A Culture of Civility, A Culture of Safety

by Heather Hylton, PA-C

Heather Hylton

Heather Hylton

It is well-established that an array of drivers can lead to professional burnout in healthcare providers.  Tait Shanafelt and John Noseworthy have described seven dimensions into which the drivers can be grouped, including culture and values, control and flexibility, and social support and community at work.  The culture of an organization sets the stage for how individuals of that organization interact and work together.  In addition, organizational culture directly impacts both the work performance of employees as well as the employees’ well-being.  Control and flexibility in healthcare are continuously challenged for a host of reasons including access, productivity pressures, and technology burdens.  Healthcare delivery is contingent upon coordinated work effort from a team, thus underscoring the importance of professionalism, mutual respect, and harmony as essential to the success of the team.

In general, the healthcare environment is highly stressful, making it more vulnerable to disruptive behaviors and incivility within this environment.  Examples of disruptive behaviors and incivility can range from overt actions such as berating or shaming staff in front of patients to more subtle actions such as impatience with or refusing to answer staff questions.  These behaviors can lead to communication problems and patient safety issues as those who are on the receiving end of or who are the target of intimidating behaviors may be reluctant to share information critical to the delivery of safe care to the patient.  This issue has commanded the attention of the Joint Commission who, in July 2008, issued a Sentinel Event Alert (SEA) on the topic of “behaviors that undermine a culture of safety.” Within the SEA, a new leadership standard was announced which requires organizations to have both a code of conduct and a process for managing disruptive and uncivil behaviors.  In addition, the American Medical Association has language specific to disruptive behaviors within its Code of Medical Ethics.

Unfortunately, incivility has been known to beget further incivility, thus compounding the problem.  Microaggressions, which may be subtle, are noted by Narjust Duma and colleagues to “represent enduring institutional and systemic imbalances of privilege and power.”  If unaddressed, microaggressions can insidiously become part of workplace culture. 

In their Toxic Organization Change System model, Elizabeth Holloway and Mitchell Kusy propose organizations implement highly-coordinated strategies at the individual, team, and organizational levels.  Christine Porath notes from her research that 98% of workers she has surveyed over the course of two decades have directly experienced uncivil behavior, and 99% have directly observed uncivil behavior.  While organizations should set standards for behavioral norms, teams can supplement this with their own code of conduct whereby all within the team are accountable to each other.  Christine Porath also offers guidance on how to interview for civility, which is an indispensable part of building a team that embraces the principle of mutual respect.   

Weeding out and addressing behaviors that undermine a civil work environment is not only essential to optimizing patient safety but can also positively impact employee engagement and retention.  Furthermore, a civil and respectful workplace must value inclusivity and seek to mitigate disparities.  Lastly, civility in the workplace can help address burnout in healthcare through enhanced professionalism, collegiality, and cultivating greater support among the team.  

JOP DAiS encourages discussion and welcomes your comments. Please note that comments are moderated; inappropriate remarks will not be tolerated.

If you have questions for our editors or have a submission inquiry please contact jopcontact@asco.org.  


Patient-reported Outcomes 2.0

How to optimize the oncology work force to respond to PRO’s

by Bobby Daly, MD, MBA and Abigail Baldwin-Medsker, MSN, RN, OCN

In my blog at the start of this year, I had highlighted five innovations to look for in 2019 in oncology care delivery that hold the promise of positively disrupting the way we practice. One such innovation is the adoption and integration of patient-reported outcomes into oncology clinical care. Basch et al.’s seminal study in 2017 demonstrated that patient reported outcomes achieved improved quality of life, fewer emergency room visits, and a five month gain in overall survival. In discussing the study at the ASCO plenary that year, Dr. Krzyzanowska advocated that active symptom monitoring during chemotherapy should be the new standard of care, but she cautioned that oncology practices must be cognizant of implementation issues in taking up this challenge. A key implementation issue is the workforce redesign that is needed to integrate PRO’s into practice. In writing this blog, we reached out to Dr. Kathi Mooney of the University of Utah, an accomplished researcher in this area to provide insight. 

Dr. Mooney’s work: A Pioneer Pivots in the Provider Responding to PRO’s

Dr. Mooney’s research in this area has explored different models for monitoring patient’s symptoms during ambulatory chemotherapy. In her first study, published in 2014 in the journal Supportive Care in Cancer , medical oncology patients used a touch tone telephone to report 10 common symptoms during chemotherapy. In the intervention group, symptoms exceeding thresholds for moderate-to-severe intensity levels generated emailed alert reports to both the patient’s oncologist and oncology nurse. In the control group patients reported their symptoms daily but understood that the data they submitted were for research purposes only and were not available for clinical action. The overall daily call adherence was 65.0% of expected days and on average 9 moderate-to-severe intensity alerts were generated per patient over the 45 study days. Mooney et al., however, found no significant difference in change of symptom severity between the two groups, and that providers rarely contacted patients after receiving alerts. The authors concluded: “Despite patients’ use of a daily symptom monitoring system and providers’ receipt of unrelieved symptoms of moderate-to-severe intensity, oncology physicians and nurses did not contact patients to intensify symptom treatment nor did symptoms improve.” This led to a pivot in research for a second study published in Cancer Medicine in 2017. In this study, the control group remained the same but in the intervention arm the alerts now went to a dedicated nurse practitioner (NP) for follow-up of poorly controlled symptoms. The NP used a guideline-based decision support system to respond. In contrast to the prior study, this NP-based model (called SymptomCare@Home or SCH) dramatically improved symptom outcomes. With a very rapid treatment benefit, SCH participants had a significant reduction in severe (67% fewer) and moderate (39% fewer) symptom days compared to usual care. We followed up with Dr. Mooney about the lessons learned from these two studies.


Work Force Models for PRO Monitoring and Management: Research Directions

In summarizing her 2017 study, Dr. Mooney wrote: “We conclude that the efficacy of automated symptom monitoring is dependent on timely oncology provider response to problematic symptoms. Despite the ease and feasibility of remote monitoring, our research suggests that without timely and proper clinical follow-up, telehealth approaches may not improve patient outcomes.” In discussing this finding with us, Dr. Mooney attributed it to provider inertia: providers had competing demands on time and expressed uncertainty about the value of following up on alerts. By creating a dedicated NP team, the SCH model was able to overcome that inertia. She notes though that it is possible to create a model where the primary oncology team manages PRO’s (this was the model Basch et al. employed in a clinical trial setting) but it would require a structure that incentivizes the primary team to respond to alerts and to monitor them as they do other important clinical data, such as labs. Implementing a dedicated team comes with its own challenges, such as fragmentation of care resulting in the oncology team being unaware of the symptom management care being provided. She found that a dedicated team works best when there is a culture of team care for patients. In addition, the NP’s tried to close the communication loop through electronic health record notes and emails to providers. Dr. Mooney also made note that the majority of the interventions implemented by the NP’s were education-based – correcting or reinforcing how patients used supportive medications – and, hence, a dedicated oncology RN model could also potentially support a successful PRO implementation. However, an RN would need ready access to a licensed prescriber for prescriptive issues such as medications or diagnostic tests. She also discovered that the NP’s found a lot of value in the decision support tool as it allowed them to operate autonomously, employ best practices in symptom care, and organize their time to provide more efficient care. Her ongoing clinical trial looks to better delineate the most essential and cost effective elements of the SymptomCare@Home program, including the NP workforce model and the decision support system, so that other institutions will be able to replicate its success.  

ASCO 2019 highlighted many programs that were trying to adapt Basch’s and Mooney’s prior work to their unique clinical environment. Determining the most efficient strategy that best serves our patients, will be of incredible value as we seek to achieve the promise of ASCO 2017 of incorporating PRO’s into the standard of care for oncology patients.


The Hospital at Home: A Bright Prospect for Oncology Care?

by Heather Hylton, MS, PA-C

For many oncology patients, the home setting is typically a place for recovery following treatment for cancer or complications of cancer.  At times, this recovery is supported with formal home care services such as nurse and physical therapy visits, home health aide assistance, infusion services, and so forth.  These home care services may or may not be paid for by public and private payers.

“Hospital-at-home” programs enable patients to receive acute care in the home setting.  The general model for these programs consists of a multidisciplinary or interdisciplinary team who follows the patient closely and provides the needed medical services, including patient visits, in the patient’s home.  These programs have been implemented internationally and have demonstrated success in reducing complications and the cost of care while maintaining safe and effective care delivery and enhancing patient and caregiver satisfaction.

Implementation of the hospital-at-home model in the United States has been more limited although Johns Hopkins established this model over two decades ago, and their outcomes mirror the successes of international implementations.

Could the hospital-at-home model be feasible for oncology care such as administering chemotherapy here in the United States?  It seems there is real opportunity for such a program at the crossroads of patient and caregiver experience, optimization of physical facility capacity and utilization, and cost containment.

To bring this paradigm to oncology would require a number of points to be addressed:

  1. Payer policy. In general, payers have had limited agility to adapt to/address payment for innovative care-delivery models such as the hospital at home.  With ongoing efforts in payment reform and a heightened focus on value-based care over fee-for-service, there is opportunity to elevate the importance of this kind of model and determine fair payment practices.

  2. Adoption and referral. The success of any kind of program such as the hospital at home requires broad acceptance of the model and the timely and appropriate referral of patients to the program.  Clarity on how to refer and simplicity in the referral process itself are requisite.  Clear information on how safety and quality of care will be maintained and what metrics will be followed will be key to illustrating the value proposition of this care-delivery model.  In addition, establishing rigorous screening and selection criteria to determine appropriate cohorts of patients to participate in the program will be paramount.  Understanding, acknowledging, and addressing stakeholder concerns is essential to implementation and scaling of the program.   

  3. Close coordination and availability of services.  With the hospital-at-home model being a surrogate for hospital/outpatient facility delivery of medical services, the supplies and services needed to provide this care at home must be readily available and able to be rapidly deployed.  Implementation of the hospital-at-home paradigm may be more challenging in resource-limited settings where vendors or general availability of services may be sparse and geography over which those services are provided are more expansive.

  4. Patient and caregiver buy-in.  The hospital-at-home construct has repeatedly shown patient and caregiver satisfaction with the model.  From a practical standpoint, providing care in the home may serve to empower patients and the familiarity of the environment of care may be a source of comfort.  While studies have shown decreased complications such as delirium and falls in this model, proper and pertinent patient and caregiver education and ongoing engagement is key. 

  5. Optimizing technology. Leveraging technology, such as telemedicine, to enhance monitoring of patients in hospital-at-home programs is key.  This may also be a keen opportunity to incorporate patient-reported data and other innovations.  

  6. Appropriate pilot studies.  While extension of hospital-at-home services to oncology seem apparent, data on safety, feasibility, and cost in this patient population are limited.  CMS and private payers should be encouraged to support studies of this model in the oncology setting.

The hospital-at-home model for oncology patients offers high potential for patient convenience and satisfaction and lower cost compared with traditional inpatient care.  To scale such a model for oncology patients may bring yet another opportunity for unconventional partnerships thinking outside of the box and leading innovation in the health care space.





Three Must See Talks From the ASCO Quality Care Symposium

Three Must See Talks From the ASCO Quality Care Symposium

The ASCO Quality Care Symposium occurred this past week in Phoenix, AZ. The scorching Arizona sun shone a bright light on a variety of issues in cancer-care delivery including financial toxicity, care redesign and quality reporting in the age of the Oncology Care Model and MACRA, and patient engagement and patient-centered care.

Read More