2023 Physician Enterprise Clinical Standards and Variation Reduction Annual Report

Physician Enterprise

Clinical Standards and Variation Reduction CY23 PORTFOLIO

Contents Our Work 8 What We Do

10 Learning Opportunities: Building Knowledge-Based Expertise

9 Clinical Workgroups

12 Our Partners

4 Welcome: A Note from Our Leadership

14 By the Numbers

Our Focus Areas Addressing Race as a Factor in Clinical Calculators 20 Evidenced-Based Guidelines Diagnosis of Chronic Kidney Disease 22 Cancer Screening 24 Screening and Treatment of Hepatitis C 26 Screening and Management of Depression in Adults and Adolescents page 28 Medical Management of Obesity in Adults 32 Management of Heart Failure 34

Health Equity and Mitigation of Disparity

Emerging Needs in Public Health Physician & Advanced Practice Provider (APP) Suicide Awareness 40 Firearm Injury Prevention 42

Guidance on Primary Prevention through Vaccination 2023 Vaccine Guidelines for Ambulatory Patients 44

Pediatric and Adolescent Medicine Pediatric Ambulatory Collaborative 46

Culture of Engagement & Well-being 48

LGBTQ+ Clinical Care Initiative 36

Recognition 54 2023 Academic Excellence Awards

Our Future 56 A Look Ahead to 2024

Our Team 58 Clinical Standards & Variation Reduction

Find Our Work 62 Key Resources

To contact us, see page 61.

A Note From Our Leadership

Welcome As we embark on a new year, we are excited to report on our journey as the Clinical Standards and Variation Reduction Team in 2023.

Our unwavering commitment to providing evidence-based care with kindness and humanity remains at the forefront of our work. We recognize the profound impact of evidence-based care in managing acute and chronic conditions — reducing disability, morbidity, and mortality for our patients. This work provides patients the gift of more quality time with their loved ones — a mission that aligns us with the mission of CommonSpirit Health.

The work of Clinical Standards and Variation Reduction resides at the intersection of quality, safety, evidence-based care, and kindness.

practice providers whose dedication and partnership in implementing this work fuels our ongoing journey toward excellence. Together, we are positively impacting the future of clinical care at CommonSpirit.

Our experience has shown that physicians, APPs, and other team members feel engaged in creating clinical guidelines when asked for their clinical voice and guidance, as they feel recognized and purposeful. This sense of purpose and recognition has a direct impact on clinical teams by unlocking feelings of engagement, mastery, professional fulfillment, and well-being.

Said another way, we are collectively building an ecosystem — weaving purpose, belonging, recognition, and clinical voice with evidence-based care, kindness, and humanity into the fabric of CommonSpirit every day, with every interaction, and for every patient.

We are inspired and grateful for the meaningful partnerships we have cultivated. The achievements highlighted in this portfolio stand as a testament to the collective dedication of our valued partners and collaborators. A special appreciation goes to our physicians and advanced

“

We are collectively building an ecosystem — weaving purpose, belonging, recognition, and clinical voice with evidence-based care, kindness, and humanity into the fabric of CommonSpirit Health every day, with every interaction, and for every patient.

”

4 | CommonSpirit Clinical Standards & Variation Reduction

It is a privilege to be a part of this extraordinary team and the larger CommonSpirit family.

With immense gratitude and excitement,

Thomas McGinn, MD, MPH, MACP System Executive Vice President Physician Enterprise

Gary Greensweig, DO, FAAFP System Senior Vice President Chief Physician Executive Physician Enterprise

Ankita Sagar, MD, MPH, FACP System Vice President Clinical Standards & Variation Reduction Physician Enterprise

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Our Work CY23 PORTFOLIO

6 | CommonSpirit Clinical Standards & Variation Reduction

Table of Contents | 7

CY23 PORTFOLIO

What We Do

Our Focus Areas

Learning Health System

Addressing Race as a Factor in Clinical Calculators 20

Our Work Clinical Standards and Variation Reduction (CSVR) focuses on elevating the use of evidence-based medicine across the Physician Enterprise and CommonSpirit Health.

Our aim is to accelerate the standardization of clinical care pathways where there is a notable evolution of evidence-based practice, denovo transformation in diagnosis and management, or an identified need for response to emerging diseases or clinical evidence.

Building Knowledge Base and Expertise

Evidenced-Based Guidelines Diagnosis of Chronic Kidney Disease 22

(People + Process)

Cancer Screening 24 Guidelines or Standard of Care

Data Analysis (Process)

EMR Interface (Platform)

Screening and Treatment of Hepatitis C 26 Screening and Management of Depression in Adults and Adolescents page 28 Medical Management of Obesity in Adults 32 Management of Heart Failure 34

FOUR MAIN COMPONENTS OF CLINICAL CARE INITIATIVES Evidence-Based Clinical Guidelines: A simplified and agreed upon standard of care that is informed by existing, updated, or new guidance set forth by professional societies.

Electronic Health Record (EHR) Interface: Leveraging the EMR as a tool to reinforce standards of care or the clinical guidelines for seamless practice integration.

Building Knowledge Base and Expertise: Improve clinical knowledge and expertise through CME learning opportunities such as Physician Enterprise Grand Rounds, Lunch & Learns, learning communities, and cohort programs.

Data Analytics: Use vetted data to assess needs, monitor performance, and plan improvements for new and existing initiatives.

Health Equity and Mitigation of Disparity

CLINICAL WORKGROUPS Our clinical workgroups are composed of physician and advanced practice provider subject matter experts, as well as a combination of clinical, academic, and regional leadership (as applicable). They are an integral part of reviewing existing evidence, weighing updates to best practice, and producing succinct guidelines for our clinical teams across CommonSpirit. Clinical workgroups are developed as necessary and with a self-limited life cycle.

To date, we have initiated and maintained 22 clinical workgroups informed by membership across the CommonSpirit footprint.

FEEDBACK “I appreciated the opportunity to add my expertise as a non-MD level provider.”

LGBTQ+ Clinical Care Initiative 36

Emerging Needs in Public Health Physician & Advanced Practice Provider (APP) Suicide Awareness 40 Firearm Injury Prevention 42

Guidance on Primary Prevention through Vaccination 2023 Vaccine Guidelines for Ambulatory Patients 44

Pediatric and Adolescent Medicine Pediatric Ambulatory Collaborative 46

Culture of Engagement & Well-being 48

“I appreciated the frequent collaboration and iteration on our efforts.”

8 | CommonSpirit Clinical Standards & Variation Reduction

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CY23 PORTFOLIO

Learning Opportunities: Building Knowledge-Based Expertise Our Work The Physician Enterprise Grand Rounds, Lunch & Learn sessions, and 5-Minute Check In with Dr. McGinn recordings provide learning opportunities for all CommonSpirit Health clinical teams and administrative leaders. Our goal is to deliver important organizational and clinical news as well as providing expert insight on relevant publications and breaking clinical topics. Dissemination of latest evidence-based data is part of the focus of our team within Clinical Standards. We often leverage events to bring these updates to our clinical teams.

We offer both Continuing Medical Education (CME) and American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) credits for Grand Rounds and Lunch & Learn attendees.

Lunch & Learns In support of physicians and advanced practice providers (APPs) screening for and managing the treatment of adolescent patients with behavioral health disorders, Clinical Standards & Variation Reduction in partnership with the Pediatric Ambulatory Collaborative hosted a series of interactive virtual Lunch & Learns focused on the management of behavioral health disorders. This series is available for all to view.

LUNCH & LEARN RESOURCES Watch Physician Enterprise Lunch & Learn recordings

5-Minute Check In with Dr. McGinn In this ongoing short video series, Dr. Thomas McGinn, EVP Physician Enterprise, shares relevant organizational news and information as well as insight from guest academic experts discussing recent research and groundbreaking studies that impact patient care and clinical practices.

5-MINUTE CHECK IN RESOURCES Watch 5-Minute Check In recordings

Grand Rounds As part of this educational series, Dr. Thomas McGinn, Dr. Gary Greensweig, and Dr. Ankita Sagar bring together clinical and academic experts to discuss relevant clinical topics ranging from innovations in cancer care to the impacts of climate change and health care burden.

GRAND ROUNDS RESOURCES Learn more about earning enduring credit Watch Physician Enterprise Grand Rounds recordings Share suggestions for topics to be highlighted at future Grand Rounds

10 | CommonSpirit Clinical Standards & Variation Reduction

FEEDBACK FROM GRAND ROUNDS ATTENDEES

“I share the YouTube links for Grand Rounds with colleagues as much as possible. The information, collaboration and feeling of community and common interest is invaluable and should not be missed. Thank you!”

“I love the detailed answers provided by the experts at the end of the webinar. They provide very practical solutions and insights that I would not have otherwise gleaned from medical journals.”

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OUR WORK

CY23 PORTFOLIO

Clinical Standards and Variation Reduction partners with subject matter experts across the CommonSpirit Health ministry to build consensus for standard of care.

Our Partners ADMINISTRATIVE AND SUBJECT MATTER EXPERT COLLABORATORS

● 12

Northwest ▲ 17

● 22 Central ▲ 12

Baylor College of Medicine Creighton University School of Medicine

System ● 15

Morehouse School of Medicine Virginia Mason Franciscan Health

Advanced Practice Leadership Council (APLC) Ambulatory Care Pharmacy Services Ambulatory Quality & Patient Experience Business Intelligence Data Solutions CommonSpirit Health Office of Diversity, Equity, Inclusion & Belonging (ODEIB) CommonSpirit Health LGBTQ+ Steering Committee CommonSpirit Health Research Institute CommonSpirit Health Oncology Clinical Institute

West ● 10 ▲ 15

Communications & Marketing Team Dignity Health Medical Foundation Dignity Health St. Mary Medical Center, CARE Center Enterprise Consulting Group Medical Informatics Population Health Physician Enterprise Core Leadership Physician Enterprise Executive Team (PEET) Regional CMO Leaders

12 | CommonSpirit Clinical Standards & Variation Reduction

●1 Mountain ▲ 3 The Mountain Region joined us in 2023.

We look forward to partnering more with them in 2024 and beyond.

●7 South ▲ 9 ● Grand Rounds Presenter or Panelist ▲ Clinical Workgroups

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CY23 PORTFOLIO

Clinical Workgroups Clinical Collaborators by Specialty 3 Behavioral Health 1

Breast Surgery

4 2

Child and Adolescent Psychiatry

Colorectal Surgery

3 Endocrinology 6 Family Medicine 4 1

Gynecologic Oncology

1

Hepatology

2023 By the Numbers

Gastroenterology

3 Infectious Diseases 6 Internal Medicine 2

Our Work

LGBTQ+ Health

5 Obesity Medicine 3 Oncology

The Clinical Standards and Variation Reduction team identifies high-priority clinical areas and utilizes evidence to formulate consensus based on our subject matter expert review. We call this our CommonSpirit Health standard of care. We frequently leverage collaboration opportunities with CommonSpirit’s clinical institutes and regions to make adoption and adaptation a reality.

1

Pediatrics

1

Physical Medicine & Rehabilitation

5 Psychiatry 1

Pulmonary Medicine

1

Thoracic Surgery

1

Transplant Hepatology

Academic Affiliation Baylor

Guidelines Generated Through Clinical Workgroups

Grand Rounds

5 Minute Check-In with Dr. McGinn

Sharing of insight from internal subject matter experts related to clinical standards

Bimonthly, online education sessions on timely topics

Ongoing short video series sharing relevant clinical and organizational news

14 | CommonSpirit Clinical Standards & Variation Reduction

Creighton

Credentials DO

APP MSW/LICSW/LCSW

4 8

PharmD

16

2

2 2

MSN, RN (non APP) 1

4

38

MD

VMFH Continued on next page.

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2023 BY THE NUMBERS

CY23 PORTFOLIO

Grand Rounds

5-Minute Check In with Dr. McGinn Total Views

Clinical Collaborators by Specialty 2

Advocacy

2

Cardiology

2

Colorectal Surgery

2

Diversity, Equity, Inclusion

4 1

18,801 views

General Surgery

1

Hematology

2

Nephrology

1

Neurology

1

Hospital Medicine

ID

9,529 4

views

3

Internal Medicine

1 0.0

Primary Care

views

Public Policy YouTube Views for CY23

Pulmonology 1.0

2.0

3.0

4.0

CME credit offered

Oncology

Palliative Care

21

Pediatrics

Pharmacy

5

Psychiatry

5

Radiology

credits

Pulmonology Thoracic Surgery

20,160

FEEDBACK

“Keeps me up-to-date on current best practices and trends.”

YouTube Views , Podcast Downloads, Google Drive Downloads

CME/MOC credits offered for Grand Rounds in CY23

Academic Affiliation (if any) Baylor

Post Grand Rounds Survey Data Do these clinical updates change the way you care for patients?

84% said yes (320 responses)

5 15

4

Ob/Gyn

3

1

GI

Live Views

4

1

19

Number of 5-Minute Check Ins with Dr. McGinn for CY23

Infectious Disease

1

1

Endocrinology

1,066

Hepatology

5

2

1

2 Misc

6 2

COVID

YouTube Views for CY23

Family Medicine

1

1

1

Endocrinology

Ethics

2

Episodes by Topic

How likely are you to recommend these Grand Rounds to others?

Creighton

Learn More You can watch or listen to current and past 5-Minute Check In with Dr. McGinn episodes and Grand Rounds Sessions on our YouTube playlist or our podcast homepage.

84% rated a 5 (Scale of 1 to 5; 325 responses) 10 VMFH

How relevant are these topics to your practice?

90% rated a 4 or 5 (Scale of 1 to 5; 325 responses) 16 | CommonSpirit Clinical Standards & Variation Reduction

*Scale of 1 to 5; 325 responses Table of Contents | 17

Our Focus Areas CY23 PORTFOLIO

18 | CommonSpirit Clinical Standards & Variation Reduction

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UPDATED IN

2023

OUR FOCUS AREAS

Addressing Race as a Factor in Clinical Calculators Our Focus Areas: Healthy Disparity & Equity In 2022, the Clinical Standards and Variation Reduction team launched an initiative to address clinical calculators which includes race as a coefficient, as identified by Vyas et al. in Hidden in Plain Sight and reports of the Ways and Means Committee Report of the US Senate.

THE WHY The pursuit of health equity is driven by CommonSpirit Health’s commitment to justice — in health care, social, economic, environmental, and public policy arenas. We recognize the health disparities that currently exist and the various systemic and structural inequities that impact the well-being of individuals, families, and communities.

SUMMARY OF FINDINGS Findings of our review can be found in the insights report.

• Estimated Glomerular Filtration Rate (eGFR): Updated guidance from NFK-ASN has been implemented across CommonSpirit (see page 21 for more details) • NCI Breast Cancer Risk Assessment Tool (GAIL Model): Updated guidance from the American Society of Clinical Oncology (See page 23 for more details) • Pulmonary Function Testing: Updated guidance from the American Thoracic Society (ATS) Given the updated recommendation from ATS, Pulmonary Function Testing (PFT) is no longer recommended for use in clinical management decision making. Our team is partnering with medical leadership, pulmonary medicine experts, and clinical engineering experts to complete an environmental scan and identify the next steps in transitioning PFTs to race a neutral calculator across the System. Watch for details coming in 2024.

Access the 2023 Insight Report here.

20 | CommonSpirit Clinical Standards & Variation Reduction

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Dr. Alisahah Jackson; Dr. Andrew Rubenstein; Dr. Angie Coscio; Dr. Anita Chandrasena; Dr. Ankita Sagar; Courtney Nanney; Dr. Dodji Modjinou; Dr. Gary Greensweig; John Kniesche; Kelvin Polk; Dr. Melissa Kaptik; Dr. Paige Harwell; Dr. Parthassarathy Raguram; Dr. Peter Silberstein; Dr. Quynh Le; Dr. Rajat Walia; Dr. Ronald Gagliano; Rachael Lytle; Rob Hoffman; Dr. Robert Wiebe; Dr. Sarika Savajiyani; Dr. Shankar Raman; Dr. Suchitra Pilli; Dr. Thomas Vendegna; Dr. Venketraman Sahasranaman; CommonSpirit Health Office of Diversity Equity Inclusion and Belonging; CommonSpirit Health Lab Teams; and Physician Enterprise leadership.

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CONTINUED IN

2023

Transitioning to 2021 CKD-EPI Estimated Glomerular Filtration Rate (eGFR) Equation Our Focus Areas: Evidence-Based Guidelines Our Clinical Standards and Variation Reduction team leveraged the Institute for Healthcare Improvement’s continuous quality improvement process by identifying partner teams and drivers of change, as well as tracking and communicating progress and key information to clinical and operational teams.

OUR FOCUS AREAS

Partner teams included experts across CommonSpirit Health

Primary Care

Nephrology Pathology

Medical Informatics

Office of Diversity, Equity, Inclusion, and Belonging

Lab Information Services

Communications Clinical and Executive Leadership Team

THE WHY The calculator to diagnose chronic kidney disease, known as eGFR, has been updated due to inherent disparity for patients of African American versus non-African American descent. The National Kidney Foundation and the American Society of

In May 2023, CommonSpirit became one of the largest health systems to transition all 140 facilities to the updated eGFR equation. In addition, the following supporting actions were completed:

Nephrology recommended this change more than three years ago. Yet, implementation in health care systems is challenging.

• Hosted multiple CME events for physicians and advanced practice providers reviewing reason and need for change • Amended eGFR laboratory reports to communicate change, including date of change • Hosted CMO meetings and town halls for administrative leaders to learn about change

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Anjali Jones; Arlene Pynadath; Akshat Karambe; Gaye Woods; John Kniesche; Karen Smith; Dr. Khalid Bashir; Lakshmi Sasidharanpillai; Max Wells; Monica Kallenberg; Nathan Tait; Dr. Nathan Ziegler; Dr. Nicholas Dietz; Dr. Poonam Sharma; Rachael Lytle; Dr. Robert Wiebe; Rosalyn Carpenter; and Dr. Vino Raj.

22 | CommonSpirit Clinical Standards & Variation Reduction

• Hosted town hall discussing the change with community-based partners, including patient groups • Communicated with external laboratory organizations to ensure change is reflected in their calculation • Collaborated with Office of Diversity, Equity, Inclusion and Belonging to engage with community members

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NEW

OUR FOCUS AREAS

IN 2023

Cancer Screenings Based on Risk Stratification

The Why

Our Focus Areas: Evidence-Based Guidelines Our vision is simple: Every primary care visit has enhanced access to patientspecific, risk-based cancer screening guidelines and recommendations based on the patient’s previous screenings and unique risk factors.

There is a growing body of evidence pointing to a risk-based stratification prior to determining appropriate screening modality and screening intervals for patients. Our multiphase initiative began with the dissemination of updated screening algorithms for breast, colorectal, and lung cancers. The guidelines are a combination of the US Preventive Services Task Force (USPSTF) age-based screening guidelines and the National Comprehensive Cancer Network (NCCN) risk-based screening guidelines.

PHYSICIAN ENTERPRISE GRAND ROUNDS

LUNG CANCER

BREAST CANCER

COLORECTAL CANCER

Leading cause of cancer death in US

Second leading cause of cancer death in US

Third leading cause of cancer death in US

Most common cancer diagnosis in US

Estimated to result in 43,170 deaths in 2023 (7% of all cancer deaths)

Estimated to result in 52,550 deaths in 2023 (8% of all cancer deaths)

Estimated to result in 127,070 deaths in 2023 (20% of all cancer deaths)

Breast Cancer Clinical Standards and Variation Reduction partnered with several teams, including primary care, pulmonary medicine, colorectal surgery, thoracic surgery and the CommonSpirit Health Oncology Clinical Institute in the development of these guidelines.

The next phase of this initiative involves leveraging “bot technology” to support enhanced EHR experience and efficiency for clinical teams and patients by highlighting pending cancer screening opportunities based on updated guidelines. We look forward to further our collaboration our partners, including teams such as medical informatics, information technology applications and software engineering, and clinical leaders.

24 | CommonSpirit Clinical Standards & Variation Reduction

Watch on Drive Watch on YouTube Listen as a Podcast

ACKNOWLEDGMENTS

Colorectal Cancer

We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Dr. Ankita Sagar; Anne Wright, DMSc, MPAS, PA-C, DFAAPA; Dr. Claire Hoppenot; Dr. Colleen O’Kelly Priddy; Dr. Devi Mukkai Krishnamurty; Dr. Gary Greensweig; Dr. Jessica Croley; Jessica Stanley MSN, FNP-BC; Dr. Julie Nangia; Dr. Kavita Chawla; Dr. Kimberly Bates; Lise Langston, PharmD; Marcia Gruber-Page, MSN, MS, RN; Dr. Melissa Gerdes; Dr. Misho Hubka; Dr. Paige Harwell; Dr. Peter Bigler; Dr. Peter Eby; Dr. Peter Emanuel; Dr. Suchitra Pilli; Rachael Lytle, RN, MSN, CPHQ; Dr. Ronald Gagliano; and the Clinical Standards Variation Reduction Steering Committee members.

Watch on Drive Watch on YouTube Listen as a Podcast

Lung Cancer

ACCESS GUIDELINES

Watch on Drive

All Guidelines

Watch on YouTube

Breast Cancer

Listen as a Podcast

Colorectal Cancer Lung Cancer

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NEW

OUR FOCUS AREAS

IN 2023

Screening and Treatment of Hepatitis C 25%

Our Focus Areas: Evidence-Based Guidelines The Physician Enterprise has adopted the guidance of the US Preventive Services Task Force (USPSTF) and the American Association for the Study of Liver Diseases – Infectious Diseases Society of America (AASLD–IDSA) to standardize our approach to curing Hepatitis C.

THE WHY

• Screening: The USPSTF recommends screening all average– risk patients ages 18–79 years for Hepatitis C at least once in their lifetime.

• Treatment: The AASLD-IDSA guidelines provide simple 8-12 week treatment options, including a daily dose of Glecaprevir 300mg/Pibrentasvir 120mg for 8 weeks OR Sofosbuvir 400 mg/Velpatasvir 100 mg for 12 weeks.

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Dr. Alan Sheinbaum; Dr. Ankita Sagar; Dr. Blaire Burman; Dr. Chia Wang; Dr. Gary Greensweig; Dr. Johnathan Zhang; Dr. Justin Reynolds; Dr. Manasa Velagapudi; Rachael Lytle; Dr. Rima El-Herte; Dr. Saira Aijaz Khaderi and Dr. Thomas McGinn. Additionally, our gratitude to Dr. Alisahah Jackson; Boomie Harvey, DNP, RN-BC; Chris Furler; Delana Henderson; Erin Sharp, PharmD; Dr. Erine Erickson; Greg Light, PharmD; Hannah Byrnes-Enoch; Dr. Jesse Singer; Dr. Joel Ward; John Ralston; Martha Koepke; Marty Koepke; Dr. Nicholas Stine; Nisha Pasupuleti; Reena John; Dr. Mark Goodman; and Ryan Crowdis for partnering in this work.

26 | CommonSpirit Clinical Standards & Variation Reduction

3.9 million people

The eradication of

4% develop

hepatocellular carcinoma

Hepatitis C is a national and global public health goal.

In the US, between 2.7 and 3.9 million persons are infected with the Hepatitis C virus.

Clinical Standards and Variation Reduction partnered with primary care, infectious disease, and gastroenterology experts in the development of these simplified guidelines. They are focused on two main tenets:

develop cirrhosis

Hepatitis C affects

Untreated hepatitis can lead to cirrhosis (5-25% of patients) and hepatocellular carcinoma (4% of patients).

With the advent of oral medical treatment, Hepatitis C is curable. .............................

HEPATITIS C PRIMARY CARE LEARNING COMMUNITIES Clinical Standards and Variation learning communities for physicians and APP champions who are interested in strengthening their knowledge in the management of uncomplicated Hepatitis C in Primary Care.

Topics include case-based approach to treatment, complications; tips on successful coverage of medications; and interdisciplinary approach to Hepatitis C management.

We are recruiting for the next session that will begin

PATIENT-FACING EDUCATION:

• Resources for patient education

Hepatitis C patient education brochures are

• Updated order sets into the EMR

National Catalog. Find ordering instructions at

• Updated screening in clinician-facing EMR alerts • Primary Care Learning Community to enhance training in managing Hepatitis C

Access Guidelines here

Reduction is hosting monthly virtual

in May 2024!

Beyond the guidelines, our team has collated multiple resources, including:

GUIDELINES ALGORITHM Hepatitis C Treatment Algorithm here

RESOURCES Project ECHO Enrollment CommonSpirit Health Specialty Pharmacy Primary Care Testimonial

PHYSICIAN ENTERPRISE GRAND ROUNDS Watch on Drive Watch on YouTube Listen as a Podcast See Presentation

available in four brand identities via the Print+ the links below or by contacting your regional Marketing and Communications leader.

LINKS Hepatitis C Screening Brochure Creative: Connected Sites Unconnected Sites — Mountain Region

If you would like to join our team or have suggestions for future projects, we encourage you to reach out to ClinicalStandards@ commonspirit.org.

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NEW

OUR FOCUS AREAS

IN 2023

Depression Screening and Management Our Focus Areas: Evidence-Based Guidelines Timely screening and subsequent management of depression can save lives. All patients 12 years of age and older should be screened annually for major depressive disorder.

THE WHY Depressive disorders are estimated to be the third leading cause of disability worldwide. In the United States, the estimated lifetime risk of a person experiencing

In support of the FY24 Ambulatory Continuum of Care Enterprise Goal of Depression Screening, Clinical Standards and Variation Reduction partnered with Ambulatory Quality, Primary Care, Ambulatory Pharmacy, and Behavioral Health to provide simplified guidelines and EMR tools for the screening and treatment of adolescent and adult patients.

INTENDED AUDIENCE FOR GUIDELINES: Physicians and advanced practice providers in Pediatrics, Primary Care and Family Medicine

a major depressive episode now approaches 30%. The incidence of suicide, which is associated with a diagnosis of depression more than 50% of the time, has been increasing and is the tenth leading cause of death in the US (NIH, 2023).

SOURCE US Preventative Task Force (USPSTF) (Adolescent and Adult), American College of Physicians (ACP), GLAD-PC Toolkit

Continued on page 30.

28 | CommonSpirit Clinical Standards & Variation Reduction

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DEPRESSION SCREENING AND MANAGEMENT

OUR FOCUS AREAS

Current Performance: Ambulatory Quality Goal Trend

STAFF AND PROVIDER RESOURCES Ambulatory Quality: Screening and Management Resource Folder

80

Cumulative Current Month

70

64.6% 64.6%

65% 64.6%

65.7% 65.3%

66.4% 65.7%

67.1% 66.3%

68.1%

67.6% 66.6% 64.1%

70.1% 70.1%

69%

71.3% 72%

72.3% 72.7%

PEDIATRIC COLLABORATIVE CARE PROGRAMS The National Network of Child Psychiatry Access Programs (NNCPAP) offers real-time access to a multidisciplinary network of mental health experts in your state, including child psychiatrists, peer-to-peer consults, vetted and personalized referrals and resources, and in some cases behavioral health CMEs. Learn more about your local NNCPAP program here.

68.2% 66.9%

May

July

Watch on Drive Listen as a Podcast

60 March

Pediatric Depression Management: Watch on YouTube

64.1% Jan.

PHYSICIAN ENTERPRISE GRAND ROUNDS

Sept.

Nov.

MANAGEMENT OF PATIENTS WITH SUICIDAL THOUGHTS Clinic Management Columbia Suicide Severity Rating Scale (Paper Version)

Represents patients seen through December 2023

ASQ Suicide Risk Screening Tool for Adolescents

Adult Depression Management: Watch on Drive Watch on YouTube Listen as a Podcast

Suicidality

ELECTRONIC HEALTH RECORD OPTIMIZATION EHR optimizations are underway for EPIC, Cerner, Allscripts, and eClinical Works to align:

Screenings Performed:

Improvement Over Baseline

265,00+

10%

Enterprise-Wide Screening Rate

72.3%

Watch on Drive Watch on YouTube Listen as a Podcast

PHQ 2 ➜ PHQ 9 Trigger Variation PHQA Trigger Screening for Adolescents

Data Source: Ambulatory Quality (Debra Rockman, RN, MBA, CPHRM, CPHQ, System Vice President Ambulatory Quality; and Kelly Bitonio, BSN, MHA, NEA-BC, CPHQ, System Director of Ambulatory Quality Services)

ACKNOWLEDGMENTS

GUIDELINES • Adult Depression Screening and Management • Pediatric Depression Screening and Management

30 | CommonSpirit Clinical Standards & Variation Reduction

We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Ambulatory Quality team and especially Debra Rockman, RN, MBA, CPHRM, CPHQ, System Vice President of Ambulatory Quality, and Kelly Bitonio, BSN, MHA, NEA-BC, CPHQ, System Director of Ambulatory Quality. Pediatric Guideline: Andrew Trindle; Christopher Schenk; Colin Walker; Debra Rockman; Delana Henderson; Dr. Erine Erickson; Dr. Gary Greensweig; Dr. Greg Light; Jennifer Stanley; John Kniesche; John Ralston; Dr. Jonathan DeHaan; Jennifer Stanley; Dr. Jose Arciniega; Dr. Jyotsna Ranga; Katie Froehlich; Dr. Karl Zeff; Kelley Green; Kelly Bitonio; Kim Hurley; Dr. Kyle Benner; Dr. Laurel L. Williams; Lee Ann Mingus; Marty Koepke; Dr. Michael Dudas; Dr. Michael Schooff; Nate Jackson; Dr. Nicholas Jansson; Dr. Monique Diaz; Dr. Pamela Davis; Paul Rains; Dr. Peter Valenzuela; Rachael Lytle; Rise Hancock; Russelyn Cruse; Salvacion Nance Quimosing; Dr. Scott Piazza; Shannon Miller; Dr. Sufen Chiu; Dr. Thomas Coburn; Dr. Thomas March; Dr. Thomas McGinn; Tracey Hunn; Dr. William A. Kehoe; Dr. Yuchen Wang and the Clinical Standards Steering Committee members.

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NEW

OUR FOCUS AREAS

IN 2023

Medical Management of Obesity in Adults Our Focus Areas: Evidence-Based Guidelines In response to the innovation of new pharmacotherapeutic agents, the popularization of their use, and the significant need to assist patients in treatment of obesity, the Physician Enterprise at CommonSpirit Health developed detailed guidelines for the indications and initiation of pharmacotherapy for treatment of obesity in adult patients. ................

These guidelines address the indications and initiation of pharmacological therapy for patients with obesity and rely on current evidence regarding the efficacy and suitability of pharmacotherapy. Lifestyle changes, dietary modification, and exercise/physical training are the fundamental approaches to weight loss. Pharmacotherapy in conjunction with lifestyle changes can provide an optimal treatment regimen for the appropriate patient candidate.

GUIDELINES

5-MINUTE CHECK IN WITH DR. MCGINN

Access guidelines here.

Watch on Drive | Watch on YouTube | Listen as Podcast

THE WHY

ALGORITHM

In 2021, obesity was prevalent in 40% of adults

Access Obesity Management Algorithm here.

GRAND ROUNDS Watch on YouTube | Listen as Podcast

aged 20 to 39 years, 44% of adults aged 40 to 59 years, and 42% among adults aged 60 and older (CDC). Furthermore, the estimated annual medical cost of obesity in the United States was nearly $173 billion in 2019 dollars (Farhana et al).

32 | CommonSpirit Clinical Standards & Variation Reduction

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Dr. Anila Chadha; Dr. Ankita Sagar; Dr. Brandon Auerbach; Erin Sharp, PharmD; Ezimma Nnyagu, PharmD; Dr. Gary Greensweig; Greg Light, PharmD; Dr. Kadapalakere Reddy; Dr. Kristopher Dunbrack; Dr. Krystal Tamura; Dr. Layla Abushamat; Dr. Mahmuda Tasneem; Rachael Lyte, RN, MSN, CPHQ; Dr. Suhani Bhakta; Thu Le, PharmD, BCGP, BCACP, APh and Dr. Toni Terry.

Table of Contents | 33

NEW

OUR FOCUS AREAS

IN 2023

Management of Heart Failure

How often, if at all, do you manage patients with a new or existing diagnosis of heart failure?

Our Focus Areas: Evidence-Based Guidelines In FY2024, CommonSpirit Health implemented a heart failure mortality goal. This goal aspires to reduce inpatient heart failure deaths. Given that patients experience heart failure and seek treatment across a continuum of care (from ED to hospital to ambulatory), primary care teams play an important role in the management of heart failure.

Clinical Standards and Variation Reduction conducted an environmental scan to understand the perspectives and experiences of primary care physicians and APPs in the management of heart failure patients. This survey highlighted areas of need and focus for future work in improving heart failure treatment among our patients in primary care.

We learned that 50% of primary care providers surveyed are managing heart failure patients in their practice, compared to 19% who refer their patients to a cardiac specialist as primary lead in management. Across the survey responses, the need for knowledge enhancement was highlighted, particularly in the following areas:

The next phase of this initiative is to organize opportunities for learning across PE. Thus, a series of CME events are planned. Physical Enterprise and CommonSpirit acute care partners will host several CME learning events in 2024.

Very Rarely | 5.8%

Never | 2.9% Rarely

UPCOMING CME LEARNING EVENTS

Feb. 2, 2024

9.8%

Advancements in Understanding the Pathophysiology of Heart Failure

33.3%

Very Frequently

16.7%

Frequently

Feb. 16, 2024 Advancements in Medical Therapy for Heart Failure

31.4%

March 1, 2024

Occasionally

THE WHY

Advancements in non-Medical Therapy for Heart Failure

The American Heart Association has reported that 50% of

Rank your confidence in various aspects of managing heart failure in your patients.

patients diagnosed with Heart Failure

35

die within five years.

30

Recent advances in medical and

Very Confident

25

Fairly Confident

Somewhat Confident

Slightly Confident

Not Confident

Behavioral Health Disorders in Heart Failure

Patient/family/ caregiver engagement

20 15

surgical therapies

10

have changed

5

the outcomes for

0 Diagnostic modalities and interpretation of results

patients with heart failure (HF).

Medication management of Heart Failure

Complexity of managing co-morbidities (i.e. CKD, DM)

Initiating/ escalating/ or continuing Heart Failure quad therapy

Patient/family discussion and referral to palliative care or hospice for end stage heart failure

• Review of most recent heart failure guidelines • Latest changes in medication management of heart failure

Rank the helpfulness of the following CME topics.

• Review of the management of complex co-morbidities (i.e. chronic kidney disease, diabetes mellitus) • Review of diagnostic modalities and interpretation of results This topic is under planning for initiatives and implementation in 2024.

Very Helpful

Fairly Helpful

Somewhat Helpful

Slightly Helpful

Not Helpful

50 40 30 20

ACKNOWLEDGMENTS

10

We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Anne Wright; Janet Holdych; Dr. John Morelli; Laurie Jenson; Dr. Melissa Gerdes and Clinical Standard and Variation Reduction Steering Committee.

0

34 | CommonSpirit Clinical Standards & Variation Reduction

Review of most recent heart failure guidelines

Update on latest changes in medication management of heart failure

Review of the management of co-morbidities

Review of diagnostic modalities and interpretation of results Table of Contents | 35

NEW

OUR FOCUS AREAS

IN 2023

Primary Driver Performed a needs assessment to identify knowledge gaps and confidence of primary care physician APPs in comprehensive primary care for LGBTQ+ patients

LGBTQ+ Clinical Care Initiative

Secondary Driver:

Our Focus Areas: Health Equity & Mitigation of Disparity CommonSpirit Health LGBTQ+ Steering Committee and the Physician Enterprise are committed to improving access to evidence-based medical care for patients identifying as members of the LGBTQ+ community. Based on this commitment and in response to a comprehensive needs assessment and clinician interest, CommonSpirit Health has launched the LGBTQ+ Clinical Care Initiative.

Building fundamental knowledge of primary care physicians and APPs

THE WHY Patients who identify as members of LGBTQ+ community have historically faced marginalization, discrimination, and inequity due to systemic bias in health care. Their clinical needs are both unique and specific and can been addressed in patientcentered primary care.

Traditionally, undergraduate and graduate medical

Goal: Improve access to comprehensive primary care for LGBTQ+ patients at CommonSpirit Health

education does not cover Physician Enterprise Grand Rounds (Sept. 8, 2023) Watch on Drive Watch on YouTube Listen as a Podcast

Offered opportunities for training for all primary care physicians and APPs on the best practices for clinical interviewing for patients

Secondary Driver: Designing an inclusive encounter (from appointment scheduling through postvisit follow up)

there is progress more recently there is a knowledge gap identified among practicing primary care physicians and advanced practice providers.

Completed interviews with existing LGBTQ+ primary care programs to identify best practices

Created a longitudinal case-based curriculum for primary care physicians and APPs

topics related to LGBTQ+ health in great depth. While

Organized an LGBTQ+ Clinical Advisory Committee with representation from primary care, system leadership, and Office of Diversity

Medical and non-medical staff training on basic tenets of equity and inclusion, especially for LGBTQ+ patients (in progress)

Host meetings with clinical and operations teams for the primary care clinical teams (in progress)

Create a central repository of resources hosted via intranetaccessible to clinical and non-clinical employees (in progress) Continued on next page.

36 | CommonSpirit Clinical Standards & Variation Reduction

Table of Contents | 37

LGBTQ+ CLINICAL CARE INITIATIVE

“

OUR FOCUS AREAS

I hope that one day, all clinicians including myself can be comfortable taking care of this patient population the same way we care for any other patient population.

”

SPECIAL DESIGNATION IN COMPREHENSIVE PRIMARY CARE FOR MEMBERS OF LGBTQ+ COMMUNITY This is a yearlong program that will train a cohort of primary care physicians and APPs on comprehensive medical care for patients who identify as the members of LGBTQ+ community. Learn more about the LGBTQ+ Special Designation program. The next training session will launch in September 2024.

RELATED WORK AND RESOURCES

If you would like to join our team or have suggestions for future projects, we encourage you to reach out to ClinicalStandards@ commonspirit.org.

Healthcare Equality Index (HEI)

LIVE-IN PERSON TRAINING (SEPT. 15) See recordings This live-in person training was hosted in Sacramento, California, on Sept. 15, 2023. Organized by Clinical Standards and Variation Reduction and sponsored by the LGBTQ+ National Steering Committee, the training included 34 physicians and APPs learners, featuring topics including:

• 2022 HEI Assessment CommonSpirit Health California Hospitals

• Trauma Informed Interview

• Learn more about the CommonSpirit Health 2024 Health Equity Index Assessments

• Primary Care: Cancer Screenings, Cardiovascular Disease screenings • Transgender Specific Primary Care Needs + Considerations • Reproductive + Sexual Health Needs + Considerations

ACKNOWLEDGMENTS

• Behavioral Health Needs + Considerations

We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Abby Lloyd-Sabin; Anjali Jones; Dr. Ankita Sagar (Executive Sponsor); Brooke Burgess; Dr. Christopher Swales (Medical Director); Cristina Harris; DeEtte Montgomery; Dr. Gary Greensweig (Executive Sponsor); Dr. J. Bianca Roberts; John Kniesche; Joshua Lumsden, PA-C; Kevin Murphy; Marcia Alcouloumre; Dr. Marie President; Mary Beth TeSelle; Paul Lovely; Rachael Lyte, RN, MSN, CPHQ; Dr. Seema Kochhar; Sheila Stinson and Shelly Schlenker.

• Implicit Bias Training: An Interactive Session and Discussion

38 | CommonSpirit Clinical Standards & Variation Reduction

Upon completion of the in-person training, 14 physicians and APPs went on to continue towards LGBTQ+ Primary Care Special Designation.

Table of Contents | 39

CONTINUED IN

2023

OUR FOCUS AREAS

Physician and Advanced Practice Provider Suicide

The updated language states:

Our Focus Areas: Emerging Needs in Public Health In 2022 and 2023, CommonSpirit Health was a supporting organization for National Physician Suicide Awareness Day, thus committing to shedding light on the physician and APP suicide epidemic and rallying physicians, APPs, their peers, and families to establish a well-being-centric atmosphere.

CommonSpirit maintained its commitment to NPSA Day in 2023.

The Physician Enterprise and National Physician Engagement Council partnered with medical staff leadership across CommonSpirit to remove barriers and stigmatizing language from credentialing applications across our ministry for physicians, APPs and Allied Health Professions (AHPs). This work closely intertwines with the work underway for well-being and professional fulfillment within Physician Enterprise.

If you know someone in crisis, please call or text the 988 Suicide and Crisis Lifeline at 988. You can also contact the Crisis Text Line (text HELLO to 741741).

Both services provide 24-hour, confidential support to anyone in suicidal crisis or emotional distress.

THE WHY Suicide is the 12th leading cause of death in the US (AFSP).

Among physicians and Advanced Practice Providers (APPs), the numbers are sobering: Every year, nearly 400 physicians die by suicide. That is the equivalent of approximately one physician or APP dying by suicide every day (Center et. al.).

Male physicians are at 1.41 times greater risk than the general population, while female physicians are at 2.27 times greater risk than the general population (Schernhammer et. al.).

40 | CommonSpirit Clinical Standards & Variation Reduction

“Because we value the importance of well-being, appropriate treatment and support for all health conditions, we have provided a list of resources at the end of this application. Do you have any health condition which would, In any way, compromise your ability to perform the essential functions of the position and/or privileges for which your qualifications are being evaluated in accordance with accepted standards of professional performance, with or without reasonable accommodations?

If you answer yes, please tell us what accommodation has been made.”

This change in language is in line with best practices in accordance with the Federation of State Medical Boards, Institute for Healthcare Improvement, American College of Physicians. This language also exists in several state medical licensing applications, including about half of those within the CommonSpirit ministry. The change will be instituted on a rolling basis as more facilities are brought into the single CommonSpirit credentialing application.

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Dr. Anita Chandrasena; Dr. Barbara Martin; Candy Hall; Dr. Greg Anderson; Dr. Kim Moore; Dr. Matthew Kodsi; Dr. Robert Wiebe; Dr. Ronael Eckman; and Suzan Konell.

JOIN THE COMMITTEE If you would like to join the Physician Enterprise Physician and APP Well-being and Fulfillment Committee, please complete an interest form.

RESOURCES Access All Suicide Prevention Resources here

For Leaders: These toolkits are an important leadership step in reviewing how to prepare team actions and protocols in the event of an attempted or completed suicide. These resources have been provided the American Federation for Suicide Prevention, American Medical Association and Mayo Clinic.

• Learn the Vital Signs • Conversation Starters • Understanding the Barriers to Access Help • *New Resource* After a Suicide A Toolkit for Medical Schools, Residency/Fellowship Programs:

For Individuals: • Learn the Vital Signs • Personal Crisis Management Plan • *New Resource* External Resources for Crisis, Peer Support, Burnout, and Substance Dependence Table of Contents | 41

UPDATED IN

2023

OUR FOCUS AREAS

Firearm Injury Prevention

The Why

In 2022, the US experienced a total of 48,117 deaths due to firearms, with suicide deaths related to firearm injury outweighing homicide deaths. Suicide deaths caused by firearms reached an all-time high at 7.65 per 100,000 (CDC).

Our Focus Areas: Emerging Needs in Public Health The exorbitant toll of firearm injuries and deaths affects the victims, survivors, loved ones, communities, and our teams.

CommonSpirit Health’s CEO, Wright Lassiter III, is among a growing list of health care CEOs who have joined the National Health Care CEO Council on Gun Violence Prevention and Safety, reinforcing the commitment of CommonSpirit to violence prevention and safety.

Physician Enterprise partnered closely with Laura Krausa, MNM, System Director for Advocacy Programs, CommonSpirit Health. Laura leads several programs across CommonSpirit related to community-based violence prevention, bringing significant expertise as a key partner in this discovery process.

A large part of our focus has been to create dialogue and inclusion with patients and community members in order to create more open and earnest dialogue focused on safety and the common good. We explored several ways in which CommonSpirit can make an impact on promotion of firearm safety by promotion of safe storage techniques, screening for firearm exposure, and community-based firearm safety and violence prevention efforts.

If you would like to join our team or have suggestions for future projects, we encourage you to reach out to ClinicalStandards@ commonspirit.org.

Access the most recent Physician Enterprise Insights Report for details regarding ongoing initiatives.

RESOURCES

• CDC Firearm Violence and Injury Prevention Basics • End Family Fire Videos • Safe Firearm Storage for Suicide Prevention

Among children aged 0-17, there were 1,262 unintentional firearm injury deaths (CDC).

• Project Child Safe

• 33% of these deaths were among children aged 11–15 years

• Intimate Partner Violence Prevention

• 29% among those deaths were among children aged 0–5 years

• Suicide Prevention

• Firearms used in unintentional injury deaths were often stored loaded (74%) and unlocked (76%) and were most commonly accessed from nightstands and other sleeping areas (30%)

Physician Enterprise Grand Rounds

• 67% of shooters were playing with or showing the firearm to others when it discharged

Firearms became the leading cause of death among children ages 1 to 19 years old - taking the lives of 4,357 children far surpassing motor vehicle deaths and other injuries (KFF).

CDC Information on Prevention Strategies • Adverse Childhood Experiences Prevention

• Youth Violence Prevention

• Part I: Firearms Safety and Injury Prevention • Part II: Advocacy and Mitigating Firearm Violence in Our Communities

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Laura Krausa; Shelly Schlenker; Physician Enterprise Leadership Team and Physician Enterprise Medical Group Leaders.

42 | CommonSpirit Clinical Standards & Variation Reduction

• 30% of child deaths by firearm were suicides • 5% were unintentional or undetermined accidents

Table of Contents | 43

UPDATED IN

2023

OUR FOCUS AREAS

2023 Vaccine Guidelines for Ambulatory Patients Our Focus Areas: Vaccinations Clinical Standards and Variation Reduction, in partnership with experts in infectious disease and pharmacy, provided simplified guidance for immunizations against common respiratory viruses such as COVID-19, influenza, pneumococcal, and Respiratory Syncytial Virus (RSV).

These guidelines are based on the latest recommendation from the Centers of Disease Control and Prevention (CDC).

THE WHY Respiratory viruses are the most frequent causative agents of disease in humans, with significant impact on morbidity and mortality worldwide. Common respiratory agents from several virus families are well adapted to efficient person-to-person transmission.

Vaccines against respiratory viruses can reduce harm for persons of all ages. It is important that providers remain up to date on the most recent vaccine recommendations.

GUIDELINES Access simplified vaccine recommendations here.

RESOURCES Recommended resources from the CDC that are routinely updated: CDC Vaccine Schedules App (all vaccine schedules from CDC) CDC Catchup Schedule (for missed doses)

ACKNOWLEDGMENTS

Immunization Schedules (based on the vaccine type, age, comorbidities)

We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Greg Light, PharmD, System Director, Ambulatory Care Pharmacy Services; Patrick N. Ellis, PharmD, System Director, Pharmacy Clinical and Procurement Services; Roy Boukidjian, MSN, CIC, NE-BC, FAPIC, CPPS, Interim System Patient Safety Officer; and Brooke Burgess, System Director, Communications.

5-MINUTE CHECK IN WITH DR. MCGINN Fall Viruses and Vaccination: What to Expect for COVID-19, Flu and RSV this year

44 | CommonSpirit Clinical Standards & Variation Reduction

Table of Contents | 45

UPDATED IN

2023

OUR FOCUS AREAS

Pediatric Ambulatory Collaborative Our Focus Areas: Pediatric and Adolescent Medicine In 2023, the Pediatric Ambulatory Collaborative focused primarily on pediatric mental health in the form of: lunch and learns, enterprise-wide clinical grand rounds, and the development of diagnosis and treatment guidelines for pediatric depression, aimed to help primary care providers better address the mental health needs of their pediatric patients.

The Collaborative continued to focus on the challenges in pediatric ambulatory care (e.g. patient portal and adolescent confidentiality, ACEs, obesity epidemic) emerging issues impacting pediatric health (RSV prevention, opioid epidemic), and providing expertise to organizational goals (firearm injuries).

If you would like to join our team or have suggestions for future projects, we encourage you to reach out to ClinicalStandards@ commonspirit.org.

THE WHY The Pediatric Ambulatory Collaborative was established in 2021 to address particular challenges faced by pediatricians in the management of chronic illnesses in the ambulatory setting.

Chaired by Dr. Michael Dudas, Chief of Pediatrics at Virginia Mason Franciscan Health, the group consists of dedicated CommonSpirit pediatricians and family practice providers who are committed to creating “healthy adults” under the rubric of pediatric roots of adult diseases.

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Michael Dudas, MD; Lilia Parra-Roide, MD; Scott Piazza, DO; Jill Walsh, MD; Mary Beth Burrell; Sara Faheem, MD; and Megan Babb, DO. 46 | CommonSpirit Clinical Standards & Variation Reduction

Table of Contents | 47

OUR FOCUS AREAS

THE WHY In 2023, the Physician Enterprise was awarded grant funding for a three-year term from the CommonSpirit Health Mission and Ministry Fund’s Community Health and Well-Being Program Grant. The goal of the Transformative Well-Being and Professional Fulfillment Initiative for Physicians and Advanced Practice Providers is to create a thriving health system with an organizational cultural and clinical practice environment that fosters physician and advanced practice provider (APP) well-being and professional fulfillment focused on purpose, belonging, recognition, and voice.

Physician and APP Well-Being and Professional Fulfillment Committee

Physician Enterprise Provider Engagement and Experience Council

Building a Culture of Engagement and Well-Being

CO-CHAIRS: Dr. Greg Anderson Dr. Gary Greensweig John Kniesche Building a Sense of Community and Connectedness

Our Focus Areas: Our Physicians and APPs The Physician and APP Well-Being and Professional Fulfillment Committee provides the framework for interventions that local markets and sites can adopt or adapt to fit their individual needs and resources. This committee is a champion for best practice interventions based on the Mayo Clinic and Stanford Models, the AMA Joy in Medicine Program, and those endorsed by the Surgeon General.

Well-Being and Professional Fulfillment CO-CHAIRS:

If you would like to join our team or have suggestions for future projects, we encourage you to reach out to john.kniesche@ commonspirit.org and haley. uustal@commonspirit.org.

Optimizing Clinical Care Delivery

CO-CHAIRS: Dr. Amy Brockmeyer Danielle Vandergriff

CO-CHAIRS: Dr. Anne Wright Dr. Marijka Grey

Dr. Barbara Martin Dr. Ankita Sagar Dr. Greg Anderson Dr. Gary Greensweig John Kniesche Peer Support and Coaching

CO-CHAIRS: Dr. Deanne Nyland Heather Chambers

Continued on next page.

48 | CommonSpirit Clinical Standards & Variation Reduction

Table of Contents | 49

BUILDING A CULTURE OF ENGAGEMENT AND WELL-BEING

OUR FOCUS AREAS

Transformative Well-being and Professional Fulfillment Initiative for Physicians and Advanced Practice Providers

The APP score, specifically, experienced the most significant improvement over the last year, moving from 3.22 to 3.47 on the overall composite score.

Building community and connectedness program is modeled after the CAFE model and is intended to support organizational values and culture.

Initiatives Address These Areas 1) building community and connectedness, 2) optimizing the work environment of clinicians, and 3) peer support.

For more information please visit the Physician Enterprise Well-Being and Professional Fulfillment website.

Optimizing the clinical care delivery subcommittee will focus on workflows, efficiency, and resources to return autonomy to clinicians.

The peer support subcommittee is an essential component of the overall cultural change away from a culture of silence towards one of sharing and acceptance; away from a culture of expected perfectionism towards an acceptance of human fallibility; away from a culture of shame and blame and towards a culture of psychological safety.

Physician Enterprise Provider Experience Index Overall Physician & APP 4.0

Physicians

3.63

3.5

The program will allow scalable strategies that support physicians’ and APPs’ well-being, provide support for individuals in duress, and focus on organizational and system issues which can be changed to mitigate the drivers of burnout in the ministry.

Overall

3.52

APPs

3.63 3.50

3.58 3.47

3.41 3.30 3.22 3.0 2021

2022

2023

Composite Provider Engagement Score Measurement The Physician Enterprise Provider Experience Index consisted of a three question composite (shown here) that was asked over a three year period (results in graph on opposite page).

50 | CommonSpirit Clinical Standards & Variation Reduction

My hospital/clinic/ facility recognizes clinicians for excellent work.

My hospital/clinic/ facility is open and responsive to my input.

My hospital/clinic/ facility leadership team involves me in decisions that affect my work.

The Physician Enterprise will also continue to collect yearly data around the Mini Z burnout score, which measures providers’ burnout. Additionally, each of the members of the initiatives described above will complete a pre-initiative Mini Z survey as well as a mid-year follow-up survey to assess progress.

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and insights of various experts in making this work possible, including: Dr. Gregory Anderson; Dr. Barbara Martin; Dr. Amy Brockmeyer; Danielle Vandergriff; Dr. Anne Wright; Dr. Marijka Grey; Dr. Deanne Nyland; Heather Chambers; Chyela Rowe; Dr. Heathen Rabin; Dr. Bruce Nitsche; John Kniesche; and all of the members of the Physician Enterprise Physician and APP Engagement and Experience Council as well as the Subcommittee members of the Well-Being and Professional Fulfillment Committee.

Table of Contents | 51

[[section break here. Needs title & icon]] Recognition CY23 PORTFOLIO

52 | CommonSpirit Clinical Standards & Variation Reduction

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RECOGNITION 2023 ACADEMIC EXCELLENCE AWARDS

Physician Enterprise Vision Awards

The Academic Excellence category recognizes how we’re advancing the practice of medicine through key research or published studies. It was open to Physician Enterprise physicians and APPs across CommonSpirit Health, as well as full-time faculty at Baylor, Creighton and Morehouse School of Medicine.

Recognition

Criteria: • Awards were based on articles published in peer-reviewed journals between January 2022 and December 2022.

Manuscripts in “pre-print” status were accepted.

The annual CommonSpirit Health Physician Enterprise Vision Awards program is intended to recognize and celebrate clinical excellence throughout the Physician Enterprise. It was developed by a diverse and multidisciplinary Physician Enterprise team of regional and local voices passionate about recognition programs, including providers, HR, quality, transformation, and patient experience.

• Criteria for selection and award were based on the potential for the publication to have a direct, immediate, relevant, and high impact effect on clinical care delivery especially focused on how providers care for our patients and communities.

• There were four categories: clinical research, health disparities research or health equity research, medical humanities, and practice innovation or high-value care or quality improvement.

2023 Award Winners

...........................................................................

Anchored on the CommonSpirit Health vision statement,

A healthier future for all, inspired by faith, driven by innovation, and powered by our humanity

Category: Practice Innovation/High Value Care Article Title: A new dawn in internal medicine education curriculum - a project for the residents, with the residents, for the residents Institution: Creighton School of Medicine Corresponding Author: Dr. Moshin Mirza, MBBS Assistant Professor

there are six specific award categories:

Inspiration

Innovation

Compassion

Academic Excellence

Patient Experience

Quality

ACKNOWLEDGMENTS We greatly appreciate the invaluable contribution and publication expertise from the Academic Excellence Award Judges including Dr. Ankita Sagar; Dr. Bernard Khor; Dr. Corey Karlin-Zysman; Dr. Gary Greensweig; Dr. Ingrid Block-Kurbisch; Dr. Julian Mitton; Dr. Mark Heinsohn; Dr. Maulik Dhandha; Michael Carter; Nicole Schumacher; Dr. Nitika Thawani; Dr. Philip Louie; Dr. Rick Greco; Dr. Alisahah Jackson; Dr. John Flynn; Dr. Ashok Balasubramanyam; Dr. Maureen Tierne; and Dr. Joann Porter.

54 | CommonSpirit Clinical Standards & Variation Reduction

Category: Medical Humanities Article Title: Infectious Diseases Management in Wound Care Settings: Common Causative Organisms and Frequently Prescribed Antibiotics Institution: Baylor College of Medicine Lead Author: Yuriko Fukata, MD, PHD Assistant Professor.

Category: Practice Innovation/High Value Care Article Title: Clinical spotlight intervention to accelerate translation of evidence-based practices in primary care Institution: Virginia Mason Franciscan Health Lead Author: Kavita Chawla MD FACP MHA Internal Medicine Physician; Member of Clinical Standards and Variation Reduction Steering Committee

Category: Health Disparities Research Article Title: A Health System’s Approach to Using CBPR Principles with Multi-sector Collaboration to Design and Implement a COVID-19 Vaccine Outreach Program Institution: Physician Enterprise Lead Author: Brisa Urquieta de Hernandez, PhD - System Director, Health & Humankindness Operations Category: Clinical Research Article Title: Lifestyle Intervention Strategy to Treat Diabetes in Older Adults: A Randomized Controlled Trial Institution: Baylor College of Medicine Corresponding Author: Dennis T. Villareal, MD - Professor Category: Clinical Research Article Title: Homologous and Heterologous Covid-19 Booster Vaccinations Institution: Baylor College of Medicine Lead Author: Robert Atmar, MD - Professor

Table of Contents | 55

Our Future A Look Ahead to 2024 This year, the work for the Clinical Standards and Variation Reduction team has been immensely exciting and gratifying. As we look to 2024, the Clinical Standards and Variation Reduction Steering Committee and our team continues to explore opportunities focused on elevating the use of evidence-based medicine across CommonSpirit Health. Stay tuned for upcoming topics and projects!

TOPICS FROM 2023 THAT WILL CONTINUE TO BE ADDRESSED INCLUDE: • Cancer Screening • Depression Management • Hepatitis C Screening and Treatment (Primary Care Learning Communities) • LGBTQ+ Special Designation Program for Primary Care Focus Topics for 2024 • Screening and management of Osteoporosis • Improving management of Chronic Kidney Disease (early evaluation, treatment, referral) • Streamlining and improving Heart Failure management in ambulatory care • Best practices in approaching SDOH screening in ambulatory care • Standardizing cognitive screening in primary care The focus of the Clinical Standards and Variation Reduction team also includes the continued surveillance of and updates to previous guidelines that have been realized.

In this way, we hope to share updated reports (as applicable) for the focus areas completed in previous years.

56 | CommonSpirit CommonSpirit Clinical Clinical Standards Standards&&Variation VariationReduction Reduction

Table of Contents | 57

RECOGNITION

Our Team Our Team: Clinical Standards and Variation Reduction Led by the Physician Enterprise Clinical Standards and Variation Reduction Steering Committee, the purpose of this team is to focus on bringing evidence-based medicine to the patient-side in a more practical, feasible, and effective manner.

We often start our project planning with our “WHY.” Clinical Standards and Variation Reduction is focused on initiatives that improve the overall quality of life for patients, their families, and our communities. We believe evidence-based medicine can improve the outcomes for our patients, thus building trust and confidence in CommonSpirit Health and the Physician Enterprise.

We believe starting with this WHY naturally enhances the experience of our patients and the engagement of our physicians and advanced practice providers.

We identify high-priority clinical areas and utilize evidence-base to formulate consensus based on our subject matter expert review of evidence. We call this our CommonSpirit standard of care. We frequently leverage collaboration opportunities with CommonSpirit’s clinical institutes and regions to make adoption/adaptation a reality.

Gary Greensweig, DO, FAAFP | System SVP, Chief Physician Executive, Physician Enterprise “The management of chronic disease through evidence-based care helps patients live longer and be healthier, allowing them to reach their elder years with less disability, less assistive devices, and more quality time for life cycle celebrations with family and loved ones. What could be more purposeful than that? It’s at the core of what we do and our mission.”

Ankita Sagar, MD, MPH, FACP | System VP, Clinical Standards and Variation Reduction, Physician Enterprise “Guiding the development and implementation of evidence-based guidelines at CommonSpirit is both an honor and a humbling journey. Furthermore, seeing our teams unite to elevate care delivery is truly inspiring. It transcends individuals, roles, and teams — it is a collective commitment to making a meaningful impact to save lives.”

John Kniesche, MPH | System Director, Physician Enterprise Support Services, Physician Enterprise “The work of Clinical Standards and Variation Reduction leans on those physicians and APP experts who actually deliver the care, to dictate how a certain clinical guideline will be shaped. In order to be a high performing clinical enterprise, it is imperative that everything we do be driven from that clinical voice, first and foremost.”

Rachel Lytle, RN, MSN, CPHQ | System Director, Clinical Standards and Variation Reduction, Physician Enterprise “The work of Clinical Standards is important because we’re offering a needed support to clinicians who are working to provide the best care for their patients and communities served. Bringing forth simplified, best practice guidance helps keep the clinicians up-to-date on what’s best in patient care, which is so vitally important to daily clinical practice.”

At the end of the day, our work is about celebrating more birthdays, anniversaries, and time with loved ones; and avoiding downstream comorbidities and disabilities.

58 | CommonSpirit Clinical Standards & Variation Reduction

Abby Lloyd Sabin | Executive Coordinator, Physician Enterprise “The work of Clinical Standards and Variation Reduction not only brings evidencebased care to patients, assisting our providers in cutting through the noise of advancements — some of which may be questionable — to zero in on the truly effective adoptions, but also serves to provide a unity among the clinical teams across the enterprise.”

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RECOGNITION

Our Steering Committee

Our Steering Committee

Meet Our Team The Clinical Standards and Variation Reduction Steering Committee is composed of physicians, advanced practice providers (APPs), and administrative leaders with an interest in evidence-based practice, and those who represent a diversity of thought, training, and experiences. ................

The Steering Committee members are tasked with: • Identifying high-priority clinical areas based on visibility, variation, volume, and value • Identifying subject matter experts in clinical areas to create self-limited clinical workgroups • Providing feedback for the proposed Standards of Care by the respective workgroups • Championing the adoption or adaptation of newly developed CommonSpirit Standards of Care across the continuum of CommonSpirit Health and the Physician Enterprise

Collaboration and inclusion are central to the work we do.

We rely on subject matter experts and all of our colleagues to ensure we are meeting the needs of the clinical teams we serve.

• Ensuring alignment of the CommonSpirit Standards of Care with the overall vision and goals of the Physician Enterprise

FEEDBACK

Anne Wright, DMSc, MPAS, PA-C, DFAAPA | System Director, Advanced Practice Ambulatory Care, Physician Enterprise

John D. Chelico, MD, MA, FACP, FAMIA | System Chief Medical Information Officer, Physician Enterprise

Brooke Burgess | System Director, Communications, Physician Enterprise

Kavita Chawla, MD, MHA, FACP | Primary Care Physician, Kirkland Medical Center, Virginia Mason Franciscan Health

Corey Karlin-Zysman, MD, SFHM, FACP | System SVP, Southwest Division, Physician Enterprise

Mark Heinsohn, MD | Internal Medicine, Chattanooga, Tennessee

Debra Rockman, RN, MBA, CPHRM, CPHQ | System VP, Ambulatory Quality

Melissa Gerdes, MD, FAAFP, CHCQM | System VP, Value-Based Clinical Strategy, Population Health

Erine Erickson, MD | System VP, Medical Informatics

Randall Pritza, MD, MMM | System SVP, Midwest Region

Ian Vallely | Division CIO, Physician Enterprise

Robert Quinn, MD | President/CEO, Dignity Health Medical Foundation System SVP, West Division, Physician Enterprise

Joel Ward, DO | System VP, Medical Informatics and Clinical Analytics

Tracy Sklar, MS, MBA | System Senior Vice President Quality

CONTACT US To learn more about the work of the Clinical Standards and Variation Reduction team, please reach out to us: Dr. Ankita Sagar Ankita.Sagar@CommonSpirit.org

Dr. Gary Greensweig Gary.Greensweig@CommonSpirit.org

Rachael Lytle Rachael.Lytle@commonspirit.org

John Kniesche

John.Kniesche@CommonSpirit.org

Please feel free to reach us at ClinicalStandards@commonspirit.org or via the PE Resource Library.

60 | CommonSpirit Clinical Standards & Variation Reduction

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Find Our Work Key Resources The CommonSpirit Health Physician Enterprise Resource Library is a secure website built to provide key tools and resources for Physician Enterprise. Check out the Clinical Standards and Variation Reduction page for all available resources from this year as well as past years.

Find more than 600 resources

Discover programs, CME trainings, links to Grand Rounds and 5-Minute Check-Ins

Read enterprise news, success stories and employee spotlights

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Physician Enterprise Grand Rounds: Enduring Credit Physician Enterprise Grand Rounds are available for enduring credit. You can view them on the Baylor College of Medicine Clinician Resources page and claim CME credit for viewing the recording. This site is a learning and career development resource available to Baylor College of Medicine and partner institutions. This site is accessible via CommonSpirit Health single-sign on and free to all CommonSpirit physicians and APPs.

62 | CommonSpirit Clinical Standards & Variation Reduction

LINKS Check out the Clinical Standards and Variation Reduction page for all available resources from this year as well as past years.

Access Grand Rounds and Clinical Symposium content here This list provides links to all Grand Round sessions offered since the beginning of our program three years ago. The sessions that are available for enduring credit are identified with an asterisk.

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