GOALS: Advance care planning (ACP) procedure codes have been established to reimburse meaningful care goal discussions; however, the utilization frequency of these codes in neurological disease is unknown. The objective...GOALS: Advance care planning (ACP) procedure codes have been established to reimburse meaningful care goal discussions; however, the utilization frequency of these codes in neurological disease is unknown. The objective of this study is to identify the association between ACP codes and healthcare utilization in chronic neurodegenerative diseases. METHODS: This is a multicenter cohort study using real-world electronic health data. Using the TriNetX database, we collected electronic health data from 92 institutions in the United States. We included patients aged 65 and older who had been diagnosed with one of four neurological diseases: Alzheimer's disease, Parkinson's disease, multiple sclerosis, or amyotrophic lateral sclerosis (ALS). Patients with congestive heart failure were included as a reference. From the 64,683,009 total patients in the database, 877,138 had Alzheimer's disease, 544,610 had Parkinson's disease, 208,341 had multiple sclerosis, 9,944 had amyotrophic lateral sclerosis, and 1,500,186 had congestive heart failure. For each disease, we compared hospitalizations and emergency department (ED) visits over a two-year period between patients with and without ACP codes documented. Then, in patients with ACP, we investigated the rates of hospitalizations and ED visits over the two years before ACP and two years after ACP to understand the impact of ACP on the healthcare utilization trend. All patients had records for at least two years after index. PRINCIPAL FINDINGS: The rate of ACP code documentation ranged from 1.8% of multiple sclerosis patients to 3.6% of Alzheimer's disease patients. After matching for demographic and health variables, usage of ACP codes was associated with significantly fewer hospitalizations for Alzheimer's disease patients. Across all diseases, there was a 20% to 30% decrease in ED visits, which was significant. Furthermore, there was a significant change in the trend of hospitalizations and ED visits for patients after ACP documentation. Patients went from increasing utilization before ACP documentation to decreasing utilization after documentation. PRACTICAL APPLICATIONS: ACP billing codes are used infrequently in neurological disease, which may indicate that reimbursement alone is not sufficient to drive code usage. Usage of ACP billing codes was associated with decreased healthcare utilization, particularly in terms of ED visits. Beyond the primary objective of providing goal-concordant care, ACP may impact the economic burden of chronic neurodegenerative disease, which has high costs of care in our aging society. There may be particular benefits with Alzheimer's disease, which had an impact on both hospitalizations and ED visits and is the most prevalent neurodegenerative disease. Future work is needed to better understand the best implementation strategy for ACP in a multifaceted approach that emphasizes patient care preferences for their illness.
GOAL: Excessively lengthy wait times for appointments with clinicians are a major source of frustration for patients, and difficulties with access represent a public health problem facing populations across all societies...GOAL: Excessively lengthy wait times for appointments with clinicians are a major source of frustration for patients, and difficulties with access represent a public health problem facing populations across all societies. As delays in care have been associated with inferior outcomes, same-day appointments have been proposed as a patient-centric means of improving healthcare delivery. However, this paradigm represents a radical shift from conventional scheduling tactics, and skepticism has long existed regarding its feasibility and real-world applicability to clinical practice. Given the limited data available about same-day access and the lack of guidance on this strategy, the need to evaluate experiences and engage in introspective reflection (i.e., examine thoughts, emotions, judgments, and perceptions) for quality improvement are paramount. Thus, the purpose of this study was to review a single-institutional practice with same-day access, focusing on lessons learned over a two-year period. METHODS: From March 2021 to March 2023, a total of 4,301 consecutive patients with newly diagnosed cancer were offered same-day appointments as part of a prospective pilot initiative conducted in the outpatient setting at a tertiary-based academic medical center. Systematic analysis demonstrated the positive impact of this initiative on access-related benchmarks. A retrospective review was conducted to identify core themes pertaining to the feasibility of the initiative with respect to its design and implementation. An interpretive synthesis was then presented in descriptive fashion. PRINCIPAL FINDINGS: Of the 3,414 patients scheduled, 477 (14%) opted for same-day appointments. While same-day appointments significantly reduced the time to consultation and treatment for patients with newly diagnosed cancer, the initiative presented new challenges-both expected and unexpected-that could have hindered its development, acceptance, and adoption. These challenges related to scheduling capacity, logistical coordination, workflow efficiency, resource allocation, and cultural change. A consistent, proactive management approach, coupled with an unwavering commitment to communication, was required to overcome these operational barriers. PRACTICAL APPLICATIONS: Same-day appointments in the ambulatory setting has the potential to improve health outcomes and care quality, while fundamentally changing the way healthcare is delivered for the betterment of patients. However, thoughtful preparation and team-based planning are imperative to establish a methodical approach that will optimize the likelihood of success. Given the potentially disruptive nature of this paradigm, the need for steady leadership, accompanied by the consistent promotion of standardized guidelines, is critical to ensure engagement among all stakeholders. Lastly, the importance of promoting positive cultural change and creating an environment of shared purpose, trust, and transparency cannot be overemphasized.
GOAL: The objective of this study was to better understand how healthcare systems' unit- and system-level leaders perceive and experience moral distress consultation services, including their utility, efficacy, and susta...GOAL: The objective of this study was to better understand how healthcare systems' unit- and system-level leaders perceive and experience moral distress consultation services, including their utility, efficacy, and sustainability. METHODS: A multimethod design was conducted in tandem across two academic medical centers with longstanding and active moral distress consultation services. Moral distress data for healthcare providers participating in moral distress consultation were collected. The authors also conducted interviews about moral distress consultation with unit and organizational leaders using a semistructured interview format. They analyzed interview transcripts using both inductive and deductive coding strategies. Relevant themes and categories were then transferred onto a thematic map for final analysis. PRINCIPAL FINDINGS: Twenty moral distress consults (10 at each institution) were held during the five-month study period. The mean reported moral distress score for all preconsult participants (n = 52) was 6.9 (SD = 2.5), with scores ranging from 0 to 10. In the combined presurvey and postsurvey group (n = 22), the mean moral distress score was 5.9 (SD = 2.2) prior to the consult and 5.3 (SD = 2.7) after the consult. Participants indicated that moral distress causes were primarily team-level-focused prior to moral distress consultation and system-level-focused after consultation. As consult data were collected, eight unit- and system-level leaders were interviewed. Leaders described moral distress consultation as valuable and empowering to unit-based staff. They endorsed the service's ability to create safe spaces for open communication about morally distressing events. Leaders also suggested the need for more diverse professional representation (outside of nursing) among consultants and participants, as well as more transparent and consistent education plans related to the service, not only to increase leaders' knowledge and awareness of moral distress, but also to increase the visibility of the consult service, both within and outside the organization. Finally, leadership teams valued qualitative accounts of morally distressing events from staff. PRACTICAL APPLICATIONS: Addressing moral distress requires intentional and systemic collaboration, including open communication between moral distress consultation leaders, participants, and unit- and system-level leadership teams. Transparent education plans, broad professional representation, and flexible success measures-including both quantitative and qualitative metrics-are necessary and should be considered for any current or developing moral distress consultation services.
GOAL: A lack of healthcare worker well-being is a serious threat to patient care quality and safety, as well as to the overall operational performance of hospitals in the US healthcare delivery system. Extreme resilience...GOAL: A lack of healthcare worker well-being is a serious threat to patient care quality and safety, as well as to the overall operational performance of hospitals in the US healthcare delivery system. Extreme resilience depletion and compassion fatigue are known to negatively influence individual well-being and have contributed to the rise in turnover in the healthcare workforce. The primary aim of this research was to identify interventions that health system leaders can use to combat resilience depletion and exhaustion among healthcare workers. METHODS: Researchers deployed a randomized controlled trial methodology to study the association between the use of regular mindfulness practices, resilience, and compassion satisfaction. After completing an initial screening questionnaire and preassessments, participants were randomized into one of two groups: (1) an experimental group with mindfulness practices as the intervention and (2) a control group. The experimental group participated in structured mindfulness practices during their regular workday on three different days per week for a minimum of 10 minutes per day. At the end of the six-week study period, both groups completed postassessment questionnaires. Results from the pre- and postassessments were analyzed to determine the correlation between mindfulness practices, resilience, and compassion satisfaction. PRINCIPAL FINDINGS: Data analysis revealed that baseline resilience scores in the experimental group increased by 4 points, with a progressive 92% power. In addition, the experimental group demonstrated a statistically significant improvement in resilience (p mean difference pre-post = .147/.002) and compassion satisfaction (p mean difference pre-post = 3.99/.019). PRACTICAL APPLICATIONS: Readily available, low-cost mindfulness practices may be introduced to hospital staff to build resilience and improve compassion satisfaction. In turn, this may help support hospital efforts to reduce turnover in the healthcare workforce.
GOAL: This research aimed to evaluate variations in perceived organizational support among physicians during the first year of the COVID-19 pandemic and the associations between perceived organizational support, physicia...GOAL: This research aimed to evaluate variations in perceived organizational support among physicians during the first year of the COVID-19 pandemic and the associations between perceived organizational support, physician burnout, and professional fulfillment. METHODS: Between November 20, 2020, and March 23, 2021, 1,162 of 3,671 physicians (31.7%) responded to the study survey by mail, and 6,348 of 90,000 (7.1%) responded to an online version. Burnout was assessed using the Maslach Burnout Inventory, and perceived organizational support was assessed by questions developed and previously tested by the Stanford Medicine WellMD Center. Professional fulfillment was measured using the Stanford Professional Fulfillment Index. PRINCIPAL FINDINGS: Responses to organizational support questions were received from 5,933 physicians. The mean organizational support score (OSS) for male physicians was higher than the mean OSS for female physicians (5.99 vs. 5.41, respectively, on a 0-10 scale, higher score favorable; p < .001). On multivariable analysis controlling for demographic and professional factors, female physicians (odds ratio [OR] 0.66; 95% CI: 0.55-0.78) and physicians with children under 18 years of age (OR 0.72; 95% CI: 0.56-0.91) had lower odds of an OSS in the top quartile (i.e., a high OSS score). Specialty was also associated with perceived OSS in mean-variance analysis, with some specialties (e.g., pathology and dermatology) more likely to perceive significant organizational support relative to the reference specialty (i.e., internal medicine subspecialty) and others (e.g., anesthesiology and emergency medicine) less likely to perceive support. Physicians who worked more hours per week (OR for each additional hour/week 0.99; 95% CI: 0.99-1.00) were less likely to have an OSS in the top quartile. On multivariable analysis, adjusting for personal and professional factors, each one-point increase in OSS was associated with 21% lower odds of burnout (OR 0.79; 95% CI: 0.77-0.81) and 32% higher odds of professional fulfillment (OR 1.32; 95% CI: 1.28-1.36). PRACTICAL APPLICATIONS: Perceived organizational support of physicians during the COVID-19 pandemic was associated with a lower risk of burnout and a higher likelihood of professional fulfillment. Women physicians, physicians with children under 18 years of age, physicians in certain specialties, and physicians working more hours reported lower perceived organizational support. These gaps must be addressed in conjunction with broad efforts to improve organizational support.
GOAL: To document shifts in rural hospital service line offerings between 2010 and 2021 and to assess the resulting impacts on hospital profitability. METHODS: We used annual Medicare cost report data for all rural hospi...GOAL: To document shifts in rural hospital service line offerings between 2010 and 2021 and to assess the resulting impacts on hospital profitability. METHODS: We used annual Medicare cost report data for all rural hospitals that did not change payment classifications between 2010 and 2021. We documented changes in the percentages of hospitals offering each of the 37 inpatient or ancillary service lines included in the data. We then used panel event studies to assess effects on hospital operating margin for specific service lines that changed most prominently during this period. PRINCIPAL FINDINGS: Twelve service lines changed by more than 5% during our period of analysis. These are highlighted by hospitals adding rural health clinics (+32%) and CT scans (+20%) and removing delivery rooms (-21%) and skilled nursing facilities (-19%). Panel event studies demonstrated that the addition or subtraction of most services did not have statistically significant impacts on future hospital operating margins. Notable exceptions were the addition of rural health clinics and the removal of delivery services, both of which positively affected future operating margins. The addition of occupational therapy services had a positive effect on operating margin in the near term, but adding MRI services had a negative effect. PRACTICAL APPLICATIONS: The finding that only a select few service line changes resulted in meaningful impacts to hospital operating margins suggests that hospital leaders should be wary of implementing such changes as a means of improving financial viability.
GOAL: Recent efforts to push hospitals to provide high-value care have relied on payment incentives. However, evidence indicates that 70% to 90% of performance improvement projects do not achieve their desired goals. The...GOAL: Recent efforts to push hospitals to provide high-value care have relied on payment incentives. However, evidence indicates that 70% to 90% of performance improvement projects do not achieve their desired goals. Therefore, in addition to managing external industry pressures, hospitals need to develop performance improvement (PI) capabilities that enable them to capitalize on improvement opportunities, effectively develop and adopt solutions, and ensure the sustainability of improvements over time. While operational capabilities enable hospitals to produce and deliver services, more is needed to attain and sustain superior performance. Dynamic capabilities drive changes in operational capabilities to meet environmental demands. Dynamic capabilities also enable hospitals to renew and reconfigure their resources to optimize performance. This paper proposes the dynamic-capabilities framework as an appropriate way to develop and manage PI capabilities in hospitals, and it discusses the implications of shifting to a strategy that is driven by dynamic-capabilities PI. METHODS: The research team designed a semi-structured interview based on a review of the literature to understand whether hospitals were engaging in the activities outlined in the dynamic-capabilities framework. Nine study participants were recruited from a convenience sample of hospital PI staff at hospitals in Massachusetts and New Hampshire. De-identified transcripts were entered into NVivo12 qualitative data analysis software, and data were thematically indexed and coded following the principles of content analysis. PRINCIPAL FINDINGS: PI structures, improvement methodologies, and weaknesses did not vary significantly among hospitals. Most hospitals had a PI department and were more likely to adopt PI projects initiated by top management. While PI staff were trained in improvement methodologies, no programs were in place that required the rest of the hospital staff to become familiar with PI methods. Common areas of weakness were PI project selection, communication, coordination, learning from current and former PI projects, and systematic approaches to sustain improvements. PRACTICAL APPLICATIONS: Dynamic PI capabilities provide an opportunity to systematically identify improvement opportunities, seize on and learn from those opportunities, and renew and reconfigure resources to optimize performance. Ad hoc PI projects are insufficient to enable a hospital to sustain superior performance. Internal and external pressures to deliver high-value patient care and services require hospitals to exceed their current PI efforts. By developing dynamic PI capabilities, hospitals will adopt a more systematic and effective approach to PI, which will likely result in superior performance.
GOAL: The U.S. hospital sector is experiencing record levels of integration, with more than half of U.S. physicians and nearly three quarters of all hospitals affiliated with one of slightly more than 630 health systems....GOAL: The U.S. hospital sector is experiencing record levels of integration, with more than half of U.S. physicians and nearly three quarters of all hospitals affiliated with one of slightly more than 630 health systems. However, there is growing evidence to suggest that health system integration is associated with more expensive and lower quality care. The goal of this research is to explore the associations between forms of health system integration and hospital patient experience scores. METHODS: A cross-section of data for the year 2019 was assembled and analyzed from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience survey. Data from the Compendium of US Health Systems, published by the Agency for Healthcare Research and Quality (AHRQ), and the American Hospital Association (AHA) Annual Survey were used to obtain independent variables and hospital-level covariates. A series of multivariable regressions was used to explore the associations between forms of health system integration and hospital patient experience scores across three domains: overall impression of the hospital; experiences with staff; and the hospital environment. Forms of both horizontal integration (i.e., number of hospitals owned by hospital-based health systems) and vertical integration (i.e., physician-hospital integration, nursing home ownership, accountable care organization [ACO] participation, group purchasing, contract management, offering insurance products, and investor ownership) were explored. PRINCIPAL FINDINGS: Although horizontal integration was not associated with any meaningful differences in patient experience scores, health systems with physician-hospital integration were associated with overall impression scores that were 2 percentage points higher than systems without physician integration. Similarly, contract management and membership in a group purchasing organization were associated with overall impression and environment scores that were 2 to 3 percentage points higher than hospitals that did not engage in those forms of integration. By contrast, investor ownership was associated with a 5% lower score for overall patient experience compared with other forms of ownership. PRACTICAL APPLICATIONS: The findings of this study suggest that hospitals in more vertically integrated systems may have higher patient experience scores than independent hospitals and those that belong exclusively to horizontally integrated systems. Thus, there are elements of vertical integration that could benefit patients and be worth pursuing. Conversely, higher degrees of horizontal integration in the form of multihospital ownership may not be of any benefit to patients and should be pursued with caution.
GOAL: Value-based care is not simply a matter of cost, but also one of outcomes and harms per dollar spent. This definition encompasses three key components: healthcare delivery that is organized around patients' medical...GOAL: Value-based care is not simply a matter of cost, but also one of outcomes and harms per dollar spent. This definition encompasses three key components: healthcare delivery that is organized around patients' medical conditions, costs and outcomes that are actively and consistently measured, and information technology that enables the other two components. Our objective in this project was to implement and measure a systemwide high-value, evidence-based care initiative with five pillars of high-value practices. METHODS: We performed a quasi-experimental study from September 1, 2019, to August 31, 2022, of a new care program at the University of Texas Medical Branch. Drawing from the ABIM Foundation's Choosing Wisely Campaign, the program was based on five pillars-blood management and antimicrobial, laboratory, imaging, and opioid stewardship-with interdisciplinary teams led by institutional subject matter experts (i.e., administrative leaders) accompanied by nursing, information technology, pharmacy, and clinical and nonclinical personnel including faculty and trainees. Each pillar addressed two goals with targeted interventions to assess improvements during the first three fiscal years (FYs) of implementation. The targets were set at 10% improvement by the end of each FY. Monthly measurements were recorded for each FY. PRINCIPAL FINDINGS: We tracked performance toward 30 pillar goals and determined that the teams were successful in 50%, 50%, and 70% of their goals for FY 2020, 2021, and 2022, respectively. For example, in the antimicrobial stewardship FY 2021 pillar, one goal was to decrease meropenem days of therapy (DOT) by 10% (baseline was 45 DOT/1,000 patient days; the target was 40.5 DOT/1,000 patient days). We measured quarterly DOT/1,000 patient day rates of 32.02, 30.57, and 26.9, respectively, for a cumulative rate of 26.9. Critical interventions included engaging and empowering providers and service lines (including outliers whose performance was outside norms), educational conferences, and transparent data analyses. PRACTICAL APPLICATIONS: We showed that a multidisciplinary approach to the implementation of an evidence-based, high-value care program through a partnership of engaged administrative leaders, providers, and trainees can result in sustainable and measurable high-value healthcare delivery. Specifically, structuring the program with pillars to address defined metrics resulted in progressive improvement in meeting value-based goals at the University of Texas Medical Branch. Also, challenges can be embraced as learning opportunities to inform value-based interventions that range from technological to educational tactics. The results at the University of Texas Medical Branch provide a benchmark for the implementation of a program that engages, empowers, and aligns innovative value-based care initiatives.
GOAL: We sought to build upon previous studies that have demonstrated how healthcare workers' ratings of their immediate supervisor's leadership capabilities relate to their well-being and job satisfaction. METHODS: In 2...GOAL: We sought to build upon previous studies that have demonstrated how healthcare workers' ratings of their immediate supervisor's leadership capabilities relate to their well-being and job satisfaction. METHODS: In 2022, we analyzed cross-sectional data from 1,780 physicians and 39,896 allied health professionals (collected in 2017) and 729 residents (collected in 2019), as well as longitudinal data from 1,632 physicians (collected from 2015 to 2017), to identify a psychometrically strong, broadly applicable, actionable, and low-burden approach to assessing supervisor leadership capability to support healthcare worker well-being. PRINCIPAL FINDINGS: The magnitude of association between our 1-, 2-, 3-, and 9-item leadership indexes and burnout, and between our 1-, 2-, 3-, and 9-item leadership indexes and satisfaction with the organization were similar to each other in the cross-sectional and longitudinal cohorts and across diverse groups of healthcare workers, including physicians, residents, and allied health professionals. The likelihood ratio for a high leadership score increased with an increasing score for each leadership measure. The area under the receiver operating characteristic curve for the 1-, 2-, and 3-item measures for a high leadership score was 0.9349, 0.9672, and 0.9819, respectively. PRACTICAL APPLICATIONS: A single item assessing perceptions of leadership capability efficiently provides useful information about leadership qualities of healthcare workers' immediate supervisors. The inclusion of this item in healthcare worker surveys may be useful for evaluating interventions and galvanizing organizational action to support healthcare worker well-being.
GOAL: The COVID-19 pandemic, healthcare market disruptors, and new digital healthcare technologies have made a substantial impact on the delivery of healthcare services, highlighting the critical roles of leaders in hosp...GOAL: The COVID-19 pandemic, healthcare market disruptors, and new digital healthcare technologies have made a substantial impact on the delivery of healthcare services, highlighting the critical roles of leaders in hospitals and health systems. This study sought to understand the evolving roles of CEOs, CIOs, and other executive leaders in the postpandemic era and highlight the adaptability and strategic vision of executives in shaping the future of healthcare delivery. METHODS: Between October 2022 and May 2023, 51 interviews were conducted with CEOs, CIOs, and other executives responsible for delivering technology solutions for 33 nonprofit health systems in the United States. They were asked to describe their backgrounds; how information solutions and technologies were viewed within their organizations' strategy, operations, and governance; and the key characteristics of executive leaders. PRINCIPAL FINDINGS: The study has found that effective CEOs have an authentic belief in technology's role in achieving their organization's mission and that contemporary CIOs are strategic executive partners who align strategy with culture to improve care. This study examines how healthcare systems are creating digitally savvy executive leadership teams that operate in a new, integrated model that unites previously siloed functions. PRACTICAL APPLICATIONS: Some healthcare CIOs are unprepared for current and future business challenges, and some CEOs are unsure how to leverage digital technologies and C-suite expertise to transform their organizations. This research provides insights into how the nation's health systems are building and sustaining leadership teams capable of adapting to the healthcare environment and accelerating organizational transformation.
The influential report Crossing the Quality Chasm: A New Health System for the 21st Century established six core objectives to enhance healthcare quality. It highlighted the necessity for healthcare to encompass safety,...The influential report Crossing the Quality Chasm: A New Health System for the 21st Century established six core objectives to enhance healthcare quality. It highlighted the necessity for healthcare to encompass safety, effectiveness, a patient-centered approach, timeliness, efficiency, and equity. This essay focuses on one of these six core objectives: a patient-centered approach. Healthcare leaders actively seek solutions to improve and ensure the delivery of high-quality care. The imperative to provide quality healthcare underscores the need for artificial intelligence (AI) to become an essential component in a patient-centered approach rather than merely an optional advantage. Despite the expansion of AI, there is a lack of understanding of how AI can improve patient-centered care. This essay examines the fundamental aspects of patient-centered care, as outlined by the Picker Institute, while also exploring the prospective role of AI in advancing the core principles of patient-centered care and proposing frameworks for applying AI in healthcare.