Trading the Operating Room for the Situation Room: A Road Map for Surgical Subspecialists Moving into Executive Leadership in Academic Health Systems and Higher Education.

Climate change is killing people. Whether directly or indirectly through extreme weather events, excessive heat, rising sea levels, air pollution, changes in vector ecology, water scarcity, or reduced food production caused by climate change, the impact is an increase in human morbidity and mortality. The health care sector in general — and academic health systems in particular — are part of the problem, responsible for significant amounts of carbon pollution emissions. Various how-to guides and manuals aim to inform and instruct health system leaders on addressing climate change in their institutions. However, the authors note they are unaware of studies that have documented the enablers that propel and the barriers that impede academic health system leaders’ engagement in climate change efforts from the experience of these executive leaders themselves. In this article, the authors report the findings of a multi-institutional qualitative descriptive study exploring to what extent academic health system executive leaders think about, plan for, and lead institutional efforts to address climate change and reduce institutional greenhouse gas emissions. The study found variability in how executive leaders are engaged in and lead sustainability and climate-change efforts in their institutions and communities. Academic health systems that are reducing their institutional greenhouse gas emissions and improving their sustainability and resilience demonstrated five key elements associated with organizational transformation: (1) responding to drivers of change; (2) demonstrating leadership commitment; (3) driving improvement initiatives; (4) aligning organizational strategies and goals; and (5) integrating across organizational boundaries. In turn, these elements suggest a road map for other academic health systems that are not yet assertively tackling their carbon pollution. This study lends evidence to why academic health systems should — and how they can — address climate change through leadership action. Academic health systems can and should be leaders in the sustainability space because of the primacy of their missions to improve the health of people and communities; to this end, they must exercise their leadership role to influence the health care delivery, research, and health professions education domains.

EnglishIn a recent Viewpoint, Dr Washington and colleagues1 proposed a convening and leadership role for academic health systems in community efforts to improve population health. Although well intentioned, we believe this vision is misguided. The authors overlooked the central role of the government public health system in advancing population health. In contrast to health care institutions, government public health agencies are mandated to protect and promote—and be accountable for—the health of their populations. Moreover, they are uniquely placed to facilitate the multistakeholder partnerships necessary to influence health at the population level, comprising academic and not-for-profit public health partners and governmental and nongovernmental agencies beyond the health sector. Government public health agencies are also positioned to enforce and catalyze the regulatory and policy changes essential for sustainable change at scale. EnglishWe fully acknowledge the critically important role of government-led public health systems as vital to ensuring and advancing population health, as described by Drs Goodman and Karpati. At the same time, we believe academic health systems can meaningfully augment (not replace) the effectiveness of government-led public health systems to improve population health. Academic health systems are institutions with substantial expertise and resources, and they are influential agents in commerce, employment, and health care delivery. During this time of transition,1 academic health systems are well positioned to contribute more significantly than they have in the past to population-wide health improvement efforts. Our Viewpoint was intended to encourage academic health systems to collaborate with other sectors and stakeholders to achieve just this aim—improve overall health and well-being in the communities they serve.

Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded and evolved amid the shift to value-based payment models and sharpened focus on patient safety, quality, community engagement, and equity in healthcare, as well as a global pandemic. In light of these changes, this study examined the transformation of CMOs and similar roles and evaluated the current needs, challenges, and responsibilities of clinical leaders today. The primary data source used in this analysis was a survey fielded to 391 clinical leaders in 290 Association of American Medical Colleges-member hospitals and health systems in 2020. In addition, this study compared responses to the 2020 survey with findings from two prior iterations of the survey from 2005 and 2016. The surveys collected information regarding demographics, compensation, administrative titles, qualifications for the position, and the scope of the role, among other questions. All surveys consisted of multiple-choice, free response, and rating questions. The analysis was conducted using frequency counts and percentage distributions. Thirty percent of eligible clinical leaders responded to the 2020 survey. Twenty-six percent of the clinical leader respondents identified as female. Ninety-one percent of the CMOs were members of the senior management team in their hospital or health system. CMOs reported that they were responsible for five hospitals, on average, with 67% indicating they were responsible for more than 500 physicians. This analysis provides hospital and health systems with insight into the expanding scope and complexity of CMOs as they take on greater leadership responsibilities within their institutions amidst a shifting healthcare landscape. In reflecting on our results, hospital leaders can understand the current needs, barriers, and responsibilities of today's clinical leaders.

Infinite cornucopia: The future of education and training in oral and maxillofacial surgery

Academic medicine and real health care reform

As quality improvement and patient safety come to play a larger role in health care, academic medical centers and health systems are poised to take a leadership role in addressing these issues. Academic medical centers can leverage their large integrated footprint and have the ability to innovate in this field. However, a robust quality management infrastructure is needed to support these efforts. In this context, quality and safety are often described at the executive level and at the unit level. Yet, the role of individual departments, which are often the dominant functional unit within a hospital, in realizing health system quality and safety goals has not been addressed. Developing a departmental quality management infrastructure is challenging because departments are diverse in composition, size, resources, and needs.In this article, the authors describe the model of departmental quality management infrastructure that has been implemented at the Johns Hopkins Hospital. This model leverages the fractal approach, linking departments horizontally to support peer and organizational learning and connecting departments vertically to support accountability to the hospital, health system, and board of trustees. This model also provides both structure and flexibility to meet individual departmental needs, recognizing that independence and interdependence are needed for large academic medical centers. The authors describe the structure, function, and support system for this model as well as the practical and essential steps for its implementation. They also provide examples of its early success.

BackgroundPSA with MDR and XDR are a growing threat, and appropriate initial treatment of this organism is critical. C/T is a novel antibiotic with broad gram-negative in vitro susceptibility among surveillance studies. However comprehensive susceptibility analyses of C/T among PSA clinical isolates in comparison with other anti-PSA antibiotics remain limited, since routine clinical C/T susceptibility testing is not typically performed.MethodsThis study assessed all adult inpatient cultures positive for PSA from 32 months at an academic health system. Antimicrobial susceptibility was prospectively performed using Kirby Bower disk diffusion and interpreted by BIOMIC V3 during routine clinical care. Initial susceptibility testing included C/T along with amikacin, aztreonam, cefepime, ciprofloxacin, doripenem, gentamicin, imipenem, meropenem, piperacillin/tazobactam, and tobramycin. MDR and XDR isolates were identified using established definitions. The primary outcome was to quantify C/T resistant PSA (includes intermediate and resistant strains). Secondary outcomes were to determine resistance to other anti-PSA antibiotics and to identify C/T activity among isolates with MDR, XDR and pan-β-lactam resistance (PBLR = all β-lactams except C/T).ResultsA total of 2990 PSA isolates from 2339 cultures in 1311 individual patients were collected. Most cultures were from the lung (45%), followed by urine (30%), and body fluids (10%). For the primary outcome, 121/2990 (4%) of PSA isolates were C/T resistant. All PSA blood cultures were susceptible to C/T. Table 1 summarizes in vitro activity of all anti-PSA agents evaluated. C/T had the greatest percent susceptibility across all culture locations including MDR/XDR PSA isolates with median MICs of 8 µg/mL. For PBLR strains 35/66 (53%) were susceptible to C/T with a median MIC of 8 µg/mL.Table 1ConclusionC/T susceptibility testing during routine care over a 2.5-year period revealed 96% susceptibility among PSA. C/T showed the highest susceptibility among all anti-PSA antibiotics for all culture locations and for MDR and XDR isolates. Given the high rates of resistance to traditional anti-PSA agents, the value of new agents with high rates of in vitro susceptibility in the gram-negative armamentarium is high.DisclosuresWarren Rose, PharmD, MPH, Merck (Grant/Research Support)Paratek (Grant/Research Support) Janet Radaatz, PharmD, Merck (Employee) Laura A. Puzniak, PhD, Merck (Employee) Ryan J. Dillon, MSc, Merck & Co., Inc., (Employee)

With the rapid growth of specialty pharmacies, including those within academic health systems, pharmacists have the opportunity to improve patient care through the management of specialty medications. Specialty pharmacists within academic health systems are uniquely positioned to overcome restrictions to medication access, financial constraints, and provider burdens that often lead to obstacles for patients to start and maintain necessary treatments. The Vanderbilt Specialty Pharmacy (VSP) model at Vanderbilt University Medical Center (VUMC) provides an example of a patient-centered, collaborative care prototype that places pharmacists directly into specialty clinics to assist with comprehensive management of patients on specialty medications. VSP integrates specialty pharmacy services within existing specialty clinics based on the needs of each individual clinic. Each clinic is staffed with at least 1 clinical pharmacist and 1 pharmacy technician. The pharmacist is integrally involved in medication selection, initiation, and monitoring. The specialty pharmacy team ensures appropriate medication access and cost, provides extensive medication education, ensures patients are adherent to treatment, and coordinates care between patients and providers using the electronic medical record. Integration of pharmacists within specialty clinics at VUMC benefits providers, the health system, and patient care. This model has demonstrated decreased provider and clinic burden, decreased time to medication approval and initiation, excellent patient and provider satisfaction, substantial patient cost savings, optimal medication adherence, and overall improved continuity of care for patients on specialty medications. Since its inception in 2011, VSP has integrated 24 clinical pharmacists and 17 pharmacy technicians into 20 specialty clinics, with continued quarterly growth. The VSP model advances the role of pharmacists in managing patients on specialty medications in collaboration with providers. The integrated collaborative approach as presented by VSP represents a best practices model for those establishing and advancing specialty pharmacy services within academic health systems. No outside funding supported this study. The authors have nothing to disclose. Study concept and design were principally contributed by Bagwell and Newman, along with the other authors. Lee took the lead in data collection, along with Carver, Bagwell, Kelley, and Newman. Data interpretation was performed by Carver, Kelley, Lee, and Bagwell, with assistance from Newman. The manuscript was written by Bagwell, Carver, Kelley, and Lee and revised primarily by Bagwell, along with the other authors.

To describe how a nursing geriatrics workgroup in an academic age-friendly health system (AFHS) designed, developed, and piloted an age-friendly dashboard (AFD) that featured select patient experience scores and nursing-sensitive indicators (NSIs) that disproportionally impact hospitalized older adults. A nurse-led interdisciplinary team developed an interactive dashboard that aggregated existing age-friendly data and allowed for stratifying by age, campus, unit, and NSIs. Pilot users included frontline unit leaders, Nurses Improving Care for Healthsystems Elders program coordinators, gerontological nurse practitioners, and nurse educators. Optimization feedback was shared by pilot users. One campus used the AFD to inform and guide a quality improvement project that yielded a 51% reduction in the falls rate of adults aged ≥65 years. The AFD is a practical example of leveraging NSIs and patient experience data to support age-friendly care by making data accessible to frontline leaders, nurses, and clinicians in an AFHS.

Using the Electronic Health Record to Identify a Cohort of Seriously Ill Patients from a Primary Care Population Across Three Academic Health Systems (FR441C)

David Stanley Precious (1944-2015)

BACKGROUND The COVID-19 public health emergency catalyzed widespread adoption of both video- and audio-only telemedicine visits. This proliferation highlighted inequities in use by age, race and ethnicity, and preferred language. Few studies have investigated how differences in health system telemedicine implementation affected these inequities. OBJECTIVE This study aims to describe patients who used telemedicine during the public health emergency and identify predictors of telemedicine use across 2 health systems with different telemedicine implementations. METHODS This retrospective cohort study included adults with diabetes receiving primary care between July 2020 and March 2021 at 2 independent health systems in San Francisco, California. Participant sociodemographic characteristics, health information, and telemedicine utilization were acquired from electronic health records. The primary outcome was visit type (any audio or video telemedicine vs in-person only) during the study period. We used multivariable logistic regression to assess the association between visit type and key predictors associated with digital exclusion (age, race and ethnicity, preferred language, and neighborhood socioeconomic status), adjusting for baseline health. We included an interaction term to evaluate health system impact on each predictor and then stratified by health system (academic, which prioritized video-enabled visits, vs safety net, which prioritized audio-only visits). RESULTS Among 10,201 patients, we found higher odds of telemedicine use in the safety net system compared with the academic system (adjusted odds ratio [aOR] 2.94, 95% CI 2.48-3.48). Patients with younger age (18-34 years: aOR 2.55, 95% CI 1.63-3.97; 35-49 years: aOR 1.39, 95% CI 1.12-1.73 vs 75+ years) and Chinese-language preference (aOR 2.04, 95% CI 1.66-2.5 vs English) had higher odds of having a telemedicine visit. Non-Hispanic Asian (aOR 0.67, 95% CI 0.56-0.79), non-Hispanic Black (aOR 0.83, 95% CI 0.68-1), and Hispanic or Latine (aOR 0.76, 95% CI 0.61-0.95) patients had lower odds of having a telemedicine visit than non-Hispanic White patients. We found significant interactions between health system and age, race and ethnicity, and preferred language (<i>P</i><.05). After stratifying by health system, several differences persisted in the academic system: non-Hispanic Asian (aOR 0.57, 95% CI 0.46-0.70) and Latine (aOR 0.67, 95% CI 0.50-0.91) patients had lower odds of a telemedicine visit, and younger age groups had higher odds (18-34 years: aOR 3.97, 95% CI 1.99-7.93; 35-49 years: aOR 1.86, 95% CI 1.36-2.56). In the safety net system, Chinese-speaking patients had higher odds of having a telemedicine visit (aOR 2.52, 95% CI 1.85-3.42). CONCLUSIONS We found disparities in telemedicine utilization by age, race and ethnicity, and preferred language, primarily in the health system that used more video visits. While telemedicine expanded rapidly recently, certain populations remain at risk for digital exclusion. These findings suggest that system-level factors influence telemedicine adoption and implementation decisions impact accessibility for populations at risk for digital exclusion.

BackgroundThe COVID-19 public health emergency catalyzed widespread adoption of both video- and audio-only telemedicine visits. This proliferation highlighted inequities in use by age, race and ethnicity, and preferred language. Few studies have investigated how differences in health system telemedicine implementation affected these inequities.ObjectiveThis study aims to describe patients who used telemedicine during the public health emergency and identify predictors of telemedicine use across 2 health systems with different telemedicine implementations.MethodsThis retrospective cohort study included adults with diabetes receiving primary care between July 2020 and March 2021 at 2 independent health systems in San Francisco, California. Participant sociodemographic characteristics, health information, and telemedicine utilization were acquired from electronic health records. The primary outcome was visit type (any audio or video telemedicine vs in-person only) during the study period. We used multivariable logistic regression to assess the association between visit type and key predictors associated with digital exclusion (age, race and ethnicity, preferred language, and neighborhood socioeconomic status), adjusting for baseline health. We included an interaction term to evaluate health system impact on each predictor and then stratified by health system (academic, which prioritized video-enabled visits, vs safety net, which prioritized audio-only visits).ResultsAmong 10,201 patients, we found higher odds of telemedicine use in the safety net system compared with the academic system (adjusted odds ratio [aOR] 2.94, 95% CI 2.48-3.48). Patients with younger age (18-34 years: aOR 2.55, 95% CI 1.63-3.97; 35-49 years: aOR 1.39, 95% CI 1.12-1.73 vs 75+ years) and Chinese-language preference (aOR 2.04, 95% CI 1.66-2.5 vs English) had higher odds of having a telemedicine visit. Non-Hispanic Asian (aOR 0.67, 95% CI 0.56-0.79), non-Hispanic Black (aOR 0.83, 95% CI 0.68-1), and Hispanic or Latine (aOR 0.76, 95% CI 0.61-0.95) patients had lower odds of having a telemedicine visit than non-Hispanic White patients. We found significant interactions between health system and age, race and ethnicity, and preferred language (P<.05). After stratifying by health system, several differences persisted in the academic system: non-Hispanic Asian (aOR 0.57, 95% CI 0.46-0.70) and Latine (aOR 0.67, 95% CI 0.50-0.91) patients had lower odds of a telemedicine visit, and younger age groups had higher odds (18-34 years: aOR 3.97, 95% CI 1.99-7.93; 35-49 years: aOR 1.86, 95% CI 1.36-2.56). In the safety net system, Chinese-speaking patients had higher odds of having a telemedicine visit (aOR 2.52, 95% CI 1.85-3.42).ConclusionsWe found disparities in telemedicine utilization by age, race and ethnicity, and preferred language, primarily in the health system that used more video visits. While telemedicine expanded rapidly recently, certain populations remain at risk for digital exclusion. These findings suggest that system-level factors influence telemedicine adoption and implementation decisions impact accessibility for populations at risk for digital exclusion.

Perioperative benzodiazepine administration among older surgical patients

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations. Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs. Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies. The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.