Optimizing care delivery in expanding health systems: Views from clinical leaders.

INTRODUCTION: In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored. METHODS: Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis. RESULTS: Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality. CONCLUSIONS: Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.

Barriers to Telemedicine Use: Qualitative Analysis of Provider Perspectives During the COVID-19 Pandemic.

BACKGROUND: Though telemedicine is a promising approach for removing barriers to care and improving access for patients, telemedicine use for many medical specialties has decreased from its peak during the acute COVID-19 public health crisis. Understanding the barriers and facilitators to the maintenance of web-based visits-one key component of telemedicine-is critical for ensuring the continuous availability of this service for patients. OBJECTIVE: The purpose of this study is to describe medical providers' perceived barriers and facilitators to the continued use of web-based visits to inform quality improvement efforts and promote sustainability. METHODS: We performed a qualitative content analysis of free-text responses from a survey of medical providers administered from February 5-14, 2021, at a large, midwestern academic institution, including all providers from medical professions that offered telemedicine (eg, physicians, residents or fellows, nurse practitioners, physicians assistants, or nurses) who completed at least 1 web-based visit from March 20, 2020, to February 14, 2021. The primary outcome was the experience of providing web-based visits, including barriers and facilitators to continued usage of web-based visits. Survey questions included 3 major domains: quality of care, technology, and satisfaction. Responses were coded using qualitative content analysis and further analyzed through a matrix analysis to understand the providers' perspectives and elucidate key barriers and facilitators of web-based visit usage. RESULTS: Of 2692 eligible providers, 1040 (38.6%) completed the survey, of whom 702 were providers from medical professions that offered telemedicine. These providers spanned 7 health care professions and 47 clinical departments. The most common professions represented were physicians (486/702, 46.7%), residents or fellows (85/702, 8.2%), and nurse practitioners (81/702, 7.8%), while the most common clinical departments were internal medicine (69/702, 6.6%), psychiatry (69/702, 6.6%), and physical medicine and rehabilitation (67/702, 6.4%). The following 4 overarching categories of provider experience with web-based visits emerged: quality of care, patient rapport, visit flow, and equity. Though many providers saw web-based visits as a tool for improving care access, quality, and equity, others shared how appropriate selection of web-based visits, support (eg, patient training, home devices, and broadband access), and institutional and nationwide optimization (eg, relaxation of licensing requirements across state borders and reimbursement for phone-only modalities) were needed to sustain web-based visits. CONCLUSIONS: Our findings demonstrate key barriers to the maintenance of telemedicine services following the acute public health crisis. These findings can help prioritize the most impactful methods of sustaining and expanding telemedicine availability for patients who prefer this method of care delivery.

Surgical Leadership Competencies for Navigating Hospital Network Expansion.

INTRODUCTION: Today, many hospitals are part of a multihospital network, which changes the context in which surgeons are asked to lead. This study explores key leadership competencies that surgical leaders use to navigate this hospital network expansion. METHODS: In this qualitative study, 30 surgical leaders were interviewed. Interviews were coded and analyzed via thematic analysis. RESULTS: We identified three key competencies that leaders felt were important leadership skills to successfully navigate expanding hospital networks. First, leaders must steer the departmental vision within the evolving hospital network landscape. Second, leaders must align the visions of the department and of the hospital network. Third, leaders must build a network-oriented culture within their department. CONCLUSIONS: As networks expand, leaders are tasked with unifying vision in their department. Leaders identified a unique opportunity to leverage their growing influence across the hospital network and invested in the people and culture of their department.

Surgical quality assurance at expanding health networks: A qualitative study.

BACKGROUND: Even after decades of network expansion and increased care being delivered within health networks, health network expansion has not led to uniform improvements in patient outcomes and satisfaction. The reasons for the lack of universal surgical quality improvement are unclear. This study used qualitative methods to understand the nuances that affect the variation in network-level surgical quality assurance and provides strategies that surgical leaders use to improve surgical quality at expanding health networks. METHODS: This qualitative study obtained information through 30 semistructured interviews conducted from August to December 2019 with surgical leaders whose institutions were associated with health networks. The topic of surgical quality assurance was an emergent theme that was informed by thematic analysis. RESULTS: Interviews with leaders revealed 3 themes with regard to surgical quality assurance. First, participants wanted standardized tools for quality measurement. Leaders frequently referred to the National Surgical Quality Improvement Program registry and shared electronic health records, but some networks did not have these available at all sites. Second, participants wanted an organizational structure that provides clear oversight over quality. Some leaders appointed executives or created committees to help manage quality improvement initiatives. Third, participants wanted a culture shift toward quality improvement. Many leaders faced resistance to quality initiatives from frontline clinicians; some implemented events and retreats to help garner support and a culture of quality. CONCLUSION: These interviews offer critical insights into 3 domains that can be leveraged for sustained improvement and detail strategies that leaders used for surgical quality assurance at hospital networks.

Challenges and Opportunities for the Academic Mission Within Expanding Health Systems: A Qualitative Study.

OBJECTIVE: To explore challenges and opportunities for surgery departments' academic missions as they become increasingly affiliated with expanding health systems. SUMMARY BACKGROUND DATA: Academic medicine is in the midst of unprecedented change. In addition to facing intense competition, narrower margins, and decreased federal funding, medical schools are becoming increasingly involved with large, expanding health systems. The impact of these health system affiliations on surgical departments' academic missions is unknown. METHODS: Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August - December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. The topic of challenges and opportunities for the academic mission was an emergent theme, analyzed using thematic analysis. RESULTS: Academic health systems typically expanded to support their business goals, rather than their academic mission. Changes in governance sometimes disempowered departmental leadership, shifted traditional compensation models, redirected research programs, and led to cultural conflict. However, at many institutions, health system growth cross-subsidized surgical departments' research and training missions, expanded their clinical footprint, enabled them to improve standards of care, and enhanced opportunities for researchers and trainees. CONCLUSIONS: Although health system expansion generally intended to advance business goals, the accompanying academic and clinical opportunities were not always fully captured. Alignment between medical school and health system goals enabled some surgical department leaders to take advantage of their health systems' reach and resources to support their academic missions.

Assessing patient usability of video visits.

BACKGROUND: Telehealth is being adopted by health systems across the country and many barriers to the expansion of video visit programs have been identified. Our study focused on the usability of video visit technology by examining technical challenges faced by patients over the course of a video visit. METHODS: We conducted a survey of patients who received care from the Michigan Medicine video visit program from January 31, 2019 to July 31, 2019. The video visit program includes more than 1,300 visits a year across more than 30 specialties. Following the completion of their video visit, all patients were invited to participate in our online survey through the patient portal. The survey included questions on patient satisfaction, motivation and technical challenges. RESULTS: We received responses from 180 patients (response rate of 26%). Overall patient satisfaction was high; 90% of respondents agreed that their video visit experience was similar to that of in-person visits and 93.3% of respondents would recommend video visits. Despite this high satisfaction rate, 36 out of 180 (20.0%) respondents cited technical issues during their video visit: video issues (n=11), audio issues (n=5), video and audio issues (n=2), slow/dropped connection (n=7), initial set-up issues (n=4), long wait time (n=3), and other (n=4). CONCLUSIONS: While most patients report a high degree of satisfaction with their video visit, a meaningful subset of patients continue to experience technical challenges.