THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXIV, No. 10
The Science of Culture A look inside health systems BY DANIEL K. ZISMER, PH.D.
L Restorative Justice Building relationships in academic medicine BY AMANDA M. TERMUHLEN, MD
hat are the barriers to my patients accessing care during a pandemic? How can we mentor students better? How do we approach colleagues following a hurtful exchange of words? The standard approach to addressing these questions is that someone, typically an authority figure, forms a task force or committee to discuss and make a decision, often without hearing from those impacted. An authority figure may impose sanctions, separating people, when it is decided that harm occurred. Processes and approaches based in restorative justice principles provide an alternative to sanctioning and separation. Restorative approaches build communication and relationships and allow the proactive building of culture, reparation of harm, or the reintegration of a person who has been separated from a community or group. Restorative Justice to page 104
et’s look at the “science of culture” in the embedded physician services organization of health systems. While trustees of health systems cannot be expected to understand all there is to know about the management and complexities of health services delivery, they can be expected to understand and be accountable for the culture of the organization served. But why are boards accountable for the culture of the health system? Isn’t that the job of management? Trustees of health systems are the keepers of the culture of the organization they serve. Our research demonstrates that the people of organizations (physicians and staff) believe “the culture of the organization is what the leaders want it to be.” The board is viewed as the ultimate authority of the organization, and by extension are the “leaders”. As such it is reasonable for the people of the organization to assume that the culture they experience is what the trustees’ want it to be. The balance of this article is presented as a “summary of the science”, our observations derived from the study of culture of physician services
The Science of Culture to page 124
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Volume XXXIV, Number 10
COVER FEATURES Restorative Justice Building relationships in academic medicine
By Amanda M. Termuhlen, MD
The Science of Culture A look inside health systems By Daniel K. Zismer, Ph.D.
DEPARTMENTS CAPSULES .................................................................................. 4 JAMES EHNES
Owen O’Neill, MD Infinite Health Collaborative
O S M O VÄ N S K Ä
Preserving independent practice
J U R A J VA L Č U H A
INTERVIEW .................................................................................. 8
PHARMACY................................................................................ 14 Minnesota’s Medical Cannabis Program A look back and a look ahead
By Nick Lehnertz, MD, MPH, MHS, and Peter Raeker, MA
Gary S. Schwartz, MD, MHA
SAR AH HICKS
Where Eye Care Fits In Bridging specialty and primary care
J E A N -Y V E S T H I B A U D E T
Please Note: Due to the COVID-19 impact on deadline schedules, this edition is published in the “flipbook” format.
Hosted by Sarah Hicks, Minnesota Orchestra’s concert season designed for TV, radio and streaming audiences continues with conductor Juraj Valčuha and violinist James Ehnes. Next, pianist Jean-Yves Thibaudet returns to the stage with Music Director Osmo Vänskä. MAR 5 · SOARING STRINGS MAR 19 · LAMENT AND BEAUT Y
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Watch on the TPT-MN channel, listen on Classical Minnesota Public Radio or stream at minnesotaorchestra.org/stream.
ART DIRECTOR______________________________________________________ Scotty Town, firstname.lastname@example.org Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email email@example.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.
PHOTOS Valčuha & Vänskä: Courtney Perry; Ehnes: Benjamin Ealovega; Thibaudet: Andrew Eccles; Hicks: Travis Anderson Photo.
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Essential Workers Emergency Leave Act Moves Forward A Minnesota House bill that would provide emergency paid leave for essential workers that they currently don’t receive is gaining momentum. The Essential Workers Emergency Leave Act, or HF41, chief authored by Rep. Cedrick Frazier (DFL-New Hope), would ensure that the frontline and essential workers during this pandemic are able to quarantine, care for a loved one with COVID, or care for a child who is distance learning without financial burden. So far 15 state representatives have signed on to support the bill. Among others, the bill is supported by the Minnesota Nurses Association, whose members, and many other essential workers were left out of other COVID-related leave bills passed by the federal government earlier in the pandemic. The Essential Workers
Emergency Leave Act would ensure they are able to quarantine safely and responsibly without dipping into their sick time, Paid Time Off (PTO) benefits, retirement savings, or going without pay entirely. “My family has been devastated during this pandemic,” said Nichole Whitney, a nurse at District One hospital in Faribault. “My three-year-old son was diagnosed with COVID. I had to stay home to care for him as well as not bring COVID to my hospital. But because it wasn’t me who was positive, we used up all my time off. We had to dip into savings to pay the bills.” Currently, nurses only qualify for Workers’ Compensation if they acquired the virus at work and test positive. Nurses are frequently exposed to the virus, and it is critical that they quarantine when exhibiting any symptoms. To ensure the safety and health of patients and the community, there are numerous instances
in which they quarantine without testing positive. In these circumstances, nurses are expected to use their own accrued PTO or sick time. In some cases, nurses have already spent down this benefit time and are forced to go without pay. “We’ve seen our own healthcare workers, our frontline in this pandemic, punished for being safe,” said MNA President Mary C. Turner, “Nurses aren’t covered if they wait for a COVID test or wait for the results to come back, or if they’re negative, but their family member is sick.” The bill would provide 100 hours of emergency paid leave to workers considered to be full time by their employer. This leave would cover nurses who have either been instructed to quarantine or exhibit symptoms while waiting for test results but later test negative. It would also cover caring for a family member that contracts COVID-19 or for childcare if their school is closed.
Essentia Acquires Catholic Health Initiative Hospitals Last month Essentia signed a letter of intent to bring 14 hospitals, now owned by Chicago-based CommonSpirit Health, a division of Catholic Health Initiatives (CHI), under its brand. Included in the agreement are 13 critical access hospitals, St. Alexis Medical Center, a full-service tertiary hospital in Bismarck, ND and all CHI associated clinics and living communities operated by CommonSpirit and CHI Health and Home homehealth and hospice services. Citing the important role that health care plays in keeping rural communities vibrant, a shared understanding will help ensure the long-term success of these facilities as the agreement moves forward. Essentia has an expanding presence providing access to comprehensive, integrated care in rural communities across
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North Dakota, Minnesota and Wisconsin. “CommonSpirit wants patients in this region to have access to a strong network of rural and tertiary hospitals, primary and specialty care, and telehealth services,” said Cliff Robertson, MD, senior vice president for CommonSpirit’s Midwest division. “Essentia Health is well-positioned to integrate these facilities into a continuum of care, while carrying on the Catholic heritage and mission of these facilities. We look forward to continuing our conversations.” From the Essentia side CEO David C. Herman, MD, said “This is an exciting opportunity to extend our passion for excellence in rural health care to additional communities,” We’re grateful that our shared Benedictine heritage and values form a strong foundation for our ongoing discussions. It would be an honor to carry on the rich tradition of high-quality Catholic health care evident today in these CHI facilities. Details of the transaction are scheduled for completion by this Summer.
New Statewide COVID-19 Vaccine Tracking Tool The Walz-Flanagan Administration has just launched a public vaccine data dashboard to detail the progress of COVID-19 vaccine allocation, distribution and administration across Minnesota. The dashboard, produced by Minnesota IT Services (MNIT) and the Minnesota Department of Health (MDH), provides a visual and user-friendly way to view key vaccination data for our state. The dashboard includes information on the number of doses promised (allocated) to the state by the federal government; shipped to Minnesota providers; and administered to Minnesotans. The dashboard will be updated daily. As the tool went live, the Centers for Disease Control and Prevention (CDC)
had promised 541,100 doses of COVID-19 to Minnesota. Of those doses, 329,450 have been shipped to providers in Minnesota along with 100,500 doses shipped to pharmacies participating in the Center for Disease Control and Prevention (CDC) Pharmacy Partnership Program for vaccination in long-term care settings. Once doses are promised by the federal government to states, it takes several days before those doses are actually shipped, so it can be a week or more before they actually arrive at their final destination and can be given to people. Vaccine is moving throughout the state, but the process takes time. The dashboard will help Minnesotans see where we are at by showing progress at different stages of the process. More than 320,000 Minnesotans have received at least one dose of vaccine. Over 85,000 people have completed their vaccination series. For currently available vaccines, a complete series is two doses of the same vaccine product separated by three or four weeks depending on the vaccine. These numbers are reflected in the dashboard.
Cuynua Regional Medical Center Recognized by MDH Cuyuna Regional Medical Center in Crosby was recently awarded Health Care Home Certification (HCH) by the Minnesota Department of Health recognizing its efforts to closely connect doctors, nurses and other clinicians with community resources to support whole-person care and facilitate the overarching goal of improving population health and well-being. The certification, completed at the end of 2020 by a virtual site inspection, is awarded for three years and verifies that the clinic has met a set of rigorous standards to provide patient and family-centered care and is working to improve the
Compassionate, Comprehensive, & Personalized care for adult and pediatric patients with neurological conditions, including:
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Sciatica Neuromuscular Disease Muscular Dystrophy Dizziness Numbness Stroke Multiple Sclerosis ALS And other neurological disorders
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MINNESOTA PHYSICIAN JANUARY 2021
overall quality and affordability of health care. HCH Certification is a free and voluntary program provided to primary clinics and organizations by the MDH. The HCH model focuses on linking primary care with wellness, prevention, self-management and community resources. Studies involving patients in health care home programs have 40 percent fewer emergency department visits and 25 percent fewer hospital admissions. “We are proud to offer our patients a certified health care home when it comes to their care,” said CRMC’s Executive Director of Primary Care and Population Health Kelly Chase, R.N. “A health care home means patients are receiving comprehensive and coordinated care led by a team of health care professionals centered around their unique needs.” In CRMC’s health care home, a Registered Nurse care manager leads the team approach
to develop a close relationship with patients and their families to better understand their medical needs, coordinate care and achieve better health. This includes streamlining access to appointments, improving communication with physicians, answering questions and planning care. “Health care home makes it easier for patients to communicate and partner with their care team,” Chase explained. “We want patients to feel empowered to take responsibility for their health in partnership with their care team.”
Summit Orthopedics Announces New Site Summit Orthopedics, an independent practice with 50 orthopedic specialists and 125 supporting providers recently announced expanding its south metro footprint. Summit employs over 800 people at 25
locations throughout Minnesota and is in the planning and development stages to open another state-of-theart orthopedic care clinic, in the city of Lakeville. The undeveloped site just off I-35 and Kenwood Trail was strategically chosen by Summit’s leadership team with help from Excelsior Advisory, a local real estate consulting firm. A commercial boom in recent years has been driving residential growth in the area, which has created a demand for specialty care clinics to support the rapidly expanding community. “Developed to meet the orthopedic needs of the growing south metro community,” says Dr. Robert Anderson, orthopedic hand surgeon and president of Summit Orthopedics, “our new Lakeville location will deliver convenient care that is personal by design. No matter what your goals are for a healthier, more active lifestyle, we are here to support you.”
The 25,000-square-foot building will offer patients advanced subspecialty orthopedic, sports, and spine care, as well as walk-in orthopedic urgent care through the OrthoQUICK clinic, with plans to be open seven days a week, from 8:00 a.m. to 8:00 p.m. Additionally, it will be home to a procedure suite for therapeutic joint injections, regenerative medicine, imaging services (MRI/X-ray), and physical and hand therapy. Pope Architects is heading architectural design, and MSP Commercial has signed on as developer, owner, and property manage. Base building construction is scheduled to start in just a few months with Summit Orthopedics expecting to treat their first patients in the new clinic in January of 2022.
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Preserving independent practice Owen O’Neill, MD Infinite Health Collaborative Please tell us about Infinite Health Collaborative (i-Health).
Please tell us about Revo Health and the services it provides for i-Health physician groups.
Revo Health, a management services organization, helps practices develop valuebased care services and provides support across several departments often referred to as “back of house.” These include revenue cycle, finance and accounting, human resources, information technology, quality, marketing, and more. Sharing these resources creates efficiencies and cost savings, fosters collaboration, and consolidates our expertise. Revo takes care of the business side, so physicians can focus on taking care of patients. What kind of framework for growth and sustainability of independent physician practices does i-Health provide?
There’s power in numbers. By banding together, we preserve our independence and strengthen our voice in the industry. These days, many small practices are getting squeezed out or bought up by large systems, and transition to becoming employed by the system. i-Health is physician-owned and led, however, so every new physician to join becomes a fellow partner and retains ownership stake in the business. Another major advantage for our operating divisions is
JANUARY 2021 MINNESOTA PHYSICIAN
We believe “...” patient-physician relationships are the heartbeat of health care.
We like to say that i-Health is a modern approach to a timeless idea. We’re an independent practice of like-minded physicians representing several unique specialties, including cardiology, colon and rectal conditions, family medicine, orthopedics, and women’s health. All of us believe that independence in health care enables physicians to focus on each patient’s individual goals without limitations, and that’s the inspiration behind i-Health. By empowering patient choice—arming patients with the tools to make their own educated health care decisions—we are earning their trust and keeping health care personal. In a nutshell, we deliver value-based care, enable physician autonomy, and preserve patient choice.
example, OB-GYN specialists from our women’s health operating division launched curbside obstetric care in response to COVID-19, performing routine checkup tests that cannot be done virtually: blood pressure, baby’s heartbeat, position of the baby, and vaccines. Similarly, Twin Cities Orthopedics (TCO) launched virtual care in under seven days, going from zero telemedicine infrastructure to providing over 1,000 virtual care visits per week. The best part is we did so without sacrificing the patient experience. Niney-nine percent of TCO’s virtual care patients say they would recommend this service to family and friends.
collaborative learning. Innovative operational initiatives such as developing prospective care bundles and collecting outcomes data takes time to develop. We’ve all experienced different stages of growing pains, so we help each other avoid re-inventing the wheel. How can independent physicians be the drivers of the industry’s improvement?
We believe patient-physician relationships are the heartbeat of health care, and we intend to keep it that way. Independent physicians have autonomy to guide patients without the limitations of larger systems, and ultimately enable patients to make their own educated health care decisions. Getting back to basics and putting the power back in patient’s hands is how we believe the industry moves forward. What are some examples of how independent physician practice contributes to innovation in the health care industry?
Our independence enables us to mobilize and test new ideas quickly without the red tape of many larger systems. In the past couple of months, for
What can you tell recent medical school graduates about the opportunities and benefits presented by the independent practice of medicine?
Our model, which centers around the patientphysician relationship, is the original health care model. Many physicians are attracted to independent practice because it reminds them why they got into medicine in the first place. i-Health provides immediate and long-term financial stability, and independence puts you in control of your own destiny. By building a strong reputation, and delivering exceptional care day in and day out, the sky’s the limit to your potential. What are some of the ways i-Health members encourage patients to be active participants in their health care decisions?
It sounds so simple to do this, but it’s not our job to tell patients what to do. We encourage patients to be in control of their own health, and it’s our job to guide patients to make the best decisions for themselves. We accomplish this by clearly explaining diagnoses, walking them through options, listening to their concerns, and answering their questions. We also use anonymous clinical outcomes data from over one million survey submissions to set realistic expectations. For example, we can tell patients considering a hip replacement that six months after surgery, 97.93% of total hip arthroplasty patients reported little to no pain lying in bed and turning over.
What benefits can i-Health provide to self-insured employers?
It’s amazing how many employers are simply unaware of the freedoms they have when it comes to customizing their benefits plans. For example, they can partner with us tomorrow to give their employees more surgical care options and better outcomes via our TCO EXCEL Surgery & Recovery program, without changing anything else about their existing plan. It’s a simple add-on model, and the best part is it actually reduces costs across the board. In fact, some local employers have already identified i-Health as a preferred tier inside of their health plans, effectively encouraging their employees/patients to consider value-based care options. New health care legislation is informed by considerable input from health plans, hospitals, and the pharmaceutical industry, but very little from physicians. How can i-Health help address this inequity?
This is a big reason why we were inspired to band together in the first place: to grow our shared voice in the industry. A voice that is focused on patient care and the delivery of innovation in the market. We deliver value-based care, which means we have actual
data to prove how we can improve outcomes and patient satisfaction, while also reducing costs. We’re putting the data to good use in these conversations. What can you tell independent physicians who may want to become part of i-Health?
We live and succeed on our own reputation, and often take the road less traveled, which isn’t for everyone. We were founded upon the promise that no matter what, the care of our patients would always come first. It’s in our DNA, and it’s what drives us every single day. The freedom we are granted as an independent practice allows us to be innovative, create meaningful solutions to complex problems, and deliver on that fundamental promise. And, ultimately, it’s how we provide value. If your core motivation as a health care provider aligns with our core principles, and you share our vision for the future of value-based care, then we would love to get to know you better.
seen many patients suffering as a result of elective surgery restrictions. We have observed increased opioid drug use and suicide attempts from patients dealing with severe pain and immobility, in addition to prolonged pain leading to poor long-term outcomes. Prolonged waiting causes stress physically, mentally, emotionally, and financially. Treatment for many of these patients was initially categorized as elective or non-essential when the COVID-19 pandemic began. The good news is that we have developed comprehensive safety protocols that have enabled us to perform more surgeries in a safe, COVID-free environment within ambulatory surgery centers. We are using a clinical risk stratification tool to determine which surgeries can be performed first, we’re testing patients and employees for the virus, we’re screening at entrances, and much more. Our patients and their families have high expectations for their care, and we want our safety standards to exceed those expectations.
The recent government response to cancel “elective” surgeries brings up several important issues. What are your thoughts
Owen O’Neill, MD, is a board-certified orthopedic
in sports medicine. He is a board member for both Infinite
On the orthopedics side in particular, we have
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9 8/6/20 11:15 AM
3Restorative Justice from cover
reintegrate students sanctioned by suspension back into school. Restorative practices are trauma-informed and can break the cycle of harm, separation, distrust, and more harm.
If the goal of academic medicine is to heal, whether by discovery of new knowledge, caring for those with illnesses, teaching the next generation Not all harmful situations are appropriate for a restorative approach. of healers, or providing accessible and equitable care for Minnesota If someone does not acknowledge they committed communities, can academic medicine improve a harm, refuses to participate in a restorative its ability to heal by incorporating restorative practice, or if potential participants in a circle wish practices into the work? This is the question to dispute a sanction and debate the facts of an posed by the Association of American Medical incident, restorative practices are not appropriate. Colleges (AAMC) who selected the University A restorative practice does not obviate the need of Minnesota Medical School as one of seven Restorative practices can for a sanctioning process and, in fact, could be colleges of medicine across the country to train a be used to improve culture. used in conjunction with sanctioning. cohort of faculty and staff members in restorative justice approaches. What is actually involved in doing a
What is the history of restorative practices and restorative justice? Restorative approaches are not new. They are deeply rooted in many Indigenous cultures, including the Ojibwe and Navajo people of North America and the Maori people of New Zealand. The term “restorative justice” emerged in the 1970s in the United States criminal justice system as a way to bring victims and those causing harm together to repair harm and rebuild relationships. Eventually, the restorative justice processes involved others impacted by the trauma or event, including families, friends, and the community. Restorative justice then expanded into other realms, particularly education, to address discipline issues and
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Many may be familiar with circle processes. Restorative circles are good for addressing issues of culture, including examining the accessibility of a clinic or exploring how to build a better mentoring program. For a restorative justice circle, there is extensive planning ahead of time. The facilitators thoroughly prepare by interviewing the participants beforehand, planning out ways for participants to connect and talk about the impacts, proposing how to build trust and community, and finally, proposing some actions for participants in the circle. Once the circle is formed and agreements around the conduct of the circle are established, the facilitators ask a series of questions that each participant answers in turn and uninterrupted. When meeting in person, a circle would involve a talking piece, an object of significance to the group or facilitators that is passed between participants and held by those speaking. A talking piece promotes respect and equity of voice. On remote platforms, the facilitators establish a way of designating whose turn it is to speak. Participants are encouraged to listen deeply and tell their own stories. Circles are built on a foundation of respect, integrity, fairness, and confidentiality. A concept that resonated with me is that participants should “take the learning, not the stories.” Rounds of questions eventually lead to the understanding of themes and then action items, if desired. Sometimes, circles are designed for exploring the understanding and impact of an external event and not to determine action items.
Why did the University of Minnesota Medical School do this pilot program?
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Excellence in all mission areas of the U of M Medical School is based on integrity, inclusion, and teams being able to work effectively together and with communities. The focus of restorative practices is to build relationships with each other as participants, repair relationships that may have been damaged, and promote healing if relationships were harmed or build community. Restorative practices can be used to improve culture, repair harm around a specific event or action, and reintegrate a person who has been separated from their work or learning environment. The goal of the U of M Medical School’s participation for the pilot program was to explore how restorative practices could be used to improve culture across all mission areas. Restorative Justice to page 244
Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers David Schultz, MD Chief Executive Officer Nura Pain Clinics
1. Chronic pain doesn’t take holidays. Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.
2. Opioids are a problem. They can also be part of the solution. According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side eﬀects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability oﬀ ered by implanted spinal drug pumps, many of the most challenging cases can be treated eﬀectively without risk of addiction.
Our thoughts on chronic pain…
3. There is no silver bullet. One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn oﬀ their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we oﬀer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.
If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.
Edina & Coon Rapids | nuraclinics.com | 763-537-1000 ©2020 Nura PA. All rights reserved.
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3The Science of Culture from cover
teams in organizations, and attitudes and beliefs direct the energy that drives performance. For healthcare organizations performance translates to clinical quality, the patient experience, economic and financial productivity, employee turnover rates, and it affects the quality of the talent the organization attracts.
organizations. Observations will refer physicians in independent practices and to employed physician groups operated by health systems, with key comparisons to independent physicians affiliated with hospitals and health systems. Understandings Employees bring basic human needs and derived from such comparisons are important, wants to the work setting, along with their since most health systems in the U.S. are staffed by personalities, personal and professional work physicians who fit into three categories; employed, histories, and their hopes, aspirations and contracted or independent. The scope of the expectations for their prospects as a member of There is no unified culture definition of organizational culture is narrowed to in most organizations. an organization. These prospects manifest as “leadership culture”. The observations, and related expectations for extrinsic and intrinsic rewards. support provided here derive from administration Leadership’s delivery on the expectations for of the CulturePulse; a proprietary evaluation the extrinsic rewards are the easier parts of tool developed by D.K. Zismer and B.J. Utecht. the equation; extrinsic rewards come in the This tool evaluates the leadership culture of forms of money, advancement, accolades organizations based on the assumption that the principal job of leaders is and recognition. Delivery on the intrinsic rewards is typically more to define, design, deploy and direct the cultures of the organizations they challenging for leadership, but can have the greater influence on the lead. The format provides boards and senior leadership teams an agenda for culture of organizations; intrinsic rewards such as trust, fairness, equity, discussions regarding the leadership culture of their organizations, including security, predictability, appreciation and fidelity to the implied promises how leadership culture affects organizational performance. of missions and values. Individual perceptions of the leadership culture Culture in organizations is a product of the human condition at work. Leaders are the principal factor in the curation of how that human condition forms individual and collective beliefs and attitudes toward the organization. Attitudes and beliefs affect the behaviors of individuals and
of organizations are profoundly affected by the expectations for a spectrum of rewards, extrinsic and intrinsic, available as a member of the organization.
Taxonomy of leadership culture Through administration of the CulturePulse to physicians, other clinicians and support staff in physician service organizations, evaluations of leadership culture observations may be drawn that help evaluate and define leadership culture. Some of these observations include the following points. There is no unified culture in most organizations; especially not in health care, including physician services organizations. Healthcare organizations are a tapestry of specialization of personnel and function. Consequently there are multiple sub-cultures within healthcare organizations. The state and status of these sub-cultures is the product of the leadership. Scores on our evaluations of culture in medical groups demonstrate that while staff may have clear perspectives on how the culture of the organization “should be” (and they will freely share their views and perspectives in our survey instrument), their perspectives on the culture of the organization overall is heavily influenced by where they work in the organization, department or division. So, while healthcare organizations are, in fact, collections of multiple subcultures, patients expect to be cared for by a unified team of professionals. Performance of the whole is a product of the multiple sub-cultures cooperating and collaborating together at consistently high levels of performance. Sub-cultures in organizations are susceptible to situational shocks and shifts. Shocks and shifts can come in a number of forms; examples include changes in leadership, internal consolidations of operating divisions and departments, budgetary performance shifts, and introductions of changes in clinical processes and programming. Shocks to one sub-culture can reverberate through others. No sub-culture operates in isolation of the others in healthcare organizations, and no sub-culture should be presumed to be stable, or impervious to shocks and shifts. Boards need to remain in-tune with how organization decisions may affect culture and performance.
JANUARY 2021 MINNESOTA PHYSICIAN
Physicians may overestimate the health of the culture of the staff in the The people of the organization will hold strong opinions on whether trenches. Physicians who have viewed CulturePulse scores of the staff in leaders work to ensure “an environment that can be trusted to be fair”. Most their own organizations, as compared with those of the physicians, have individuals in organizations understand that not every decision made by said things like “I guess we’re out of touch” and “we’re in LaLa land”. It leaders will be pleasing to them, but they do expect leaders will make every is important to remember that while patients’ decision based upon values of fairness and equity. perspectives of their encounters with their The predictability of perceived trust, fairness and physicians matter, the status of other subcultures equity can be strong predictors of individuals’ encountered by patients matter as well. Inasmuch motivation to perform at the highest levels on as patients will believe the physicians in clinical behalf of a mission. settings are leaders of the organization, including How individuals rate the last item on the Physician organizations are keen all clinical programming and related services, they observers of how leaders interact. CulturePulse; i.e., “I believe the culture of the will attribute the condition of the full culture they organization is as good as it should be” will encounter to the physicians; i.e., “it must be what predict their response levels to all other items on they want it to be, they’re in charge.” the evaluation tool. For example, if a respondent The factors (individual items on the CulturePulse) that most influence the opinions of the state and status of the people affiliated with one sub-culture may not be influential for others. Here again, the leaders of organizations should presume there is no unified or commonly held perspectives of the state and status of culture in organizations, nor is there a uniform approach to how leaders should address the cultures of the groups they lead. There is a somewhat pervasive assumption held by students of culture that if the people of the organization understand the mission of the organization and know how they fit with and contribute to the mission, individuals are more likely to hold the status of the culture in high regard. Our results demonstrate that while important, these two can operate independently of individuals’ perceptions of the culture; i.e., one’s understanding the mission and their belief that they contribute meaningfully to that mission may have little bearing on their perceptions of the culture they work in every day. So, when the people of the organization reflect an understanding and belief in the mission, and they understand how they make meaningful contributions to the mission, leaders should not presume that all is well with the individuals’ perceptions of the culture and “where they live” in the organization.
rates the state of the culture of the organization at the lowest level on the scale, it is probable they will rate all other items at low levels. Likewise those who rate the last item at high levels will tend to rate all others at high levels on the scale. While such findings may seem to be a statement of the obvious, the key point for trustees here is the breadth of the effect an individuals’ perceptions of the leadership culture can have. To be specific, if an individual rates the leadership culture at a low level they are likely to rate another 20 key leadership culture factors presented in the evaluation tool at low levels. To put this observation in the practical, if 15% of the work force in the physician services organization rate The Science of Culture to page 224
Other repeating patterns of culture in healthcare organizations Leaders’ abilities and inclinations to hold all to high levels of performance accountability are meaningful to the people of organizations. We typically see a stark “downdraft” in survey scores, across the board on this factor. “Holding all physicians to the same high standards of patient care quality” can be a very strong predictor of how physicians rate the quality of hospital leadership and the overall culture of health system leadership. Staff in physician organizations are keen observers of how leaders interact to cooperate and collaborate with their peers (other leaders) for the good of the organization, and staff will routinely hold opinions of whether individual leaders behave in the best interests’ of the organization or self interest. The people of the organizations will also hold strong opinions on the whether leaders reflect the values of the organization in their decisionmaking, and leadership behaviors. A common mistake of leaders is creation of a “silo culture”. Extremes here can make those they lead feel stifled and even trapped by their leaders. Healthier cultures foster and encourage cooperation, collaboration and problem solving between departments, and division or clinical specialties.
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CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD
niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.
Physician/employer direct contracting
CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144
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ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.
Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124
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Minnesota’s Medical Cannabis Program A look back and a look ahead BY NICK LEHNERTZ, MD, MPH, MHS, AND PETER RAEKER, MA
ince it first launched in 2015, Minnesota’s Medical Cannabis Program has provided health care practitioners a treatment option for patients who sometimes are facing debilitating medical conditions, helping to improve their quality of life.
Change and growth have been constant for the program. When the Minnesota Legislature authorized the creation of the state’s Medical Cannabis Program in 2014, the law included nine medical conditions that qualified a patient to receive medical cannabis. Since then, the list of qualifying conditions has grown to 15, with two new conditions becoming eligible in August 2021. The program has seen steady growth in other ways. As of Sept. 30, 2020, the program had 1,778 health care practitioners – which include Minnesota-licensed medical doctors, physician assistants, and advanced practice registered nurses – who can certify patients to receive medical cannabis. That is an increase of 10% or 166 additional practitioners from the previous year.
As of Sept. 30, 2020, there were 25,356 patients actively enrolled in the Medical Cannabis Registry, up 41% or 7,395 patients from the same time in 2019. The current active patient number is slightly inflated because patient enrollments are not expiring during the COVID-19 pandemic (see ‘How COVID-19 impacted program operations’).
New Cannabis Patient Centers open Growth in the program in 2020 also means that patients across Minnesota have more options to getting their medicine closer to home. State law now allows Minnesota’s two medical cannabis manufacturers (Leafline Labs and Vireo Health of Minnesota) to each operate up to eight dispensaries, double the amount the legislature originally authorized when medical cannabis was first legalized. Leafline Labs opened a new Cannabis Patient Center in Willmar in April 2020, with new centers planned for Mankato, Golden Valley, and Rogers. They already operate dispensaries in Eagan, Hibbing, St. Cloud, and St. Paul. Vireo Health opened new dispensaries in Hermantown, Blaine, Burnsville, and Woodbury in 2020. The company already has locations in Bloomington, Minneapolis, Moorhead, and Rochester. Their Cannabis Patient Centers operate under the name of Green Goods.
How COVID-19 impacted program operations
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Minnesota’s health care system experienced significant disruptions as a result of the COVID-19 pandemic. The state took action early to allow for telemedicine options for patients and health care practitioners who are participating in the Minnesota’s Medical Cannabis Program. On March 31, 2020, Minnesota Governor Tim Walz signed an Executive Order that ensured the continuing operations of the Medical Cannabis Program during the COVID-19 Peacetime Emergency (read the full text of the Executive Order at mn.gov/governor/assets/Signed%20 EO%2020-26%20Filed_tcm1055-425757.pdf). COVID-19 is particularly dangerous for people with serious underlying health conditions. Many patients participating in Minnesota’s Medical Cannabis Program are seriously ill and often immunocompromised. The Executive Order is making it easier for patients to stay at home and limit their interactions with people outside of their home, reducing the risks associated with COVID-19. Among the key provisions of the Executive Order, participating health care practitioners can certify a patient’s qualifying medical condition after a visit through videoconference, telephone, or other remote means; the Executive Order temporarily waives the requirement that the certification be made only after an in-person visit. The certifying health care practitioner must still meet the applicable professional standards of care when certifying a patient’s qualifying medical condition. Normally, patients are also required to re-enroll on an annual basis; the Executive Order extends enrollments that are expiring during the pandemic to 60 days after the peacetime emergency ends.
While the Executive Order is temporary and will remain in place for the duration of the state of emergency, it provides flexibility for health care practitioners in the program as well as staff who work at Cannabis Patient Centers. As part of the temporary changes, the state’s medical cannabis manufacturers are providing telephone pharmacist consults and curbside pickup at Cannabis Patient Centers to dispense medical cannabis to patients or their registered caregiver.
Qualifying medical conditions to expand in 2021 The Minnesota Department of Health accepts petitions from the public from June 1 through July 31 every year for new qualifying medical conditions and delivery methods. In 2020, Commissioner of Health Jan Malcolm approved petitions for sickle cell disease and chronic vocal or motor tic disorder as qualifying medical conditions.
As part of the additional study, MDH will convene a work group that will include health care practitioners who are treating patients with anxiety disorder. More information about the work group is available at the Office of Medical Cannabis website at www.health.state.mn.us/medicalcannabis.
Change and growth have been constant for the program.
When the Minnesota Legislature authorized the creation of the state’s Medical Cannabis Program, the law included nine conditions that qualified a patient to receive medical cannabis. Since then, the list of qualifying conditions has grown to 15. Those qualifying conditions include: • Cancer*
During the 2020 petition process, MDH received written comment from only one practitioner – an addiction psychiatrist – who had concerns about making anxiety a qualifying medical condition for medical cannabis. On the other hand, MDH received nine pages of public comment in support of adding anxiety as a qualifying medical condition.
Among the concerns raised, anxiety is a broad term for a group of specific disorders. In addition, there is evidence that using cannabis can contribute to and make anxiety worse for some people. Adding to the complexity of the issue, the available evidence on the effectiveness of medical cannabis on anxiety disorders is limited due to the federal restrictions on medical cannabis research. In addition to convening the work group, MDH staff will reach out to other states with medical cannabis programs that have anxiety as a qualifying medical condition and gather additional information about their patients’ experiences.
• Glaucoma • HIV/AIDS
Minnesota’s Medical Cannabis Program to page 204
• Tourette syndrome • Amyotrophic lateral sclerosis (ALS) • Inflammatory bowel disease, including Crohn’s disease • Seizures, including those characteristic of epilepsy • Severe and persistent muscle spasm, including those characteristic of multiple sclerosis
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• Terminal illness with a probable life expectancy of less than one year* • Intractable pain • Post-traumatic stress disorder (PTSD) • Autism • Obstructive sleep apnea • Alzheimer’s disease • Chronic pain *If the illness or its treatment produces one or more of the following: severe or chronic pain; nausea or severe vomiting; or cachexia or severe wasting.
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Anxiety disorder petition to undergo more study In 2020, MDH considered a petition for anxiety disorder in addition to sickle cell disease and chronic vocal or motor tic disorder for new qualifying medical conditions. The petition for anxiety disorder was not approved, but Commissioner Malcolm said that the agency would commit to a deeper look at the condition in early 2021 and move forward carefully.
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This is the third time anxiety has been petitioned, with earlier petitions received in 2017 and 2019. MINNESOTA PHYSICIAN JANUARY 2021
Where Eye Care Fits In Bridging specialty and primary care GARY S. SCHWARTZ, MD, MHA
hen I was in medical school and matched in ophthalmology, a friend who is now a urologist started referring to me as an “eye dentist”. His logic was that because my patients would not need to undress and could be examined in a chair rather than a bed, that my practice would look more like a dentist’s than a physician’s. We laughed about this at the time, but throughout my training and career I have been repeatedly surprised by how often the truth behind his joke has shown through. As with other specialties, the clinical, surgical, and business aspects of eye care have changed dramatically in the 30 years since I matched. Cataract surgery is still the most commonly performed surgical procedure in the United States, now is usually performed in physician-owned ambulatory surgery centers rather than hospitals. The use of lasers to “cure” patients of their dependence on eyelgasses has not only been proven effective and safe, but has also moved from the fringes of the eye care community to the mainstream. And advancements in eye care have not solely been surgical. For instance, there are now dozens of well-tolerated eyedrops available for
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the treatment of glaucoma, while in my residency there were only two or three, and each of these had its list of troublesome side effects. Despite all the medical and surgical advancements, eye care delivery is still fundamentally a combination of preventative and specialty care, where the concept of the “eye dentist” is at the root of the question, “Where does eye care fit into a patient’s overall health care?”
Eye Care as Primary Care I am occasionally asked whether I consider myself a specialist or primary care doctor. I answer by saying that I am a primary care doctor for my patients’ eyes. In this regard, patients do not need to be referred to see me as they do for other types of specialists. Think about it – a patient with cardiac symptoms will usually be referred by their primary care provider (PCP) to a cardiologist. Likewise, a patient with GI symptoms will usually be referred by their PCP to a gastroenterologist. Although many patients are referred to me by their PCP’s, at least as many will find me on their own through advice of a friend, relative, or a Google search, and their PCP may never know that they were seen by me. Why is this? I believe the answer to this question has to do with why the term “eye dentist” resonates. Most Americans know to see their dentist twice a year for cleanings and to give their dentist the opportunity to look for potential problems. Most of us keep to this schedule even though we are almost always asymptomatic. We also understand that what our dentist provides us is separate from and parallel to what our medical PCP does. They both take care of the parts of us that they are responsible for, usually without communicating with one another. There is a good chance your PCP does not know who your dentist is, and your dentist does not know who your PCP is.
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For many of my patients, I perform the same type of service for their eyes that their dentist does for their teeth (minus the cleaning). Patients return to me on a schedule that I deem appropriate without either of us seeking input from their PCP. I update glasses and contact lens prescriptions (similar to a hygienist’s doing a cleaning) and look for signs of eye disease (much like a dentist’s looking for cavities). I usually will not send a letter back to the PCP for this type of service, and if I did, the PCP would likely not devote a lot of time to reading it. My patients remain fully clothed and are examined in a chair instead of a bed, exactly as my urologist friend predicted.
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Another parallel with the dental profession lies in our ability to help PCP’s predict systemic disease. For instance, the status of the gums and teeth can allow dentists and hygienists to give feedback to PCP’s about their shared patient’s cardiovascular status. As eye doctors, we can do something similar. When we examine the posterior segment of a patient’s eye, it is the only time that a doctor can directly view that patient’s vascular system in vivo. In this way, we can often help diagnose vascular conditions such as hypertension, atherosclerotic disease, and diabetes mellitus before they even make it onto a patient’s problem list.
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Eye Care as Specialty Care
Frequency of Evaluation
Many eye doctors spend very satisfied careers engaged in the type of practice described above – the routine care of patients without significant disease. However, we are also trained as a specialist, and spend much of our time diagnosing and treating diseases such as glaucoma, uveitis, strabismus, cataract, macular degeneration, and so on. Many patients with disease are culled from our routine patient populations, while others are referred to us by their PCP’s. Once in our practices, some patients are best managed with surgical solutions (strabismus, cataract, retinal detachment, etc.), while others are better managed with medical ones (glaucoma, uveitis, dry eye, etc.).
Every 5-10 years
Every 2-4 years
Every 1-3 years
65 and older
Every 1-2 years
Patients that need medical or surgical care will often share waiting-room space with routine ones, and most of our clinic schedules have a combination of both types of patients. What adds to the complexity is that some patients with mild medical problems (non visually-significant cataract, for example) will think of their exams as “routine”, and wonder why their visit may be coded as a medical one.
How Often Should Healthy Patients See an Eye Doctor? We have established that eye doctors serve two functions for patients: (1) we are primary care doctors for their eyes, and (2) we medically and surgically manage eye diseases. One of our national organizations, The American Academy of Ophthalmology (AAO), has created the following recommendations for the timing of routine eye care in completely asymptomatic adults who do not require spectacle correction (eyeglasses or contact lenses):
The main reason for us to perform scheduled eye examinations on otherwise healthy people is to discover problems early enough in the course of the disease that patients can be treated successfully. The analogy to dentistry is apt again. The dentist probes and x-rays to find small asymptomatic cavities that can be more easily treated while still in the early stages. If these cavities go undetected, they can lead to bigger problems that require more invasive and costly repairs, often with different definitions of success. Dentists, of course, are not the only ones who understand the importance of testing asymptomatic people in order to catch diseases at stages that are more easily and successfully treatable. Blood pressure monitoring, routine bloodwork, colonoscopies, mammograms, and Pap smears are all examples of this strategy within medicine. The routine eye examination is just one more example of where someone is looking for early disease in populations of asymptomatic individuals. The AAO schedule for routine eye exams is a rough guide, and many situations exist where patients should be seen more frequently. Diabetics, Where Eye Care Fits In to page 184
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3Where Eye Care Fits In from page 17 retinopathy, age-related macular degeneration, and precancerous choroidal of course should be seen annually, along with patients on certain high-risk nevi. In each of these cases, early detection can lead to sight-saving, or even medications (most notably hydroxychloroquine). Anyone in eyeglasses or life-saving results. contact lenses should also be seen annually to Summary have their prescriptions updated. Patients with As eye doctors we are both primary care providers family histories of glaucoma, age related macular for the eye, and specialists that PCP’s should degeneration, early cataract, or many other refer patients to for the medical and surgical significant causes of vision loss should also be seen Ophthalmologists are not management of diseases of and around the more frequently than are listed above. only medical and surgical eye. Primary care providers should familiarize specialists, but also primary Because of its asymptomatic nature and ability themselves with the recommendations for timing care doctors for the eyes. to cause irreversible vision loss, the single most of routine eye examinations as published by the important reason to follow the AAO’s schedule for AAO, understanding that this schedule represents routine eye examinations is glaucoma. Glaucoma the bare minimum, and many patients with affects about one in every fifty Americans (3 specific situations should be seen more often than million people), is completely asymptomatic until what is listed here. Evaluating asymptomatic very late in the course of the disease, and is difficult to diagnose with the patients routinely is the single best way for us to not only diagnose and equipment available to the average PCP. Importantly, vision loss from treat asymptomatic eye diseases at stages when treatment is most effective, glaucoma cannot be reversed, so all treatment regimens are focused on the but also aid PCP’s in the diagnosis and management of many systemic prevention of vision loss, which is the opposite of cataract or wet macular diseases. For these reasons, PCP’s should refer their asymptomatic, healthy degeneration management, where treatment is based on the reversal of vision patients for eye exams in much the way they refer them for colonoscopies, loss. If we diagnose glaucoma in someone once they notice their vision loss, mammograms, and the like. it is usually much, much too late for us to help them in a meaningful way. There are additional diagnoses that are also important to diagnose early, while patients are still asymptomatic. Some of these include diabetic
Gary S. Schwartz, MD, MHA, is President of Associated Eye Care, and Co-Chair and Executive Medical Director of Associated Eye Care Partners.
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3Minnesota’s Medical Cannabis Program from page 15 Looking ahead While still prohibited under federal law, medical states and four territories, and cannabis can be legally purchased by anyone over 21 years old in 15 states and three territories (South Dakota voters in 2020 approved an amendment to legalize medical cannabis and adult-use cannabis in the state). Also of note for Minnesota, in 2020 the Red Lake and White Earth nations approved medical cannabis programs through referendum and are in the process of standing up those programs.
treatment can change their patients’ lives. Among the results for patients certified for intractable pain, for instance, practitioners reported on how medical cannabis cannabis is legal in 36 treatment resulted in reducing dosage or eliminating medications that patients used for pain. Between 2015 and 2017, of the 1,166 MDH survey responses for intractable pain patients, nearly 60 percent of the practitioners reported a reduction of pain medications for their patients, with 382 surveys (33%) indicating a decrease in opioid medication for their patients. Some patients were Some patients were even even able to eliminate opioid use. able to eliminate opioid use. Whatever the future holds on possible expansion of the program, health care practitioners interested in participating are encouraged to visit the Office of Medical Cannabis website at www. health.state.mn.us/medicalcannabis or email email@example.com. The website provides information about how practitioners can enroll, which is done online and takes only a few minutes.
Policy discussions about legalizing adult use of cannabis have picked up in Minnesota, with supporters citing racial disparities and criminal justice reform as some of the reasons for changing the law. Discussions are also taking place on the potential for expanding the state’s Medical Cannabis Program, which is considered one of the most restrictive programs in the country. State law limits the program to two manufacturers and 16 Cannabis Patient Centers, and does not allow for use of medicine in plant form. Advocates are expected to introduce a bill during the 2021 Minnesota Legislative session to allow plant form in the Medical Cannabis Program.
Nick Lehnertz, MD, MPH, MHS, is a medical specialist at MDH in the Division of Infectious Disease Epidemiology, Prevention and Control.
Peter Raeker, MA, is the communications planner for the Office of Medical
What impact is the program having on its patients? MDH asks health care practitioners participating in the program to take note of how medical cannabis
Cannabis at MDH.
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3The Science of Culture from page 13 the overall leadership culture as a “1” (lowest score on the 1-7 scale) this class of respondents is also likely to rate 20 other key contributors to leadership culture at similarly low levels.
Relevance to a Governing Board
evaluation, and plans for its ongoing development. The state and status of the leadership culture should also represent an area of performance evaluation, and ongoing development for members of the senior leadership team. The governing board and the senior leadership team are viewed by the people of the organization as the guardians and keepers of the corporate culture.
As physicians gain more insight into the science Let’s return to a foundational, going-in premise of culture they become more able to effect positive of the article; “trustees own the cultures of the change within their health systems, no matter organizations they govern.” To repeat, while how large or small. Better understanding of the Mission performance trustees of healthcare organizations can’t be is job #1 of governance. business dynamics that drive corporate decisionexpected to understand all the complexities making allows them to be more active partners in and intricacies of operating a hospital or health system, they can be expected to understand, that process. in-depth, the state and status of the cultures of the organizations they govern. Why? Because, Daniel K. Zismer, Ph.D. is Co-Chair and CEO of the culture of the organization will affect the Associated Eye Care Partners, LLC, Also, Endowed Scholar, Professor Emeritus mission performance of the organization, and mission performance is job and Chair, School of Public Health, University of Minnesota. #1 of governance. For trustees who accept the premise that a governing board owns organizational culture, the question of “what to do next” follows. The answer to the question lies with the right relationship with the CEO. The CEO is directly responsible to the board. Boards have responsibility and accountability for one employee; the CEO. Boards should engage with the CEO directly and routinely, on the state and status of the leadership culture of the organization, including its ongoing assessment and
Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.
Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist
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3Restorative Justice from page 10 Four faculty members, across the research, education, and clinical missions, and two staff members from education and human resources completed training from the AAMC in December of 2020. The group who went through the training continues to meet monthly to plan where and when restorative circles can be incorporated into the work of the U of M Medical School. The early experiences in the conduct of circles are revelatory. A patient-experiencefocused circle yielded a completely different understanding of what we “know” or what we expected. The participants and facilitators truly appreciated the stories, the insights into the perspectives of others, and the co-creation of new ideas to address the purpose of the circle.
as mentees and, now, as mentors. They discussed ideals and what they wanted the future to look like. They talked about barriers and obstacles. They reached a common understanding they otherwise would never have obtained. That common understanding allowed them to quickly envision changes to improve the mentoring culture.
Experiences in the conduct of circles are revelatory.
I helped facilitate a circle focused on mentoring with another participating university in the AAMC training program. The circle consisted of an administrator, faculty members, and students. After meeting for one hour, the circle proposed an action plan of individual and organizational recommendations to improve mentoring at the institution. The participants went from nervous, anxious, and curious to motivated, excited, and grateful. The participants gained a better understanding of what faculty members and students experienced
Circles can also address specific issues of harm. People sometimes communicate things in the heat of the moment that they regret. There is the accidental reply all email, the all caps email, or the hurtful social media post where colleagues who are friends may see and feel hurt by a post. These are not infrequent events. Often the incident is buried, where it causes divisiveness, fuels factions, and perpetuates bad feelings. If the incident falls under human resources purview, a person may get “written up” or reprimanded for the behavior and threatened with sanctions.
Restorative justice provides an alternative to burying the incident. With careful preparation and facilitation, the victim can explain the impact of the comment. The person who said it can provide context for saying it, express regret and a desire to repair the damaged relationship. The victim can explain what it would look like to repair the harm. Of significance, the bystanders- those who witnessed the event, those who heard about it later, those who spread word of the incident - also get to tell their stories, describing the impact of the incident on them. People in support of the victim and for the person who caused harm can be engaged to help in rebuilding trust and in preventing future incidents. An understanding can be reached and actions agreed to, if appropriate for the situation. Restorative justice in academic medicine can also involve reintegration of members who are separated from the school. Separation, whether due to leave, illness, or disciplinary action, can harm multiple groups of people within the separated person’s work community. The U of M Medical School hopes to one day be able to work with those separated from work to smooth re-entry.
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In summary, restorative justice, practices, and approaches are not new. They will sound and feel familiar to many. Restorative practices differ from many processes currently used to address harm in that they focus on rebuilding relationships and healing instead of punitive approaches that separate people and do not build trust and community. Restorative practices are not for every situation though. The use of restorative practices in academic medicine is a valuable way to improve culture, repair harm, and reintegrate those members of the community who have been separated. Restorative practices are one way academic medicine can improve discovery, teaching, and the provision of care to better heal all those we serve.
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