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To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

Background: Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice. Methods: We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science. Results: Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making. Conclusions: In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs. Registration: URL: https://clinicaltrials.gov ; Unique identifier: NCT04164004.

OBJECTIVE To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making. PARTICIPANTS AND METHODS A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates. RESULTS Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P

BACKGROUND Peripheral arterial disease (PAD) is underdiagnosed, partially due to a high prevalence of atypical symptoms and lack of physician and patient awareness. Implementing clinical decision support tools powered by machine learning algorithms may help physicians identify high risk patients for diagnostic workup. OBJECTIVE The Consolidated Framework for Implementation Research (CFIR) was used to evaluate barriers and facilitators to implementation of a novel machine-learning based screening tool for peripheral arterial disease amongst physician and patient stakeholders. METHODS Semi-structured interviews were performed with physicians and patients from the Stanford University Department of Primary Care and Population Health, Division of Cardiology, and Division of Vascular Medicine. Participants answered questions regarding their perceptions towards machine learning and clinical decision support for peripheral arterial disease detection. Rapid thematic analysis was performed using templates incorporating codes from CFIR constructs. RESULTS 12 physicians (6 primary care physicians, 6 cardiovascular specialists) and 14 patients were interviewed. Barriers to implementation arose from six CFIR constructs: complexity, evidence strength and quality, relative priority, external policies and incentives, knowledge and beliefs about intervention, and individual identification with organization. Facilitators arose from five CFIR constructs: intervention source, relative advantage, learning climate, patient needs and resources, and knowledge and beliefs about intervention. Physicians felt that a machine learning-powered diagnostic tool for PAD would improve patient care but cited limited time and authority in asking patients to undergo additional screening procedures. Patients were interested in having their physicians use this tool but raised concerns about such technologies replacing human decision-making. CONCLUSIONS Patient and physician reported barriers towards the implementation of a machine learning-powered PAD diagnostic tool followed three interdependent themes: (1) Low familiarity or urgency in detecting peripheral arterial disease; (2) Concerns regarding the reliability of machine learning; (3) Differential perceptions of responsibility for PAD care amongst primary care versus specialty physicians; (4) Patient preference for physicians to remain primary interpreters of healthcare data. Facilitators followed two interdependent themes: (A) Enthusiasm for clinical utility of the predictive model; (B) Willingness to incorporate machine learning into clinical care. Implementation of machine learning powered-diagnostic tools for PAD should leverage provider support, while simultaneously educating stakeholders on the importance of early PAD diagnosis. High predictive validity is necessary for machine learning models, but not sufficient for implementation.

Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention.The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and health care utilization, including clinic visits, testing, hospitalizations, and emergency department visits. As a sub-study, PRO-HF will also evaluate the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice.PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.

Context The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017. Objectives Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls. Methods We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation. Results Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships. Conclusion Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.

Introduction Reports from patients and healthcare workers dealing with COVID-19 underscore experiences of isolation and fear. Some of this experience results from the distancing effect of masks, gloves, and gowns known as Personal Protective Equipment (PPE). One approach to bridging the divide created by PPE is the use of PPE Portraits, postcard-sized pictures affixed to PPE. Objective Our confidential, email-based survey aimed to quantify provider attitudes towards PPE Portraits. Methods PPE Portraits were piloted at an academic, safety-net health system experiencing a COVID-19 patient surge in April-May 2020, necessitating use of full PPE for COVID-positive patients and surgical masks in all hospital settings. Our survey assessed staff exposure to PPE Portraits, attitudes towards PPE Portraits, and potential program expansion. For staff wearing PPE Portraits, we also assessed perceptions of interactions with other staff and patients/families and impact on personal wellbeing. The University of Massachusetts Medical School’s IRB designated this a quality improvement project (#H00020279). Results Over half of survey respondents (n=111/173, 64%) reported exposure to PPE Portraits. Attitudes towards PPE Portraits were positive overall, with agreement that PPE Portraits were a good idea (89%), improved provider mood (79%), enhanced perception of team connection (72%) and more positive among those who reported exposure. Open-ended responses (n=41) reinforced positive survey data, and also raised concerns about infection control (n=6), cost/logistics (n=5), and provider vulnerability (n=3). Conclusions Providers report that PPE Portraits may represent a positive, patient-centered idea that helps reassure patients, is well-received by interdisciplinary staff, and may enhance patient and team interactions. Potential adaptations to address concerns include “photo pins,” and donor/ patient and family experience department support for costs. Key Message This article describes a cross-sectional study that investigated provider perceptions on the use of PPE Portraits, an intervention that addresses the barrier to patient-provider connection presented by the use of PPE. The results suggest that implementation of the PPE Portrait Project is feasible, acceptable, and effective.

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.

BACKGROUND: Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient–provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience). METHODS: We sourced data from PubMed, EMBASE, and PsycInfo (January 1997–August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient–provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider–patient dyad), and quadruple aim outcomes. RESULTS: Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands. DISCUSSION: Simple, low-demand patient–provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05525-2) contains supplementary material, which is available to authorized users.

ObjectiveEarly in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system.MethodsWe employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest).ResultsFive interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement).ConclusionsOur needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.

Background As of August 2021 up to 30% of Americans were uncertain about taking the COVID-19 vaccine. Some healthcare personnel (HCP) also delayed or declined vaccination. Objective Identify barriers and facilitators of Veterans Health Administration (VHA) HCP vaccination program Design: Key informant interviews with employee occupational health (EOH) providers Participants: 38 VHA EOH providers representing 26 of VHA’s regionally diverse healthcare systems. Approach: Thematic analysis elucidated 5 key themes, and specific strategies recommended by EOH Key Results: Implementation themes included: 1) Leverage diverse skillsets through multidisciplinary effort, specifically COVID-19 vaccination teams with clear goals/roles. 2) “Focus like a laser”: invest in processes and align resources with priorities, including specific strategies of: creating detailed processes, eg. logistics plan to prevent wastage and allocate excess vaccine doses; addressing time trade-offs for personnel involved in vaccine clinics by suspending everything non-essential; designating process/authority to shift personnel where needed; and proactively involving leaders to support resource allocation/alignment. 3) Expect and accommodate vaccine buy-in occurring over time, including specific strategies of: preparing for some HCP slow buy-in; aligning buy-in facilitation with identities and motivation; encouraging word-of-mouth and hyper-local testimonials. 4) Overcome misinformation through trustworthy communication, with specific strategies including: tailoring communication to individuals and addressing COVID vaccines “in every encounter”; leveraging proactive institutional messaging (e.g., townhalls, Q&As) to reinforce information; inviting bi-directional conversations about hesitancy. 5) Use existing and newly developed communication channels to foster sharing and learning across teams and sites, eg. a national VHA EOH listserv. Conclusions Expecting deliberation allows systems to prepare for complex distribution logistics, and conversations that are trustworthy, bi-directional, and identity-aligned - overall supporting mandate goals. Ideally, organizations 1) provide time for conversations about vaccines; those conversations would 2) address individual concerns and foster bi-directional shared decision-making, 3) be informed by identity-based motivation, and 4) delivered by identity-concordant individuals.

PURPOSE: Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team. METHODS: Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data. RESULTS: Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only “control of work” approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P

Stacie Vilendrer,1 Alexis Amano,1 Steven M Asch,1,2 Cati Brown-Johnson,1 Amy C Lu,3 Paul Maggio4 1Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA, 94305, USA; 2VA Center for Innovation to Implementation, Menlo Park, CA, 94025, USA; 3Department of Anesthesia, Stanford School of Medicine, Stanford, CA, 94305, USA; 4Department of Surgery, Stanford School of Medicine, Stanford, CA, 94305, USACorrespondence: Stacie Vilendrer, Division of Primary Care and Population Health, Stanford University School of Medicine, 1265 Welch Road, Mail Code 5475, Stanford, CA, 94305, USA, Email staciev@Stanford.eduPurpose: Physicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians’ choosing. Formal evaluations of such programs are lacking.Methods: To understand the impact of Stanford Health Care’s physician-directed reinvestment in its first year (2017– 2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program’s impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.Results: Physician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one’s existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.Conclusion: A physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.Keywords: physician incentives, professional autonomy, cost savings, motivation, quality improvement, program evaluation, quality indicators, health care, organizational innovation, work engagement

BACKGROUND Hypertension is the most prevalent and important risk factor for cardiovascular disease, affecting nearly 50% of the US adult population; however, only 30% of these patients achieve controlled blood pressure (BP). Incorporating strategies into primary care that take into consideration individual patient needs, such as remote BP monitoring, may improve hypertension management. OBJECTIVE From March 2018 to December 2018, Stanford implemented a precision health pilot called Humanwide, which aimed to leverage high-technology and high-touch medicine to tailor individualized care for conditions such as hypertension. We examined multi-stakeholder perceptions of hypertension management in Humanwide to evaluate the program’s acceptability, appropriateness, feasibility, and sustainability. METHODS We conducted semistructured interviews with 16 patients and 15 health professionals to assess their experiences with hypertension management in Humanwide. We transcribed and analyzed the interviews using a hybrid approach of inductive and deductive analysis to identify common themes around hypertension management and consensus methods to ensure reliability and validity. RESULTS A total of 63% (10/16) of the patients and 40% (6/15) of the health professionals mentioned hypertension in the context of Humanwide. These participants reported that remote BP monitoring improved motivation, BP control, and overall clinic efficiency. The health professionals discussed feasibility challenges, including the time needed to analyze BP data and provide individualized feedback, integration of BP data, technological difficulties with the BP cuff, and decreased patient use of remote BP monitoring over time. CONCLUSIONS Remote BP monitoring for hypertension management in Humanwide was acceptable to patients and health professionals and appropriate for care. Important challenges need to be addressed to improve the feasibility and sustainability of this approach by leveraging team-based care, engaging patients to sustain remote BP monitoring, standardizing electronic medical record integration of BP measurements, and finding more user-friendly BP cuffs.

Background Growing demand for medical assistants (MAs) in team-based primary care has led health systems to explore career ladders based on expanded MA responsibilities as a solution to improve MA recruitment and retention. However, the practical implementation of career ladders remains a challenge for many health systems. In this study, we aim to understand MA career aspirations and their alignment with available advancement opportunities. Methods Semi-structured focus groups were conducted August to December 2019 in primary care clinics based in three health systems in California and Utah. MA perspectives of career aspirations and their alignment with existing career ladders were discussed, recorded, and qualitatively analyzed. Results Ten focus groups conducted with 59 participants revealed three major themes: mixed perceptions of expanded MA roles with concern over increased responsibility without commensurate increase in pay; divergent career aspirations among MAs not addressed by existing career ladders; and career ladder implementation challenges including opaque advancement requirements and lack of consistency across practice settings. Conclusion MAs held positive perceptions of career ladders in theory, yet recommended a number of improvements to their practical implementation across three institutions including improving clarity and consistency around requirements for advancement and matching compensation to job responsibilities. The emergence of two distinct clusters of MA professional needs and desires suggests an opportunity to further optimize career ladders to provide tailored support to MAs in order to strengthen the healthcare workforce and talent pipeline.

Background: The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient’s treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. Aim: Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. Design: A qualitative thematic analysis of semi-structured interviews. Setting/participants: Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. Results: Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can “overwhelm” providers. Conclusions: Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.

AIM: Patients are asking health care providers about e-cigarettes, vaping, and other electronic nicotine delivery systems (ENDS). Provider advice on ENDS has varied greatly, suggesting a need for evidence-based continuing medical education (CME). SETTING: A novel free online CME course was developed on ENDS risks and benefits, product types (e.g., vape pens, pods), and screening and counseling best practices for adults, adolescents, and different smoker profiles (e.g., daily, social). PARTICIPANTS: From January 2017 through June 2018, 1061 individuals accessed the course: 46% physicians, 7% physician assistants, 7% nurse practitioners, 15% nurses, 4% pharmacists, and 28% allied health/student/other; 41% were international. PROGRAM DESCRIPTION: The course was built from observed online patient-provider interactions. Through video role-plays, expert interviews, and interactive activities, the course engaged learners in the evidence on ENDS. Completers earned 1.5 CME units. PROGRAM EVALUATION: A total of 555 health care providers earned 832.5 CME units. Pre- to post-test scores significantly increased from 57 to 90%; 76% rated the course as above average (41%) or outstanding (35%); 99% indicated the course was free of commercial bias. DISCUSSION: Addressing the growing need for balanced provider education on ENDS, this interactive online CME engaged learners and increased knowledge on devices and evidence-based cessation approaches.

BACKGROUND: While barriers to physician wellness have been well detailed, concrete solutions are lacking. OBJECTIVE: We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness. DESIGN: We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals. PARTICIPANTS: Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor). APPROACH: Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach. KEY RESULTS: Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment. LIMITATIONS: In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings. CONCLUSION: Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04913-y) contains supplementary material, which is available to authorized users.

Purpose The potentially vast supply of unused opioids in Americans’ homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement. Methods We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities. Results While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic. Conclusion A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.