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In November’s Annals of Internal Medicine, Lucey and Donaldson bring to light the worldwide shortage of yellow fever vaccine. While no one in Lancaster anticipates a yellow fever epidemic this year, it is very much a concern worldwide, particularly in those African, Latin American and Caribbean countries which share the Aedes aegypti vector. Over 26 million doses of vaccine have been distributed to Brazil alone, and the WHO estimates that 1.4 billion doses will be needed over the next 10 years. U.S. vaccine production is limited to one facility, producing 500,000 doses annually for global travel alone. Internationally, the shrinking number of production sites has accelerated production, but in the short term, stockpiling is prevalent.
Health systems across the country are facing shortages of intravenous fluids, critical cardiac medications, even the IV bags themselves. The shortfalls have been precipitated by incapacitation of a shrinking number of facilities producing low-margin items. Hurricane Maria devastated Puerto Rico and incapacitated plants producing IVF. The fires in California reduced the capacity of dobutamine production, impacting inpatient care and outpatient cardiac testing. At Lancaster General Health, Dr. Paul Newman, Bill McCune and Lanyce Roldan have put together a clinical team to explore therapeutic substitutions and work processes to best use the resources we have. Dan Atkinson and Celine Huggins have leveraged our relationships with vendors to expand inventory and maintain vital care services. Huddle boards at the hospital operations, director, and unit levels have facilitated rapid adjustments and communication to bedside clinicians, and accelerated implementing alternative therapies.  Again, shrinking numbers of production facilities; increasing, inconsistent demand; and the importance of low-margin items will force us to be better stewards of our resources.  It is not if the next shortage will occur but only when. With Med Staff and operational leadership tied into the huddle system, we will be better able to respond. 
System thinking
Several years ago, LG Health tasked an outside firm to help reduce our internal costs to ultimately reduce overall health-care costs in our community. This affected all departments, with a great deal of success -- some from enhanced efficiencies but most successfully those areas which improved work flow, process and collaboration with physicians and physician leadership. While the outside firm helped us with national benchmarks, many ideas came from our own departments -- a trend that continues today in our Lean transformation efforts.
The Medical Staff Office was told to stop paying for beepers or bagels. We did not pay for beepers, and we refused to give up the bagels! However, we did discover a gap between clinical credentialing, payer enrollment approval and physician start dates. In the past, this was a sequential work flow: clinical credentialing, Medicare enrollment, then commercial enrollment. Medicaid approval often took months. As the number of newly hired employed physicians grew, uncompensated work followed. Independent practices have managed this gap by altering the start date, with some success.  We estimated 60 to 90 days of uncompensated work per newly hired provider, and as hiring approached 60 providers per year, this was real money. Our consultant partners took this idea with them as well.
Several attempts were made to break down this silo, using Cactus software to share information across the two departments, electronic applications and identifying common information to reduce the number of applicant queries. In the end, the silos won, and only small gains were seen.
A new initiative with our Penn colleagues -- a centralized verification organization -- would offer a way to combine clinical credentialing and payer enrollment. After months of work, LGH Med Staff leadership with the help of the bylaws committee has designed a pathway to ensure that applicants are screened according to our bylaws, then administratively verified centrally. Completed applications will be presented for approval by the LGH Med Staff leadership, chiefs, chairs, credentials committee and MEC prior to going to the BOT.  This new process will require a change in the current bylaws and will be discussed at the December Medical Executive meeting. We believe the new process will preserve our cultural standards, while accelerating payer enrollment for employed physicians and reducing uncompensated care.
Many thanks to the nearly 50 physicians and APPs who responded to our November Progress Notes survey around professional wellness and satisfaction. While several commented, “enough with the surveys” -- I get it -- many wrote lengthy responses, particularly around what constituted a “good day.”  Operational themes included starting and finishing on time, allowing adequate time to spend with both their patients and the teams providing the services. A predictable finish time allows for time with loved ones.  Physicians frequently referenced their efforts to help their patients and seeing those outcomes. Noble work. Several highlighted the importance of professional/collegial connections with their peers, both during and after the workday, and perhaps help with those troubling activities of daily professional living that get in the way.
No one should be surprised by the reported barriers to the “good day.” Most referenced the increasing demands of payer authorization, clinical documentation and population health management through the electronic health record, which has enabled work to be performed outside the office setting. Many offered scribes and administrative help as solutions to the growing list of non-patient-care duties.

The Med Staff Office is working closely with LGHP’s newly formed professional wellness group to act on these themes. The MSO will soon offer a concierge/ombudsman service to hopefully reduce/simplify some of the non-professional life challenges and build out-of-office collegial connections (social events). Finding space for hospital APPs to gather will be a priority. A pilot scribe program for ambulatory providers is being considered. And a simple physician onboarding program could help connect new physicians with support services and coach/mentor opportunities.  
There’s still time to take the survey by clicking here. Thank you for sharing your thoughts and for taking the time to read Progress Notes. We have tried to feature articles on fellow professionals and in a small way foster a sense of professional community across the staff.


Lee M. Duke II, M.D.
Chief Physician Executive
Progress Notes' Editor-in-Chief


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