J Healthc Manag
· 2023 Mar-Apr 01 · PMID 36692421
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GOAL: Board diversity is increasingly important for hospitals and healthcare systems, with national attention focused on eliminating health disparities and improving health equity. Yet, it remains a challenge despite con...GOAL: Board diversity is increasingly important for hospitals and healthcare systems, with national attention focused on eliminating health disparities and improving health equity. Yet, it remains a challenge despite concerted efforts by leading professional associations (e.g., American College of Healthcare Executives) to galvanize their constituents around the importance of the issue. METHODS: This study used survey data from The Governance Institute to explore the ethnoracial and gender diversity of hospital boards spanning 2011 through 2021. PRINCIPAL FINDINGS: The results showed modest gains in the mean number of female board members, although a small proportion of hospital boards still have no female representation. There was little change in the number of boards with ethnic minority representation until an uptick in 2021, likely in direct response to high-profile racial incidents and protests. PRACTICAL APPLICATIONS: Intentional and sustained efforts are necessary to increase diversity and create a culture of inclusion that fosters meaningful engagement of diverse board members.
GOAL: Measures taken by healthcare organizations to address COVID-19 highlighted the long-standing lack of childcare infrastructure required to support healthcare workers. This study, designed to provide evidence to supp...GOAL: Measures taken by healthcare organizations to address COVID-19 highlighted the long-standing lack of childcare infrastructure required to support healthcare workers. This study, designed to provide evidence to support operations at an academic medical center, looked at the influence that in-house and emergency childcare could have on the retention, recruitment, and productivity of healthcare workers. This study also outlined the implications that childcare, or its lack, has for healthcare organizations during and after the COVID-19 pandemic. METHODS: We conducted a 35-question electronic employee survey (under institutional review board approval) during pandemic-induced public school closures, which included both quantitative and qualitative (write-in) questions. PRINCIPAL FINDINGS: The survey results showed that weekday on-site childcare was very or extremely important to more than half of survey respondents, the majority of whom were staff members (28%) or physicians (25%), followed by administrators (15%), researchers (12%), others (10%), nurses (5%), educators (2%), and residents (1%). Sixty percent of respondents reported that emergency on-site childcare was extremely important (34%) or very important (26%). Almost half (49%) reported that emergency childcare needs have disrupted their work in the past year, including canceling of clinics or surgical cases. Analysis of qualitative comments via a strategy based on coding and categorization showed that, when asked how childcare influences their work choices, employees responded that childcare availability has limited the hours or times they could work, that lack of childcare has prevented career growth, that they left a previous job or will leave their current job because of childcare needs, or that they stayed at a previous job or have remained in their current job longer because of the availability of childcare. PRACTICAL APPLICATIONS: Although data from this mixed-methods study support findings in the literature that there is a need for in-house and emergency childcare, the data suggest that current employees at this academic medical center do not currently expect it, likely because such childcare is not generally available at most academic institutions. With increased rates of burnout and healthcare workers leaving the field since COVID-19, offering in-house and emergency childcare provides hospital systems with new opportunities to retain and recruit physicians, nurses, and staff, as well as to improve their well-being and productivity.
GOAL: The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pan...GOAL: The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pandemic. In this study, we examined hospitals' financial performance following the onset of the pandemic. METHODS: We used data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System. The study sample included all general acute care and critical access hospitals that receive Medicare payments. The primary outcomes included operating margins, net patient revenues, operating expenses, and uncompensated care costs. We tested for average changes from 2019 to 2020 in hospitals' financial outcomes. We also tested for changes in financial outcomes across samples stratified by hospital characteristics: ownership type (investor-owned, nonprofit, and public), Medicaid disproportionate share hospital status, rural status, county uninsured rate quartile, and Medicaid expansion status. PRINCIPAL FINDINGS: Our sample consisted of a balanced panel of 4,059 hospitals (8,118 observations) with data spanning 2019 and 2020. Across the full sample of hospitals, operating margins declined by an average of 5.3 percentage points between 2019 and 2020, equating to a 130% reduction from 2019 levels. Underlying these margin declines, net patient revenues declined by 3.2% on average, while operating expenses increased by 1.5%. We observed no changes in uncompensated care costs despite the large number of job losses that accompanied the pandemic. When stratifying the analysis by hospital characteristics, differences were observed across ownership types. Notably, investor-owned facilities were less affected financially than nonprofit and public hospitals. Although safety-net and rural hospitals generally fared no worse than their non-safety-net and nonrural counterparts, hospitals located in Medicaid expansion states experienced steeper declines in operating margins relative to hospitals located in nonexpansion states, driven by larger relative declines in patient revenues. PRACTICAL APPLICATIONS: The operating margin declines we observed can be attributed to supply-chain issues, persistent labor shortages, and suspension of elective services. The Affordable Care Act reforms in health insurance markets likely helped to insulate hospitals from increases in uncompensated care costs. In the shifting context of the pandemic, it is important to understand hospitals' financial performance so that measures can be taken to address further financial distress that may eventually lead to increased consolidation, hospital closures, and lower quality of care. Our findings stress the need for targeted responses that are tailored to underlying hospital characteristics. Temporary and targeted increases in inpatient and outpatient service prices can help offset revenue losses from the deferment of nonurgent care. Other policies can address the ongoing workforce challenges and supply-chain issues.
GOALS: Throughout the COVID-19 pandemic, hospitals and their staffs have been pushed to their limits. Hospitals have had to rethink how they support community health while also providing critical acute care services to c...GOALS: Throughout the COVID-19 pandemic, hospitals and their staffs have been pushed to their limits. Hospitals have had to rethink how they support community health while also providing critical acute care services to combat the morbidity and mortality associated with COVID-19. As anchor institutions, hospitals have a significant effect on not only community health and well-being but also on local economies as primary employers and contractors. This study aimed to understand how the pandemic reshaped interactions with community members, staff, and other community organizations and changed the nature of hospital-community engagement among for-profit hospitals. METHODS: We recruited leaders of for-profit hospitals, systems, and a business association that represents for-profit hospitals. We interviewed 28 participants in various leadership roles via telephone or videoconferencing and then thematically coded interview transcriptions. The themes identified in early interviews guided the structure of forthcoming interviews. PRINCIPAL FINDINGS: For-profit hospitals appear motivated to address community health needs as anchor institutions in their communities, and these efforts have strengthened and changed in important ways as a result of the COVID-19 pandemic. In this study, three themes emerged regarding the influence of COVID-19 on hospital-community relationships: Hospitals refocused outreach and engagement efforts to support employees, found essential new ways to safely engage with the community through partnerships and collaborations, and were reminded of the critical roles of social and cultural factors in the health and well-being of individuals and communities. PRACTICAL APPLICATIONS: Hospitals may be able to use lessons learned during the pandemic to support the growing need for community engagement and attention to social determinants of health. The themes that emerged from this study present valuable opportunities for hospitals to carry forward the lessons learned over the course of the pandemic, as they have the potential to improve the delivery of healthcare and community engagement in day-to-day operations as well as in crises.
GOAL: Retention of advanced practice providers (APPs) is an issue of critical importance to healthcare leaders. High APP turnover negatively affects an organization's ability to meet patient needs, maintain quality of ca...GOAL: Retention of advanced practice providers (APPs) is an issue of critical importance to healthcare leaders. High APP turnover negatively affects an organization's ability to meet patient needs, maintain quality of care, and control costs. Our goal was to identify any association between intent to leave and specific survey factors; analyze the distribution of scale factors from the survey; and describe differences among the APP roles, specialties, and length of employment. METHODS: This study used a self-administered questionnaire for APPs at a large university medical center to determine job satisfaction rates and intent to resign. The survey used a modified Misener Nurse Practitioner Job Satisfaction Scale and Anticipated Turnover Scale. PRINCIPAL FINDINGS: We received surveys from 102 providers (for a 38.9% response rate). Results were used to determine the correlation between job satisfaction and intent to leave and to identify possible factors involved in APP commitment to the hospital and intent to stay. We found that APPs reported the most satisfaction in benefits, followed by time (i.e., time available for answering messages, reviewing laboratory and other test results, seeing patients, scheduling work). Intrapractice partnership/collegiality received the lowest satisfaction score. Extrinsic factors such as monetary bonuses available in addition to salary, reward distribution, involvement in research, conflict resolution, and opportunity to receive compensation for services performed outside normal duties were common dissatisfiers. PRACTICAL APPLICATIONS: This survey may help hospitals identify in real time the triggers of APP dissatisfaction and intent to resign. In addition, the results may guide possible revisions to hospital policies and practice procedures to improve APP commitment and decrease turnover intent. Additional surveys in similar university teaching hospital systems could confirm comparable intrinsic and extrinsic factors that are relevant to the satisfaction and turnover of APPs.
Hung DY, Rundall TG, Lee J
… +2 more, Khandel N, Shortell SM
J Healthc Manag
· 2022 Nov-Dec 01 · PMID 36350582
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GOAL: This study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach...GOAL: This study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events. METHODS: We conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency. PRINCIPAL FINDINGS: There were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages. PRACTICAL APPLICATIONS: Overall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.
GOAL: Although women make up most of the healthcare workforce, they are underrepresented in higher levels of leadership positions. Leadership development programs for early careerists, such as administrative fellowships,...GOAL: Although women make up most of the healthcare workforce, they are underrepresented in higher levels of leadership positions. Leadership development programs for early careerists, such as administrative fellowships, have been suggested as one strategy for accelerating gender equity in leadership roles. However, the potential impact of these programs has not yet been the subject of systematic evaluation. In this study, we examined the (1) benefits of administrative fellowship programs on career attainment and (2) differences in attainment by gender. METHODS: We completed this study using a data set involving alumni from a consortium of 11 graduate healthcare management programs whose students frequently pursue administrative fellowships. Our data included individual-level demographic and career attainment data for graduating classes from 5, 10, and 20 years prior to the reference year. Using multiple regression analysis, we tested the relationship of three independent variables-graduation year, gender, and completion of a fellowship-on career attainment. This analysis enabled us to determine differences in overall career attainment by gender, evaluate the role of fellowships in career attainment, and consider the differential impact of fellowships on attainment by gender. PRINCIPAL FINDINGS: Our findings suggest that fellowship programs accelerate leadership career paths for individual leaders, but that the effect is stronger for males than their female counterparts. PRACTICAL APPLICATIONS: These findings not only support the value of administrative fellowships for early careerist leadership development but also suggest that closing the gender disparity gap in leadership may require additional and focused career-supportive strategies. We provide recommendations for healthcare organizations in developing their administrative fellowship programs to help minimize the gender disparity in healthcare leadership positions. Furthermore, we discuss research implications and future areas of research in administrative fellowships.
Stephens J, Kieber-Emmons AM, Johnson M
… +1 more, Greenberg GM
J Healthc Manag
· 2022 Nov-Dec 01 · PMID 36350580
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GOAL: Administrative burden is one of many potential root causes of physician burnout. Scribe documentation assistance can reduce this burden. However, traditional in-person scribe services are challenged by consistent s...GOAL: Administrative burden is one of many potential root causes of physician burnout. Scribe documentation assistance can reduce this burden. However, traditional in-person scribe services are challenged by consistent staffing because the model requires the physical presence of a scribe and limits the team to a single individual. In addition, in-person scribes cannot provide the flexible support required for virtual care encounters, which can now pivot geographically and temporally. To respond to these challenges, our health network implemented an asynchronous virtual scribe model and evaluated the program's impact on clinician perceptions of burnout across multiple outpatient specialties. METHODS: Using a mixed-methods, pre-/postdesign, this evaluation measured the impact of an asynchronous virtual scribe program on physician burnout. Physicians were given the Professional Fulfillment Index tool (to self-assess their mental state) and free-text comment surveys before virtual scribe initiation and again at 3-, 6-, and 12-month intervals after program implementation. Descriptive statistics of survey results and qualitative review of free-text entries were analyzed for themes of facilitation and barriers to virtual scribe use. PRINCIPAL FINDINGS: Of 50 physician participants in this study, 42 (84%) completed the preintervention survey and 15 (36%) completed all 4 surveys; 25 participants (50%) discontinued scribe use after 12 months. Burnout levels-as defined by dread, exhaustion, lack of enthusiasm, decrease in empathy, and decrease in colleague connection-all trended toward improvement during this study. Importantly, quality, time savings, burnout, and productivity moved in positive directions as well. PRACTICAL APPLICATION: The cost burden to physicians and the COVID-19 pandemic inhibited the continued use of asynchronous virtual medical scribes. Nevertheless, those who continued in the program have reported positive outcomes, which indicates that the service can be a viable and effective tool to reduce physician burnout.
DeCicco D, Krupica TM, Pellegrino R
… +1 more, Dimachkie ZO
J Healthc Manag
· 2022 Nov-Dec 01 · PMID 36265174
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GOAL: Downcoding at nonprofit healthcare institutions can account for significant revenue losses that, in turn, can affect the amount and quality of care they provide. Using the inpatient medical note to assess the compl...GOAL: Downcoding at nonprofit healthcare institutions can account for significant revenue losses that, in turn, can affect the amount and quality of care they provide. Using the inpatient medical note to assess the complexity of care, we wanted to quantify the visit coding distribution at the largest tertiary care center in West Virginia and to improve the documentation and coding if found to be below national benchmarks. METHODS: We measured the number of encounters and associated documentation of level 1, 2, and 3 visits among hospitalists. We compared our data to national benchmark data. We then implemented a multifaceted, multidisciplinary intervention to improve documentation and coding. PRINCIPAL FINDINGS: We found a significant average increase of level 3 admission history and physical visits of 76% ( p < .0001) and 112% ( p < .001) for subsequent encounters compared with baseline preintervention visit types. With team-based coding interventions in place, documentation accurately now reflects the complexity of care delivered. Based on Medicare reimbursement rates, this new accuracy has led to an increase in revenue of $233, 988.79 per 10,000 encounters. APPLICATIONS TO PRACTICE: Provider knowledge of medical billing and coding guidelines is essential. In particular, large academic institutions typically operate on small margins, so even simple adjustments and quality improvement efforts in billing and coding can help immensely by accurately representing the amount and quality of medical services. An institution can markedly improve revenues by coding notes to reflect the true complexity of care that is delivered.
GOAL: Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare lead...GOAL: Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key areas for both theoretical and practical elaboration. We conducted a scoping review to frame our understanding of this largely unexplored dynamic of moral distress and better situate our existing knowledge of moral distress and leadership. METHODS: Using moral distress theory as our conceptual framework, we evaluated recent literature on moral distress and leadership to understand how prior studies have conceptualized the effects of moral distress. Our search yielded 1,640 total abstracts. Further screening with the PRISMA process resulted in 72 included articles. PRINCIPAL FINDINGS: Our scoping review found that leaders-not just their employees- personally experience moral distress. In addition, we identified an important role for leaders and organizations in addressing the theoretical conceptualization and practical effects of moral distress. PRACTICAL APPLICATIONS: Although moral distress is unlikely to ever be eliminated, the literature in this review points to a singular need for organizational responses that are intended to intervene at the level of the organization itself, not just at the individual level. Best practices require creating stronger organizational cultures that are designed to mitigate moral distress. This can be achieved through transparency and alignment of personal, professional, and organizational values.
GOAL: For decades, hospitals performing cardiac surgery have carried the cost of implementing quality improvement activities and reporting quality outcomes. However, the financial return of such investments is unclear, w...GOAL: For decades, hospitals performing cardiac surgery have carried the cost of implementing quality improvement activities and reporting quality outcomes. However, the financial return of such investments is unclear, which weakens the incentive for hospitals to invest in quality improvement activities. This study explored the relationship between a hospital's measured quality and its financial performance. METHODS: Using data from the American Hospital Association and Hospital Compare from 2014 to 2018, we performed an observational study of hospitals performing cardiac surgery. We used mixed-effects regression models with fixed-year effects and random intercepts to explore associations between measured quality and hospital financial performance. Our dependent variables were margins (profit divided by revenue) and financial distress; our independent variables included Patient Safety Indicator 90 (PSI-90) and hospital characteristics. PRINCIPAL FINDINGS: Our sample included 4,927 hospital-years from 1,209 unique hospitals. Hospitals in the worst-performing PSI-90 score quartile experienced a lower operating margin (-1.26%, 95% CI [-2.10 to -0.41], p = .004), a lower total margin (-0.92%, 95% CI [-1.66 to -0.17], p = .016), and an increased odds of financial distress in the next year (OR: 2.12, 95% CI [1.36-3.30], p = .001) when compared with the best-performing hospitals. PRACTICAL APPLICATIONS: Our exploration into financial distress provides managers with a better understanding of the relationship between a hospital's measured quality and its financial position. In reflecting on our findings, hospital leaders may consider viewing patient safety as a modifiable factor that can improve their organization's overall financial health. Our findings suggest that excellent safety performance may be both financially and clinically beneficial to hospitals.
GOAL: Given that length of stay (LOS) of acute myocardial infarction (AMI) patients has a significant impact on the utilization of hospital resources and the health status of communities, this study focused on how best t...GOAL: Given that length of stay (LOS) of acute myocardial infarction (AMI) patients has a significant impact on the utilization of hospital resources and the health status of communities, this study focused on how best to monitor LOS of AMI patients admitted to U.S. hospitals by employing statistical process control (SPC). METHODS: Data were abstracted from the Healthcare Cost and Utilization Project Nationwide Readmissions Database between 2010 and 2016. A total of 1,491 patients were examined in the study. Patients who were admitted to nonfederal government (public) hospitals in metropolitan areas of at least 1 million residents with the primary diagnosis of AMI were abstracted. They were excluded if they developed AMI secondary to an interventional procedure or surgery, died during their index hospitalization, and were admitted and discharged on the same day. Patients were also excluded if they were discharged to short-term hospitals, nursing facilities, intermediate care facilities, home healthcare, or against medical advice. Individual moving range (I-MR) charts were used to monitor LOS of individual AMI patients in each subgroup from 2010 to 2016. PRINCIPAL FINDINGS: The results showed I-MR charts could be used to indicate statistically out-of-control signals on LOS. Specifically, I-MR charts showed that LOS decreased between 2010 and 2016. LOS appeared to be longer at teaching hospitals compared to nonteaching hospitals and varied by gender. Female patients appeared to stay longer than male patients in the hospitals. PRACTICAL APPLICATIONS: The application of SPC and control charts can facilitate improved decision-making in healthcare organizations. This study shows the value of integrating control charts in administrative and medical decision-making processes. It may also help healthcare providers and managers achieve higher quality and lower cost of care.