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26 May 2016

Sheridan Pediatric Anesthesiologist Co-Authors Case Report in the May 2016 Journal of Pediatric Surg

The May 2016 Journal of Pediatric Surgery Case Reports includes a case report co-authored by four physicians including Jeffrey P. Morray, M.D., a pediatric anesthesiologist with Valley Anesthesiology Consultants in Phoenix, AZ. The report presents the case of an 11-year-old girl who had been experiencing facial swelling and intermittent right arm swelling for several weeks. She had been seen by numerous providers who presumed that these symptoms were caused by allergies and who treated them initially with antihistamines and then steroids. These medications alleviated her swelling only briefly. When her symptoms returned, she was treated with a second round of steroids and an antibiotic. After being referred to an otolaryngologist, a dermatologist and an allergist, eventually she was admitted to the hospital. Her workup upon admission included an echocardiogram that revealed a very large tumor that had formed in the area of the chest between her lungs. The tumor was compressing her superior vena cava, the second-largest vein in the human body. These findings were confirmed by CT (Computed Tomography) scan, a diagnostic imaging test that creates detailed images of internal organs, bones, soft tissue and blood vessels.

Numerous enlarged lymph nodes in the patient’s neck and lung region suggested lymphoma. Because swelling made it difficult to examine the lymph nodes in the neck, the surgical team determined that a surgical biopsy under a general anesthetic would be the best course of action.

The case report presents in detail how doctors used a sternal elevator system for emergency elevation of the patient’s breastbone as a bridge to ECMO (a treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a very ill child) until doctors were able to treat the mass definitively and stabilize the patient. The surgery required a complex anesthesia strategy to minimize the risk of airway collapse.

To learn more, read the full case report.

24 May 2016

MACRA Gets Real: What It Really Means for Doctors

MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – was signed into law more than a year ago. Yet it’s only recently (April 27, 2016) that the Centers for Medicare and Medicaid Services (CMS) finally released the first major proposed regulation under the law. The proposed rule on the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) Incentive lays out the two payment track options under MACRA (referred to collectively by the CMS as the Quality Payment Program or QPP).

MACRA fundamentally changes how Medicare pays physicians and other clinicians who participate in the program. A key feature is the permanent repeal of the CMS’s unpopular Sustainable Growth Rate (SGR) formula for calculating how medical clinicians are reimbursed under the Medicare Physician Fee Schedule (PFS). SGR was designed to control Medicare’s spending on physician services. It increased payments when spending on physician services grew at a slower rate than the gross domestic product (GDP). Conversely, when physician spending grew faster than GDP, SGR cut payments. It was a simplistic solution to a complex problem.

From the time SGR was implemented in 1997, doctors were vocal in their opposition to the formula, which “left physicians in a constant state of uncertainty and threatened patients’ access to care.” For the next 18 years, clinicians strongly fought for SGR’s repeal. Over the years Congress enacted 17 “doc fixes,” repeatedly staving off temporarily the implementation of large and annually increasing cuts to fees for physicians’ services. The MACRA legislation passed last year averted a catastrophic 21.2 percent cut in Medicare’s payment rate for clinicians that otherwise would have taken effect on April 1, 2015.

According to the CMS, the goal of this legislation is to "reward better care, not just more care," moving away from fee-for-service or volume-based reimbursement methodology toward a value-based payment system (ultimately targeting 85 percent of all Medicare payments being tied to quality or value). MACRA purports to streamline the parameters for earning Medicare payments and minimize the burden on participants, and The American Medical Association has hailed this bipartisan legislation as a victory for medical practitioners.

Now that the CMS has released more details about how its new physician payment and reporting rules would work, however, it’s not clear whether (or, if so, how much) the burden of reporting will be reduced. In fact, for those on the MIPS track, reporting could be even more complex, detailed and expensive than before.


Under the MIPS option, the payment calculation is based on a composite performance score comprising four weighted performance categories: 50 percent quality (PQRS), 10 percent resource use, 25 percent meaningful use of certified EHR and 15 percent clinical practice improvement activities. These percentages may change over time, again producing uncertainly in the physician community.

The MIPS payment track takes a carrot-and-stick approach, and financial risk is a prominent feature. Doctors have upside opportunities if their MIPS composite performance scores are high; they also risk significant financial penalties if they do poorly. The portion of a physician’s at-risk Medicare reimbursement revenue will increase significantly during the 2019–2022 ramp-up period. In 2019, 16 percent is at risk, with potential penalties of up to 4 percent and potential bonuses of up to 12 percent. In 2020, the at-risk amount increases to 20 percent (-5 percent to +15 percent). In 2021, that number goes up to 28 percent (-7 percent to +21 percent). And from 2022 on, fully 36 percent of a doctor’s Medicare reimbursement revenue stream will be at risk (-9 percent to +27 percent). These percentages include the downside risk, upside gain and potential bonus payments. The program is overall revenue-neutral — a “Hunger Games” approach where the losers will pay the winners.

This makes MIPS a good choice for physicians who can demonstrate consistently excellent performance across the four weighted categories, especially care quality (which is weighted at 50 percent of the composite score) and can comply with the onerous reporting requirements. The rewards for superior performance are significant. But the reporting requirements will be burdensome. And doctors whose performance is poorer than that of their peers will risk significantly lower payments.

The APM track is the CMS’s preferred option, and the proposed rule provides are financial incentives for clinicians who participate in Advanced Alternative Payment Models to the required extent (by receiving enough of their payments or seeing enough of their patients through Advanced APMs). Accountable Care Organizations (ACO) and Patient-Centered Medical Homes (PCMH) are examples of Advanced APMs. The participation requirements will increase over time. During the first five years (2019–2024) qualified participants will receive a five percent annual bonus (Medicare Part B incentive payment). From 2026 on, clinicians who meet the qualification standards will receive a higher fee schedule update than doctors who do not participate “significantly” in an Advanced APM. From 2019 on, qualified participants also will be exempt from the MIPS payment adjustments and their associated financial risk and uncertainty.

According to the CMS, “Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily-required demonstrations where clinicians accept both risk and reward for providing coordinated, high quality, and efficient care. These models must also meet criteria for payment based on quality measurement and for the use of EHRs.”

The CMS’s proposed rule includes a list of models that would qualify as Advanced APMs, and it would update this list annually to add new qualified payment models. Beginning in performance year 2019, clinicians also could qualify for incentive payments based in part on participation in Advanced APMs developed by non-Medicare payers, such as private insurers or state Medicaid programs. The proposed rule also would create a Physician-Focused Payment Technical Advisory Committee to review and assess additional physician-focused payment models suggested by stakeholders. It is unclear how physicians will have input into what qualifies as an APM, which has the potential to shift the power to the payers in the determination of these arrangements.

It’s also not entirely clear how physicians participating in APMs would need to demonstrate that they meet the required threshold for share of provider revenue in APMs (i.e., with two-sided risk). Will a physician need to open up his or her entire book of business in order to provide evidence of qualification for incentives?

Advantage: Payers

MACRA is a huge boon for payers, helping them determine the value of the care that physicians provide, which will then dictate payment. With the consolidation of five of the biggest payers to three (since Aetna purchased Humana and Anthem bought Cigna), these private payers are larger and more influential. All of them want value-based care and will insist on value-based contracts. And it’s likely that they will start adding to their reporting requirements to match the CMS quality measures.

Payers’ increasing influence is also evident in MACRA, which shifts risks from the payers to the physicians, especially in the MIPS payment track.

MIPS Reporting Requirements Will Be Onerous

MACRA does, indeed, streamline reporting requirements for the MIPS track in the sense that it combines the requirements of the electronic health record meaningful use program, the Physician Quality Reporting System (PQRS) and the Value-based Payment Modifier (VBPM). It also adds a new category, clinical practice improvement activities. Beginning in 2017, MIPS-track providers (for most specialties) will need to report nine PQRS measures that cover three of the six National Quality Strategy Domains (Effective Clinical Care, Patient Safety, Person and Caregiver-Centered Experience & Outcomes, Communication and Care Coordination, Community/Population Health, Efficiency and Cost Reduction) and one cross-cutting measure.

But other aspects of MACRA are likely to make reporting more cumbersome for providers who choose this payment track. CMS requires all providers to prepare for both the MIPS and APM payment tracks. Although the new payment rules don’t go into effect until 2019, medical providers on the MIPS track will need to move from claims-based quality reporting to reporting via a qualified clinical data registry (QCDR) by Jan. 1, 2017 – the start of the new performance periods for MIPS and APMs. Those who don’t will face significant penalties starting in 2019.

Requiring these providers to submit their performance metrics reporting via a qualified clinical data registry to avoid penalties will make that data easier for CMS to analyze. But it also will put a significant additional burden on clinicians, who will need to contract with a CMS-approved QCDR to complete the collection and submission of PQRS quality measures data to CMS on their behalf. Now not only will providers have to collect, audit and validate the quality data, they also will need to prepare it for upload to the QDCR as an XML file according to CMS’ detailed technical specifications.

Exacerbating “Measure Fatigue”

Over the past decade, the number of quality measures directed at US health care providers by Medicare, Medicaid and private health insurance plans has continued to grow at a rapid pace. Collecting, analyzing and reporting data has become complex, time-consuming and expensive, resulting in “measure fatigue” that is a significant factor in the current physician burnout epidemic. A recent study reported in Health Affairs found that U.S. physician practices in four common specialties spend, on average, 785 hours per physician and more than $15.4 billion each year dealing with the reporting of quality measures. Now with MACRA, providers on the MIPS track will also need to contract with a QDCR and prepare the data to comply with CMS’ technical specifications and also simultaneously report both claims-based data and registry (QCDR) data, adding more time, complexity and expense for physicians and further exacerbating the problem of “measure fatigue.”

In recent years, “measure fatigue” has caused many clinicians to take early retirement rather than deal with the increasingly complex and overwhelming quality reporting requirements. These new additional administrative and financial burdens will hit doctors in individual private practice and small physician groups the hardest, and more clinicians likely will choose to become employees of a large company like Sheridan that will take care of most of the burden for them.

Sheridan puts a high priority on supporting physicians. We believe in letting doctors be doctors so they can focus on providing the best possible care to patients with optimal, efficient use of resources. As part of our commitment to the “Quadruple Aim,” we have made – and continue to make – a significant investment in developing sophisticated tools that will significantly streamline the way our clinicians capture and report data as well as the amount of data they need to actively capture.

Ignore Quality Reporting at Your Peril

The core of the proposed Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) Incentive rule is physician accountability. Quality reporting must also encompass capturing the patient clinical experience in a reportable manner.

Many doctors and medical group leaders still don’t have the basic infrastructure to measure performance on reported measures or to determine which measures to report based on their current performance. But not reporting quality measures is simply not a viable option going forward. The more granular and impactful reporting of quality measures is a “burning platform” for healthcare, and failure to comply with all payers’ reporting requirements will imperil the fiscal health and survival of physicians and medical groups of all sizes. Building and refining quality reporting and performance management infrastructure is now a matter of survival.

By January 2017, every Sheridan service line from Anesthesia to Pain Management will have a fully functional, fully deployed, service line-specific Patient Care Measurement tool that will provide reporting for payers, regulatory bodies, and our leadership team and facility partners. These tools will give our clinicians both ease of use and maximal reporting compliance in this dynamic new payment landscape. These tools will allow us to capture, analyze and report on data that goes far beyond what the CMS, payers and regulatory bodies such as The Joint Commission/AAAHC will require, serving as key strategic and clinical tools that will help us develop best practice guidelines at the local and national levels.

19 May 2016

The Physician Burnout Epidemic, Part 1: Root Causes of This Alarming Trend

Physician burnout is a huge – and growing – problem, not just for doctors, but also for the entire healthcare system and the population it serves. In a recent survey by Studer Group of more than 350 practicing physicians, a staggering 90 percent of respondents said they have experienced symptoms of burnout at some point in their career. And 65 percent of those who have experienced burnout said they have considered leaving medicine.

A Disturbing Trend With Serious Implications

Physician burnout has increased dramatically in recent years. According to a 2015 Medscape article that compared the responses of respondents to both the 2013 and 2015 surveys for the Medscape Physician Lifestyle Report, 46 percent of respondents said they suffered from burnout in the 2015 survey, compared to fewer than 40 percent of respondents in 2013. An analysis from researchers at the Mayo Clinic and the American Medical Association shows an even bigger jump: The percentage of physicians who said they are suffering burnout rose from 45 percent in 2011 to 54 percent in 2014. According to the report, “Burnout and satisfaction with work-life balance among U.S. physicians are getting worse. American medicine appears to be at a tipping point with more than half of U.S. physicians experiencing professional burnout. Given the extensive evidence that burnout among physicians has effects on quality of care, patient satisfaction, turnover, and patient safety, these findings have important implications for society at large.”

This trend is even more disturbing in the face of the growing physician shortage. Surgeon General Vivek Murthy, M.D., MBA spoke about the severity of this issue in a recent interview with MedPage Today. “The suicide and burnout rate is very high,” he said, “and this is concerning to me because we're at a point in our country where we need more physicians, not fewer; we need more people entering our profession, not fewer…I am particularly interested in how to cultivate emotional well-being for healthcare providers. If healthcare providers aren't well, it's hard for them to heal the people for whom they are they caring.”

What’s Fueling the Increase in Physician Burnout?

The causes are well documented, with regulatory burdens, lack of work-life balance, changes to payment arrangements and the increased computerization topping the list of complaints. Physicians responding to the Medscape Physician Lifestyle Report ranked “Too many bureaucratic tasks” as the most important cause of burnout, followed by “spending too many hours at work.” Changes to the healthcare system that affect doctors’ earnings also have taken a toll: 2015 respondents cited insufficient income as the third most important cause, up from fifth place in 2013. And increasing computerization of physicians’ medical practices jumped dramatically from ninth place in 2013 to fourth place in 2015.

A 2013 analysis by the American Medical Association (AMA) and RAND Health found that while doctors approve of electronic health records (EHRs) in concept and appreciate being better able to access patient information remotely, as well as the promise of improvements in care quality, the current state of EHR technology has significantly worsened their professional satisfaction. Most of their frustration stems from current EHR systems’ poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information because of interoperability issues, and degradation of clinical documentation. In a December 2015 article on WBUR’s CommonHealth site, former practicing doctor-turned-writer Diane W. Shannon, M.D., M.P.H. shared an internist’s explanation of frustration with EMR finally drove her to leave medicine: “If I took the time to actually talk with my patients, which is what drew me to medicine in the first place, it meant I fell behind and then spent hours and hours at home in the evening doing the required data entry.” In his inaugural address to the Connecticut State Medical Society’s House of Delegates last year, incoming president Henry E. Jacobs, M.D., J.D. wrote that “No study existed or exists today that demonstrates EMR decreases errors, increases efficiency, or lowers costs. Studies do show, however, that it has demoralized doctors and nurses and is a major component of job dissatisfaction and angst about where medicine is heading.”

Dr. Jacobs expressed doctors’ current frustrations in blunt terms. “The practice of medicine has become that of technician-bookkeeper-data entry clerk,” he wrote. “Government intervention into medicine has empowered insurance companies and CMS, using perverse incentives, bureaucratic regulations, and economic pressure, to force doctors to practice medicine their way…Clinical judgment was made an anachronism and guidelines morphed into mandates…Rigid adherence to protocols had some lethal consequences for patients. We are now serving under a cookie cutter paradigm.”

Physicians and practice managers who participated in the AMA-Rand Health study also cited the cumulative burden of externally imposed rules and regulations as a major source of frustration and professional dissatisfaction. Gerald A. Maccioli, M.D., Sheridan’s Chief Quality Officer, explained the scope of the problem: “There are more than 500 state quality measures in total, and only 20 percent cross over among states and medical specialties. Individual insurers and even health organizations often require their own metrics as well. This lack of standardization creates an almost unbearable administrative burden for doctors.” In February, the Centers for Medicare and Medicaid Services and the America’s Health Insurance Plans trade group took a first step in trying to standardize quality metrics, finally reaching consensus on how to measure physician quality in seven medical areas. But these initial seven “core measure” are far from comprehensive and won’t go into effect for years.

Doctors participating in the AMA-Rand Health study also expressed frustration that the increased demand for care (caused in part by the expansion of healthcare coverage to millions of previously uninsured Americans under the Affordable Care Act) limits the time they can spend with each patient, sometimes detracting from the quality of care they can provide.

Physician, Heal Thyself?

Focusing on personal wellness, such as a healthy diet, regular exercise, taking short breaks and practicing mindfulness meditation, can help and give doctors some tools within their control. The AMA’s STEPS Forward™ practice transformation series includes modules on improving physician resiliency and preventing physician burnout that focus on wellness activities and programs. But it’s hard for doctors to find time to exercise, eat well, meditate, take short breaks, and incorporate other wellness activities into their routines when they barely have time for themselves as it is. And most of the contributing factors are outside doctors’ control.

Sixty-six percent of the doctors who responded to the Studer Group survey said they don’t have the tools or resources to help themselves or their peers with this problem, and 54 percent said their leaders are not actively taking steps to treat or prevent burnout. More and more physicians are joining health systems, hospitals or large physician services companies as a refuge from the daunting administrative and legal burden of complying with government and carrier regulations and rules. Physician leaders have a responsibility, not only to doctors but also to patients and to health systems, to help relieve as much of this burden as possible so that physicians have the time and focus they need to provide high quality care.

Part two of this series will address the important role of physician leaders in combating the burnout epidemic.

17 May 2016

Memorial Regional Hospital Delivers Advanced Heart Failure Care

At Sheridan, we’re proud that our partner facilities consistently achieve some of the top distinctions in healthcare. Our physician leaders make this possible — as they continually identify ways to streamline processes, improve patient care satisfaction and push their departments to achieve more.

One such leader is Dr. Robert Brooker, chief of cardiac anesthesia and director of adult transplant and heart failure services at Memorial Regional Hospital in Hollywood, Fla. Dr. Brooker is responsible for developing anesthetic protocols and care systems for the hospital’s top ranking cardiac surgery program. Since 2009, Memorial has been awarded the Society of Thoracic Surgeons’ top honor — three stars in all three categories: isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) and AVR+CABG surgeries. These star rankings reflect excellence in surgical and medical expertise, advanced technology and compassionate patient care.

In addition, to his role as chief of cardiac anesthesia, Dr. Brooker also director of adult transplant and heart failure services. With his leadership and support, Memorial Regional Hospital now offers some of the most advanced treatments for heart failure, including ventricular assist device (VAD) and ECMO programs. In 2014, Memorial received approval from United Network for Organ Sharing (UNOS) to launch an adult heart transplantation program at the hospital. Memorial’s Adult Cardiac Transplant Heart Program is the first of its kind in Broward County, and one of only two programs in South Florida.

We congratulate Dr. Brooker and the Memorial team on 13 successful adult heart transplants to date! To learn about the team’s remarkable achievement, check out this video:

10 May 2016

Pain Management Boosts Patient Satisfaction

The mandates around pain as “the fifth vital sign” and the impact of patient satisfaction on HCAHPS scores have made pain management a high priority for healthcare providers. Patients’ perceptions of how well their pain was managed can have a major influence on their levels of satisfaction with their overall care experience, and improvements to pain management have been shown to boost both patient satisfaction and hospital revenues

Healthcare providers can be caught between a rock and a hard place when it comes to patient satisfaction with pain management. Many physicians feel increasing pressure from patients to prescribe opioid medications when those patients feel that the relief provided by acetaminophen and NSAIDS is inadequate. Some hospitals are trying pain mitigation alternatives, such as administering pain killers and other medications through transdermal patches or nasal sprays rather than intravenously to avoid patients’ negative associations with needle pain.

While treating patients’ physical pain is a major focus, addressing patients’ and caregivers’ fears and concerns and setting their expectations appropriately also can have a significant impact on their satisfaction with their pain management and overall care. In a Becker’s Hospital Review article, Dr. Adam Blomberg, Sheridan’s National Education Director for the Anesthesiology Division, and Chief of Anesthesiology at Memorial Regional Hospital in Florida, said that excellent communication and better patient and caregiver education are key.

Physicians are accustomed to speaking quickly and using medical jargon, which can confuse, overwhelm and sometimes intimidate patients and their caregivers. This type of ineffective communication can further increase their anxiety and stress and lead them to seek answers to their questions and concerns from more approachable and easier-to-understand, but often unreliable, sources. “Physicians who speak with patients clearly, politely and empathetically have been known to receive higher patient satisfaction scores,” said Dr. Blomberg. He also stresses the importance of giving patients a voice, letting them express their concerns and questions and addressing them directly and understandably.

Setting expectations clearly, matter-of-factly and in a timely manner is equally important. Patients are often unsatisfied because of unrealistic expectations, which set everyone up for failure. Dr. Blomberg explained that simply letting the patient know, “yes, you will have some pain but we will work together in addressing that pain, whether it be with medications or regional anesthesia,” can improve satisfaction. So can letting patients know in advance if the pain medication they will be receiving is intended to dull the pain and make it tolerable rather than eliminate it completely.

Patient education also plays an important role in reducing anxiety and making patients feel more empowered. Educating patients about types of anesthesia, the anesthesia team members’ roles, and what to expect before, during and after surgery can be very helpful. While direct, personal communication between providers and patients is essential, ideally they should be supplemented with easily accessible education materials such as Sheridan’s Anesthesia Patient Education portal, which provides an efficient, cost-effective way to provide patients with a reliable source of relevant and helpful information about their upcoming surgery.

To learn more about our anesthesia and pain management programs and our strategies for patient education and communication, contact our anesthesiology division.

6 May 2016

Physician Spotlight: Gerald A. Maccioli, MD, FCCM

Dr. Maccioli serves as Sheridan’s Chief Quality Officer. Before joining Sheridan in 2015, he practiced Anesthesiology and Critical Care Medicine for more than 27 years. He served as Director of the American Society of Anesthesiologists (ASA) for North Carolina and as Chair of the ASA Section on Education and Research. He also served as President of the Society of Critical Care Anesthesiologists. As the Chair of the American Medical Association (AMA) Committee of Innovators, Dr. Maccioli played an influential role in developing comprehensive, progressively responsible healthcare reform strategies. He continues to serve on the AMA’s Quality Improvement Advisory Committee (QIAC) as well as the Committee on Practice Sustainability and Professional Satisfaction.

Dr. Maccioli is a highly respected subject matter expert on a wide range of medical topics. He has been an invited speaker at more than 70 state and national meetings on diverse topics including resuscitation, critical care medicine, public policy, payment reform and quality improvement. He also has contributed to or written more than 50 clinical papers, abstracts, editorials and book chapters. 

He completed a Fellowship in Cardiothoracic Anesthesiology and Critical Care Medicine at Duke University after completing his Residency in Anesthesiology at the University of North Carolina at Chapel Hill. 

Dr. Maccioli is a strong advocate for ensuring care quality in the move to value-based care using a variety of approaches, including using Kaizen events for engaged process improvement and urging healthcare leaders to frame all decisions with the “quadruple aim” in mind to prevent physician burnout and improve care delivery. He’s also a proponent of optimizing pre-admissions testing and establishing standardized, evidence-based care guidelines.

Large healthcare organizations that have vast pools of data to analyze and learn from, as well as a large team of dedicated physicians, need to lead the way in care quality innovation and establishing evidence-based best practices. Dr. Maccioli’s experience, expertise and leadership are helping Sheridan do just that.

4 May 2016

Overcrowded EDs and Population Health

Unsurprisingly, yet another study has linked ED inefficiency with poorer population health outcomes. This time from George Washington University, the study found that the most crowded quartile of EDs had a much lower rate of adoption for common techniques that reduce overcrowding, such as bedside registration and surgical schedule smoothing. This finding is made more concerning by the fact that adoption of these techniques is increasing across hospitals as a whole. While the general adoption trend is positive, the hospitals most in need are also the ones improving the slowest.

Dr. Jesse Pines, a professor of emergency medicine and health policy at GWU and one of the study's authors, believes that a lack of resources is partially to blame. In an interview with the Washington Business Journal, he argued that cost can often be a barrier to adoption, saying that “the places that have been effective at reducing crowding have had to invest a lot of time and money into it.” If CMS were to penalize hospitals based on ED crowding in the future, it could potentially exacerbate the problem.

We agree with Dr. Pines, but also want to highlight the myriad options available for low-cost efficiency improvements in EDs. In most of the cases we've seen at our hundreds of partner hospitals, major investments in time and infrastructure aren't necessary to achieve significant efficiency gains. More often than not, some small tweaks to existing processes can deliver very high returns. The challenge is figuring out what those tweaks are, and how they should be systematized.

Process and Communication Errors

Most efficiency drains fall into one of two categories: process and communication. Let's start with communication. Contrary to popular belief, miscommunication is one of the leading causes of ED errors. Fortunately, it is also one of the easiest to solve. In our work – and particularly in Dr. David Mishkin's communication drill practice – we have found that simple changes in the way ED teams communicate information to one another can significantly reduce error rates and increase efficiency. Even just a few hours of communication drills can have a noticeable impact.

Process errors can be more challenging, but still require less investment than one might think. While large investments in software, systems and infrastructure are a necessary part of the complete solution, many process problems can be solved without them. Perhaps the best example of this principle is Kaizen, a continuous process improvement methodology that invites all members of a team to collaboratively design solutions to process problems.

One of the core ideas of Kaizen is that the people who regularly execute processes are also the ones with the best ideas on how to improve them. Giving these individuals a forum in which to share and develop their ideas consistently leads to more effective and lower cost solutions than top-down approaches. We have seen this play out in hundreds of our partner hospitals and are even beginning to apply the concept to less concrete processes, such as employee engagement.


Dr. Pines is right to emphasize the importance of large scale, top-down efforts to address ED inefficiencies. However, equal emphasis should be placed on the simple process and communication errors that are at the heart of many common efficiency drains in the ED. In many cases, solving these problems using Kaizen and other employee-driven methodologies is more attainable and cost-effective goal than a top-down overhaul.

If you're interested in learning more about how we have used Kaizen, communication drills and other strategies to improve ED efficiency, please check out our “The Evolving Emergency Department” white paper.

25 April 2016

The Drive for Process Improvement Part 5: Elevating Transformative Vision

Three leaders from the International Consortium for Health Outcomes Measurement (ICHOM) – a nonprofit founded by organizations known for progressive business practices and rigorous research: Harvard Business School, The Boston Consulting Group and the Karolinska Institutet – published an article in Harvard Business Review that analyzes the success some healthcare organizations have had in implementing patient outcomes measurement programs. The article lists five steps that should be applied when implementing major change or process improvement within healthcare systems. This blog post is the final in a five part series that critique and nuance each ICHOM step from a Kaizen perspective.

Be Prepared

The final imperative outlined by the ICHOM is to use early successes to scale and spread innovation. Scaling and spreading transformative improvements to hospitals can assist the healthcare system in the transition to value-based care. In this sense, communication of best practices between providers has the potential to benefit the entire healthcare system. Each organization has its own unique characteristics, therefore it is essential to make sure that scaled process improvements are rock solid and adaptable in implementation. At Sheridan, we have developed a robust system to ensure success in expanding improvements to other organizations.

We understand that in order to adapt an improvement to another setting, it is essential to form a foundation of standard work that provides those responsible for implementation with a specific understanding of how the improvement needs to function. An illustrative analogy can be found in football. For proper execution, a quarterback needs to know exactly where each of his players is going to be, when they will be there, and what responsibility each of his teammates has. Furthermore, the best way to ensure this understanding is through a precise language of illustration via X’s and O’s. To gain an understanding of how an improvement needs to look and function in a variety of different settings with different teams is an incredible challenge, standard work sheets illustrating the new process, expected timing, work content, and results must be made simple and transparent, this is the only way to effectively implement a change to its full potential.

Beyond Quantitative Goal-Setting

We invest in people as our most important resource. No matter how often a similar problem is encountered at different facilities the solution is always dependent on the factors present at a specific site, canned solutions are not viable. The greatest likelihood of sustained success if through the training and practice of the individuals actually doing the work. After participating on a kaizen individuals on the team should be able to analyze their own process going forward and solve the problems specific to their own role in the workflow. We regard every Kaizen team member as both a learner and a problem solver. Kaizen is a system that enables people to leverage their own unique perspective with effective team communication. We are confident that our events will leave each Kaizen team member more adept at solving problems through a communicative, systematic approach. In this sense, we regard Kaizen as a dual objective system. Even if the implemented process improvement does not have the desired impact, you have empowered your staff with skills necessary to re-evaluate and readjust the process. The most important outcome of the Kaizen is to enable staff to approach problem-solving logically and cooperatively through application of the scientific method.

Indeed, Sheridan has implemented a system to scale and spread its own vision of Kaizen process improvement to many organizations nationwide. In Part 2 of this series, we described how the facilitator acts as arbiter and guide for the Kaizen. Integral to the guidance of the facilitator is making people understand the skills they are quickly developing through their Kaizen experience. 50-70 percent of the time facilitators also work with trainees called facilitator technicians to train them to conduct Kaizens themselves. Facilitator technicians tag along for three to six Kaizen events before they conduct their own guided facilitation. With each event leading up to their facilitation, the technician gains additional responsibility. Technicians are invited to discuss with the facilitator how they would approach a problem. If the suggested approach is correct, the technicians are permitted to present their perspectives to the group. At Jupiter Medical Center in Florida, two facilitator technicians trained under an extensively experienced facilitator through five Kaizens. In the sixth, they were permitted to co-facilitate the event while their mentor shadowed for assistance. Through their extensive experience, the mentor’s guidance and their own collaborative effort, they effectively conducted a successful Kaizen.

Executive Guidance

After an event, the administration will review the outcome with Sheridan facilitators in order to determine where efforts need to be focused next. Additionally, Sheridan staff will engage in a walkabout to gain a visual sense of what’s working and what needs improvement. Ultimately, the review and walkabout enable targeted scaling and spreading to optimize the rate of change among our partners to ensure the implementation of best practices. If we were to constantly conduct Kaizens, we would constrain the staff and sub-optimize efficiency. The final goal of the targeting is to prevent organizations from spreading their human, technical and financial resources too thin. This strategy allows our work to amount to a controlled burn (rather than a raging wildfire) that will permit continuous, sustainable process improvement.

Finally, we want to recognize the high expectations that Sheridan’s administration has for both itself and the entire staff. President of Physician Services Robert Coward expects an outline to demonstrate a logical, clear approach to lean process improvement. These expectations constantly encourage Sheridan employees to proactively evaluate their own thinking when addressing a problem.

Final Thoughts

The imperatives developed by the ICHOM demonstrate the broad requirements of successful implementation of process improvement, but they are not complete. These imperatives must be nuanced through a Kaizen approach to allow organizations and people to internalize the changes made and to continually drive progress. We find there are two fundamental lessons in our analysis that the ICHOM misses in its presentation.

First, people are an organization’s most important resource. Without soliciting consistent input from a diverse selection of stakeholders, it will be impossible to optimize a process. Furthermore, cultivation of analytic problem-solving skills among your staff will determine the long-run prosperity of the organization. It is important to build a culture that promotes both independent thought and absolute commit to teamwork. In this sense, it is essential to constantly encourage employees.

Second, process improvement is never entirely complete. Organizations and their constituents need to constantly re-evaluate their myriad procedures in order to determine where deficiencies exist and what practices could offer solutions. You can only act as a leader in the value-based healthcare industry with consistently open communication and commitment to progress.

These lessons represent how organizations need to approach innovation to be successful in the future. Healthcare is a dynamic field and professionals must respond to its changes in order to provide the best care affordably. Only with a deep understanding of how lean processes are developed, maintained and constantly improved will healthcare providers achieve a premier standard of care.

Previous Series Installments:

Part 1: Making Champions of Believers

Part 2: Assembling Your Dream Team

Part 3: Commit to Your Vision

Part 4: Effectively Celebrating Progress

22 April 2016

Spotlight on Sheridan’s Comprehensive Teleradiology Solutions

Sheridan’s recently released FRESH ES/CTS Newsletter for Q1 2016 features FAQs with Chief Glenn Kaplan, M.D. about our teleradiology solutions. FRESH ES stands for Final Reads Electronically from Sheridan Healthcare Eco-System. This technology platform allows radiologists to view cases from multiple hospitals across the country, including relevant prior studies, and render a preliminary or final interpretation. The latest version enables radiologists to stream images rather than downloading the full DICOM data set. Among its many benefits, FRESH ES integrates the workflow between hospital-based radiologists and referring physicians, greatly increases efficiency, and enables significantly improved diagnostic accuracy and patient care. 

CTS, which stands for Comprehensive Teleradiology Solutions, is led by practice director Richard B. Sanders, DHA, MPH, FACHE. It oversees Sheridan’s teleradiology physician and support teams and deploys and maintains the FRESH ES platform.

The newsletter also presents highlights of FRESH ES/CTS achievements in 2015, including significant improvements in physician productivity and expanded services. Last year CTS read roughly 400,000 cases and 240,000 wRVU, with an impressive average turn-around time of only 14 minutes. Its call center was 100 percent staffed during hours of reading.

To better serve internal customers, CTS increased coverage for evenings, medical leave, plain films and onsite locums and facilitated PRN IR coverage. To better meet external customer needs, CTS also provided ER plain film services for 10 new facilities, added pediatric sub-specialization for two medical centers, expanded to cover three new facilities and three freestanding emergency rooms, and secured three facility trauma designations.

Sheridan is a leader in using teleradiology services to streamline processes, increase physician productivity and ensure timely, high-quality patient care. We support the growth of teleradiological health systems that establish measurable quality standards and accountability for diagnostic accuracy, appropriate utilization, service level excellence and patient care.  

20 April 2016

Sheridan Launches Investigator Initiated Research Program

As a physician-led company, Sheridan aims to support and develop our physicians’ expertise in the clinical, management and leadership arenas. This year, in order to build on and support the research interests and efforts of our physicians, we are launching Sheridan Scientific Intelligence, an investigator initiated research unit. The new group will provide resources and support for physician-initiated research and will complement the work done through our clinical research team. The program will be led by Jana Barlic-Dicen, Ph.D., Manager of Investigator Initiated Research. As a large, multispecialty organization, Sheridan has an opportunity to serve the broader medical community by addressing unmet research needs.

Sheridan Scientific Intelligence will serve the needs of our physicians, our partner institutions, and the medical community by:

  • Encouraging physicians to partner with Sheridan on their investigative research so they can take advantage of Dr. Barlic-Dicen’s extensive experience and expertise in this area, from helping to refine the idea for the study for greater impact (e.g., larger reach, stronger testing methods/data) to providing guidance and support regarding statistical analyses, publication, presentation and exposure for the physicians’ research findings.
  • Ensuring that all investigator initiated research is conducted in compliance with all federal, state and local regulations, especially when it involves patients.
  • Using the research findings to improve on current best practices at Sheridan’s partner hospitals and helping to publicize them so that other medical institutions and society as a whole can benefit from the research.

Sheridan Scientific Intelligence also will help to fund a certain number of studies each year. A call for research proposals will be sent to Sheridan physicians in the next few months.

Some of the areas that Sheridan physicians either have begun to research or have expressed interest in investigating include improvements to anesthesiology practices for obese and diabetic patients, and finding better radiology approaches and equipment, particularly for breast cancer imaging.


About Dr. Barlic-Dicen

Jana Barlic-Dicen, Ph.D. is the author of numerous peer-review publications and has been a speaker at multiple national and international meetings. She received her Bachelor of Science with Honors at the University of Ljubljana (Slovenia) and her Ph.D. in Microbiology and Immunology at the University of Western Ontario (London, Ontario, Canada). Dr. Barlic-Dicen was the recipient of the National Institutes of Health Intramural Research Training Award and served her post-doctoral research fellowship at the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. She was a recipient of a prestigious Wellcome Trust Research Career Development Fellowship during her tenure at Imperial College London. She also served as a Principal Investigator at the Cardiovascular Biology Research Program at the Oklahoma Medical Research Foundation and as a faculty member in the Department of Cell Biology at the University of Oklahoma College of Medicine, where her research was funded by the award from the National Institute of General Medical Sciences.