The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022.

INTRODUCTION: Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography. METHODS: We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age. RESULTS: From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+). CONCLUSIONS: Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.

Equity, diversity, and inclusion in the Multinational Association for Supportive Care in Cancer: a global membership survey.

Equity, diversity, and inclusion (EDI) are essential for healthcare organizations since they allow for the development of programs and initiatives that bring together diverse perspectives and knowledge. Global multidisciplinary organizations, such as the Multinational Association for Supportive Care in Cancer (MASCC), need to understand the perspective of their members regarding EDI to identify opportunities to enhance diversity and inclusiveness and to better meet the needs of members from different backgrounds and resources. The MASCC Health Disparities Committee designed a survey to identify issues related to disparities faced by MASCC members when providing supportive care to patients with cancer and to examine the EDI landscape within the organization. Here, we report results related to EDI initiatives within the organization. Two-hundred and eighteen MASCC members responded to the survey (response rate 10.2%). The results indicated that respondents were generally satisfied with how MASCC manages leadership, membership, and organization-related EDI issues. Opportunities for improvement noted by respondents included developing strategies to foster a more diverse membership, improving communication regarding diversity in the organization, and increasing EDI content in educational sessions and publications. The results of this survey represent the first attempt at understanding how to improve EDI within MASCC and will be utilized to guide further initiatives and programs.

Assessing health care leadership and management for resilience and performance during crisis: The HERO-36.

BACKGROUND: Whereas organizational literature has provided much insight into the conceptual and theoretical underpinnings of organizational leadership and management during emergencies, measures to operationalize related effective practices during crises remain sparse. PURPOSE: To address this need, we developed the Healthcare Emergency Response Optimization survey, which set out to examine the leadership and management practices in health care organizations that support resilience and performance during crisis. METHODOLOGY: We administered an online survey in April to May 2022 to health care administrators and frontline staff intimately involved in their hospital's emergency response during the COVID-19 pandemic, which included a sample of 379 respondents across nine rural and urban hospitals (response rate: 44.4%). We used confirmatory factor analysis and quantile regressions to examine the results. RESULTS: Applying confirmatory factor analysis, we retained 36 items in our survey that comprised eight measures for formal and informal practices to assess crisis leadership and management. To test effectiveness of the specified practices, we regressed self-reported resilience and performance measures on the formality and informality scores. Findings show that informal practices mattered most for resilience, whereas formal practices mattered most for performance. We also identified specific practices (anticipation, transactional and relational interactions, and ad hoc collaborations) for resilience and performance. PRACTICE IMPLICATIONS: These validated measures of organizational practices assess emergency response during crisis, with an emphasis on the actions and decisions of leadership as well as the management of organizational structures and processes. Organizations using these measures may subsequently modify preparedness and planning approaches to better manage future crises.

Diversity Management: Practical Application in a Healthcare Organization.

If you are not confused, you don't know what's going on. -Jack Welch In commenting on the business environment today (1994), Jack Welch could have been talking about healthcare organizations experiencing the double-barreled assault on two sweeping changes simultaneously. Not only are hospitals preparing for yet-to-be-determined changes in national healthcare delivery systems but they are doing so in the midst of shifting demographics in both the population and employee base. While many make the case for managing diversity, we would like to go one step further in offering a framework for developing an organization's ability to build an inclusive environment that gets the best from its staff and provides the best service to its customers.

Public Opinions About Surgery in Older Adults: A Thematic Analysis.

OBJECTIVE: To examine public opinions of surgery in older adults. BACKGROUND: Increasing numbers of older adults are undergoing surgery. National healthcare organizations recognize the increased risks of postoperative complications and mortality in the older surgical population and have made efforts to improve the care of older adults undergoing surgery through hospital-level programs. However, limited research has explored the opinions and responses of the wider U.S. public regarding surgery in older adults. METHODS: We performed a qualitative, thematic analysis of reader comments posted in response to online newspaper articles relating to surgery in older adults. Articles were published in 2019-2020 and targeted for a popular press audience. RESULTS: Nine hundred eight reader comments posted in response to 6 articles relating to surgery in older adults were identified. Articles were published in online editions of print newspapers with a digital circulation between 1.3 and 5.7 million subscribers. Three themes were identified: (1) wariness/distrust towards healthcare: including general distrust of medicine and distrust of surgery, (2) problems experienced: ineffective communication and unrealistic expectations, and (3) recommended solutions: the need for multidisciplinary teams and patient-centered communication. CONCLUSIONS: Overall, the public viewed surgery in older adults with wariness/distrust due to ineffective communication and unrealistic expectations. Specialized surgical care tailored to the unique needs of older adults is needed. The public perspective suggests that U.S. health systems should strongly consider adopting programs that provide care to meet the unique needs of older adults undergoing surgery and ultimately improve both patient outcomes and their surgical experience.

The Evolution of Employee Assistance Programs to Best Support Healthcare Organizations.

GOAL: Employee assistance programs (EAPs) have been evolving since they first became prevalent in the 1970s. The important counseling component of EAPs is sometimes lost in discussions about what they do, with many EAPs marketing a broad portfolio of services such as childcare, elder care, legal referral, and other concierge services rather than counseling. The objective of this study was to examine outcomes for the EAP of one organization (Mayo Clinic), compare them to outcomes reported in the literature, and gain insights to help all healthcare organizations best support their employees. METHODS: Consistent with customary EAP practice, data for this study was collected through an anonymous survey link distributed by e-mail to users of individual counseling as well as users of organizational consulting services such as advising leaders and supervisors and leading educational sessions. PRINCIPAL FINDINGS: All (n = 82) individual counseling respondents indicated they would recommend the EAP, none reported worse symptoms, 90% decreased their stress levels, 92% reduced their feelings of anxiety, 88% enjoyed an overall improvement in mood, and 95% developed new skills. If their concern was work-related, 96% agreed the counselor understood the work culture and was able to provide helpful guidance; of the clients who were feeling burned out, 86% agreed they gained strategies to reduce its symptoms. Thematic analysis of individual counseling services indicated that participants highly valued their counselors. Regarding organizational consulting services, respondents (n = 50) indicated EAP services increased their confidence as leaders, supported their work, and provided tangible guidance. They appreciated having an internal EAP counselor. Thematic analysis of organizational consulting services indicated that EAP supported leaders by listening, coaching, and empowering them to normalize issues. PRACTICAL APPLICATIONS: EAPs have evolved into distinct internal, external, and hybrid internal-external models. Internal model counselors are company employees with inside knowledge of company culture, external EAP model counselors are contracted outside of the company, and hybrid models combine a small cadre of internal counselors with the support of outside contractors. Regardless of the model, EAP counselors must collaborate with internal stakeholders, notably the human resources department, to efficiently identify and troubleshoot employee relational issues and allow for customized initiatives to improve mental health. Based upon these findings and the authors' direct experiences with EAP providers, components of an ideal EAP are outlined to show how EAPs can best support employees. Healthcare leaders seeking to add EAP services are advised to focus on offerings that are custom fit to the organization.

The role of health care organizations in patient engagement: Mechanisms to support a strong relationship between patients and clinicians.

BACKGROUND: Patient engagement (PE) is critical to improving patient experience and outcomes, as well as clinician work life and lowering health care costs, yet health care organizations (HCOs) have limited guidance about how to support PE. The engagement capacity framework considers the context of engagement and examines precursors to engagement, including patients' self-efficacy, resources, willingness, and capabilities. PURPOSE: The aim of this study was to explore clinician and patient perspectives related to mechanisms through with the HCOs can facilitate PE through the lens of the engagement capacity framework. METHODOLOGY/APPROACH: We administered an online open-ended survey to clinicians and patient advisors across the United States, including questions focused on the influences of, barriers to, and skills and tools required for PE. A common theme emerged focusing on the role of HCOs in facilitating engagement. Our analysis examined all responses tagged with the "health care system" code. RESULTS: Over 750 clinicians and patient advisors responded to our survey. Respondents identified offering advice and support for patients to manage their care (self-efficacy), providing tools to facilitate communication (resources), working to encourage connection with patients (willingness), and training for HCO employees in cultural competency and communication skills (capabilities) as important functions of HCOs related to engagement. CONCLUSION: HCOs play an important role in supporting a strong partnership between the patient and clinicians. Our study identifies important mechanisms through which HCOs can fulfill this role. PRACTICE IMPLICATIONS: HCO leadership and administration can help establish the culture of care provided. Policies and initiatives that provide appropriate communication tools and promote culturally competent care can increase engagement.

Empirical Evaluation of the Possible Contribution of Group Practice of the Transcendental Meditation and TM-Sidhi Program to Reduction in Drug-Related Mortality.

Background and Objectives: CDC data indicate that the U.S. is experiencing a sustained epidemic of drug-related mortality, with such deaths exceeding a record 100,000 in 2021, up 47% from 2019. Opioids, especially the synthetic opioid fentanyl, account for approximately 75% of this mortality. This study evaluates a proposed Consciousness-Based® approach that may possibly help reduce trends in drug-related fatalities by mitigating what WHO refers to as an "epidemic of stress" in society that helps fuel drug misuse and other negative public health trends. This approach involves providing support in public and private sector public health initiatives for individual and group practice of a subjective, evidence-based meditation procedure suitable for those of all educational, cultural, and religious backgrounds: the Transcendental Meditation® (TM®) technique and its advanced aspect, the TM-Sidhi® program. Materials and Methods: Segmented-trend regression analysis of monthly CDC data on U.S. drug-related fatality rates (dfr) from a prospective social experiment (2002-2016) was used to replicate and extend prior peer-reviewed research. Results: As hypothesized, (1) practice of the TM and TM-Sidhi program by a group of theoretically predicted size (√1% of the U.S. population) was associated with a statistically and practically significant reduction in dfr trend during the five-year "demonstration period" of the quasi-experiment; and (2) monthly dfr trend subsequently increased during the five-year follow-up period when the group fell below the required size (both p's < 0.0001). The estimated total percent decrease in dfr during the demonstration period was 35.5%, calculated relative to the baseline mean. This decline was followed by total dfr increases of 11.8% and 47.4% relative to the demonstration-period mean during the two phases of the follow-up period. Conclusion: Existing evidence warrants implementation and further evaluation of this approach in U.S. public health initiatives.

Bundled Payment Episodes Initiated by Physician Group Practices: Medicare Beneficiary Perceptions of Care Quality.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative incentivizes participating providers to reduce total Medicare payments for an episode of care. However, there are concerns that reducing payments could reduce quality of care. OBJECTIVE: To assess the association of BPCI with patient-reported functional status and care experiences. DESIGN: We surveyed a stratified random sample of Medicare beneficiaries with BPCI episodes attributed to participating physician group practices, and matched comparison beneficiaries, after hospitalization for one of the 18 highest volume clinical episodes. The sample included beneficiaries discharged from the hospital from February 2017 through September 2017. Beneficiaries were surveyed approximately 90 days after their hospital discharge. We estimated risk-adjusted differences between the BPCI and comparison groups, pooled across all 18 clinical episodes and separately for the five largest clinical episodes. PARTICIPANTS: Medicare beneficiaries with BPCI episodes (n=16,898, response rate=44.5%) and comparison beneficiaries hospitalized for similar conditions selected using coarsened exact matching (n=14,652, response rate=46.2%). MAIN MEASURES: Patient-reported functional status, care experiences, and overall satisfaction with recovery. KEY RESULTS: Overall, we did not find differences between the BPCI and comparison respondents across seven measures of change in functional status or overall satisfaction with recovery. Both BPCI and comparison respondents reported generally positive care experiences, but BPCI respondents were less likely to report positive care experience for 3 of 8 measures (discharged at the right time, -1.2 percentage points (pp); appropriate level of care, -1.8 pp; preferences for post-discharge care taken into account, -0.9 pp; p<0.05 for all three measures). CONCLUSIONS: The proportion of respondents with favorable care experiences was smaller for BPCI than comparison respondents. However, we did not detect differences in self-reported change in functional status approximately 90 days after hospital discharge, indicating that differences in care experiences did not affect functional recovery.

Measuring the Trustworthiness of Health Care Organizations and Systems.

Policy Points Current efforts to measure and improve trust in health care focus on changing patients' attitudes rather than measuring and improving the trustworthiness of health care organizations and systems. We present a conceptual model to understand and explain the constructs of trust and trustworthiness in the context of health care through the application of existing theories of human behavior. Developing and publicly reporting measures that can enable patients, particularly from historically marginalized groups, to better assess the trustworthiness of providers is necessary to promote health care equity.

Group Practice Size Consolidation in Emergency Medicine.

STUDY OBJECTIVE: Practice consolidation is common and has been shown to affect the quality and cost of care across multiple health care delivery settings, including hospitals, nursing homes, and physician practices. Despite a long history of large practice management group formation in emergency medicine and intensifying media attention paid to this topic, little is known about the recent practice consolidation trends within the specialty. METHODS: All data were obtained from the Centers for Medicare and Medicaid Services Physician Compare database, which contains physician and group practice data from 2012 to 2020. We assessed practice size changes for both individual emergency physicians and groups. RESULTS: From 2012 to 2020, the proportion of emergency physicians in groups sized less than 25 has decreased substantially from 40.2% to 22.7%. Physicians practicing in groups of more than or equal to 500 physicians increased from 15.5% to 24%. CONCLUSION: Since 2012, we observed a steady trend toward increased consolidation of emergency department practice with nearly 1 in 4 emergency physicians nationally working in groups with more than 500 physicians in 2020 compared with 1 in 7 in 2012. Although the relationship between consolidation is likely to draw the most attention from policymakers or payers seeking to negotiate prices in the near term and advance payment models in the long term, greater attention is required to understand the effects of practice consolidation on emergency care.

The deployment of balanced scorecard in health care organizations: is it beneficial? A systematic review.

BACKGROUND: Balanced Scorecard (BSC) has been implemented for three decades to evaluate and improve the performance of organizations. To the best of the researchers' knowledge, no previous systematic review has performed a comprehensive and rigorous methodological approach to figure out the impact of BSC implementation in Health Care Organizations (HCO). AIMS: The current work was intended to assess the impact of implementing the BSC on Health Care Workers' (HCW) satisfaction, patient satisfaction, and financial performance. METHODS: The authors prepared the present systematic review according to PRISMA guidelines. Further, the authors customized the search strategy for PubMed, Embase, Cochrane, Google Scholar databases, and Google's search engine. The obtained studies were screened to isolate those measuring scores related to HCW satisfaction, patient satisfaction, and financial performance. The Risk of Bias (RoB) in the non-Randomized Intervention Studies (ROBINS-I) tool was used to assess the quality of observational and quasi-experimental studies. On the other hand, for the Randomized Controlled Trials (RCTs), the Cochrane (RoB 2) tool was used. RESULTS: Out of 4031 studies, the researchers included 20 studies that measured the impact of BSC on one or more of the three entities (HCW satisfaction, patient satisfaction, and financial performance). Throughout these 20 studies, it was found that 17 studies measured the impact of the BSC on patient satisfaction, seven studies measured the impact on HCW satisfaction, and 12 studies measured the impact on financial performance. CONCLUSION: This systematic review provides managers and policymakers with evidence to support utilizing BSC in the health care sector. BSC implementation demonstrated positive outcomes for patient satisfaction and the financial performance of HCOs. However, only a mild impact was demonstrated for effects related to HCW satisfaction. However, it is worth noting that many of the studies reflected a high RoB, which may have affected the impacts on the three primary outcomes measured. As such, this systematic review reflects the necessity for further focus on this area in the future. Moreover, future research is encouraged to measure the real and current impact of implementing BSC in HCO during the pandemic since we did not find any.

Identifying desired qualifications, tasks, and organizational characteristics of practice managers-a cross-sectional survey among group practice physicians in Germany.

BACKGROUND: The increase of centralization developments in primary and secondary care practices may cause the organizational needs to increase as well, as the practices grow in size. This continuous change is observed in different stages in various countries since, from the perspective of a physician, it is reinforced by the benefits it adds to flexible work configuration, professional exchange and specialization. However, in order to benefit from the joint practice system, the proper managerial skills of practice managers are required, as doctors are not naturally prepared to fulfill such tasks. This study thus aims to gain insight into physicians' views in group practices and acquire a greater understanding of expectations towards practice management and the emerging role of practice managers (PM). METHODS: A cross-sectional study design was employed which utilized an anonymous online questionnaire. In total, 3,456 physicians were invited to participate in the study between February 8th and March 17th 2021 by the Association of Statutory Health Insurance Physicians of Baden-Württemberg, Germany. Bivariate and multivariate analyses were applied to characterize the expectations of physicians towards practice management. RESULTS: The survey yielded 329 replies (9,5%). 50% of the participating practices already had a PM employed. In general, these practices were larger than practices without a PM. Most physicians (85%) considered a medical background to be essential for the task of a PM. While practices without a PM considered it important for PMs to have medical qualifications, practices with a PM favored qualifications in business administration. 77.2% of physicians preferred to educate and recruit PMs out of their current practice staff. Competence in organizational tasks, such as coordination of tasks and quality management, was considered to be an essential skill of a PM and had the highest agreement levels among those surveyed, followed by staff management of non-physicians, billing, bookkeeping, staff management of physicians and recruiting. Based on multivariate regression analysis, larger practices valued the role of a PM more and were more likely to employ a PM. Notably, the effect that size had on these items was more substantial for generalists than specialists. CONCLUSIONS: The benefits and importance of PMs as well as the potential for delegation are recognized, in particular, by larger practices. The positive feelings that physicians who already employ PMs have towards their contribution to ambulatory care are even more significant. Pre-existing medical support staff has been identified to be the most desirable candidates for taking on the role of PM.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service.

BACKGROUND: Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women. METHODS: A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework. RESULTS: Themes identified were the woman's experience, midwifery workforce capabilities, identifying "gold standard care", the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives. CONCLUSION: There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Midwife-centred management: a qualitative study of midwifery group practice management and leadership in Australia.

BACKGROUND: Midwifery group practice (MGP) has consistently demonstrated optimal health and wellbeing outcomes for childbearing women and their babies. In this model, women can form a relationship with a known midwife, improving both maternal and midwife satisfaction. Yet the model is not widely implemented and sustained, resulting in limited opportunities for women to access it. Little attention has been paid to how MGP is managed and led and how this impacts the sustainability of the model. This study clarifies what constitutes optimal management and leadership and how this influences sustainability. METHODS: This qualitative study forms part of a larger mixed methods study investigating the management of MGP in Australia. The interview findings presented in this study are part of phase one, where the findings informed a national survey. Nine interviews and one focus group were conducted with 23 MGP managers, clinical midwife consultants, and operational/strategic managers who led MGPs. Transcripts of the audio-recordings were analysed using inductive, reflexive, thematic analysis. RESULTS: Three themes were constructed, namely: The manager, the person, describing the ideal personal attributes of the MGP manager; midwifing the midwives, illustrating how the MGP manager supports, manages, and leads the group practice midwives; and gaining acceptance, explaining how the MGP manager can gain acceptance beyond group practice midwives. Participants described the need for MGP managers to display midwife-centred management. This requires the manager to have qualities that mirror what is generally accepted as requirements for good midwifery care namely: core beliefs in feminist values and woman-centred care; trust; inclusiveness; being an advocate; an ability to slow down or take time; an ability to form relationships; and exceptional communication skills. Since emotional labour is a large part of the role, it is also necessary for them to encourage and practice self-care. CONCLUSIONS: Managers need to practice in a way that is midwife-centred and mimics good midwifery care. To offset the emotional burden and improve sustainability, encouraging and promoting self-care practices might be of value.

Factors contributing to innovation readiness in health care organizations: a scoping review.

BACKGROUND: Increasing innovation readiness of healthcare organizations is necessary to meet upcoming challenges, including population aging, staff shortages and reduced funding. Health care organizations differ in the extent to which they are innovation ready. This review aims to clarify the concept of innovation readiness and identify which factors contribute to innovation readiness in health care organizations. METHODS: A scoping review was conducted based on the framework from Arksey and O'Malley. PubMed/MEDLINE, CINAHL and Web of Science were searched for studies that (a) aimed to contribute to scientific knowledge about innovation readiness of health care organizations, (b) were peer-reviewed, (c) reported empirical data and (d) were written in English, Dutch or German. Factors researched in the included studies were bundled into 4 overarching main factors and 10 sub-factors. RESULTS: Of the 6,208 studies identified, 44 were included. The majority (n = 36) of the studies had been conducted since 2011 and almost half of the studies (n = 19) were performed in hospitals. Of the 44 studies, 21 researched factors contributing to innovation readiness in the implementation stage of the innovation process. The authors used a variety of words and descriptions addressing innovation readiness, with hardly any theoretical frameworks for innovation readiness presented. Four main factors and 10 sub-factors contributing to the innovation readiness of health care organizations were summarized: strategic course for innovation, climate for innovation, leadership for innovation and commitment to innovation. Climate for innovation (n = 16) was studied the most and individual commitment to innovation (n = 6) was the least studied. CONCLUSION: Our study identified four main factors contributing to the innovation readiness of health care organizations. Research into innovation readiness of health care organizations is a rather new field. Future research could be directed towards defining the concept of innovation readiness and the development of a framework for innovation readiness. More understanding of the interplay of factors contributing to innovation readiness in all stages of the innovation process and in diverse health care settings can support health care managers to structurally embed innovation. This review contributes to the first stage of theory building on factors contributing to innovation readiness of health care organizations.

Fostering a just culture in healthcare organizations: experiences in practice.

BACKGROUND: A just culture is regarded as vital for learning from errors and fostering patient safety. Key to a just culture after incidents is a focus on learning rather than blaming. Existing research on just culture is mostly theoretical in nature. AIM: This study aims to explore requirements and challenges for fostering a just culture within healthcare organizations. METHODS: We examined initiatives to foster the development of a just culture in five healthcare organizations in the Netherlands. Data were collected through interviews with stakeholders and observations of project group meetings in the organizations. RESULTS: According to healthcare professionals, open communication is particularly important, paying attention to different perspectives on an incident. A challenge related to open communication is how to address individual responsibility and accountability. Next, room for emotions is regarded as crucial. Emotions are related to the direct consequences of incidents, but also to the response of the outside world, including the media and the health inspectorate. CONCLUSIONS: A challenge in relation to emotions is how to combine attention for emotions with focusing on facts, both within and outside the organization. Finally, healthcare professionals attach importance to commitment and exemplary behavior of management. A challenge as a manager here is how to keep distance while also showing commitment. Another challenge is how to combine openness with privacy of the parties involved, and how to deal with less nuanced views in other layers of the organization and in the outside world. Organizing reflection on the experienced tensions may help to find the right balance.

Trends in Orthopedic Surgeon Practice Consolidation From 2008 to 2019.

BACKGROUND: In the past decade, physician practices have merged into larger group practices (ie, horizontal consolidation) and have been acquired by hospitals and health systems (ie, vertical consolidation), leaving fewer practices independent. The implications of these changes can be profound, affecting the prices for and spending on physician services, access to care, patients' choice of providers, and quality of care. METHODS: We used IQVIA data on orthopedic surgeon practice sites that included information on health system or hospital ownership, group medical practice participation, and average patient volume. We calculated the number and size of group medical practices as measures of horizontal consolidation and the percentage of practice sites owned by a health system or hospital as a measure of vertical consolidation. We also calculated the Herfindahl-Hirschman Index to measure market concentration. RESULTS: We found significant horizontal and vertical consolidation nationally and across all regions of the United States. This consolidation has led to much more concentrated markets, as measured by Herfindahl-Hirschman Index, for orthopedic surgeon services. These trends are consistent with studies looking at consolidation of other types of providers. CONCLUSION: Orthopedic surgeon practices, like other provider types, have consolidated at a rapid rate over the past decade. A variety of factors may have contributed, including the move away from fee-for-service to alternative payment arrangements, changes in Medicare payment policies, private equity activity, and evolving physician preferences. Due to the potential impacts of this consolidation, more research is needed to examine some of these contributing factors.

Impact of Advanced Practice Provider Integration into Multispecialty Group Practices on Outcomes Following Major Surgery.

Background. While advanced practice providers (APPs) are increasingly integrated into care delivery models, little is known about their impact in surgical settings. Given that many patients undergo surgery in multispecialty group practice settings, we examined the impact of APP integration into such practices on outcomes after major surgery. Methods. We used a 20% sample of national Medicare claims to identify 190 101 patients who underwent 1 of 4 major surgeries (coronary artery bypass graft [CABG], colectomy, major joint replacement, and cystectomy) at multispecialty group practices from 2010 through 2016. The level of APP integration was measured as the ratio of APPs to physicians within each practice. Rates of mortality, major complications, and readmission within 30 days of discharge after the index surgery were compared between patients treated in practices with low, medium, and high levels of APP integration using multivariable regression analysis. Results. Relative to patients treated in practices with low APP integration, those treated in practices with medium or high APP integration had significantly lower rates of mortality (2.4% [low integration] vs 1.9% [medium integration] vs 2.0% [high integration]; P < .01), major complications (34.1% [low] vs 31.2% [medium] vs 30.2% [high]; P < .01), and readmission (11.7% [low] vs 10.6% [medium] vs 10.1% [high]; P < .01). This relationship was consistent for virtually all outcomes when considering each surgery type individually. Conclusions. Integration of APPs into multispecialty group practices was associated with improved postoperative outcomes after major surgery. Future research should identify the mechanisms by which APPs improve outcomes to inform optimal utilization.

Professional Behavior and Value Erosion: A Qualitative Study of Physicians and the Electronic Health Record.

GOAL: Occurrences of physician burnout have reached epidemic numbers, and the electronic health record (EHR) is a commonly cited cause of the distress. To enhance current understanding of the relationship between burnout and the EHR, we explored the connections between physicians' distress and the EHR. METHODS: In this qualitative study, physicians and graduate medical trainees from two healthcare organizations in California were interviewed about EHR-related distressing events and the impact on their emotions and actions. We analyzed physician responses to identify themes regarding the negative impact of the EHR on physician experience and actions. EHR "distressing events" were categorized using the Accreditation Council for Graduate Medical Education (ACGME) Physician Professional Competencies. PRINCIPAL FINDINGS: Every participating physician reported EHR-related distress affecting professional activities. Five main themes emerged from our analysis: system blocks to patient care; poor implementation, design, and functionality of the EHR; billing priorities conflicting with ideal workflow and best-practice care; lack of efficiency; and poor teamwork function. When mapped to the ACGME competencies, physician distress frequently stemmed from situations where physicians prioritized systems-based practice above other desired professional actions and behaviors. Physicians also reported a climate of silence in which physicians would not share problems due to fear of retribution or lack of confidence that the problems would be addressed. PRACTICAL APPLICATIONS: Physicians and administrators need to address the hierarchy of values that prioritizes system requirements such as those required by the EHR above physicians' other desired professional actions and behaviors. Balancing the importance of competing competencies may help to address rising burnout. We also recommend that administrators consider qualitative anonymous interviews as an effective method to uncover and understand physician distress in light of physicians' reported climate of silence.