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Hospitals start to address their energy-hog problem


For Kaiser Heath News

Hospitals are energy hogs.

With their 24/7 lighting, heating and water needs, they use up to five times more energy than a fancy hotel.

Executives at some systems view their facilities like hotel managers, adding amenities, upscale new lobbies and larger parking garages in an effort to attract patients and increase revenue. But some hospitals are revamping with a different goal in mind: becoming more energy-efficient, which can also boost the bottom line.

“We’re saving $1 [million] to $3 million a year in hard cash,” said Jeff Thompson, the former CEO of Gundersen Health System in La Crosse, Wis., the first hospital system in the U.S. to produce more energy than it consumed back in 2014. As an added benefit, he said, “we’re polluting a lot less.”

The health care sector — one of the nation’s largest industries — is responsible for nearly 10 percent of all greenhouse gas emissions — hundreds of millions of tons worth of carbon each year. Hospitals make up more than one-third of those emissions, according to a paper by researchers at Northeastern University and Yale.

Increasingly, though, health systems are paying attention:

  • Gundersen Health System in Wisconsin employs wind, wood chips, landfill-produced methane gas — and even cow manure — to generate power, reporting more than a 95 percent drop in its emissions of carbon monoxide, particulate matter and mercury from 2008 to 2016.
  • Boston Medical Center analyzed its hospital for duplicative and underused space, then downsized while increasing patient capacity. Among other changes, it now has a gas-fired 2-megawatt cogeneration plant that traps and reuses heat, saving money and emissions, while supplying 41 percent of the hospital’s needs and acting as a backup for essential services if the municipal power grid goes out.
  • Theda Clark Medical Center in Wisconsin is saving nearly $800,000 a year — 30 percent of its energy costs — after making changes that included retrofitting lights, insulating pipes, taking the lights out of vending machines and turning off air exchangers in parts of its building after hours.
  • Kaiser Permanente aims to be “carbon-neutral” by 2020, mainly by incorporating solar energy at up to 100 of its hospitals and other facilities. One already in use — at its Richmond (Calif.) Medical Center — is credited with reducing electric bills by about $140,000 a year. (Kaiser Health News is not affiliated with Kaiser Permanente.)

While the environmental benefits are important, “what I’ve seen over the years is cost reductions are the prime motivator,” said Patrick Kallerman, research manager at the Bay Area Council Economic Institute, which released a report this spring outlining ways the hospital industry can help states such as California reach environmental goals by becoming more efficient.

Some of its recommendations are simple: replacing old lighting and windows. Others are more complex: powering down heating and cooling in areas not being used and updating ventilation standards first set back in Florence Nightingale’s day. Such tight standards “might not be necessary,” Kallerman said. Loosening them could help save money and energy.

When Bob Biggio was hired in 2011 to oversee Boston Medical Center’s facilities, hospital leaders were about to launch a broad redesign. Yet the hospital was also facing serious financial struggles. He put the move on hold while analyzing how the hospital was using its existing space, looking for unused or duplicative areas.

“My first impression with data I had gathered was our campus was about 400,000 square feet bigger than it needed to be, said Biggio. “A square foot you never have to build is most efficient of all.”

The new design is smaller but more efficient, handling 20 percent higher patient volume and eliminating the need for ambulance transportation between far-flung areas of the campus. It also cut power consumption by 42 percent from a 2011 baseline.

While the hospital sunk a lot of money into the renovation, the center was able to sell off some of its land to help offset the costs, leading to about a five-year return on investment, Biggio said.

“We are a safety-net hospital with a large Medicaid population,” he said. “So this is the last place people expect to see the type of investments and progress we’ve made.”

But how to sell that in the C-suite?

The environmental argument wasn’t how Thompson convinced executives at Gundersen.

“At no point did I mention climate change or polar bears,” said Thompson.

Instead, he focused on the organization’s mission to improve health — and the potential cost savings.

“There are multiple examples — at Gundersen and other places — where, if we’re thoughtful, we can improve the local economy, lower the cost of health care and decrease the pollution that is making people sick,” he said.

But hospitals’ energy efficiency efforts vary, with only about 10 percent attempting changes as dramatic as those done at Gundersen, estimated Alex Thorpe, a hospital energy expert at Optum Advisory Services, a consulting firm owned by UnitedHealth Group.

“About 50 percent are in the middle,” he added, perhaps because these investments are weighed against other capital needs.

“If you have a well-known doctor that wants a new cutting-edge piece of equipment, then it can be hard to make the business case [for investing in alternative energy],” said Thorpe.

Of the more than 5,000 hospitals in the country, about 1,100 are members of Practice Greenhealth, a nonprofit that promotes environmental stewardship. Fewer than 300 hospitals qualify as Energy Star facilities, an Environmental Protection Agency program that recognizes buildings that rank in the top quartile for energy conservation among their peers.

Greenhealth estimates its members average about a million dollars a year in savings, but it all depends what steps they take.

There are modest savings from such things as reducing the heating and air conditioning in operating rooms during hours they are not in use, with median annual cost savings of $45,398, a report from the group notes. Other energy reduction efforts net another median $53,599 in annual savings, while swapping older lighting for new LED bulbs in operating rooms saves another $3,329.

Individually, those savings are not even rounding errors in most hospitals’ total expenses, which are measured in the millions of dollars.

Still, within facility expenses, energy use accounts for 51 percent of spending, so even modest cuts are “significant,” said Kara Brooks, sustainability program manager for the American Society for Healthcare Engineering.

Ultimately, that may affect what hospitals charge insurers and patients.

“If hospitals can lower peak demand through energy efficiency efforts, that will directly impact their pricing,” said Thorpe.

Tech issues stand in way of making CMS payment models work well

This is from FierceHealthcare:

“As providers gear up to participate in CMS’s revamped payment models, one major hurdle stands in the way for many: technology.

“Deirdre Baggot, Ph.D., a healthcare business strategist who has worked with more than 200 hospitals to implement value-based payment models, told FierceHealthcare in an interview that fee-for-service healthcare didn’t really require providers to manage large data sets the way that new advanced payment models do.

“Even as providers invest in better electronic health records and other technological upgrades, plenty of the work and data remains in silos, making it hard to access and use effectively, she said. ”

To read the whole article, please hit this link.


3 key elements in improving hospitalist patient scores


An article in NEJM Catalyst cites the importance of physician-to-physician coaching and medical director engagement in improving hospitalist patient scores. Among the conclusions:

  • “Transparent data sharing is critical to the success of any program.
  • “Physician coaching skills are an essential qualification for the physician lead chosen to interact with physicians.
  • “Engagement of medical directors who can reinforce training and review monthly scores on an ongoing basis is imperative.”


Feds to ask ACOs to take on more risk

From FierceHealthcare:

“A long-awaited proposal from the Trump administration will ask Accountable Care Organizations (ACO) to take on more risk going forward, a move that is likely to drive providers out of the program.

The proposed rule (PDF) issued by the Center for Medicare & Medicaid Services (CMS) on Aug. 9, shrinks the amount of time ACOs can be in an upside only model to two years. Currently, 82 percent of ACOs participating in the Medicare Shared Savings Program (MSSP) are in an upside only model.

Additionally, those in a Track 1 upside only model would only be able eligible to take in 25 percent of any savings. Under the current program, Track 1 ACOs take a 50 percent cut. In an upside model, ACOs get a portion of any savings generated in treating patients but are still paid by CMS if they incur losses.”

To read the full Fierce article, please hit this link.

Tough to track hospital ACO performance indicators

Authors of an article in NEJM Catalyst discuss how hospital-based Accountable Care Organizations (ACOs) are facing big hurdles in tracking performance indicators. They conclude:

“ACOs are a broad-stroke model for changing how health care is delivered. Analysis of {an American Hospital Association} survey results highlights the reasons that a broad tool is challenging: It is difficult to get data at the level of granularity required to resonate with individuals, and primary care physicians have limited control over the wide range of care their patients receive over the course of a year. A more targeted tool, like bundled payments, where one defined episode of care can be studied, measured, and perfected, may be a better answer and could even be used within an ACO to distribute capitated payments.”

To read the article, please hit this link.


Stanford’s chief wellness officer takes on physician burnout


For Kaiser Health News


‘Stanford Medicine hired Dr. Tait Shanafelt as chief wellness officer last year, not so much for the well-being of the patients — but of the physicians.

An oncologist and hematologist by training, Shanafelt, 46, has become a national leader in the movement to end physician “burnout” — the cumulative effect of years of stress that can compromise patient care and cause doctors to leave medicine. After 12 years at the Mayo Clinic, Shanafelt now heads up Stanford’s WellMD Center, dedicated to physician health. He also serves as an associate dean of the Stanford University medical school.

He lives in Portola Valley, Calif., with his wife, a nurse, who works part time, and their four children, ages 4 to 13.

Dr. Tait Shanafelt (Julie Greicius/Stanford School of Medicine)

Shanafelt’s goal is to address the systemic problems in medicine — long hours, a culture of blame, endless record-keeping — and find solutions that go far beyond yoga classes or free ice cream for doctors.

Shanafelt’s research “has raised national awareness of physician burnout,” said Dr. Christine Sinsky, an Iowa physician and vice president of professional satisfaction for the American Medical Association, who has co-authored studies with Shanafelt. “Because of his work, institutional leaders now understand the importance of addressing burnout,” she said. And “improvement is possible.”

It’s a high-stakes effort, one joined by other physicians and researchers nationwide: Roughly 300 to 400 doctors die by suicide each year, and physicians rank among the occupations with the highest risk of death by suicide. A 2017 National Academy of Medicine paper, co-authored by Shanafelt, found that more than half of U.S. physicians experienced “substantial symptoms” of job burnout.

Shanafelt spoke to California Healthline recently about his work. The interview has been edited for length and clarity.

Q: How did you come to be interested in physician burnout and well-being?

It’s a bit of a fluke, to be honest. As an internal medicine resident 20 years ago, I was supervising a team of interns [when my supervisor] asked, “What are you observing?” I said that burnout is affecting the care we give to patients. We did that first study — it was one of the first to show links between burnout and patient-care outcomes. It became an absolute lightning rod. It completely opened a national dialogue on the topic.

Q: How is physician burnout linked to quality of care?

We’ve shown in a number of studies that every one point increase in burnout [as measured by a survey] increases the risk of a medical error in the next three months. Other studies have shown that if a hospitalized patient is being cared for by a doctor who’s burned out, their recovery takes longer. … Burned-out physicians are more likely to [leave their jobs] or work part time, and that’s disruptive to the continuity of care for their patients. Burned-out doctors are twice as likely to have patient complaints from the ombudsman and complaints of unprofessional behavior.

Q: What is it about the physician culture that leads to burnout?

[The notion] that physicians are superhuman and that normal human limitations don’t apply to us. The way we trained physicians to do 36 hours on a shift and somehow, we thought we’d be as good in Hour 36 as we were in Hour 1. We know that’s not true for any profession. We also tend to have a culture of invincibility and … a lack of vulnerability with colleagues.

Q: How have you handled burnout personally?

I have a clear sense of the things that really matter to me, both professionally and personally, and try to make choices that are aligned with that. I have accountability partners — one of whom is my wife — who ask, “Are you living consistent[ly] with the things that matter most?” Being able to recognize within yourself when you need to take a break and step away and have rest and use your vacation in a strategic way, I think about these in far more intentional ways than I did earlier in my career.

Q: What are some changes you’d like to see in medical education to prevent burnout?

We probably need to imbue future physicians with different values about self-calibration and self-care as necessary skills. There needs to be a greater culture around vulnerability and supporting each other in the demands of the work.

We also need to understand the unique challenges and demands of each specialty. A surgeon and a radiologist have different jobs. Emergency physicians, for example, have high rates of burnout but also high rates of work-life satisfaction.

But unless we as a profession have a dialogue about burnout more broadly, all the things we do in training will have a limited impact. The minute new doctors go into practice, they look at behavior of their more senior colleagues and they’re instantly going to adopt that behavior.

Q: How has the consolidation of health care — with fewer independent practice physicians — affected doctor burnout?

It’s a double-edged sword. A larger system has opportunities to think about the way work is distributed to provide more flexibility and to create systems of peer support. … But by the same token, many health care organizations also restrict autonomy, and people have less flexibility than they might have had in a small group practice. … They’re held accountable for productivity expectations and expected to overwork. We need to give people a voice. … We need to help leaders not treat people as cogs or widgets.

KHN’s coverage of these topics is supported by California Health Care Foundation and Blue Shield of California Foundation

Exiting silos to improve public health-health system coordination

An article in NEJM Catalyst looks at how to better coordinate the functions of public health officials and private-sector health systems. The authors write:

“Moving toward a comprehensive community wellness vision requires a fundamental transformation of how healthcare and public health engage with one another. Previously siloed organizations may find they have duplicative efforts that are ripe to be streamlined. For example, we reviewed cases where local health department funding to address certain public health objectives was made dependent on performing a certain service (e.g., reproductive health counseling), even if the local healthcare system was already efficiently and effectively providing that service for the same population. Rather than reject the funding from the state or federal government, local public health was compelled to implement a duplicative service. A structured partnership that arranges consolidation of these repeat programs could free limited resources within a community to be redirected to other health needs.

To read the article, please hit this link.

Physicians are said to grapple with their ‘moral injury’

An essay in STAT suggests that “moral injury,” not “burnout,” is the biggest problem for physicians now.

 The authors write:

“Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

“Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work”.

“The term ‘moral injury’ was first used to describe soldiers’ responses to their actions in war. It represents ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.’ Journalist Diane Silver describes it as ‘a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”’

“The moral injury of healthcare is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of healthcare.”

To read the piece, please hit this link.

Population-health approaches seen needed to address high-need GI patients

MedPage Today reports:

“As in other medical conditions, a small fraction of high-need, high-cost patients with gastrointestinal (GI) and liver diseases contribute disproportionately to hospitalization costs, according to a nationwide database analysis published in Clinical Gastroenterology and Hepatology.

“The study found that across five common diseases, patients in the top two deciles of hospital utilization accounted for well over half of hospital costs and those in the top decile accounted for more than a third of costs, and in one case, reached almost 40% of costs.

“‘Population health management strategies directed toward identifying these high-need, high-cost patients and implementing multi-component chronic care models may improve the quality of care and reduce costs of care,’ the study’s senior author, Siddarth B. Singh, M.D., of the University of California at San Diego, told MedPage Today.”

To read the database analysis, please hit this link.

To read the Med Page article, please hit this link.

Trying to measure performance in healthcare


From NEJM Catalyst:

“{W}hat constitutes high performance in healthcare? Three-quarters of  NEJM Insights Council members say there is little consensus around a definition. Yet there is some agreement on the key elements and indicators. A culture of excellence is the top attribute of a high-performing organization, followed by aligned goals among all stakeholders.

“Very few respondents say that individual stars among physicians and staff create high performance. We find this heartening; it is a validation of the industry move toward integrated, team-based care. Plentiful finances also fell low on the list of key attributes. Lack of financial resources need not be a deterrent in becoming a high-performing organization.

“We were surprised, however, by how survey respondents weighted cost considerations in the value equation of high performance. Almost all respondents says high quality and excellent patient safety are extremely important, but low cost falls to the bottom of the list of indicators. These results do not reflect the Triple Aim of healthcare, which values high-quality care, population health, and low cost equally.”

To read the article, please hit this link.

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