulas also providing support to patients.
A report published earlier this month by The Commonwealth Fund provides insights into the U.S. maternal mortality crisis. The report found that the United States has a higher maternal mortality rate than 13 other high-income countries. The report shows that the United States and Canada have the lowest supply of midwives and obstetrician-gynecologists among the high-income countries, and OB/GYNs outnumber midwives in the United States, Canada, and Korea.
Millie's model of care features collaboration and innovation, says Amy Kane, MD, medical director at the maternal care clinic.
"The model involves midwifery care with the support of a trained doula," she says. "Our doulas play the role of a support person in collaboration with the team. Our doulas provide prenatal and postpartum support, but they are not present at a birth."
Millie works in collaboration with physicians whenever patients have conditions that make them high risk, Kane says.
"We do not provide direct physician care, but we have strong relationships with the maternal-fetal medicine groups in the community, private OB/GYN groups in the community, and hospitalists who provide OB/GYN care," she says. "So, our midwives always have the support that they need, and our patients always have the support they need. If a patient develops a high-risk pregnancy, our midwives can hand them off directly to a physician for their care."
For most pregnancies, the most important Millie team member is the midwife, Kane says.
"The patient has a midwife who sees the patient throughout their pregnancy and the postpartum period," she says. "Most patients have the same midwife for all of their visits, but patients also get the opportunity to see other midwives on the team. Midwife visits are both in-person and virtual."
Tech support is one of the innovative elements of Millie's care model.
"One of the special things about Millie is the educational resources on our app," Kane says. "Even when you have longer prenatal visits like we do, there is never enough time to teach patients as much as they need to know. So, providing educational resources is critical. It is hard to get the right information—the Internet is vast, and it is hard for patients to find reliable sources of information."
Millie has an effective care model because the clinic is setting up a situation where patients are cared for by clinical professionals who are appropriate for the level of care that the patients need, says Mark Simon, MD, MMM, CMO at Ob Hospitalist Group.
"They have midwives involved to deliver care for low-risk patients and medium-risk patients," he says. "They can make an OB/GYN available for high-risk patients and any surgical interventions. They have the doulas engaged from a support perspective, which makes a lot of sense."
The Commonwealth Fund report indicates the importance of midwives in maternal care, Simon says.
"An interesting finding of the report is that the United States is one of the countries that has the lowest supply of midwives," he says. "If you look at how we have obstetrical care providers in this country, we are heavily physician focused. A country like Norway, which has one of the lowest maternal mortality rates, has essentially the same number of obstetricians per live births as the United States, but they have 15 more midwives per 1,000 births."
Midwives should play a larger role in U.S. maternal care, Simon says.
"I am a physician, and physicians provide great care in obstetrics, but physicians are not the be all and end all in maternity care," he says. "Clearly, the numbers indicate that we need more clinicians such as midwives providing maternity care in this country to help address maternal mortality and morbidity. Midwives are part of the solution, and they should be adopted more frequently than they are today. Hopefully, we are moving in that direction."
A higher reliance on midwives in maternal care would help address a shortage of obstetricians in the United States, Simon says.
"We just do not have enough physicians practicing obstetrics in this country," he says. "It takes a long time to train physicians, and relying on obstetricians alone is not the most effective way to deal with our maternal mortality and morbidity crisis. A better model is to have physicians working in concert with midwives."
Generating results
Data indicates Millie's model of care is driving good clinical outcomes.
The C-section rate among Millie's low-risk, first-time mothers is 21.7% compared to the national rate of 26.3%
Millie's patients have a low preterm birth occurrence rate at 3.01% compared to the national rate of 10.49%
Millie's patients experience a low birthweight rate at 3.66% compared to the national rate of 8.52%
Compared to OB/GYN-led clinics, Millie has a lower cost of care, according to Anu Sharma, MS, Millie CEO and founder.
"Clinical studies and the experience of peer nations has shown that midwifery-led care leads to fewer C-sections and other interventions for low-to-moderate risk pregnancies," she says. "Midwifery-led care is also less expensive than OB-led care in terms of staffing costs."
Millie excels at early detection and management of risk, which lowers costs, Sharma says.
"In addition to C-sections, other drivers of cost are related to poor management of care and late detection of risks," she says. "These result in readmissions, preterm births, NICU stays, and unnecessary emergency room usage."
As OhioHealth came out of the coronavirus pandemic, its quality and safety team decided there was a need to do an entire reset across the health system.
OhioHealth has made becoming a high-reliability organization a top priority for the 16-hospital health system.
High reliability was pioneered in the aviation and nuclear energy industries. At health systems, hospitals, and physician practices, it includes focusing on patient safety and limiting medical errors.
OhioHealth launched its high-reliability effort a year ago, saysTeresa Caulin-Glaser, MD, senior vice president and chief clinical officer of the health system.
"As we came out of the coronavirus pandemic, our quality and safety team decided that we needed to do an entire reset across the health system," she says. "The goal was to get everybody back into understanding what we needed to be focusing on and working together across the health system to create a high-reliability organization."
At health systems, the foundation of high reliability is safety, but becoming a high-reliability organization generates widespread benefits, Caulin-Glaser says.
"When you focus on safety, you are automatically improving your quality," she says. "You are automatically improving your service to the patient. You are improving the culture of the organization to be safety-first. Financially, you gain a benefit because you do not have unnecessary hospital readmissions, long lengths of stay, or errors that are costly for the organization and the patients."
Teresa Caulin-Glaser, MD, is senior vice president and chief clinical officer of OhioHealth. Photo courtesy of OhioHealth.
Taking the first step
Driving high reliability at a health system starts with education, Caulin-Glaser says.
"The messaging and importance of this initiative came from Steve Markovich, our president and CEO," she says. "His message was: Everybody is training. If you were an executive, you were training. If you were working in accounting, you were training. Everyone in the organization was training on universal skills for high reliability."
OhioHealth has been training employees on several universal skills:
S.T.A.R.: Employees are encouraged to stop, think, assess, and react.
Make a 50-second connection: Caregivers are encouraged to make a connection with their patients in the beginning of a clinical interaction. For example, a provider can ask how the patient is feeling and about family members. The goal is to know important things about the patient and focus attention on the patient.
Speak up: Staff members have been trained to validate and verify everything they do that touches patients. For example, if a caregiver is administering medication, they are expected to validate and verify that they have the right patient, the right medication, the right timing of administration, and the right dose. In an operating room, if a surgeon asks for an instrument and a nurse is not sure that they heard the request clearly, the nurse is expected to stop and ask a clarifying question to make sure the right instrument is provided.
Communicate clearly: For example, if a patient is in the emergency room, then is transferred to a medical floor in the hospital with direction to receive 325 mg of aspirin, the nurse receiving the patient should ask whether the patient needs 325 mg of aspirin. The nurse is repeating the direction and asking the emergency room staff to verify the prescribed medication.
Practice empathy: Team members should make empathetic statements such as, "I hear you are not feeling well today, and you had a bad night with little sleep." All employees should listen to patients' concerns and acknowledge them.
Caulin-Glaser says the education program is working.
"About 90% of the leaders across OhioHealth have received high-reliability training," she says. "Our goal is to have 70% of our associates—more than 15,000 people—trained by the end of this month. We want to have 100% of our associates trained by the end of September. High reliability is part of our onboarding training."
The value of reporting systems
OhioHealth has established a daily tiered huddle process to report on four kinds of events: patient safety incidents, workplace injuries, workplace violence, and anything that needs to be escalated to senior leadership.
Tier 1 huddles are conducted with frontline healthcare workers.
Tier 2 huddles feature frontline leaders, who try to resolve issues that arise in the Tier 1 huddles.
Tier 3 huddles address issues that are escalated from Tier 2 huddles, with managers and directors in attendance.
Tier 4 huddles handle issues escalated from Tier 3 huddles, with hospital presidents and their leadership committees in attendance.
Tier 5 huddles are held at noon and address the most serious and repetitive issues reported by the other tiers, and participants include the chief clinical officer, president and CEO, chief operating officer, chief nursing executive, chief information officer, and the vice president of quality and safety.
"Our tiered huddles have helped us to find out what is happening in the health system and to proactively address issues," Caulin-Glaser says. "We are having fewer repetitive issues, and we are getting ahead of issues."
OhioHealth also has an online platform for staff members to report patient safety events. The platform is easy to access and use, Caulin-Glaser says. Over the past year, the health system has experienced a 30% increase in patient safety event reporting.
Safety teams review all safety event reports, and there is a review process for any safety events that are considered serious, Caulin-Glaser says.
"If there are events that we feel need a deep dive, we conduct a root cause analysis that is sent to senior leaders, who determine what we have learned and what actions are going to be put in place," she says.
Expected improvements
OhioHealth has lofty expectations for the impact of its high-reliability initiative.
"Our quality will improve, and we have already seen quality gains," Caulin-Glaser says. "We have been working on high-reliability skills to reduce the mortality rate in our hospitals, and we have seen that number improve. We expect to decrease unnecessary infections such as central line infections and catheter infections. We are expecting to see a reduction in surgical site infections because staff are being more careful."
The health system is expecting to see gains in patient satisfaction, Caulin-Glaser says. They’re hoping that patients will report that they were heard in the hospital and that all members of their team understood the care plan, she says.
In addition to reducing hospital readmissions, length of stay, and costly errors, OhioHealth is expected to reap other financial benefits from its high-reliability initiative, Caulin-Glaser says.
"By establishing high reliability in our outpatient clinics, we hope to be treating patients proactively, so they do not require hospitalization, which should reduce expenses for the patients as well as the organization," she says. "If we become known as a high-reliability organization, it should drive more patient volume to the organization, which will increase revenue."
The hospital has not had a central line-associated bloodstream infection or a catheter-associated urinary tract infection in the past eight months.
AdventHealth Celebration hospital has made gains by doubling its infection prevention and control (IPC) staff.
Infections including healthcare-associated infections are a major concern at hospitals. Healthcare-associated infections include central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs).
The Centers for Medicare and Medicaid Services (CMS) penalize hospitals that report high rates of healthcare-associated infections through the Hospital-Acquired Condition Reduction Program. In 2021, CMS penalized nearly 800 hospitals for healthcare-associated infections, with about $254 million in lost revenue.
AdventHealth Celebration has increased the hospital's IPC staff from 2.0 to 4.8 full-time equivalents. There have been several benefits from increasing the IPC staff, says Alric Simmonds, MD, vice president and CMO of AdventHealth Celebration and chief health equity officer for AdventHealth.
"First, increasing the IPC staff allowed them to have more of a proactive presence in the operating rooms, on the inpatient floors, and the ICUs," he says. "Second, it allowed them to be able to integrate more with our physicians. Third, it allowed them to have a more proactive understanding and thorough analysis of infection prevention challenges as well as the opportunity to conduct more education about the importance of infection prevention."
Since AdventHealth Celebration's IPC staff was doubled, all hospital-acquired infections have been low compared to national benchmarks, Simmonds says. "We have gone eight months without a CAUTI or CLABSI," he says.
A powerful business case can be made for having robust IPC staffing, Simmonds says.
"Under our guardianship, patients have the expectation that they will have an excellent outcome without complications such as infections," he says. "From a revenue standpoint, there are penalties from CMS for infections. There can also be erosion of the CMS five-star rating for hospitals, which affects our marketing. In addition, hospital-acquired infections can impact our Leapfrog patient safety score."
There also is a "material impact" from hospital-acquired infections, Simmonds says. "If you have an infection, you need to provide additional care such as antibiotics and wound care. So, having an effective IPC staff decreases the cost of care," he says.
One of the initiatives that has been launched by AdventHealth Celebration's enlarged IPC staff is a CAUTI Bootcamp.
"We train staff on how a CAUTI arises," Simmonds says. "The bootcamp addresses how we can remove catheters in a timely manner. The training includes sterile technique, the proper cleansing of the perineum, proper glove utilization, and proper insertion and maintenance of catheters."
Guiding the hospital's clinical staff on appropriately reducing catheterization of patients is a crucial element of the CAUTI Bootcamp, Simmonds says. "We need to seize on opportunities to not have an indwelling catheter for a patient," he says.
The bolstered IPC staff at AdventHealth Celebration is having a far-reaching impact on the hospital, Simmonds says.
"They can be ever-present," he says. "They are part of our leadership team. They are a member of our Patient Safety and Quality Committee. They are driving metrics. They help shape the culture of safety and high reliability from a hygiene and infection-prevention standpoint. They are a clinical arm that is tactically deployed to address infection concerns, and they get in front of infection concerns so that patient harm is prevented. They are additive to the clinical outcomes that we achieve at our hospital."
Virtual care has become a widespread and effective area of medicine, says David Vega, MD, MBA, senior vice president and CMO at WellSpan.
"If you had asked me just a few years ago, I would have said virtual care is best for those patients who have minimal physical complaints that need to be evaluated," he says. "For example, the use of virtual care for mental health concerns grew very rapidly, while virtual health in the non-behavioral health space lagged behind. Then COVID hit. In our organization, we went from about a few hundred virtual visits per year to a few hundred virtual visits per day within just a couple of weeks."
When it comes to virtual care, necessity is the mother of invention, Vega says.
"For a subset of the population, virtual care quickly solved the problem of providing care in the ambulatory space and limiting possible exposure to COVID," he says. "Since then, both providers and consumers have learned that a great deal of care can be delivered safely and effectively virtually. This includes care for both acute illnesses and chronic conditions."
Virtual care is not appropriate or possible for all healthcare interactions, Vega says.
"Virtual care has limitations related to physical exams or procedures when needed. Acute emergencies such as heart attacks and severe injuries still need immediate, in-person attention," he says. "There is also diagnostic testing like blood tests and imaging studies that obviously cannot be performed virtually; although the overall management of a patient may involve virtual care. In addition, there are very complex diagnoses that may require in-person evaluation."
In addition, some patients face barriers that make using virtual care difficult, Vega says.
"On the consumer side, there are people who do not have access to the needed technology for virtual visits, or they may lack the digital literacy to use telehealth options effectively," he says. "There are also some individuals who have visual or hearing impediments that may make virtual care difficult to use."
In the podcast, Vega also focuses on how virtual care is being used at WellSpan:
How a partnership with Concert Health has created a collaborative care model that is increasing access to mental health services in the primary care setting
How working with KeyCare has increased the number of virtual visits that are available at WellSpan
How the health system is working with Artisight to help nurses in the inpatient setting
How WellSpan is conducting remote patient monitoring with virtual nursing
University of Texas Health Science Center at San Antonio and University College at the University of Texas at San Antonio are offering an MD/MS in artificial intelligence dual degree.
Two Texas-based schools are the first educational institutions to offer an MD/MS in artificial intelligence dual degree.
The dual degree is being offered by University of Texas Health Science Center at San Antonio and University College at the University of Texas at San Antonio. Planning for the dual degree program began in 2018, and the program launched in 2022.
Leaders at the schools saw the increasing importance of AI in healthcare when they started planning for the dual degree program, says Ronald Rodriguez, MD, PhD, director of the MD/MS in AI program and professor of medical education at the University of Texas Health Science Center at San Antonio.
"In 2018, there was a recognition that data science and data analytics were going to become increasingly important in the healthcare workforce," he says. "In the health sciences realm, we were increasingly aware that machine learning and artificial intelligence techniques were becoming more used in the basic sciences. We predicted that there was going to be an explosion of AI in the health sciences and healthcare. We wanted to be at the beginning of this development."
"A physician trained in AI brings a unique skill set that enhances traditional medical practice," Fink says. "By leveraging a formal AI education, they can help us create ways to improve diagnostic accuracy, personalize treatment plans, streamline operations, and contribute to groundbreaking medical research. Additionally, there are emerging areas for AI integration that are not yet fully known and have potential to impact our patients and organizations to an even greater degree. The integration of AI into healthcare represents a significant step toward more efficient, effective, and patient-centered care."
Fink says he would "certainly" be in favor of hiring a doctor who graduated from the MD/MS in AI dual degree program.
Teaching doctors about AI
There are three pathways through which students can apply to the dual degree program: computer science, data analytics, and robotics, Rodriguez says.
"Most of our students are going through the data analytics pathway," he says. "We have been recommending students follow the data analytics pathway because it does not require as much theory in computer science. Data analytics is more of a practical and applied-education approach."
The core elements of the MS in AI degree include understanding how to implement the tools of artificial intelligence, Rodriguez says.
"Those tools include machine learning, neural networks, deep learning, convolutional neural networks, and natural language processing," he says. "All of these tools are essentially the toolbox to be able to create the artificial intelligence applications that are being used in healthcare right now."
Teaching doctors about AI should put more physicians in leadership roles in the development of the technology, Rodriguez says.
"For the most part, development of these technologies has been done through computer scientists and data analysts as opposed to being developed by physicians," he says. "By having physicians drive development of the technology, we can ensure that it is focused on patient-centered care and health outcomes in a way that is not driven necessarily by business interests such as profits."
Two EHR tools, a deterioration index and a sepsis alert, have helped to drive hospital mortality rate reductions.
Several initiatives at RWJBarnabas Health over the past two years have led to a significant reduction in the hospital mortality rate.
Coming out of the coronavirus pandemic, leadership at the West Orange, N.J.-based health system realized there was room to improve the mortality rate at their 12 acute care hospitals, says Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer.
"We recognized a couple of years ago the opportunity to improve our mortality outcomes after doing an analysis of those outcomes across the health system's hospitals," he says. "We saw that we could improve."
RWJBarnabas put together a team to create "tactics" that could move the needle on mortality, and they encouraged hospital CMOs and CNOs to focus on ways to improve mortality, Anderson says.
Andy Anderson, MD, MBA, is executive vice president and chief medical and quality officer at RWJBarnabas Health. Photo courtesy of RWJBarnabas Health.
EHR alerts are drivers of change
The health system is using two tools in the Epic EHR to facilitate those improvements.
An AI-based tool called the deterioration index looks broadly at a patient’s healthcare data, including vital signs, history, physical exam, and laboratory results.
"The deterioration index predicts whether a patient is more or less likely to die," Anderson says. "There is a red, yellow, and green alert system. If the alert is red there is a high likelihood that the patient is going to die. When the deterioration index indicates that a patient is at risk of dying, we send a rapid response team to intervene at the bedside."
The rapid response team is typically staffed by a physician or advanced practice provider as well as a nurse, Anderson says.
"They go to the bedside, examine the patient, and make a determination on the spot about whether the patient needs to go to the ICU," he says. "The rapid response team contacts the patient's hospital care team and gives their assessment as quickly as possible.”
"We have seen powerful results," he adds. "The deterioration index saves lives."
The other tool is a sepsis alert. The EHR tool scans patient data and can pick up on the likely presence of sepsis, the body's life-threatening reaction to an infection that has been linked to about a third of hospital deaths nationwide.
Once the EHR flags a patient with a sepsis alert, hospital care teams move quickly to intervene, Anderson says.
"We have worked to have a standardized order set for patients who are septic," he says. "We are making sure they are getting the right antibiotic, making sure they get an antibiotic quickly, making sure they get fluids, and making sure there is appropriate monitoring of these patients. We also make sure the source of the sepsis is identified, whether it is pneumonia or another source."
Anderson says the health system has also created a team to develop best practice for sepsis management.
Mortality review process and ICU care
RWJBarnabas has also launched a mortality review process, which basically means reviewing and learning from a patient's death.
"Each of our hospitals has a team that reviews those cases and identifies whether there are any learning opportunities," Anderson says. "They go back and educate the team that took care of a deceased patient when learning opportunities arise."
The health system can then take those lessons from its 12 hospitals, put them in a single database, and identify common themes, Anderson says.
"For example, we may identify themes in cardiology or neurology cases, then we can go back to the service line and discuss how they can perform better or think differently in the future," he says. "Sometimes, there is nothing to learn from a death, but other times there is something to learn, and we must share that knowledge."
Another mortality reduction initiative has focused on ICU care, Anderson says.
"We are making sure that patients who are on ventilators are getting the right care," he says. "We are making sure that we have appropriate staffing in our ICUs. We are making sure we have enough ICU beds."
Generating results
RWJBarnabas is heading in the right direction by focusing on the right things, Anderson says.
"We have reduced mortality by 20% across our health system hospitals over the past two years," he says.
The mortality reduction initiatives reflect how RWJBarnabas approaches patient safety and quality in three ways, Anderson says.
"No. 1, we are using data to drive improvement," he says. "We know more clearly how we are doing and the goals we need to achieve. We are monitoring mortality data over time. No. 2, we are working as a health system, sharing best practices, and identifying the best ways to do this work. No. 3, we are using our electronic health record as a driver of change. Examples of using the EHR to address mortality include the deterioration index and the sepsis alert. Epic is helping us standardize best practices."
RWJBarnabas is sharing information about its mortality reduction efforts through dashboards and a monthly meeting called the High-Reliability Organization Cabinet, which includes leadership from all 12 hospitals.
"We are looking at the outcomes regularly," Anderson says. "We are looking at the tactics regularly. We are making sure that progress is being made regularly."
The performance improvement effort was implemented at every one of the health system's hospitals.
A surgical antimicrobial prophylaxis bundle at Banner Health has reduced surgical site infections, mortality, length of stay, and hospital readmissions.
A surgical site infection occurs at the site of a surgical incision on the skin or in deep tissue. Surgical site infections occur in as many as 4% of inpatient surgical procedures, and they are a significant cause of morbidity and mortality after surgery, according to the Agency for Healthcare Research and Quality.
Banner Health reported on the impact of its surgical antimicrobial prophylaxis bundle at this week's APIC Annual Conference. The data reported features more than 57,000 surgical cases from January 2019 to December 2023. Four types of surgery were included in the data: hip arthroplasty, knee arthroplasty, colorectal surgery, and abdominal hysterectomy.
Antiobiotic management is the core element of the bundle, says William Holland, MD, MHA, senior vice president of care management and chief medical informatics officer at Banner Health. Holland functions as a health system CMO, with responsibilities in areas including quality, safety, infection prevention, regulatory affairs, clinical performance improvement, and clinical supply chain. The CMOs of Banner Health's largest hospitals report to him.
"We want to make sure that patients get the correct antibiotic before surgery, which varies based on the procedure," Holland says. "We want to make sure that patients get the right dose of antibiotic, which is mainly dependent on the patient's weight. We make sure we time administration of an antibiotic before surgery appropriately—most medications are administered an hour before surgery. If a surgery takes a lot of time, we re-dose the antibiotic during surgery."
Implementation of the bundle generated several positive results:
Surgical site infection rates for knee arthroplasty procedures decreased 15.2%
The bundle was associated with a four-day reduction in hospital length of stay
Overall mortality rates decreased 4.4%
Average 30-day hospital readmission rates fell by 3.9%
"By reducing surgical site infections, we reduced the time that patients needed to be in the hospital on antibiotics, so we reduced length of stay," Holland says. "Anytime a patient is going to be in the hospital for a prolonged period of time or a patient has an infection that becomes septic, you increase the risk of mortality. So, by reducing surgical site infections, we reduced mortality. The healthier and more functional we could send patients home, we reduced the risk of readmissions."
Developing and implementing the bundle
Development and implementation of the surgical antimicrobial prophylaxis bundle followed Banner Health's model for performance improvement, Holland says.
"It is a stepwise process that starts with clinical leaders identifying an opportunity in medical literature or internal data," he says. "Several years ago, guidelines were released around antibiotic utilization to decrease surgical site infections. The idea was to get the right dose of antibiotic into the blood or tissue to decrease the potential colonization of bacteria."
After the opportunity was identified, Banner Health started looking at internal data with a structure called clinical consensus groups, which are typically led by a physician and a nurse, Holland says.
"These groups have peers from across the health system and the different hospitals have representation," he says. "In this case, a clinical consensus group looked at the literature and internal data to try to understand whether we had consistent performance across the health system and to identify facilities that were doing really well and others that were not doing well. They focused on driving a level of consistency across the organization."
The surgical antimicrobial prophylaxis bundle was endorsed by the members of the clinical consensus group. Then the initiative went up to the clinical leadership team, which is the most senior leadership team in the organization, and those leaders endorsed the bundle as an expected practice. Then Banner Health developed resources to implement the bundle such as process engineers, informatics, and program managers.
Finally, the health system put together an "implementation bundle" that was deployed at Banner Health's hospitals. "Typically, the leads for the implementation bundle are CMOs and CNOs, who identify delegates at their facility to drive the change," Holland says. "Then there were monthly meetings with those folks to measure improvement."
The most challenging aspect of the implementation process was re-dosing of antibiotics during surgery, he says. "With the re-dosing of antibiotics during surgery, we had to do some additional measures to educate surgical teams, to provide reminders, and to help them understand that element of the bundle."
Performance improvement best practices
Involving physicians and nurses in the design and implementation of the surgical antimicrobial prophylaxis bundle was crucial in the initiative's success, Holland says.
"When you are looking to drive a change like this that is going to have a broad impact and involve large teams of staff members, you must have people who do this type of work involved in the change," he says. "That is why we have a conscious effort to bring physicians and nurses together. That is why we have a structured process to define the problem we are going after."
Implementing the bundle at all of the health system's hospitals was also crucial, Holland says.
"Many times, health systems try to tailor approaches to performance improvement for each hospital in the organization," he says. "However, we look for consistency. We want the experience for our patients to look the same no matter which one of our hospitals they go to. Our expectation is that the level of care that a patient gets should be consistent whether they are at one of our critical access hospitals or one of our large tertiary care centers."
Connie Savor Price says physician burnout leads to medical errors and compromises the quality of care.
Addressing physician burnout is fundamental to promoting patient safety and care quality, says Connie Savor Price, MD, MBA, CMO at Denver Health.
Physician burnout was widespread before the coronavirus pandemic and spiked during the public health emergency. A study found that from September 2019 to January 2022, overall emotional exhaustion among healthcare workers increased from 31.8% of staff members to 40.4%.
Physician burnout has a significant negative impact on patient care, says Savor Price, who is a member of the HealthLeaders CMO Exchange.
"If a physician comes to work and feels tired or burned out, which is a feeling of disengagement sometimes to the level of despair, that can lead to medical errors," she says. "We know from data that physicians who are experiencing high rates of burnout are more likely to make diagnostic mistakes, treatment mistakes, and medication mistakes. If burnout gets to the point of depression, which is something that physicians who are burned out may experience, that leads to reduced attention to detail, cognitive impairments, and lapses in clinical judgment."
Denver Health has been working intentionally to reduce physician burnout for the past eight years. There is no silver bullet to address the problem, Savor Price says.
"There is not a singular solution to the problem, but we know we must work on it regardless of the challenges," she says. "We must try different things and make continued efforts to move the needle because provider burnout has a big impact on patient safety and quality."
To address physician burnout, healthcare organizations need to know their medical staff and know what factors are contributing most to burnout, Savor Price says.
"At an institution like Denver Health, a major driver of burnout is moral dilemmas," she says. "We have many patients who come into our emergency departments who are uninsured or under-insured. We can't always offer the full spectrum of services to those patients because they do not have the right type of resource to be able to afford services. As a physician, that situation is incredibly distressing."
So, one of the physician burnout initiatives at Denver Health has been to offer patients services for insurance enrollment. "We are doing everything we can to support the patients, which is important for our medical staff," Savor Price says.
Connie Savor Price, MD, MBA, is chief medical officer of Denver Health. Photo courtesy of Denver Health.
Physician burnout initiatives
In addition to helping uninsured and under-insured patients, Denver Health has launched many other physician burnout initiatives.
A primary effort has been to address excessive workload and administrative burdens such as documenting clinical care in the electronic medical record, Savor Price says.
"One of our most successful clinician burnout initiatives that was launched about three years ago has been at-the-elbow support in using the electronic medical record, which is Epic," she says. "We have had Epic 'super users' who are very knowledgeable in how to use the EMR to make themselves more efficient work with other clinicians. These super users have been working with their peers to show them how to efficiently document clinical care."
This at-the-elbow support effort has been conducted in the outpatient setting and the inpatient setting. Denver Health data shows that the initiative has reduced physicians' documentation time after their shifts have ended as well as overall documentation time.
Another primary physician burnout effort has been to promote a collegial environment with organizational support around opportunities for professional development, peer networking events, support groups, and medical staff events, Savor Price says. "We want to make Denver Health a collegial and pleasant place for our clinicians. For many clinicians, it is important to be happy at work and to have friends at work. We know from data that clinicians who have some friendships at work tend to be happier and stay in their jobs."
To select and develop physician burnout initiatives, Denver Health has used the health system's Medical Staff Executive Committee and a subcommittee of that group called the Provider Engagement and Wellness Committee to challenge the frontline medical staff to come up with initiatives.
"One of the proposals that came out of this effort was to create a Women in Medicine Mentoring Group," Savor Price says. "We know that mentorship programs can reduce burnout. A group of 25 female physicians met quarterly to talk about shared challenges, especially challenges that were unique to women. For example, they talked about balancing their careers and outside life. This mentorship program is something we are going to continue to support going forward because of the impact it has had on the first cohort of women, and we plan to expand the program to a new cohort in the coming year."
Other physician burnout initiatives that have come out of the Provider Engagement and Wellness Committee include lunch-and-learn sessions, yoga classes, and task-shifting.
"The task-shifting initiative has included focusing on paperwork tasks that are burdensome and annoying for physicians, who feel their most valued skills are related to clinical work such as diagnostics and treatment," Savor Price says. "In one of our clinics, we hired medical assistants to take on the burden of answering MyChart messages and tackling paperwork that the physicians could offload. This task-shifting has not only improved productivity. It is smart from a business perspective because it promotes physicians functioning at the top of their licenses."
Another physician burnout initiative that has come from the feedback of frontline clinicians is a plan to step up efforts to provide public recognition, Savor Price says.
"I am working with our communications department to profile some of our doctors," she says. "There are inspiring stories that come from patients and the peers of clinicians. I want to highlight clinicians who do community service. We will highlight these clinicians internally and externally. We can celebrate them on social media and other venues to help them know that we are proud of the work they do. Whether it is a single provider or a group of providers, we want to take advantage of telling their stories."
Measuring initiative impact
It is important to measure the impact of physician burnout initiatives, Savor Price says.
For several years, Denver Health has been using the Mini Z survey, which is an annual survey used to measure burnout. The health system plans to poll physicians and other staff members on a quarterly basis with two of the Mini Z survey questions, Savor Price says. "The first question is, 'Overall, I am satisfied with my current job.' Respondents answer the question on a five-point scale, which goes from strongly disagree, disagree, neutral, agree, and strongly agree. The second question is, 'I feel a great deal of stress because of my job.' The second question calls for the same five-point scale."
Savor Price acknowledges that Denver Health "has a long way to go" in addressing physician burnout.
"We have been largely stagnant on the annual Mini Z survey; and during the coronavirus pandemic, we slid backward," she says. "In the last survey, we made great progress, especially in addressing workload and stress. In terms of the national average for physician burnout, we were at the national average before the pandemic, slid to above average during the pandemic, and returned to average after the pandemic. Meeting the national average is not our goal—we need to do better."
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Health systems are shifting away from disease-based care.
Sentara Health is embracing a human-centric model of care.
Historically, clinicians have practiced disease-centric care, which focuses on at-the-moment health concerns and episodes. But more and more clinicians are shifting to holistic approaches to care that focus on keeping their patients healthy and partnering with patients to meet health goals.
The human-centric model of care is more of a psychological approach, says Jordan Asher, MD, MS, executive vice president and chief clinical officer of Sentara.
"How does the patient think?" Asher says. "What makes the patient tick? What are the patient's human conditions that cause them to be activated and engaged? The magic happens when you use the human-centered approach to impact disease management."
Asher cites an example of treating an obese patient. In doing a motivational interview, the patient said she was embarrassed when she took her grandson to an amusement park, and they could not go on the roller coaster because the safety bar could not fit over her.
The patient's care team decided to make her health goal to take her grandson to the amusement park the next summer and ride the roller coaster with him. That activated and engaged the patient: It was a care plan that solved a problem that she wanted to solve. The next summer, the patient sent Sentara a picture of her sitting on the roller coaster.
"The care team knows what the problem is, and they find out what can motivate the patient to solve the problem," Asher says. "If I can figure out the patient's activation and engagement motivation, then I figure out the best way to communicate with the patient, I am taking a human-centered approach. I am activating and engaging the patient and figuring out the best way to communicate in the way that works best for the patient to take care of a disease issue."
The primary benefit of shifting from a disease-centric model of care to a human-centric model of care is being able to treat the patient as a whole human being versus a person with a disease.
"The patient is going to respond better to the care team," Asher says.
Another benefit of the human-centric approach is improving the clinician experience.
"Clinicians want to help their patients," Asher says. "Nothing is more unfortunate than when clinicians do not see their patients getting better. By taking a human-centric approach, the patient's likelihood of getting better goes way up, and the joy of clinicians taking care of the patient goes up as well."
The human-centric approach also leads to better outcomes, Asher says, because patients are more engaged and activated to improve their health.
"We have learned over the years that if a clinician just tells a patient what to do, it may not change anything," Asher says. "For example, most people who smoke know it is bad for them. They still smoke despite someone telling them not to smoke. We need to identify what engages and activates a smoker to help them quit."
Getting clinicians to practice human-centric care
Under the disease-centric approach to care, physicians have been trained to diagnose and treat patients to prevent mortality and morbidity.
This is a futile effort, Asher says.
"Physicians fail 100% of the time because eventually every patient dies," he says. "Our definition of success needs to change to where the patient feels they are living life to its fullest. The best way to do that is through the human-centric approach because it helps patients live their lives to the fullest."
"If the physician is helping patients live their lives to the fullest in the patients' manner, it is a better definition of success and gives the physician a better feeling of living up to their calling," Asher says.
Sentara is promoting the human-centric model of care among clinicians through three channels.
"No. 1, we are reaching out to medical schools such as Eastern Virginia Medical School to get the human-centric model of care into the curriculum," Asher says. “No. 2, once we talk with our physicians about the 'why' behind the human-centric approach to care, they start asking for more information. No. 3, by wrapping around care teams that are doing this kind of work, physicians can still diagnosis and treat patients, but the overall team approach is helping to create the human-centric model of care."
The team approach to human-centric care has several elements, Asher says.
One team member can focus on understanding the patient’s activation and engagement level and work with the rest of the team to improve those motivations. Other team members can focus on the specific disease or health concern and how to address them. And other team members can identify the barriers faced by the patient and plot how to overcome them.
"The team considers the patient's social needs, activation and engagement, and disease state, then the team works together based on what is best for the patient," Asher says.
The burnout rates for Allegheny Health Network physicians and nurses are below national averages. Here's how its CMO did it.
At Allegheny Health Network(AHN), a six-year journey to improve the well-being of physicians, advance practice providers, and other staff is generating positive results.
There are three primary reasons why CMOs should be concerned about clinician well-being, says Donald Whiting, MD, CMO at AHN and president of Allegheny Clinic. Promoting well-being is essential for retention of clinicians, clinician well-being has been linked to the overall quality of patient care, and well-balanced clinicians perform their jobs better than clinicians who are struggling with well-being, Whiting says.
"As the CMO, you want your clinicians to come to work and put all of their energy toward taking care of their patients," Whiting says. "To do that, you need to address both the basic and advanced needs of your clinicians."
About six years ago, Thomas Campbell, MD, MPH, proposed creating a physician wellness program to Whiting. At the time, Campbell was serving as chairman of emergency medicine at AHN. He is now vice president of wellness at the Pittsburgh-based health system.
"I wanted to launch a physician wellness program because I had been doing research on burnout," Campbell says. "Dr. Whiting wanted to include more than just physicians, so our decision was to create a program for physicians, residents, advanced practice providers, and nurses. The intent was to grow the program to include all employees."
After launching dozens of wellness initiatives, AHN has made significant progress in boosting staff well-being. In recent years, physician burnout has trended 10 percentage points lower than the national average. In 2023, AHN earned recognition from the American Medical Association for demonstrating a commitment to promoting clinician well-being through proven efforts to address work-related stress and burnout.
"For our physicians as well as our nurses, we have been below the national averages for burnout," Campbell says. "In national surveys, there has been physician burnout as high as 62%. Our highest burnout rate for physicians has been about 52%."
To promote clinician well-being, CMOs and other leaders need to start with understanding the environment clinicians are in and the stressors that they are facing, Whiting says. "When we launched our well-being program, we started by surveying our physicians and advanced practice providers in several categories around the components of Maslow's Hierarchy of Needs. There were specific questions about safety at work, hours of work, the ability to take time for meals, and the respect of peers."
Well-being interventions
AHN began its efforts to promote clinician and nurse well-being by focusing on "low-hanging fruit," Campbell says.
The health system's first annual wellness survey indicated that many clinicians and nurses were not aware that they could reach out for behavioral health help. Leaders publicized the fact that behavioral health services were available to all employees through AHN's Employee Assistance Program, which also was made available to non-employed independent clinicians.
AHN's internal behavioral health group created a 24/7 help line for employees. "That was a great success, and it has continued since the beginning of our wellness program," Campbell says. "It is a foundational program."
The early annual wellness surveys found that some basic needs were not being met. Staff members were not taking meal breaks and they were getting dehydrated from not taking a break to drink water. "We made a big push among physicians, residents, and the nursing staff to get people focused on meal breaks," Campbell says. "Our parent organization, Highmark, gave us a grant to create water stations in our hospitals at convenient locations."
The annual wellness survey found female clinicians had higher burnout scores than male clinicians, which matched national data. There were cultural responsibilities impacting female clinicians such as the need to get children to school in the morning, so the health system implemented flexibility for start times and job-sharing capabilities.
Over time, after the low-hanging fruit had been grabbed, AHN began tackling more challenging aspects of promoting well-being, Campbell says. "We are working on initiatives that are much more difficult such as creating a caring culture to care for each other. We are trying to find ways for people to still take their breaks despite staffing shortages. We are trying to make sure physicians can take their vacations without checking patient messages in their electronic in-boxes."
Some AHN well-being initiatives launched during the coronavirus pandemic have become permanent.
"We now have 'decompression rooms' that people can go to when they are stressed out. These are quiet rooms with massage chairs and resources for people to reach out if they need help," Campbell says. "We also created another 24/7 help line for people in the emergency department and critical care. In addition, we started a peer support program for physicians and nurses so they could get help when they were at the end of their rope—if they were hesitant to reach out to a clinical professional, they could reach out to a peer."
In recent years, AHN has launched several new and innovative well-being initiatives.
The health system hired a wellness officer for each institute on the medical staff, Campbell says. "These wellness officers are my panel of experts for fields including surgery, obstetrics-gynecology, family medicine, and internal medicine. Almost all of these wellness officers have gone to programs on burnout and completed Stanford Medicine courses on well-being."
Last year's AHN wellness survey found improvement in the burnout scores related to electronic health record work, Campbell says. "We asked specific questions about the in-box because we knew that was a driver of burnout. What we found was that burnout from the EHR in-box got better for our physicians but a little worse for our advanced practice providers. What I think happened is that some of the work got pushed to the APPs, and now they need help."
For the clinician resident group, AHN has posted a couple of recent successes, Campbell says. "For example, the residents have complained that they have a lot of administrative tasks and other things that make their life difficult such as interruptions in their workday. Instead of equipping them with pagers, we got them cellphones, so they could be reached by text, which is less disruptive than a page, especially when they are at home. We also have provided healthy food in the resident lounges."
For the APPs, AHN has launched several initiatives because they are critical to getting work done, Campbell says. "We created an APP council, so their voices would be heard. In addition, every hospital medical staff executive committee has an APP representative, so their voice is heard in those forums. They have become more integrated with the leadership of the institutes."
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Teresa Caulin-Glaser, MD, is senior vice president and chief clinical officer of OhioHealth. Photo courtesy of OhioHealth.
Andy Anderson, MD, MBA, is executive vice president and chief medical and quality officer at RWJBarnabas Health. Photo courtesy of RWJBarnabas Health.
Connie Savor Price, MD, MBA, is chief medical officer of Denver Health. Photo courtesy of Denver Health.
