Conference Coverage: April 2024

ACCC Business Summit 2024

What Are the Steps to Quality Improvement in Cancer Care?

The past 25 years have brought a revolution in the attention to quality in health care, dating from the 1999 Institute of Medicine Report, To Err Is Human: Building a Safer Health System.¹ After the first wave of change focused on reducing medical errors, work shifted toward quality standards that produce the best outcomes. In cancer care, this has given rise to efforts such as the American Society of Clinical Oncology’s Quality Oncology Practice Initiative, or QOPI.²

But how does an institution update its metrics or institute a new quality improvement (QI) project? What happens when a giant health system acquires a smaller one and the quality metrics must be integrated? How are processes changed or added to the workflow without driving down morale or causing staff to quit?

Christina Southey

There are known processes for this, said consultant Christina Southey, who led a group of oncology care professionals through the February 28, 2024, preconference workshop, “Adopting New Innovations in Oncology,” which offered an outline for how to bring a QI idea to fruition. The session took place ahead of the 50th Annual Meeting and Cancer Center Business Summit of the Association of Cancer Care Centers with ACCC’s Oncology Practice Transformation and Integration Center, or OPTIC, which helps practices implement new treatment options or clinical guidelines.

Southey started by asking about barriers to change, and participants offered plenty:

• Physicians may have big ideas about QI tools, but the staff who have to keep the hospital or clinic running are pressed for time and may be less interested in learning to use them. As one participant said, “People like to stay in their own lane.”
• There is agreement that the current focus on disparities is warranted, but less consensus on what to do once disparities are identified.
• Standardizing workflows is very difficult; there is variation from clinic to clinic, even within the same organization.
• Agreeing on what are the right data and getting it can be a challenge.
• It is difficult to align incentives.
  

Adopting an Innovation
Southey explained the concept of “diffusion of innovation,” developed by Everett Rogers, which categorizes different types of people based on the pace at which they adopt innovation.³ Understanding this pattern is important as health care considers the pace of adopting elements of artificial intelligence into the workflow.

Innovators are the risk takers who will try a new technology or system when it is brand new and very expensive, before the problems are ironed out. Early adopters tend to be younger opinion leaders but are more selective about which innovations they try. Those in the early majority come next; this group is larger and adopts an innovation when it is clear the innovation will become part of the workflow. Next come the late majority, who are slower to accept the innovation and do so with some resistance. Finally come the laggards, who may refuse to adopt the innovation unless there is a penalty.

Each part of the population plays a role, Southey said. “Our innovators are the ones who are going to be helping us figure out what some of the key barriers are within the system,” she said. They are “helping the public advocate for some of the larger changes that are needed so that the earlier adopters have a slightly smoother road to be able to adopt this new technology.”

Attributes. Southey outlined Rogers’ attributes of innovation, which should be considered when deciding whether to pursue a project. What is the relative advantage over the current method? Does it offer compatibility with the current work pattern? In terms of complexity, is it difficult to understand and apply? Does the innovation offer trialability—can it be attempted in advance at low risk? What is the observability; in other words, can it be seen in advance among early adopters?

In health care especially, Southey said, very few want to be the first to adopt an innovation, but many are willing to be among an early wave.

Approaching an Innovation Adoption—or Lack of Adoption
Key questions to ask before deciding to pursue an innovation are: What is the nature of the problem you are trying to solve? What are you trying to achieve? And each must be broken down into discrete steps:

• Observe to gain understanding.
• Speak with staff, patients, and caregivers to gain all perspectives.
• Diagram or brainstorm solutions.
• Design measures to evaluate success.

QI projects should be evaluated to see how they align with the Model for Improvement, a process developed by Associates in Process Improvement⁴ that includes 2 parts:

• It asks 3 fundamental questions, which can be addressed in any order.
• It uses the “plan, do, study, act” or PDSA method to test changes and then adapt based on results.
  

Setting and Achieving Goals
Southey took breaks during the workshop for participants to discuss challenges in their own clinics or workplaces to setting and achieving QI goals. One project involved getting nurse navigators involved earlier in the process when patients with stage I to III breast cancer ended up in the emergency department and needed follow-up care. Another discussed the feeling of being overwhelmed with the wave of data—of different types—and trying to figure out where to start. Still others said that within a large health system, the QI priorities of different geographic locations will not be the same, and this must be addressed. Some suggestions included the following:

• Use data to identify which subgroups are not benefiting from current approaches.
• Ensure that activities make sense for the patient population and work with a trusted community organization to confirm this. What the health system or cancer center thinks should be the top priority may not be the community’s priority.
• Have small group conversations with diverse groups of 10 to 15 patients.
• Have a sense of what is a reasonable amount of time for change to occur.
  

Approaches to Measurement
Southey explained both the different types of measures and how important measurement is to the success of QI initiatives. Process measures involve steps that physicians and staff perform, while outcomes measures assess the clinical results that occur as a result of the processes; necessarily, outcomes take longer to measure.
“Process measures are the things that are going to be our bread and butter with improvement projects because those are the things that we have more control over,” Southey said. “Measuring the steps in the process and how reliable they are helps us to know that if we’re doing these things, then we have a relatively high degree of confidence that our outcomes will eventually be able to move, even if it’s going to take longer to see that data over time.”

Outcomes measures do matter, however. Southey said 4 to 8 were optimal to get the right amount of data without collection being overwhelming.

Balancing measures were described as “consequences” of a QI project. They can be positive or negative and include things such as increases in staff workload, additional costs, savings, or movement in measures such as patient satisfaction.

Selecting the right types of data matters greatly—as much as possible, Southey said, using preexisting data points that are already collected is preferred. Timeliness counts. Using data points collected only once a year will not allow a clinic team to see if their efforts are working, as data need to be gathered monthly or even weekly—and displayed graphically in a place that everyone can see.

And the best possible outcome is if positive results can connect to a federal or state program that can reward the institution with a better rating or increased revenue.

Southey concluded by reviewing some sample tools that clinics can use for brainstorming and QI project development. All, she said, should develop a prediction and a question that the team is trying to answer.
QI projects, she said, should be integrated into the normal course of the day. The more frequently teams are engaging with the data, the better. “You want this data to be an active part of your discussion at every single meeting,” she said.

References
1. Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. National Academies Press (US); 2000.
2. About QOPI certification. American Society of Clinical Oncology. Accessed March 5, 2024. https://society.asco.org/practice-patients/quality-improvement/quality-programs/qopi-certification-program/about-qopi
3. Change management theories and models – Everett Rogers. NSW Agency for Clinical Innovation. Accessed March 5, 2024. Change_Management_Theories_and_Models_Everett_Rogers.pdf (nsw.gov.au)
4. Model for Improvement. Institute for Healthcare Improvement. Accessed March 5, 2024. https://www.ihi.org/resources/how-to-improve

Integrating the EHR for Precision Medicine Has Evolved

For all the possibilities of precision medicine, whether a patient gets a targeted therapy still comes down to the decision of a busy doctor to order biomarker testing. Then, upon getting the results, to properly use the information to prescribe the right therapy if a patient has a mutation that can be targeted.

Data show that at each step, doctors fail to make the right choice approximately half the time. And for years, having an electronic health record (EHR) that could not integrate genomic testing information was part of the problem—but that’s changing.

On February 29, 2024, a panel at the Association of Cancer Care Centers’ 50th Annual Meeting & Cancer Center Business Summit explored aspects of what technology is available and the steps institutions can take to make the leap to an integrated system.

Sigrun Hallmeyer, MD

Moderated by Sigrun Hallmeyer, MD, medical director for Advocate Lutheran General Hospital Cancer Service Line and Cancer Survivorship Center, the panel featured:

• Jonathan Katchmore, associate vice president of commercial diagnostic strategy at Loxo Oncology;
• Christopher McNair, PhD, associate director for data science and director of cancer informatics, Sidney Kimmel Cancer Center and assistant professor in the Department of Medical Oncology at Thomas Jefferson University, the flagship institution of Jefferson Health;
• Brian Davis, genomics implementation lead at Epic; and
  Nate Wade, PharmD, MBA, BCOP, associate director of clinical oncology at Flatiron Health.

“Precision medicine has really become standard of care” Hallmeyer said. “Indications are ever expanding,” she said. Use of therapy to hit targets is “not [only] prolonging life and reducing toxicity [also] saving lives.”

However, there are still many barriers to patients receiving testing, the biggest one being that access comes down to the decision of individual physicians. “The clinician has to constantly understand which diagnosis is the appropriate diagnosis in which a particular test may be appropriate,” Hallmeyer said.

It’s not only having scientific knowledge, such as knowing whether a test is even actionable, but it’s also daily practicalities, such as knowing how to use a testing company portal and remembering the password.

Ordering the wrong test can have financial ramifications, because then a patient’s testing coverage may be exhausted and a physician may have missed a critical gene. Bringing information into the EHR is critical, but getting there takes time and commitment, the panel explained.

Missed Opportunities
Katchmore highlighted the growth of precision medicine in clinical trials, saying the rise of precision medicine has improved survival. However, for the physician in everyday practice, it’s “almost impossible” to keep up with the growing number of trials involving biomarkers.

Although physicians often think they are testing for an actionable biomarker, he pointed to a study that showed only 46% of patients with lung cancer received testing for all 5 recommended biomarkers.¹ What’s worse, among patients who are tested and found to have an actionable mutation, only 48% received the appropriate therapy. “We often refer to that as winning the genomic lottery and not being able to cash in on that lottery ticket,” he said.

Why are so many patients missing out? What are the gaps? Katchmore said having molecular tumor boards where community oncologists feel they are heard—and where challenging cases can be aired—can be very effective. “There are data showing now that many of these patients are now benefiting greatly,” Katchmore said. One key is to make these boards multidisciplinary, he said, so all stakeholders feel part of these outcomes.

Real-World Implementation
McNair described the process undertaken at Jefferson Health to fully integrate a systemwide precision medicine structure, which was needed as the health system grew to 14 hospitals across Pennsylvania and New Jersey. More physicians were using testing, and there was no consistency in the use of vendors, even within the same type of cancer—and none of the data was making its way into the EHR. “It was chaos,” he said.

McNair partnered with a medical oncologist who shared his vision for a fully integrated system, and they created a multistakeholder team that included members from information technology (IT) and those with access to health system leadership, which is an essential piece. He advises institutions and health systems to strike a balance between having “too many cooks” but not enough members to have the right voices involved. Doing this up front prevents problems later on, he said.

The group developed a charter and developed information on which tests were most frequently used, as well as costs and materials that would be needed for integration. McNair said the team didn’t do all their work themselves; they required vendors to collect some of it, although the process would necessarily reduce the number of vendors. Keys to success included finding ways to reduce complexity in the workflow and to make the integration reproduceable as tests were added. Education ahead of the launch was important, too.

He advised the group to develop metrics to track success—and to not try to impose external logic on how IT does things. McNair said the first integration was the most painful, but once physicians and staff see it succeed, “you’ll have people clamoring for more.”

An Epic Evolution
To get an idea of Epic’s reputation, Hallmeyer introduced Davis by saying he would discuss how the EHR giant would tell “how to make Epic work for us instead of us working for it.” Davis described Epic’s genomic module, which he said is not so new anymore and is designed to help the community oncologist who has limited resources. “It’s essentially liberating the genomic data from the PDF,” Davis said. “Imagine a place within the EHR that you can treat just like any other clinical data. You can query it; you can easily interact with decision support.”

As the EHR connects with testing laboratories, “data harmonization is happening naturally,” Davis said. Epic continues to work on issues such as coding systems and portability, and the need for data standards is evident.

He also addressed the provider efficiency challenges that Hallmeyer mentioned. “Even if you’re integrating with a laboratory and all you’re getting back is a PDF, it’s still worth doing that—getting the discrete data is definitely beneficial,” he said. Electronic ordering is still better than “having to jump out into a web browser and order something in a portal, then try to find the scan and upload it into the media tab.” These steps can be eliminated with an electronic connection to the laboratory—it may be just a start, but it’s still an efficiency gained.

Biomarkers as a Quality Metric
Wade noted that for practices taking part in the Enhancing Oncology Model, use of appropriate biomarkers will be a quality metric, so he expects to see the practices that have signed on for the CMS payment model to continue advancing in this area.

Flatiron Health, known for its OncoEMR and Flatiron Assist products, is integrated with Caris Life Sciences; Foundation Medicine, Inc; and Guardant Health, Inc, and Wade said there is another major integration coming shortly. He concurred that the ability to order tests within the EHR was more efficient, adding that it is also important to “make those results more actionable and easily retrievable.”

Wade agreed that having the PDF in the structured results is important, but it’s also important to make it “more accessible and easier for the physician to find 1 week, 1 month, 6 months, or even a year later. That’s a tremendous value we provide.”

Flatiron is experimenting with helping physicians with decision support features that reflect real-world realities, including the fact that payers drive many decisions. When it first rolled out a tool that included biomarker cohort regimens in the National Comprehensive Cancer Network (NCCN) guidelines, the feedback was that NCCN has many regimens that meet guidelines—and physicians would like to bump their preferences to the top. Now, that is possible.

Flatiron is also experimenting with options that show which choices reflect which payer preferences. That might put some off, Wade said, “but if you’re a physician, at the end of the day, the payer is ultimately who decides [how] to pay for that medication.”

Reference
Robert NJ, Espirito JL, Chen L, et al. Biomarker testing and tissue journey among patients with metastatic non-small cell lung cancer receiving first-line therapy in The US Oncology Network. Lung Cancer. 2022;166:197-204. doi:10.1016/j.lungcan.2022.03.004

Treating the Whole Person in Cancer Care: Addressing Comprehensive Services

Krista Nelson, MSW, LCSW, OSW-C, FAOSW, became president of the Association of Cancer Care Centers (ACCC) in 2021 as the world emerged from the global pandemic. Her presidency was dominated by issues such as staff shortages and burnout, which remain a priority.
On February 29, 2024, at ACCC’s 50th Annual Meeting & Cancer Center Business Summit, Nelson, who is the manager for supportive care at Providence Cancer Institute, led a discussion on a challenge that predates the pandemic but has perhaps become more urgent: how to meet patients’ needs beyond getting rid of the cancer or managing the nausea and other adverse events.

When a person has cancer, Nelson said, nothing is the same, and those needs must be addressed.

She described a patient who had received top-line therapies for her tumor. “Particular attention was paid to her molecular and genetic data,” Nelson said. “Radiation was expertly calibrated. From a medical perspective, everything was perfect.”

Krista Nelson, MSW, LCSW, OSW-C, FAOSW

Yet the woman was in tears. She did not feel like herself; she felt disconnected from her partner and she wasn’t exercising like she once did. “I know we’ve all seen this scenario,” Nelson said. “We have to change what the standard of care is.… And some of you might not even know where to start.”

To gain insights, Nelson had assembled a panel with experts on navigation, advocacy, sexual health, LGBTQ issues, exercise, and mental health.

Standards, billing codes for patient navigation.
Jennifer Bires, MSW, LCSW, OSW-C, executive director, Life With Cancer and patient experience at Inova Health System, described the revolution in patient navigation that has occurred in recent years, with the development of professional standards for oncology navigation and the recently published Medicare billing codes, which allow for reimbursement outside a payment model.^1,2

Bires noted that while many navigators are nurses or social workers, some are nonclinical staff. Navigators do many things, from helping with scheduling to advising patients on issues with financial toxicity. The mix of different types of navigators is a good thing, she said, because it allows cancer centers to pair patients with the type of assistance they need and it allows navigators to work at the top of their license.

Standards were developed by navigators, she noted, and new articles on the topic are being published every day.

“Any time we do something, we want to be sure we’re enhancing the quality,” she said. “Using these standards and these competencies…can ensure that your navigators are really operating within the standards that we’re putting in place to make sure that people are providing the care that patients need.”

She said having new standards and billing codes represents the culmination of the vision of Harold Freeman, MD, the Harlem physician who developed the first cancer care navigation program in the 1970s.
Clearly, idea of navigation is not new. “But what is new is the energy and excitement around navigation,” Bires said. “If you’re paying attention to what’s going on in health care systems, people are talking about navigation in the way that they never have before…. They’re paying attention because they know navigation works. So while it’s not something new, we have momentum.”

The role of advocacy. By the time the session began, Nicole Tapay, JD, had already had a full day. As ACCC’s director of cancer care delivery and health policy, she had gathered members that morning for the group’s first day on Capitol Hill since the pandemic. For her, advocacy is personal: Her mother was diagnosed with ovarian cancer when Tapay was a young woman about to be married. Because her father was a physician, navigating the clinical decisions was not the issue. But helping her mother figure out the “life” part was an eye-opener for Tapay, who contacted the American Cancer Society and helped connect her mother with a member of her local wellness community. Ultimately, her mother lived more than 5 years after diagnosis.

Today, Tapay staffs the ACCC government affairs committee, which is tackling issues such as implementing the new navigation billing codes, drug shortages, and financial toxicity. For a long time, she said, she separated her personal story from her professional life. But now, “It’s a pretty big reason why I’m standing here today, in the role that I have,” she said. “That was my trigger to get into this area.”

Talking about sexual health. Jessie Dorne, MHS, PA-C, is willing to go where few will: She talks to patients with cancer about their sexual health.

The physician’s assistant in gastrointestinal oncology has developed expertise in a highly important and hugely underserved area: helping patients with cancer deal with symptoms and effects of cancer treatment on their sexual health and intimacy. She came to the session armed with data: 90% of patients report that this is their top unmet need in cancer care. The more advanced treatments may be the top culprits, as 50% of patients say they stop all sexual activity after a stem cell transplant. Childhood cancer survivors report difficulty with sexual function later in life.

This really isn’t a surprise. “Let’s look at what we do to our patients and imagine why and how this could affect their sexual health,” Dorne said. It’s not just the physical effects of treatment, although these are considerable. “Because sexual health is psychosocial as well as medical, a lot of my patients talk about their negative body image. They’ve had a mastectomy; they will have a large midline vertical incision and an ostomy appliance. How do you feel confident in your body with your partner?”

Relationship dynamics change as a partner becomes a caretaker. “The 2 cancers that have the highest rates of divorce are cervical cancer and breast cancer because they happen to women in their 30s,” she said. The loss of both intimacy and fertility devastates relationships.

Dorne said she hopes to inspire others to take the same journey she has and gain expertise in helping patients and their partners have these conversations. Most providers have no training in this area. “It’s this hot potato topic,” she said. The medical oncologist may say, “Talk to the surgeon” and the surgeon may say, “Find a urologist.”

“No one wants to own this.”

Dorne said it’s important to get rid of assumptions that patients don’t want to be intimate or that it’s not on their mind if they don’t raise the issue. Patients may be embarrassed and religious or cultural biases create barriers. “This is very, very well studied,” she said.

To start conversations, for example, Dorne may suggest that other women have had a certain issue and ask if a female patient is experiencing the same problem. The idea that the patient is not alone opens the floodgates, she said.

Often the National Comprehensive Cancer Network’s (NCCN) Distress Thermometer is the screening tool that starts the conversation. NCCN guidelines also call for asking patients about sexual health at intervals, as symptoms or problems may evolve as sex hormones deplete over time, Dorne said.

When Dorne decided to train to help patients with their sexual health, she became credentialed through the North American Menopause Society. Online training is available. Her prescriptions include lubricants or moisturizers, and many items are not expensive. For pharmacologic therapy, she refers patients to a consulting urologist. “This is a great role for an [advanced practice provider]. The person can become the local referral.”

It helps for patients to hear that “you are not alone.”

Unique needs of the LGBTQ community. Mandi Pratt-Chapman, PhD, associate professor of medicine at George Washington University and associate center director, Patient-Centered Initiatives and Health Equity for the GW Cancer Center, addressed where the health system falls short in meeting the needs of patients with cancer who identify as part of the LGBTQ community. She said there are multiple challenges here:

• Typically, we don’t ask patients about sexual orientation or gender identity.
• Even when we are willing to ask, we don’t know how to ask about gender identity—and the data are not standardized.
• We aren’t collecting data so we are making assumptions—which is not good science.
• We aren’t documenting data in fields that are interoperable.
• We aren’t trained to meet the needs of LGBTQ people with cancer.

“What do we need in terms of good care for queer people?” Pratt-Chapman asked. To collect good data, we must be willing to ask—just as we must be willing to ask about sexual health. The health system, Pratt-Chapman said, must be willing to grasp the importance of why these data are needed and how to use them.

Training and research cannot improve without better data collection—and no one should make assumptions about how data are being collected, she said. All training must address the current cultural and political context; for example, it’s completely reasonable that a transgender person might not want to identify themselves, given the action taken to force Vanderbilt University to turn over these patients’ records.

And sometimes researchers just get it wrong. “We have a forthcoming paper in JCO Oncology Practice providing some recommendations on how to ask these questions,” Pratt-Chapman said. When the National Academies issued a report charged with synthesizing existing data, “some of the measures that were out there don’t really work. So when you have a question about gender identity that asks you to select one—male, female, or transgender—it doesn’t really work for lots of reasons, because male and female are sex constructs; they are not gender constructs. You can be male and transgender or cisgender.”

“It’s very difficult when you provide questions like that and ask someone to select one,” Pratt-Chapman said.

Research and training issues. When Pratt-Chapman started a research project on sexual health for patients treated in radiology and radiation oncology, “there were no articles on postsurgical affirming care.” So she set to work doing interviews in 3 English-speaking countries, and she learned that all 3 health systems require selection of male, female, or nonbinary before the electronic health record will advance to the next field. “So, we’re not there yet.”

There are billing and insurance gaps. There are no budgets for oncologists to counsel patients on the unique challenges of the LGBTQ population. An out gay physician reported that he is assumed to be culturally competent to treat a transgender patient but he has no more training than anyone else.

An audience member asked what health systems could do to make physicians more comfortable.

“Why are we so worried about the provider being comfortable?” Pratt-Chapman asked. The provider’s job is to treat the patient; it’s their job to have humility and try.

“You’re going to make mistakes. Keep learning.”

Moving and mental health. Jay Harness, MD, chief medical officer, Maple Tree Cancer Alliance, presented evidence on “exercise oncology,” which involves getting cancer patients to move to reduce fatigue, anxiety, and depression and improve bone health. This is a young discipline, but the results are promising: Harness said studies have collected data on 2600 patients through last year that show increases in muscular endurance, and 75.9% reported feeling more positive, along with 59% adhering to therapy.

Of interest to payers, patients taking part had fewer hospital stays and shorter stays when they were admitted, and there was an overall 47% decrease in readmissions.³ Studies also report improvements in all-cause mortality with specific improvements in breast, prostate, and colorectal cancer.

Harness was clear that patients are not completing intense training or running long distances. These are brisk walks, light resistance training, and stretching. The key is to get the patients started and to keep them showing up. “You know what doesn’t work? Brochure therapy.”

Lisa Marquette Porat, MSW, LCSW, FAOSW, US lead, patient advocacy, BeiGene USA, concluded the session with a call for advocacy for patient mental health. Lack of adequate staffing generally, including those trained to work with cancer patients, is a significant problem. So is the lack of mental health workers who can work with oncology staff.
Porat called for more attention to a “culture of care,” through a collaborative care model.

“This is not just burnout,” she said. How caregivers take care of themselves is a key factor in how well they can care for patients.
Several audience members said this has been on the ACCC agenda for years but it’s hard to move the needle. The expectation of many workplaces is that health care workers just have to put up with long hours and challenging working conditions.

Nelson asked, “Can you imagine if the Commission on Cancer had standards to support the staff?”

It’s not easy, Porat said. “We have to work together both in our institutions and between our institutions,” she said. “We have to work together or the people who suffer are our patients.”

References
1. Oncology navigation standards of professional practice. Clin J Oncol Nurs. 2022;26(3):E14-E25. doi:10.1188/22.CJON.E14-E25
2. Bonavitacola J. Rule change for patient navigation billing is a boon to oncology care, practice leaders say. Am J Manag Care. 2024;30(2):SP110.
3. Wonders K. Supervised, individualized exercise programs help mitigate costs during cancer treatment. J Palliat Care Med. 2018;8(4):338. doi:10.4172/2165-7386.1000338

Retaining Health Care Workers Starts With Insights on “How We Can Stop Breaking Them”

If you ask any administrator of an oncology practice or hospital about their biggest challenges, staffing will be at or near the top of their list. Long hours, staffing gaps, and difficult conditions were simmering before the COVID-19 pandemic, but the extended brutality of that event set workers’ unhappiness on fire. Older physicians and nurses retired, whereas others quit.
Data from the American Hospital Association showed that full-time equivalent staff per occupied bed dropped 3% in the first year of the pandemic, whereas patient acuity rose 6%. In other words, there are fewer staff to treat sicker patients.¹

Katherine Meese, PhD

To understand how the pandemic set off this exodus and what can be done to care for health care workers, the Association of Cancer Care Centers (ACCC) invited Katherine A. Meese, PhD, an assistant professor in the Department of Health Services Administration at the University of Alabama at Birmingham, to share insights on what it takes to rebuild bonds with today’s health care workforce. The ideas are included in her book, The Human Margin: Building the Foundations of Trust. Meese offered the keynote address at the ACCC 50th Annual Meeting and Cancer Center Business Summit on February 29, 2024, in Washington, DC.
Meese discussed the phrase, “no margin, no mission,” attributed to Sister Irene Kraus, founder of the Daughters of Charity National Health System. This refers to the fact that without operating funds, a hospital or health clinic cannot stay open, noble intent aside. However, Meese argues that “margin” also refers to the people who care for patients. When surgeries are canceled because there are no nurses, or when health systems hire staff with limited credentials because no one else is available, care suffers.

The humans who care for patients have needs that go unfulfilled when they are asked to work 30-hour shifts, when they can’t take a bathroom break, or when they can’t stop to have a snack, she explained. “I have the goal of trying to understand our humans, how we can stop breaking them, and how we can fix them,” Meese said.

Workforce conditions were eroding before the pandemic, but then several things happened at once: Working conditions reached disaster levels and stayed there for more than a year, staffing levels dropped and stayed low, and seeing colleagues die from COVID-19 caused other workers to reassess their willingness to accept the status quo.

“When death feels closer to people, when you’re seeing young physicians dying…[and] coworkers [and family members are] getting sick—when that feels closer to you, you start to reevaluate life,” she said. In health care and in other fields, a “great reshuffling” took place as workers decided they would no longer engage in “purposeless” work or persist in a toxic workplace culture where they felt unappreciated.

Between 2020 and 2022, Meese said, the health system lost 10% of its physicians, and more than half of those in health care who switched jobs did not return to the same industry. More recent health care workforce data have been promising; they show raw numbers starting to return to prepandemic levels (although nursing and elderly care remain below February 2020 levels).2 However, the average age of health care workers has plummeted as experienced workers have left, and the “demand side” has soared as an aging population demands more care. In cancer care, a recent study showed that 134,000 cases went undiagnosed during the first 10 months of the pandemic, and those more advanced cancers are now being treated.³

Meese highlighted that there are still troubling signs in the health care workforce: Burnout and stress affected 75% of the workforce in 2022 vs 60% in 2018,4 and the suicide rate for female physicians is 1.46 times higher than that of male physicians.⁵ A different approach is needed than one that churns through staff, “as if a 40-year-old nurse with 20 years of experience is somehow comparable to someone who just came out of a BSN program,” she said.

In health care, “we treat people as more disposable than we do in other industries, where it’s not even a human-centric industry. So, I think we have a pretty severe requirement here—and an opportunity—to rehumanize the work of health care,” Meese said.

Perhaps redesigning an exam floor to reduce a doctor’s steps and squeeze in 2 more patients per shift is not the best idea, Meese explained. She would argue that the doctor may need that walk down the hall to collect their thoughts before they see the next patient. “If we’re not creating a work environment like that, we’re going to have people burn out and leave.”

How Workers Flourish
There is evidence of what conditions are needed for workers to excel and be happy, and Meese said health care provides some of them.⁶ A model of this environment includes several core elements: It should create positive emotions and offer engagement or focused time on the task, where workers can get into a flow without interruption. “We know that when people have to task switch, it leaves something called cognitive residue,” Meese said. “We take a little bit of the previous task with us into the next thing.”

The workplace should offer time to form relationships, which is becoming increasingly difficult in health care. A job should offer opportunity for a sense of accomplishment, which health care provides. However, this is more challenging as fields become more specialized and multiple team members have a role in each patient’s care.

One thing the brain is not optimized for is decision-making in distress, Meese said. The human brain can rise to occasion for brief periods of intense stress, but an extended period of chronic stress can result in an atrophied prefrontal cortex, she explained. This is what occurred in the pandemic, and failing to acknowledge that workers have not recovered is
both wrong and dangerous.

“Creating healthy work is not just the right thing to do. It’s not just important for meeting our broader goals of the organization to improve the health of the community,” Meese said. “We [also] don’t want to mess up people’s brains for the long term.”

Recruitment and Retention
Meese then reviewed evidence from health care worker surveys, which measured correlates of retention and a net promoter score (NPS), or qualities that would cause the worker to recommend the enterprise to someone else. The top correlates of retention, in order, were burnout, organizational support, a sense of belonging, and recognition. The top NPS factors, in order, were organizational support, trust in senior leaders, resource availability, recognition, and a sense of belonging.⁷
What about money? More so than other professions, health care workers are drawn by a sense of purpose. Money ranked seventh on the list of correlates of retention, so it does matter—but not in the way some may think.⁸ “When people say it’s the money…they might actually be saying, ‘You can’t pay me enough to put up with all [these other things]. You can’t pay me enough to stay in an environment where I don’t have these things.’”

A MIT analysis of 1.4 million Glassdoor reviews of health care workers found that the top reason workers chose to leave an organization was a toxic corporate culture. Lack of recognition and a poor response to COVID-19 were also listed.⁹ “All these things lead to low levels of trust,” Meese said.

Trust and Forgiveness
What are the elements that build trust? The first ones, Meese said, are competency and consistency. Others are honesty, including owning your mistakes, building relationships, communicating directly with employees “instead of cascading everything,” and clarifying expectations so there are no surprises. Finally, in health care, safety matters to workers.

In health care, workers know that administrators were faced with tough decisions and no good options, Meese said. What contributes to anger is the fact that when mistakes happened, so often no one apologized.
“Science says there are benefits of forgiveness in the workplace, that it can restore the physical and mental health of both the person apologizing and the person accepting the apology or forgiving,” Meese said. “It restores our sense of humanity…and it can lead to better innovation, productivity, job satisfaction, and organizational performance. For all these reasons, apologizing and forgiveness has to become a new core leadership competency.”

References
1. Data brief: health care workforce challenges threaten hospitals’ ability to care for patients. American Hospital Association. Accessed March 11, 2024. https://www.aha.org/fact-sheets/2021-11-01-data-brief-health-care-workforce-challenges-threaten-hospitals-ability-care
2. Telesford I, Wager E, Hughes-Cromwick P, Amin K, Cox C. What are the recent trends in health sector employment? Peterson-KFF Health System Tracker. December 13, 2023. Accessed March 12, 2024. https://bit.ly/3ViNor1
3. Burus T, Lei F, Huang B, et al. Undiagnosed cancer cases in the US during the first 10 months of the COVID-19 pandemic. JAMA Oncol. Published online February 22, 2024. doi:10.1001/jamaoncol.2023.6969
4. New surgeon general advisory sounds alarm on health worker burnout and resignation. News release. HHS. May 23, 2022. Accessed March 11, 2024. https://www.hhs.gov/about/news/2022/05/23/new-surgeon-general-advisory-sounds-alarm-on-health-worker-burnout-and-resignation.html
5. Olfson M, Cosgrove CM, Wall MM, Blanco C. Suicide risks of health care workers in the US. JAMA. 2023;330(12):1161-1166. doi:10.1001/jama.2023.15787
6. Meese KA, Colón-López A, Singh JA, Burkholder GA, Rogers DA. Healthcare is a team sport: stress, resilience, and correlates of well-being among health system employees in a crisis. J Healthc Manag. 2021;66(4):304-322. doi:10.1097/JHM-D-20-00288
7. Meese KA, Boitet LM, Sweeney KL, et al. Don’t go: examining the relationships between meaning, work environment and turnover intention across the entire healthcare team. J Multidiscip Healthc. 2024;17:353-366. doi:10.2147/JMDH.S437816
8. Meese KA, Colón-López A, Dill R, Naik GA, Cendoma PJ, Rogers DA. Perceptions of inequitable compensation reductions among healthcare workers during Covid-19. J Health Care Finance. 2021;48(2).
9. Sull D, Sull C. How do nurses rate their employers? MIT Sloan Management Review. October 18, 2023. Accessed March 11, 2024. https://sloanreview.mit.edu/article/nursing-satisfaction-index/