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882726 AOR XXX10.1177/0003489419882726Annals of Otology, Rhinology & Laryngology Gilani et al research-article 2019

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Annals of Otology, Rhinology & Laryngology 2020, Vol. 129(2) 170–174

Electronic Consults in Otolaryngology: A Pilot Study to Evaluate the Use, Content, and Outcomes in an Academic Health System

© The Author(s) 2019 Article reuse guidelines:

https://doi.org/10.1177/0003489419882726 sagepub.com/journals-permissions DOI 10.1177/0003489419882726 journals.sagepub.com/home/aor

Sapideh Gilani, MD, FACS 1 , Krishna Bommakanti, BA 2 , and Lawrence Friedman, MD 3

Abstract Objectives: To categorize the primary reasons for electronic consults (eConsults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. Methods: This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding eConsults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. Results: The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. Conclusions: eConsults to otolaryngology were primarily for ear concerns. Of the eConsults, 82.4% did not require in-person follow-up. We therefore conclude that the use of eConsults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of eConsults, which may to the more efficient use of resources.

Keywords eConsult, otolaryngology, primary care, referral, consult

Introduction Integrated health systems are becoming increasingly com mon in the US and one cornerstone of such systems is the interdependency between PCP and specialty care provider. At the same time, greater pressure is being brought to create more efficient and effective systems of care in order to decrease cost and maintain patient-centeredness. Traditionally, any referral placed by a PCP automatically triggers an in-person visit with a specialist, something that has led to appointment backlogs, delayed diagnosis and poor patient satisfaction. 1,2 Referral issues are particularly relevant to otolaryngology, since ear, nose, and throat com plaints comprise up to 8.5% of primary care visits. 3 This has led to wait times to see an otolaryngologist can reach up to 5months in some regions of the country. 3,4

The development of electronic consultation (eConsult) systems has sought to address these problems and streamline patient care. 1,5,6 eConsults are created by PCPs who have a clinical question that is outside their expertise but that they do not feel requires an in-person evaluation. 6,7 The eConsult is generated in either an independent eConsultation platform 1 Department of Surgery, Division of Head and Neck Surgery, University of California San Diego, San Diego, CA, USA 2 University of California San Diego School of Medicine, La Jolla, CA, USA 3 Department of Internal Medicine, University of California San Diego, San Diego, CA, USA Corresponding Author: Krishna Bommakanti, BA, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92092, USA. Email: kbommakanti@ucsd.edu

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Table 1. Baseline and follow-up study characteristics. Study Population (n=64) Age (years), mean (SD)

or through an electronic medical record environment shared by both PCP and specialist allowing the specialist to view prior medical records and document in so their con sult is immediately available to the referring PCP. The pri mary goals of eConsults are to prevent unnecessary referrals for management that could occur in the primary care setting. A secondary goal is to enable patients to access specialty advice more quickly while reducing wait times for more seriously ill patients. 7-9 Others have shown that eConsults are associated with shorter wait times for spe cialty care, improvement in provider communication and referral quality, and high levels of satisfaction among PCPs, specialists, and patients. 4,10,11 Although eConsults have been widely adopted across most specialties, little information exists about their role in otolaryngology. 12 While promising, only one prior study done in Canada has looked at eConsult referral patterns to otolaryngology and what impact this system has had on the number of in-person office visits. 12 We sought to analyze the primary reasons for eConsults to otolaryngology at a large tertiary referral center. Additionally, we looked at whether or not the use of an eConsult system has the ability to prevent unnecessary office visits. Methods After obtaining University of California San Diego IRB approval, a retrospective chart review was performed to collect data on all patients who were referred to our clinical practice by 42 primary care physicians within the UC San Diego Internal Medicine or Family Medicine groups by eConsult between 2016 and 2017. eConsults were not placed by nurse practitioners or physician’s assistants. All eConsults were performed by a faculty member in the divi sion of otolaryngology, Dr. Sapideh Gilani. eConsults were placed and received using Epic Systems software and it is the requesting provider who determines whether a request should be classified as an eConsult. Demographic data including age, gender, and insurance status was collected. Complaints were categorized as: (1) ear, (2) nose, (3) throat, or (4) neck-related. Proposed interventions were catego rized as (1) education only, (2) medical treatment, or (3) surgery. We also recorded time to completion from when the consultation was placed by the PCP and whether or not a subsequent in-person office appointment was made. Finally, we took note of the chief complaint and proposed PCP diagnosis for all patients. Statistics were conducted with SPSS Statistics® Version 24. Univariate statistics were computed for the relationships between age, sex, type of complaint, and intervention provided. We conducted multinomial logis tic regression to assess for the relationship between age, sex, and type of complaint. All tests were set at a signifi cance level of P < .05.

54.6 (16.5)

Sex

Male

41 28

Female

In-person follow-up recommended? Yes

17 (26.5%) 47 (73.4%)

No

Average time to response (days), mean (SD) Average time to in-person follow-up (days), mean (SD)

2 (3.7)

91.1 (123)

Results The study population includes 64 patients who had eCon sults placed to otolaryngology. Five patients were excluded because an eConsult was referenced in the PCP note but not available in the system or an eConsult was erroneously placed and immediately converted to a referral for an in person consultation. eConsults were answered during clinic time and responses took 5 to 10minutes per consultation. Table 1 summarizes baseline and follow-up patient char acteristics. An average of five eConsults were placed per month and ranged from 2 to 9 per month. With the excep tion of a spike in eConsult placement in December 2016, there was no clear trend in the number of eConsults placed over time (Figure 1). The average age was 54.2 years and 60.9% of patients were male. The average response time was 2days and 17 patients (27%) had in-person follow-up. Notably, there is a difference between the number of patients who were recommended in-person follow-up by an oto laryngologist (Table 3) and the number of patients who ultimately sought in-person follow-up (Table 1). Eleven patients were recommended to be seen in-person but only six made a follow-up, while an additional 11 patients opted for a clinic visit even though this was not explicitly suggested in the eConsult. Table 2 classifies complaints as ear, nose, or throat con cerns. When stratified by age and sex using binary logistic regression, no statistically significant differences were found in the likelihood to require in-person consultation ( P = .817). The specific diagnosis or reason for referral within each category, along with the proposed interven tions, are also listed in Table 2. Tinnitus was the most com mon reason for an eConsult to be placed, making up 18.8% of all of complaints. Other frequent complaints included hearing loss (10.9%), ear infections (10.9%), sinusitis or rhinitis (9.4%), and hoarseness (9.4%). For all cases of tin nitus and hearing loss, an audiogram was recommended and obtained. For cases of hoarseness in which laryngopharyn geal reflux was suspected, treatment with a proton pump inhibitor was recommended.

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Figure 1. Number of eConsults placed by month.

Table 2. Complaints within each ENT subcategory.

Table 2. (continued)

Number of Patients (%)

Number of Patients (%)

Complaint

Complaint

Ear Tinnitus

Parotid cyst

1 (1.4%) 1 (1.4%) 2 (2.9%)

12 (17.4%) 8 (11.6%)

Submandibular sialadenitis

Hearing loss

Temporomandibular joint dysfunction

Middle ear dysfunction (acute or chronic otitis media, Eustachian tube dysfunction, tympanic membrane perforation)

6 (8.7%)

Total

69 (100%)

Note . The total reflected in this table (69) is greater than the total number of patients in the study (64) because some patients presented with multiple complaints.

Cerumen removal

2 (2.9%)

Nose Sinusitis

4 (5.8%) 2 (2.9%) 1 (1.4%) 1 (1.4%) 1 (1.4%) 1 (1.4%)

Rhinitis/rhinorrhea

Table 3 categorizes the initial interventions offered to patients via initial eConsultation as (1) education only (no intervention), (2) suggestion of medical management to be provided by the PCP, or (3) surgical management. A sugges tion for providing medical management (67.2%) or surgical management (20.3%) comprised the majority of interven tions offered. In-person consultation was recommended in 17.2% of all cases. Table 3. Interventions offered in response to initial eConsult referrals. In-Person Follow-Up Required? Yes No Total P -value Education only 1 (12.5%) 7 (87.5%) 22 Suggest medical therapy 5 (11.6%) 38 (88.4%) 43 Suggest surgical therapy 5 (38.5%) 8 (61.5%) 13 Total 11 (17.2%) 53 (82.8%) 64 .075

Epistaxis

Nasal obstruction

Incidental finding on imaging Benign nasopalatine cyst Throat Lip/oral lesion, tongue laceration Chronic cough/gastroesophageal reflux disease (GERD)

7 (10.1%) 1 (1.4%)

Hoarseness Sore throat Dysphagia Dysgeusia

5 (7.2%) 1 (1.4%) 1 (1.4%) 1 (1.4%) 1 (1.4%) 1 (1.4%) 1 (1.4%)

Fibroma

Incidental finding on imaging

Other (canceled)

Neck Thyroid mass or thyroid nodules

3 (4.3%) 5 (7.2%)

Neck mass

(continued)

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2 to 9. 12 Although this is a pilot study and might not repre sent the full volume of eConsults if an entire institution par ticipated, it is reasonable to extrapolate the ratio of one specialist to 42 primary care physicians when estimating the time that would need to be spent answering eConsults on a monthly basis. Response rate and time are particularly important given that the majority of these initial responses were conclusive and did not require further follow-up with otolaryngology. Previous studies have shown that tradi tional referrals can have up to 6months of wait times and patient satisfaction is low. 16-18 A large study by the Canadian Medical Association found that 58% of PCPs surveyed about their referral practices used wait time as a determi nant of whether or not to refer a patient to an otolaryngolo gist. 10 Our findings build on the findings of previous studies suggesting that eConsults could streamline the referral pro cess and ensure that patients who have complaints that do not need to be addressed in-person do not have to wait long periods of time for a specialist appointment. This could simultaneously increase the availability of appointments for patients whose complex problems require in-person otolar yngology visits. Although we found that the average time to convert an eConsult to an in-person visit was 91days, it ranged from 2days to 405days. This suggests that appoint ments were scheduled based on clinical context and it is therefore unclear whether the reason for the delay is due to a lack of available appointments or a lack of urgency in scheduling the in-person visit. The major strength of this study is that to our knowledge no other study has reported on the use of eConsult in otolar yngology. A limitation of this pilot study is the retrospective design from a single center and by a single case reviewer. Future studies should be conducted prospectively across several institutions and with multiple providers within each institution. Additionally, it would be interesting to survey PCPs to determine how the introduction of the eConsult sys tem has modified their workflow and referral patterns within the field of otolaryngology. An important next step in evalu ating the feasibility of eConsults in otolaryngology would be to monitor patient and provider satisfaction before and after the introduction of the eConsult system once it has been extended to the entire otolaryngology division. Based on previous studies, some possible metrics for evaluation are wait times, patient travel times, educational value, and access to specialty input. 10,19 At our institution, we did not do cost analysis for this project. We promoted the eConsult pos sibility among our physicians using established existing communication channels such as electronic newsletters and presentations at division meetings. Future studies could study cost savings and cost avoidance in determining which of the patient satisfaction metrics, if any, are most tied to the potential cost savings that eConsults could provide. Future studies could also study reimbursement requirements for such services.

Discussion The interplay between PCPs and specialists is essential to providing patients with the best care. This pilot study focused on a retrospective analysis of 64 patients who had eConsults placed to the University of California, San Diego Department of Otolaryngology by their UCSD PCPs. PCPs at our institu tion were reimbursed for placing eConsults by half work relative value units (wRVUs) and the participating specialist was paid $50per eConsult. Both were paid internally by fac ulty to encourage use of the system. Under current Centers for Medicare and Medicaid (CMS) guidelines, our institution does not charge for eConsults; however, this may change as the guidelines continue to take shape. We found that the aver age response time to the initial consult was 2days and only 17.2% of all patients required follow-up office visits. Our study provides new information regarding eConsult referral patterns in otolaryngology and corroborates existing studies about common complaints seen in otolaryngology offices. 2,3 As other studies have shown, we found that the majority of eConsults were for ear (41%) or throat (29%) related complaints. 8 Our data indicate that the vast majority of eConsults could be handled with medical management by the PCP (67.2%) or education only (12.5%), and most patients across both groups did not require an in-person office visit. It is not surprising that most visits did not require additional follow-up because many problems in oto laryngology can be managed without surgical interven tion. 13 Tinnitus and hearing loss were the two most common complaints in our study and others. 13-15 This is in contrast to a large study by Kohlert et al 12 in 2017, in which thyroid goiter and oral mucosal lesions were the most commonly identified topics for eConsult placement. eConsults are par ticularly useful in this case for educating the patient and PCP about how to manage this condition over time and when additional workup by an otolaryngologist might be necessary. The most commonly proposed interventions in these situations were audiograms. If there was concern for a sudden change in hearing, in-person consultation with ENT was recommended. A similar recommendation for medical management followed by in-person visit for persistent symptoms was made for other common complaints, such as chronic sinus issues or hoarseness. In cases where conser vative management was recommended, another treatment modality or in-person referral were indicated as alternatives if the initial plan was not successful within a given time period. This provided PCPs with multiple courses of action as well as a guide for when a further consultation with a specialist might be warranted. One benefit that our study identified is the quick response time to eConsults, which was 2days on average (Table 1). The quick response time is consistent with other studies and could be due to the fact that the volume of eConsults was not overwhelming, averaging 5 per month but ranging from

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Conclusion We found that the majority of interventions recommended by otolaryngology were either medical management or edu cation, both of which can be done via telemedicine and without in-person office visits. Overall, 82.8% of patients did not require in-person follow-up with Otolaryngology. 100% of nasal eConsults did not require in-person follow up with Otolaryngology. Efforts should be made to promote the widespread use of eConsults, which leads to the more efficient use of resources across multiple disciplines. Acknowledgments Dr. Gilani would like to thank Shuxiang Liu for help with data extraction, Dr. Elizabeth Rosenblum and Dr. John Pang for invalu able support with this paper. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Lowenstein M, Bamgbose O, Gleason N, Feldman MD. Psychiatric consultation at your fingertips: descriptive analy sis of electronic consultation from primary care to psychiatry. J Med Internet Res . 2017;19(8):e279. 2. Weiner M, El Hoyek G, Wang L, et al. A web-based gen eralist–specialist system to improve scheduling of outpatient specialty consultations in an academic center. J Gen Intern Med . 2009;24(6):710-715. 3. Benninger MS, King F, Nichols RD. Management guide lines for improvement of otolaryngology referrals from primary care physicians. Otolaryngol Head Neck Surg . 1995;113(4):446-452. 4. Hofstetter PJ, Kokesh J, Ferguson AS, Hood LJ. The impact of telehealth on wait time for ENT specialty care. Telemed J E Health . 2010;16(5):551-556. 5. Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse specialties and ORCID iDs Sapideh Gilani https://orcid.org/0000-0001-6183-623X Krishna Bommakanti https://orcid.org/0000-0001-9857-7681

primary care providers. Telemed J E Health . 2013;19(10):733 738. 6. Liddy C, Drosinis P, Keely E. Electronic consultation sys tems: worldwide prevalence and their impact on patient care-a systematic review. Fam Pract . 2016;33(3):274-285. 7. Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF, Kushel MB. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med . 2010;25(10): 1123-1128. 8. Mahalingam S, Pepper C, Oakeshott P. Reducing inappropri ate ENT referrals. Br J Gen Pract 2013;63(613):404-405. 9. Chen AH, Murphy EJ, Yee HF. eReferral—a new model for integrated care. N Engl J Med . 2013;368(26):2450-2453. 10. Scott JR, Wong E, Sowerby LJ. Evaluating the referral pref erences and consultation requests of primary care physicians with otolaryngology – head and neck surgery. J Otolaryngol Head Neck Surg . 2015;44(1):57. 11. Hysong SJ, Esquivel A, Sittig DF, et al. Towards success ful coordination of electronic health record based-referrals: a qualitative analysis. Implement Sci . 2011;6(1):84. 12. Kohlert S, Murphy P, Tse D, et al. Improving access to oto laryngology–head and neck surgery expert advice through eConsultations. Laryngoscope . 2017;128(2):350-355. 13. Hannaford PC, Simpson JA, Bisset AF, Davis A, McKerrow W, Mills R. The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland. Fam Pract . 2005;22(3):227-233. 14. Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guide line: tinnitus executive summary. Otolaryngol Head Neck Surg . 2014;151(4):533-541. 15. Martz E, Chesney MA, Livneh H, Jelleberg C, Fuller B, Henry JA. A pilot randomized clinical trial comparing three brief group interventions for individuals with tinni tus. Glob Adv Health Med . 2018;7:2164956118783659 2164956118783659. 16. Palen TE, Price D, Shetterly S, Wallace KB. Comparing virtual consults to traditional consults using an electronic health record: an observational case–control study. BMC Med Inform Decis Mak . 2012;12(1):65. 17. Ulloa JG, Russell MD, Chen AH, Tuot DS. A cohort study of a general surgery electronic consultation system: safety impli cations and impact on surgical yield. BMC Health Serv Res . 2017;17:433. 18. Otto ME, Senter C, Gonzales R, Gleason N. Referring wisely: orthopedic referral guidelines at an academic institution. Am J Manag Care . 2016;22(5):e185-e191. 19. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic con sultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare . 2015;21(6):323-330.

Managing an Intergenerational Workforce: Strategies for Health Care Transformation January 2014

A report from the AHA Committee on Performance Improvement

American Hospital Association 2013 Committee on Performance Improvement

​

Marlon L. Priest, MD Executive President and Chief Medical Officer Bon Secours Health System, Inc. Michael G. Rock, MD Medical Director, Mayo Clinic Hospitals/Mayo Foundation Mayo Clinic PamelaT. Rudisill, DNP, RN Vice President, Nursing and Patient Safety Health Management Associates, Inc. Donna K. Sollenberger Executive Vice President and Chief Executive Officer University of Texas Medical Branch Health System Arthur A. Sponseller, JD President and Chief Executive Officer Hospital Council of Northern and Central California Richard J. Umbdenstock President and Chief Executive Officer American Hospital Association Raymond P.Vara, Jr. President and Chief Executive Officer Hawaii Pacific Health

Georgia Fojtasek, RN, EdD President and Chief Executive Officer Allegiance Health Nancy A. Formella, MSN, RN Chief Operating Officer Beth Israel Deaconess Medical Center Raymond Grady Trustee Northwest Community Healthcare Mary Henrikson, MN, CENP Vice President for Patient Care Services St.Anthony Summit Medical Center Mary Anne Hilliard, BSN, JD Chief Risk Counsel Children’s National Medical Center

James A. Diegel Committee Chair President and Chief Executive Officer St. Charles Health System Mark C.Adams, MD Chief Medical Officer Franciscan Health System

Richard Afable, MD President and Chief Executive Officer Hoag Memorial Hospital Presbyterian

Barclay E. Berdan Chief Operating Officer and Senior Executive Vice President Texas Health Resources Damond Boatwright Chief Executive Officer Overland Park Regional Medical Center ThomasW. Burke, MD Executive Vice President and Physician-in-Chief University of Texas MDAnderson Cancer Center

RussellW. Johnson Senior Vice President of Network Development Centura Health

Douglas Leonard President and Chief Executive Officer Indiana Hospital Association RaymondW. Montgomery II President and Chief Executive Officer White County Medical Center Sarah Patterson Executive Vice President and Chief Operating Officer Virginia Mason Medical Center

John Duval Chief Executive Officer Medical College of Virginia Hospitals

Mary BethWalsh, MD Executive Medical Director and Chief Executive Officer Burke Rehabilitation Hospital

Laura Easton President and Chief Executive Officer Caldwell Memorial Hospital

Suggested Citation: American Hospital Association, Committee on Performance Improvement. (2014, January). Managing an intergenerational workforce: Strategies for health care transformation . Chicago, IL: Health Research & Educational Trust.

For Additional Information: Maulik S. Joshi, DrPH, (312) 422-2622, mjoshi@aha.org

Accessible at: www.aha.org/managing-intergenerational-workforce

© 201 4 Health Research & Educational Trust.All rights reserved.All materials contained in this publication are available to anyone for download on www.aha.org, www.hret.org or www.hpoe.org for personal, non-commercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publication or in the case of third party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation.To request permission to reproduce any of these materials, please email hpoe@aha.org.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Acknowledgments

The AHA Committee on Performance Improvement would like to acknowledge the following organizations and individuals for their invaluable assistance and contributions to the committee’s work:

Alison S.Avendt, MBA,Vice President, Professional and Support Services, ProMedica Toledo Hospital

Luke B. Barnard, MS, Manager, HR Analytics andWorkforce Planning, ProMedica

Bonnie Bell, ExecutiveVice President for People and Culture,Texas Health Resources

Bonnie Clipper, DNP, RN, CENP, FACHE, Chief Nursing Officer, Medical Center of the Rockies

Jim Finkelstein, President and CEO of FutureSense, Inc.,Author of Fuse: Making Sense of the New CogenerationalWorkplace

Mina Kini,Administrative Director, Diversity and Inclusion,Texas Health Resources

Kathleen Nelson, RN, MSN, Chief Nursing Officer, Eastern Idaho Regional Medical Center

Rhoby Tio, MPPA, Program Manager, Hospitals in Pursuit of Excellence, Health Research & Educational Trust

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Table of Contents Executive Summary............................................................................................................................................................4 Introduction........................................................................................................................................................................6 Multiple Generations in theWorkplace.........................................................................................................................8 Strategies to Support Health CareTransformation..................................................................................................15 Building a Strong Generational Foundation.................................................................................................17 Establishing Effective Generational Management Practices......................................................................19 Developing Generational Competence........................................................................................................22 Creating High-PerformingTeams...................................................................................................................................24 Case Studies......................................................................................................................................................................26 Additional Examples of Intergenerational Management Strategies.......................................................................40 The Future Workforce...................................................................................................................................................41 References.........................................................................................................................................................................42 Endnotes............................................................................................................................................................................43

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Executive Summary Generational diversity is rapidly changing workforce dynamics. Each generation has different priorities, attitudes, communication styles, work approaches and ways to interact with colleagues, which influence organizational culture and performance.There are also common and unifying characteristics across all generations that can be leveraged to create optimal teams, critical for future health care models. Leveraging these generational strengths and differences will give hospital and care system leaders an edge as the health care field moves from the “first curve,” where hospitals operate in a volume-based environment, to the “second curve,” a value-based care system and business model. Leaders that develop robust and productive multigenerational teams, leveraging each cohort’s strengths, will be well positioned to handle “life in the gap,” the transition between the two curves. In 2011, the American Hospital Association Committee on Performance Improvement (CPI) released Hospitals and Care Systems of the Future, identifying several must-do strategies and core competencies to help leaders manage life in the gap and achieve the Triple Aim of health care: improve the health of the population (our communities), improve the individual care experience and reduce the per capita cost of health care. Building a robust organizational culture that can adapt to change is essential to achieve these goals.To build a healthy culture, leaders need to harness all employees’ potential to achieve optimal organizational performance and ensure excellent patient care. With the workforce becoming increasingly diverse, the 2013 AHA CPI explored the effects of the intergenerational workforce on hospital organizational culture and patient outcomes. Leaders who capitalize on the commonalities and differences of each cohort can create a dynamic and engaged workforce and gain a competitive edge in attracting and retaining productive employees, even with labor shortages. Each generation brings a different set of values, beliefs and expectations to the workplace, from the traditionalists (born before 1945), baby boomers (born 1946 to 1964), Generation X (born 1965 to 1980) to the millennials (born after 1980). Leaders need to develop strategies to engage these different groups simultaneously to achieve optimal clinical outcomes and patient experience. In contrast, organizations that fail to effectively manage a generationally diverse workforce will experience high employee turnover; pay higher costs for recruitment, training and retention; and have lower patient experience scores and worse clinical outcomes. The figure “Strategies for Managing an IntergenerationalWorkforce” presents factors that influence how individuals approach work and provides strategies for hospital leaders to implement. Hospitals leaders that leverage the strategies can create high-performing teams adaptable to evolving health care needs. Of the recommended strategies, it is essential that every organization start with: ¾ ¾ conducting an intergenerational evaluation to determine the organization’s workforce profile and develop a comprehensive plan; ¾ ¾ implementing targeted recruitment, segmented retention and succession planning strategies; and ¾ ¾ developing tailored communication strategies that cultivate generational understanding and sensitivity. As workforce demographics shift, jobs, scope of practice, team roles and professional education in the health care field will trump current care delivery structures and necessitate innovation. Hospitals and care systems that implement intergenerational strategies and practices—critical to redesigning care delivery—will achieve second-curve outcomes. Success will elude those organizations that fail to do so.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Figure: Strategies for Managing an Intergenerational Workforce

Hospitals and care systems of the future

• Conduct an intergenerational evaluation to determine the organization’s workforce profile • Acquire intergenerational talent • Segment retention strategies

• Customize management and communication styles • Leverage employees’ strengths • Tailor recognition and rewards • Encourage collaboration in the workplace Establish effective generational management practices Develop generational competence

• Develop generational understanding • Participate in formal mentoring programs • Improve communication skills and generational sensitivity

Build a strong generational foundation

Strategies for managing an intergenerational workforce

Religion Environment

Ethnicity

Disability Race and Education Level

Generation Y/Millennials: Born after 1980

Age

Socio

economic Status

Intergenerational

The Intergenerational Workforce Traditionalists: Born before 1945 Baby Boomers: Born 1946–1964 Generation X: Born 1965–1980

Political

Historical Events

Gender

Factors of diversity that influence

the characteristics and attitudes of individuals

Source: AHA CPI, 2014.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Introduction By the next decade, the U.S. health care industry will face workforce shortages due to aging employees and to more patients living longer as a result of new treatments and technology.There will be a generational gap between older patients and younger health care providers that will impact the level and quality of care. Several efforts are in place to address labor shortages, such as the expansion of allied health professional careers, emerging health care occupations and expansion and acceleration of clinical education programs. Expansion of allied health professional careers In the last two decades, health care delivery in the United States transformed from a segmented care model into a multidisciplinary model.This development, along with managed care, the aging population and increased need for rehabilitation services, resulted in an expansion of allied health professional careers. 1 Emerging health care occupations Health care reform and the movement toward patient-centered care will increase employment opportunities in newer health care occupations such as community health workers, chronic illness coaches, patient advocates and home- and community-based service navigators. 2 These new members of the health care team improve patient health and support independent living, with a focus on emphasizing prevention and avoiding unnecessary hospitalization, thereby lowering costs and increasing health care access for more individuals. 3 Expansion and acceleration of clinical education programs In recent years, universities have increased capacities in medical and nursing schools by expanding their size and creating accelerated programs for some clinical professions. 4 Why the Intergenerational Workforce? For the first time in modern U.S. history, there will be four generations in the workforce.This report explores the characteristics of each generation and their impact on the health care industry.The generations are defined as follows: Individuals from different generations may bring vastly different sets of values, beliefs and expectations to the workplace.They have different priorities, attitudes, communication styles and ways to engage with peers and work design that is influencing organizational culture and performance. Ignoring these differences can be detrimental for any organization. However, leaders who capitalize on these inherent differences can create a dynamic and engaged workforce needed to achieve health care’s Triple Aim: improve the health of the population (our communities), improve the individual care experience and reduce or control the per capita cost of health care. Capitalizing on these differences will also give health care leaders a competitive edge in attracting and retaining productive employees, even with labor shortages. In addition, some individuals born on the cusps of generations—“cuspers”—understand and resonate with both groups. Organization may want to build strong relationships with cuspers and leverage their abilities to bridge generational commonalities and differences in areas such as communication styles and reward and recognition preferences. ¾ ¾ Traditionalists (born before 1945) ¾ ¾ Baby boomers (born 1946–1964) ¾ ¾ Generation X (born 1965–1980) ¾ ¾ GenerationY/Millennials (born after 1980)

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Preparing Hospitals and Care Systems for the Future The 2011 AHA Committee on Performance Improvement report, Hospitals and Care Systems of the Future , identified must-do strategies and core organizational competencies to help leaders achieve the Triple Aim of health care.Two must-do strategies and four core organizational competencies support building a strong organizational culture, essential to developing the future workforce. 2. Utilize evidenced-based practices to improve quality and patient safety 3. Improve efficiency through productivity and financial management 4. Develop integrated information systems 5. Join and grow integrated provider networks and care systems 6. Educate and engage employees and physicians to create leaders 7. Strengthen finances to facilitate reinvestment and innovation 8. Partner with payers 9. Advance an organization through scenario-based strategic, financial and operational planning 10. Seek population health improvement through pursuit of the Triple Aim The must-do strategies are: 1. Align hospitals, physicians and other providers across the continuum of care

The core organizational competencies are: 1. Design and implement patient-centered, integrated care 2. Create accountable governance and leadership 3. Plan strategically in an unstable environment 4. Promote internal and external collaboration 5. Ensure financial stewardship and enterprise risk management 6. Engage employees’ full potential 7. Collect and utilize electronic data for performance improvement

This report identifies approaches and initiatives to help health care leaders deploy the boldfaced strategies and competencies. Hospital leaders must focus on developing organizational culture, particularly managing the intergenerational workforce, to find success in the second-curve, value-based environment. Figure 1 illustrates intergenerational management strategies that will ultimately lead hospitals and care systems to achieve second-curve outcomes.

Figure 1: Managing an Intergenerational Workforce to Achieve Second-Curve Outcomes

Intergenerational Management

Must-do Strategies and Competencies

Second-Curve Outcomes

• Build a strong generational foundation • Establish effective generational management practices • Develop generational competence

• Align clinicians and hospitals • Engage employees in transformation • Deliver optimal team-based, patient-centered care • Have an organizational culture to support execution

• Optimal clinical outcomes • Optimal patient experience • Reduction in total cost of care

Source: AHA CPI, 2014.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Multiple Generations in the Workplace

Generational Demographics

As people in the United States are living and working longer, the workforce composition has shifted and will continue to become more generationally diverse (see Figures 2 and 3).

Figure 2: U.S. Population by Generation

Figure 3: Estimates and Projection of Generations in the U.S. Workplace 2010–2020

Source: U.S. Census Bureau, American Community Survey, 2007.

Source: U.S. Census Bureau, American Community Survey, 2007.

Workforce Continuum People in each generation are in different stages of their professional careers, as illustrated in Figure 4. Millennials are slowly entering the workplace and are projected to comprise 50 percent of the workforce by 2020. Generation Xers are advancing their careers in the workforce. Most Gen Xers are middle managers, while baby boomers fill leadership roles and are approaching retirement. Due to the 2008 recession, millennials are less likely to be employed than were Generation Xers and baby boomers at their age 5 , and baby boomers are delaying retirement and working longer. 6 Most traditionalists have retired, with only about 5 percent or less active in the workforce today. 7

Figure 4: Intergenerational Workforce Continuum

Source: AHA CPI, 2014.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Generational Interaction in the Workplace According to a Lee Hecht Harrison survey, more than 60 percent of employers are experiencing tension between employees from different generations.The survey found that more than 70 percent of older employees are dismissive of younger workers’ abilities, and nearly 50 percent of younger employees are dismissive of their older colleagues’ abilities. The generational tension is a result of different historical experiences and attitudes (Figure 5). Each generation was influenced by the same factors; however, each generation experienced these factors differently. For example, traditionalists and many baby boomers grew up before the civil rights movement while Generation X and millennials grew up after the Civil Rights Act of 1964, thereby shaping their views on race, religion and gender. How the generations experienced such events affects their perceptions of commitment, company loyalty, task management, project execution and professional development. Cultural differences also influence the characteristics and attitudes of individuals in the workplace. For example, new Americans and permanent residents may have different business etiquettes than natural-born Americans in the same generation.These groups may differ in communication styles, their attitudes toward management and organizational hierarchies, and how they value time in the workplace and cope with work volume. Regardless of the factors impacting generational dynamics in the workplace, a standard level of professionalism in the health care industry is expected of every employee.This ranges from ethical standards of clinical practice that are embedded in licensing requirements to U.S. laws that protect patient privacy, such as the Health Insurance Portability and Accountability Act.

Figure 5: Factors of Diversity

Source: AHA CPI, 2014.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

To illustrate the challenges of managing a diverse workforce, health care leaders need an understanding of how each generation experienced the same factors.Table 1 highlights characteristics associated with each generation, their experiences and their views.

Table 1: Overview of Characteristics for Each Generation

Traditionalists Baby Boomers Generation X Millennials

MajorTrait

Loyalty

Competition

Self-reliance

Immediacy

Eclecticism, self reliance, free agents, work/ life balance, independence MTV,AIDS, Gulf War, 1987 stock market crash, fall of communism/Berlin Wall, Challenger shuttle explodes

Community service, cyberliteracy, tolerance, diversity, confidence Internet, social media, 9/11 terrorist attack, deaths of Princess Diana and Mother Teresa Internet, smart phones (text messaging), social media, instant messaging

Sacrifice, loyalty, discipline, respect for authority

Broad Traits

Competitive, long work hours

Watergate, women’s rights, JFK assassination, civil rights and Martin Luther King Jr., VietnamWar, man walks on the moon

Great Depression, WorldWar II, Cold War, KoreanWar, suburban sprawl begins, first satellite launches

Influential Events

Mobile phone, Walkman, computer

Defining Invention

Fax machine, radio Personal computer, television

Latchkey kids, high divorce rate

Family

Traditional, nuclear

Disintegrating

Blended families

An incredible expense

Education

A dream

A birthright

A way to get there

Cautious, conservative, save, save, save

Put it away, pay cash

Money

Buy now, pay later

Earn to spend

Source: Adapted from a compilation by “FutureWorkplace” found in The 2020Workplace by Meister, J. andWillyerd, K., 2010. NewYork: HarperCollins. Copyright 2010 by Jeanne C. Meister and KarieWillyerd.

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Millennials

Background There are 80 million millennials in the United States, and they are the largest age group in American history. 8 Even with the 2008 recession, millennials are picky about work and do not take a job just to have one.According to a study conducted by Monster.com and Millennial Branding in 2013, only 26 percent of millennials would stay with their current employer and 55 percent viewed their current employers as temporary or a stepping stone in their careers. 9 Work style and preferences Millennials are technologically savvy.They grew up with personal computers and used the Internet for the majority of their lives.A majority also use social media on a daily basis.Their major trait includes instant gratification.According to a National Institutes of Health study, 40 percent of millennials believe they should be promoted every two years, regardless of work performance. Working with different generations Millennials seek mentorship to grow in their careers. Managers and supervisors can combine daily or weekly challenges with constant feedback and recognition to engage employees in this group and increase their productivity. 11 Background Gen Xers are known as the latchkey kids who found themselves at home alone or taking care of siblings because both of their parents were working.As a result, Gen Xers grew up to be independent. The prime wealth-building period of Gen Xers was affected by the 2008 recession.Without much wealth to begin with, they lost 45 percent of it—an average of about $33, 000. 12 Due to this lower net worth and downward mobility in retirement, Gen Xers are the cohort least likely to exceed the wealth of baby boomers. 13 Work style and preferences About 77 percent of Gen Xers will pursue working for an employer that offers increased intellectual stimulation. 14 To engage this group, managers and supervisors need to present new and challenging projects since Gen Xers want to gain new skills and advance their careers.To support employees of this group, managers and supervisors can provide immediate and thoughtful feedback. Gen Xers value flexibility and freedom in the workplace.According to a Catalyst study in 2001, among Gen Xers, 51 percent of females and 37 percent of males are willing to leave their current position for a job that allows telecommuting, and 61 percent of females and 45 percent of males would leave their current employer for a company that offers flexible work hours. Working with different generations Having lived in an era when corporations were failing and laying off employees, Gen Xers are mistrustful of institutions and authority and therefore cautious about investing in working relationships with their employers. 15 Generation X

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation

Baby Boomers

Background The 2008 recession had a detrimental effect on baby boomer’s retirement accounts; individuals aged 55–64 lost 25 percent of their savings. 16 As a result, baby boomers are remaining in the workforce longer than the previous generation.According to the Employee Benefit Research Institute, many in this generation may need to work up to 13 more years to recover from their losses. Organizations can entice this group with retirement-oriented benefits such as a 401(k) plan and medical insurance. 17 They can also continue to motivate and retain this group by offering flexible work hours or more vacation time. 18 Work style and preferences Baby boomers have a strong work ethic, superior communication skills and are emotionally mature. 19 They are also dedicated, loyal and committed to their organizations and professional accomplishments. In the workplace, baby boomers communicate effectively in informal settings and respond best during group meetings or in places where open dialogue is encouraged. 20 Working with different generations Baby boomers are currently leading companies and different generations in the workplace.Their management style is fairly authoritarian.To better motivate Generation X and millennial employees, baby boomers can incorporate an approach that is encouraging and supportive. 21 Background Traditionalists grew up during wartime and postwar periods.They witnessed their parents struggle to make ends meet during the Great Depression of the 1930s. Having lived and adapted to an environment of scarcity, they became financially prudent and value job security.A majority of traditionalists also served in the military during the first and secondWorldWars.Therefore, it is no surprise that they prefer leadership styles that follow a top-down chain of command in the workplace. Work style and preferences Traditionalists bring institutional experience and wisdom to the workplace. 22 With a work ethic described as “command and control,” this generation respects the hierarchical structure of the organization and follows rules.To leverage traditionalists’ strengths, leaders should clearly identify their roles and tasks in the organization. Unlike the other generations, this cohort prefers written forms of communication and tends to be uncomfortable communicating through the use of technology. 23 Working with different generations Traditionalists are loyal to their employers and consider their jobs a lifetime career.They respect authority and follow the rules and chain of command in the workplace.Traditionalists also honor professional seniority and believe that individuals should pay their dues to advance their career. Traditionalists

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Managing an IntergenerationalWorkforce: Strategies for Health Care Transformation