An element of clinician engagement is giving them meaningful ways to influence a healthcare organization, a new CMO says.

To be successful in clinician engagement, healthcare organizations must give clinicians ways to influence the institution, says the new CMO of Medical City Denton and Medical City Argyle.

Glenn Hardesty, DO, was named CMO of the Denton, Texas hospital and its Argyle campus in August. He previously served as assistant CMO at Medical City Dallas.

Medical City Denton is an acute-care hospital and Level 2 trauma center that has 232 licensed beds; Medical City Argyle has 12 licensed beds. Both are part of Medical City Healthcare, a division of the HCA Healthcare health system.

Hardesty says clinician engagement is more of a philosophy than a series of interactions.

"Just because you have a medical staff golf tournament doesn't mean that you are engaging the physicians," Hardesty says. "You want to make sure that they have real input into the organization. You want to build structures so that they have meaningful ways to contribute to the health system and to make clinical decisions."

Medical City Healthcare has medical staff structures at each of its hospitals, according to Hardesty.

"How you utilize those structures can vary from facility to facility and health system to health system," he says. "We use the medical staff structures to hear the voice of the clinicians and to drive change. We also do an annual physician engagement survey to identify things that are top-of-mind among our physicians."

CMOs need to meet physicians where they are and actively listen, Hardesty explains.

"You don't want to pay lip service," he says. "You want to make sure that when physicians tell you something important, you take action when possible. If you can't take action, you need to tell the physicians why."

CMOs need to establish trust with their clinicians to engage them successfully, according to Hardesty.

"Without trust, engagement does not work," he says. "You build trust by experience over time. You can't come in on Day 1 and engage clinicians. It takes time to build trust. Trust is something that you must earn. You must have multiple encounters, and those encounters must be seen to have integrity."

Glenn Hardesty, DO, is CMO of Medical City Denton and Medical City Argyle. Photo courtesy of Medical City Healthcare.

Promoting quality care

There are two primary factors to promoting quality care in the hospital setting, according to Hardesty.

First, nursing is crucial to promoting quality.

"You must have nursing onboard in a quality plan and quality efforts to be successful," Hardesty says. "If you do not have the nurses on your side, if they do not have the bandwidth, if they do not have the understanding, your quality efforts are for naught."

The second factor is leadership visibility.

"Visibility as a leader goes a long way in promoting quality," Hardesty says. "When I left Medical City Dallas and came to Medical City Denton, the nurses gave me some advice. They said I was very visible, and I needed to keep that up, particularly with the nursing staff."

A major quality initiative that Hardesty helped lead at Medical City Dallas was limiting C. diff infections.

"With a quality initiative such as C. diff reduction, we found it takes everyone to be successful," Hardesty says. "It involved nursing and environmental services, for example. If the rooms are not cleaned properly, you can contaminate one patient to the next."

Part of the initiative involved targeting patients who were at high risk of infection.

"At Medical City Dallas, C. diff reduction was a challenge because there were specialized service lines such as bone marrow transplant that had high-risk patients," Hardesty says. "Those patients are extremely immunocompromised, and C. diff is easily passed in those kinds of units."

Key elements of the C. diff reduction initiative included training nurses on infection prevention, ensuring environmental service staff cleaned patient rooms effectively, and bolstering testing for C. diff.

"We wanted to know when C. diff tests were ordered and to make sure tests were ordered appropriately—that was a big part of what we did," Hardesty says. "We tested patients on arrival at the hospital if we suspected they had C. diff to identify patients early on, so those patients could be isolated and not expose other patients."

The C. diff reduction initiative generated positive results.

"When we started the initiative, we were having several cases per month at Medical City Dallas, and when I left the hospital, we were down to a small handful of cases per month," Hardesty says.

Risk management

In the hospital setting, risk exists everywhere, according to Hardesty.

"The key to risk management is to avoid engaging in unnecessary risk," Hardesty says. "You need to keep the preoccupation with failure front-and-center when dealing with risky situations."

Care teams should compare the alternatives before moving forward to avoid risk, Hardesty explains.

"For example, in the emergency department, you don't want to make moves until you are ready," he says. "You want to move appropriately and deliberately. You want to avoid rushing to judgment. You should pull back, use the resources you have at your disposal, make a decision as a team, then move forward."

Risk management and patient safety have a common theme, according to Hardesty.

"In risk management, you want to identify scenarios before they escalate," he says. "When it comes to mitigating risk, it helps to recognize risk early and address it sooner rather than later."

Clinicians should avoid using medical jargon when communicating with their patients, says this CMO.

For clinicians, communicating in a clear and understandable manner is crucial for providing quality care.

According to the Centers for Disease Control and Prevention, only 12% of U.S. adults are highly proficient in health literacy.

"Medspeak" is characterized as medical terminology used by clinicians that leads to communication gaps with patients. Medspeak gets in the way of effective shared decision-making for clinicians and patients.

There are several steps clinicians can take to make sure they communicate medical terminology and procedures effectively, and it's the CMO's job to make sure their clinicians are aware of medspeak and how to avoid it.

"The jargon, the abbreviations, and the terms we use in medicine seem natural to clinicians, but patients often do not understand these terms," says Donald Whiting, MD, CMO of Allegheny Health Network and president of Allegheny Clinic. "Clinicians can fly through an explanation without getting the patient engaged, then leave them behind."

Medspeak undermines shared decision-making, according to Whiting.

"If a patient does not understand the problem they are trying to solve, then they cannot make an informed decision," Whiting says. "If a patient does not understand the components of the problem and the decision process, then that gets in the way of shared decision-making."

There are three primary warning signs that medspeak is leading to a communication breakdown, Whiting explains.

"The warning signs include when you look into a patient's eyes, and they are not connecting," Whiting says. "Another warning sign is when you are having a conversation and you think you are explaining things, but the patient is just shaking their head. Another warning sign is when the patient is not asking questions."

Donald Whiting, MD, is CMO of Allegheny Health Network and president of Allegheny Clinic. Photo courtesy of Allegheny Health Network.

Avoiding medspeak

There are several steps clinicians can take to communicate medical terminology and procedures effectively with the 88% of U.S. adults who are not highly proficient in health literacy, Whiting says.

• When patients come into a doctor's office, they are often nervous. Clinicians should make patients feel comfortable—greet them warmly, make eye contact, and listen to the patients' questions. Clinicians need to connect with their patients.
   

• Once a clinician has connected with a patient, the clinician should use plain English to explain things rather than using jargon and terminology.
   

• Clinicians should start a medical conversation with the basic components and make sure the patient understands the components. That involves speaking clearly, speaking slowly, and getting feedback from the patient.
   

• Sometimes, a patient comes in with specific questions, but the patient and the clinician talk past each other. In these situations, the clinician should use the patient's questions in their own words to help address their concerns.
   

• It is important to not rush through a discussion. The clinician should take the time to pause periodically and make sure the patient understands what has been said. The clinician should ask the patient questions to make sure they are understanding the content that is being explained to them.
   

• Clinicians can use images and graphics to explain medical terminology or procedures.
   

• A clinical encounter with a patient should be interactive conversation because the clinician and the patient can be clear that they are talking about the same thing and that they are on the same page. With a two-way conversation, the clinician can make sure what they are saying is comprehended by the patient.
   

• For a clinician, the best metric to determine whether you are communicating effectively with your patient is when the patient asks relevant questions about what you are saying.

With quality measure saturation in value-based contracts, many primary care physicians feel set up to fail.

Research conducted at the Providence health system shows primary care physicians are overwhelmed with quality measures in value-based contracts.

One of the primary criticisms of payers' value-based contracts is that there is little to no coordination of quality measures for which clinicians are held accountable. In addition, value-based contracts have been adopted for quality improvement in primary care despite mixed evidence of their positive impact.

A research letter published recently by JAMA Health Forum found that primary care providers at Providence have been saddled with an overwhelming number of quality measures in value-based contracts. The research features data collected from more than 800 primary care providers from 2020 to 2022.

The research letter includes the following key findings:

• Value-based contracts contained a mean of 10.24 quality measures.
   
• Primary care physicians faced a mean of 57.08 quality measures across 7.62 value-based contracts.
   
• Medicare value-based contracts had more quality measures than commercial or Medicaid value-based contracts. The mean number of quality measures in Medicare value-based contracts increased from 13.14 in 2020 to 15.04 in 2022.

"Previous research on value-based contracts suggests these models have not lived up to their potential," the research letter's co-authors wrote. "We found saturation of the quality measure environment as a possible explanation: average physicians were incentivized to meet 57.08 different quality measures annually."

An overload of quality measures represents an unsustainable burden on primary care practices, according to the research letter's co-authors.

"Value-based contracting is intended to incentivize care improvement, but it is unlikely a clinician or practice can reasonably optimize against 50 or more measures at a time," the co-authors wrote.

Impact of quality measure saturation

The senior author of the research letter told HealthLeaders that the study's findings were unexpected.

"We were shocked by what we found," said Ari Robicsek, MD, chief analytics and research officer at Providence. "Effectively, the level of industry disorganization leads to a situation where individual physicians have way more quality metrics than they can possibly be expected to manage."

Robicsek compared the situation to the Olympic biathlon event, where competitors cross-country ski as fast as they can, then stop to try to hit targets with a rifle.

"Primary care physicians are expected to provide care to as many patients as they possibly can and deal with their patients' problems in the office," Robicsek said, "then all of a sudden, the physicians have to interrupt the flow of patient care to hit targets on quality metrics."

Most primary care practices are not configured to do both things simultaneously, according to Robicsek.

"It is disruptive, frustrating, and ultimately, when you have a large number of quality metrics, they become white noise," Robicsek said. "The quality metrics either become ignored or they create a sense for providers that they are set up to fail."

There are two ways to ensure that a primary care practice hits a target on a particular quality metric such as making sure patients are getting their breast cancer screening, Robicsek explained.

One way is to put the burden of the work on administrators, which requires hiring staff to look at lists of patients who have not yet received their breast cancer screening. Administrative staff will reach out to these patients, communicate back and forth with the patients if they have questions, place the screening orders, and follow up to make sure the screening was conducted.

"There is administrative cost to hitting a target on a quality metric this way," Robicsek said.

The other way is to expect primary care physicians to hit quality metric targets as part of their daily workflow. Under this system, when patients come in to see primary care physicians, the physicians must talk to the patients about quality metrics such as breast cancer screening or diabetes screening.

"The challenge is that primary care physicians are working with patients to address their problems in relatively short visits, then we are expecting them to fit in the administrative task of hitting quality metrics," Robicsek said.

Instead of expecting primary care physicians to remember to "close gaps" in quality measures, many practices have reminders in the electronic medical record (EMR) to prompt physicians to talk with their patients about quality metrics such as breast cancer screening. As the doctor is trying to go through their workflow and the patient wants to talk about a particular clinical problem, the EMR interrupts with quality metrics that need to be addressed.

"These alerts are interruptive, distracting, and can substantially affect the flow of a physician-patient encounter," Robicsek said.

Quality metric saturation contributes to physician burnout, according to Robicsek.

"If you feel set up to fail, and you feel that you can't do your job, that is going to contribute to feelings of moral distress and exhaustion," Robicsek said.

Reforming value-based contracts

Quality metrics in value-based contracts need to be redesigned so they are more manageable for physicians, according to Robicsek.

"There is no way that any physician is going to be able to manage 57 different quality metrics in their practice, while also trying to be a doctor," Robicsek said.

In principle, quality metrics that create incentives to provide great care are a good thing, but the current execution of quality metrics in value-based contracts is counterproductive, Robicsek explained.

"When they are done in a completely uncoordinated way such that a physician has way more metrics than can possibly be salient in their day-to-day practice," Robicsek said, "you do something worse than having no quality metrics at all."

The first step in the redesign process would be coordination among the different payers about what a limited set of quality metrics would be for use across the board for primary care physicians, according to Robicsek.

"Ideally, metrics would be chosen where there is an evidence base that demonstrates that incentives for metrics improve outcomes for patients," Robicsek said. "There also needs to be an evidence base suggesting that the set of metrics when used simultaneously benefits patients."