A Conversation with Dr. Aditi Nerurkar, Leading Stress and Resilience Expert

Dr. Aditi Nerurkar, MD, MPH

Dr. Aditi Nerurkar is a Harvard physician, Forbes contributor, and an NBC News medical commentator. Her expertise is in the science of stress, resilience, and burnout. She offers insights in optimizing mental health, wellbeing, and productivity during the Covid-19 pandemic and beyond.

Dr. Nerurkar is on faculty at Harvard Medical School in the Division of Global Health & Social Medicine and serves as the Co-Director of the Harvard Clinical Clerkship in Community Engagement. Prior, she worked in global public health in Geneva, Switzerland with a World Health Organization collaborating center.

NHPCO had the opportunity to sit down with Dr. Nerurkar and ask her a few questions about leading high-quality programs in the healthcare sector, and her lessons learned over the years. NHPCO questions are italicized for clarity.

How will we know when the pandemic is over? Will we know when we have reached the “new normal?”

We are officially in the post-pandemic era from the policy perspective. On May 5, the World Health Organization (WHO) declared the end of the global health emergency but still said that COVID continues to be a global health threat. We are at present entering the new normal. That doesn’t mean that people won’t continue to get COVID or to be hospitalized and potentially die from the infection, it simply means we don’t have the policy guardrails, funding, and coordination we once did when it was considered a global health emergency. There are many downstream implications of this, many of which we cannot understand or begin to perceive now.

Why should hospice and palliative care teams enhance their focus on burnout and mental health? Where should they begin?

Every industry should be focused on mental health at this time because we are seeing unprecedented levels of mental health issues among employees across sectors. We’ve endured a major global event with broad ramifications on mental health, stress, and burnout. Particularly for those in the healthcare sector, this is especially marked. Prior to the pandemic, we were already noticing a rise in burnout among healthcare staff.

However, the pandemic exponentially accelerated this rise. We now have an epidemic of burnout among healthcare workers. We need to heal the healers

There are so many ways to begin to focus on protecting healthcare workers mental health and burnout. The first is to remove the burden of responsibility off the individual healthcare workers. This is a system-wide issue that needs systemic solutions. Broader institutional approaches to protect burnout must be instated. The American Medical Association has a wide array of resources and data on how to do this within an institution.

At the same time, we can support our healthcare workers by normalizing and validating this experience for them. Data shows that 60-72% of healthcare workers have at least one feature of burnout. We must do more to aid in burnout recovery for these individuals, who are now the majority.

You note that the pandemic has created an “occupational health crisis.” What does that mean?

We refer to the pandemic as a public health crisis, which it has been. But it’s also been an occupational health crisis and a mental health crisis. Mental health has been the shadow pandemic. We’ve seen an unprecedented rise in stress and burnout during the pandemic as well as a rise in stress-related conditions like anxiety, depression, and insomnia. The focus on recovery should include both individual and institutional factors. We must help individual healthcare workers recover from their burnout, but we also must focus on systemic solutions to help create more sustainable working conditions and an environment that supports the mental health needs of the individual workers. When an organization’s culture and an employee’s experience can align, that’s when mental health is optimized.

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If you’re interested in learning more from Dr. Nerurkar, she was a keynote speaker at the NHPCO 2023 Virtual Interdisciplinary Conference. Her session recording, The Reentry Phenomenon: A Blueprint to Navigate the New Normal, is now available in the conference portal for attendees. If you are not yet registered for the conference, register now and access the recording along with an extensive on-demand content library offering 22+ hours of CE/CME-eligible education.

NHPCO members can also find more resources on the end of the PHE through the NHPCO Regulatory and Policy Alerts webpage, under Updates and Alerts and titled “Final CMS Guidance for the Expiration of the COVID-19 Public Health Emergency (5/2/23).”

 

A Conversation with Dr. Ted James of Harvard Healthcare System

NHPCO had the opportunity to sit down with Dr. James and ask him a few questions about leading high-quality programs in the healthcare sector.

Ted James, MD, MHCM, FACS
Medical Director and Vice Chair, Beth Israel Deaconess Medical Center
Associate Professor of Surgery, Harvard Medical School

Dr. Ted James is a medical director and lecturer within the Harvard Healthcare System with extensive experience in efforts to advance healthcare. He leads international programs focused on digital health, clinician engagement, and patient experience, and collaborates with healthcare executives and industry experts from around the world.

He is an author who writes about the trends shaping the future of medicine and strategies for transforming the healthcare ecosystem. Dr. James has received numerous awards for his contributions to teaching, leadership, and quality. One of his greatest professional satisfactions comes from partnering with others to reimagine healthcare in ways that improve organizational performance and the wellbeing of patients, care teams, and communities.

NHPCO had the opportunity to sit down with Dr. James and ask him a few questions about leading high-quality programs in the healthcare sector, and his lessons learned over the years. NHPCO questions are italicized for clarity.

Why should hospice and palliative care teams enhance their focus on quality?

Focusing on quality improves patient outcomes and enhances the patient and family experience, which results in greater confidence in the care team. These have been shown to improve pain and symptom management. Essentially, the quality focus improves the patient's overall quality of life. Quality also leads to more efficient and less costly care, which is critical in the era of value-based care. Lastly, focusing on quality is a source of professional satisfaction

Where should hospice and palliative care teams begin in their quality improvement process? What does an organization focused on quality look like?

Start with a comprehensive assessment of current performance and then identify areas for improvement. This should be a leadership-supported, team-based approach with measurable goals and action plans to address identified gaps in care. Regular monitoring and measurement of outcomes with a constructive, not punitive, focus should be done to track progress and make necessary adjustments. The organization should be focused on continuous quality improvement, always seeking to elevate the next level.

What advice do you have for hospice and palliative care teams focusing on clinical innovation and leadership development?

Embrace change. Foster a culture where change is welcomed and seen as necessary to meet the future needs of patients. Leaders should promote psychological safety where people feel safe to ask questions, admit mistakes, challenge norms, and provide new ideas. Create venues for brainstorming and collaboration. Having opportunities for individual growth and professional development are also critical. Finally, realize that we can all be leaders and take ownership in making things better.

How can hospice and palliative care teams overcome resistance to new ideas?

People are not so much resistant to change as they are resistant to uncertainty. Conveying the "why" behind change, the purpose, can be a powerful way to motivate others. Involving people in the change process is also crucial to getting by in and overcoming resistance to new ideas.

What are some organizational best practices to encourage leadership at every level?

One of the best ways to foster leadership is simply to provide leadership opportunities. Make sure people have opportunities to initiate and lead projects. Seek out people who show potential and give them a chance to shine. Make certain to encourage autonomy and ownership; nothing will stifle leadership development like micromanagement. It also helps to recognize and reward good leadership.

How do you become a high-performing team? How do you know if you are a high-performing team?

High-performing teams need open communication, shared goals, structured processes, and, most importantly, mutual respect and mutual support. Great teams also have high expectations for the team and for individual members. They regularly evaluate their performance, deal with conflicts effectively, and celebrate wins collectively.

What advice can you share on how to enact transformation at different scales (i.e., system/organization-wide versus departmental)?

It requires tailoring the approach to the specific context. Organization-wide transformation needs centralized leadership, extensive strategic planning, and strong communication channels. Departmental transformation needs engaged champions who can spearhead targeted interventions. Well performed departmental initiatives that align to the goals of the organization will often scale to system wide. programs.

What are some steps hospice and palliative care leaders can take to develop leaders at all levels of an organization? What mistakes are healthcare leaders currently making when it comes to leadership development?

Mistakes in leadership development include neglecting to offer adequate resources and support, not recognizing and rewarding leadership behaviors, and not promoting a culture of inclusivity and diversity.

What are some tips that care team members can use to center their focus on the greatest priority of healthcare (and often, the reason for their connection to their work) – the patient?

Prioritize meeting the needs of our patients. We can understand their needs by actively listening to patients and families. Other key approaches are to communicate with empathy, strive to meet patient's physical, emotional, cultural and spiritual needs, convey respect, and empower patients through education and shared decision-making.

What’s the best piece of advice you’ve ever received?

That's a difficult one. I've received good advice from many mentors over the years. I think we should all view patient care as a calling. Also, we should remain curious and never stop learning. Healthcare is constantly evolving and being open to new ideas is essential for quality improvement.

What are some leaders doing that other leaders should be doing?

Leaders should think about how healthcare can innovate to improve the patient experience, including leveraging technology to improve care coordination and patient outcomes. We've seen great advances in other industries that are meeting user needs through technology and innovation. By embracing change and learning lessons from outside healthcare, leaders can drive positive changes.

Are there any other questions that we should have asked you that you’d like to ask and answer yourself?

Clinical teams are under a great deal of stress. Burnout is a serious threat. We should be asking how to use the power of teams and teamwork to support and revitalize the clinical workforce. Leaders and individual team members can take steps to promote mutual support, psychological safety, and a sense of inclusiveness and belonging that helps to address these challenges and allows teams to thrive.

 

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If you’re interested in hearing more from Dr. James, he was a keynote speaker at the NHPCO 2023 Virtual Interdisciplinary Conference. His session recording, Revitalizing Your Healthcare Teams Through Action-Based Leadership, is available in the conference portal until May 24. Attendees can watch and re-watch the presentation to glean takeaways for them and their teams.

Patient Safety Awareness Week March 2023

Why Safety?

By Aparna Gupta, DNP, FACHE, CPHQ, CRNP

Safety in healthcare is a cure-all – yet how many of us put safety front and center? From wearing seat belts, to washing hands, to crossing the street, the mechanism of safety is (mostly) well entrenched in all of us. Yet when it comes to identifying safety risks, reporting adverse events, or keeping patients and clinicians safe, we are prone to miss the point. The Institute of Medicine has established six domains of healthcare quality – safe, effective, patient centered, timely, efficient, and equitable care .

The first domain is safety. Delivering safe care means that adequate assessments have been done in a consistent, efficient, and equitable manner and that the right patient is receiving care in the right way, at the right time. Which also means that medical waste (unnecessary intervention) is avoided and patient outcomes including the experience of care are optimized. In other words, we accomplish the triple aim – maximize the patient experience of care, quality, reduce cost and enhance outcomes.

But wait, there’s more. What about clinician safety? Our interdisciplinary team members that are in the patients’ homes are exposed to a plethora of risk, the most recent being demonstrated during the COVID pandemic. While these are unsung superheroes, we need to focus on the safety of our staff. Not only physical safety, but psychological safety as well. As much as we need to ensure our staff are protected and feel safe to report any security incidents for their selves, we also need to ensure that the organization nurtures a just culture, whereby staff can “say something” when they “see something”.

It is well known that organizations that focus on a just culture see higher rates of “near miss” reporting – events that could have harmed the patient but didn’t reach the patient just yet. When these organizations make it safe and non-punitive for staff to report near misses, we see better workflows, higher standards of care and better communication between the interdisciplinary team (IDT).

Communication plays a big role in ensuring safety both for  staff and  patients. When the IDT talks to each other and shares important information at the right time and in the right way, the coordination of care reaches a new horizon. Safety tools like SBAR become the language that keeps care focused on the patient and the family.

As we celebrate Patient Safety Awareness Week, I cannot help but think of James Reasons Swiss Cheese Model (BMC Health Serv Res. 2005; 5: 71.) which explains how complex functions like taking care of a human being can be simplified when the whole team gets a say, has input, and works together to put patients’ safety first. Let’s keep our patients, our communities and ourselves safe by working together, trusting each other, and leaning on one another. Happy Patient Safety Awareness Week 2023!

About the author:

Aparna Gupta is the Vice President of Quality with National Hospice and Palliative Care Organization. Aparna is a board-certified adult nurse practitioner and has served in various roles ranging from executive leadership, operations, and clinical care delivery across healthcare. She holds a national certification in healthcare quality and is a Fellow with the American College of Healthcare Executives.

To learn more from NHPCO about improving your organization's quality and safety, register for the upcoming 2023 Virtual Interdisciplinary Conference.

A Letter to Grief - Part Two

By Emily Marge, MPS, NHPCO Veterans Services Specialist

Last year, I ventured into sharing my experience with my uncle's death due to suicide. I wrote my first NHPCO Updater blog post five months after his passing. I was afraid to be vulnerable but hoped that sharing my feelings might help me. The experience allowed me to be comfortable sharing something personal while examining how my professional life intertwines with my grief. The anniversary of his transition into the afterlife was in August. Our family laid him to rest in the National Veterans Cemetery in New York where he always wanted to be, alongside his fellow sisters and brothers who served. To this day, I can hear the echo of “Taps” playing at his funeral and think of him when I feel the stitches on the folded flag in his honor. The death of my uncle is a moment in my life which will forever be part of me, but it does not define me.  

I know I'm not alone as someone who experienced grief from the passing of a loved one due to delayed internments, travel plans, and mandates from the pandemic. I suspect some of you have experienced this in your personal or professional life. If you have, know that you are not alone. While painful, grief can also bring us peace, but it can take years for us to accept that—I know I have yet to. However, I hope one day to be comfortable again around Veterans, who so often remind me of my uncle, without fear of emotions rising up like a tidal wave. Instead, I want to ride the wave with balance; even if I fall a few times, I will get back up again.  

Many in the hospice community including patients, caregivers, staff, and family members, experience these waves of grief, getting back up only to soon be knocked down again by the next wave. When I find myself trying to get up—reaching for air—I work to remember positive moments and realize my uncle’s impact on this world. He may not have had children or married his sweetheart, but he created communities that still benefit from his actions today, even if they do not know his name. His legacy lives on not just through the work he did for fellow Veterans and friends, helping them back up when they got knocked down, but also through my sister and me. We both strive to honor his legacy by continuing to give back; even if we can impact just one person, we never know if or how the resulting ripple effect may touch others. This is how I will get back up from the wave that crashes down on the not-so-good days, knowing that I'm continuing his legacy of kindness.  

If you’re looking for additional support, I recommend checking out the information on bereavement care offered by CaringInfo.org, a program of NHPCO. You might also check out NHPCO’s Facebook, Twitter, and LinkedIn pages for an ongoing conversation about TV series, podcasts, books, and movies that may help you talk about death and grief more openly in tandem with professional support. NHPCO has shared a variety of lists on death-or-grief related resources to consider engaging with, and our community members have left many more in the comments that have helped them and their loved ones. 

If you’d like to take action to advance the crucial, ongoing work of bereavement care providers, and expand access to grief support across the nation, urge your Member of Congress to support the Grief Resilience Investment and Education Fund Act. I’ve done so and encourage you to do the same. 

I want to be kind to myself and honor all forms of the word grief this holiday season. I hope you’ll join me.  

How Doulas Help Hospices Meet Their Mission

By Beth A. Eck, PhD

In June of 2019, I began my quest to become a hospice death doula volunteer. For those who may not be familiar, an end-of-life doula guides individuals transitioning to death and their loved ones through the dying process. After a heady turn of events, I recently completed my first year as the Director of End-of-Life Doula Services for Hospice of the Piedmont in Charlottesville, Virginia. I am a practicing doula for hospice and palliative patients, but in my unanticipated “encore career,” I also train and supervise new hospice doulas, communicate with the interdisciplinary team (IDT), and run consultation groups. My job is a full-time, salaried position; I’ll share a little about that journey below, but more importantly, offer practical steps for hospice agencies to incorporate the end-of-life doula role.

After I returned from my first end-of-life (EOL) doula training in May of 2019, I knocked on the door of my non-profit hospice where I had been volunteering for the previous six months. I asked the volunteer department for supervisory hours (required for the training organization’s certification process) and was told they would need to know more about doulas and what I was requesting. I wrote up a five-page single-spaced proposal replete with footnotes—the occupational hazard of an academic. I covered the support a doula offers; I stated why the work did not require a particular degree or professional background; I offered how doulas offer complementary supports and not duplicative ones (i.e., they did not take the place of social workers or volunteers), and I argued that exploring the proposition was mutually beneficial—I would find out if I was suited to doula work, and they could find out if it was the kind of discipline they wanted to invest in. Because the number of doula training organizations seemed to be proliferating, I knew doulas were becoming more mainstream, and I argued that our hospice could be a leader in working with doulas rather than dismissing their potential impact. I knew I would not be the last to knock on the door.

 Bureaucracy is bureaucracy and so the process was not as straightforward as I assumed, but after many internal discussions, my proposal made it up the chain of command for approval. Even so, there was an overriding concern about structure. To have a doula, even a volunteer one, seemed to require some rethinking of the organizational chart as well as a clear delineation between existing volunteers and doula volunteers.

 If doulas are volunteers, will all patients have equal access to their services? If we have many doulas, who will supervise them? What if we train them and they decide not to volunteer for us and are privately hired by families instead? What if patients don’t want ‘just’ a volunteer anymore and only want doulas? These are legitimate concerns, and the answer for your organization may be different than it was for mine. Instituting an in-house doula program, or incorporating trained doulas into your fold, is not without its hiccups, but my organization and I would argue that it is well worth the effort.

 If you are not ready to hire a Director of End-of-Life Doula Services or have an in-house training program, I want to share what I have learned about how a doula can gain legitimacy within hospice teams and bring value to the organization. Some of these suggestions assume the doulas have a flexible schedule. If they do not, it will require some creative substitutes.

1.     Embed your doulas within an interdisciplinary team. During the orientation period, they can introduce themselves and learn faces, names, and roles without a patient assignment, and can comment on cases where a doula would be helpful.

2.     Arrange for the doulas to shadow team members. This is something a typical volunteer does not do. Shadowing a social worker and chaplain is likely enough, and these disciplines are good choices because doulas will work closely with them while supporting the patient.  The “ride-along” will provide an opportunity to dispel concerns about overlapping roles and help to build bridges.

3.     Discuss and decide on patients for the doulas to serve. Generally, patients who make a good fit are those who are interested in doing life review or legacy work, practical planning, or storytelling. They are patients who wish to plan their own active dying period and/or would like more presence at their bedside. They are also patients whose families welcome this kind of support.

Another barrier hospices may face when first integrating doulas into their programs is that doulas generally work with only one to two patients at a time to ensure those patients and their loved ones have the best experience possible. Doula work is intimate; they can spend hours with patients at any given visit, prohibiting a large caseload. From an administrative viewpoint, this may not sound good. Why is it worth having doulas if they cannot see very many patients?

·       Medicare regulations can make it difficult for dedicated clinical care team members to spend the amount of time they would like with patients; doulas can fill in that space, deepening relationships.

·       Because of this relationship, doulas help hospices achieve the desired continuity of care. We are with patients through each transition in their death journey.

·       Hospices are evaluated on their ability to provide a good patient care experience. Doulas are a bridge to comprehensive team communication as they fill in gaps about patients and their families. Their ability to spend long periods of time with patients means they can provide an intensive layer of emotional support.

·       An in-house doula program need not cost much. Thus far, our program is staffed by volunteers, and we offer the training for free. All costs associated with the doula program are covered by philanthropic dollars. There is some cost to market the program, but death doulas may present a very attractive donor opportunity. If you bring on board doulas trained outside your organization, they need only be trained as volunteers by your hospice to participate.

Having doulas work with your hospice is a win-win, though the road to victory is not necessarily easy. You cannot anticipate every question, scenario, or challenge, and it will take patience to make it work. Hospices were the first iteration of the “death positive movement.” Doulas are the newest. Let’s work together to make sure everyone has their good death.

Beth A. Eck, PhD, is a practicing death doula and the Director of End-of-Life Doula Services at Hospice of the Piedmont (HOP) in Charlottesville, Virginia. Beth started at HOP on August 1, 2021, where she was hired to develop an in-house death doula training program. Beth did her own training with the International End-of-Life Doula Association and Going with Grace. She is National End-of-Life Doula Alliance (NEDA) proficient and a member of the NHPCO’s End-of-Life Doula Council. She earned her PhD in 1996 from the University of Virginia and is an Emeritus Professor of Sociology at James Madison University where she taught for 25 years, most recently in the area of death and dying.

NHPCO’s End-of-Life Doula Council promotes awareness and understanding of the end-of-life doula role. The council is currently seeking feedback on the role of end-of-life doulas in hospice; share your perspective now. To learn more about end-of-life doulas, register for the 2022 Virtual Interdisciplinary Conference to access the on-demand content library through December 31, 2022 and view the session: “Workforce Shortage is REAL…Doulas Offer Real Options.”