Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. Confronting that, we are seeing systems and processes being reimagined. In this episode, we sit down with David Willis to talk about expanded care settings, particularly reimagining patient flow in healthcare organizations. He dives deep into the reasons behind the renewed focus on patient flow, including shifting patient preferences, staffing challenges, and financial considerations. What is more, Dave emphasizes the need for administrators to address these issues by optimizing bed utilization, reducing the length of stay, and improving discharge planning. From identifying current challenges to finding solutions and new approaches, Dave gives us key insights that will help you meet the evolving needs of patients, healthcare providers, and the entire organization. Tune in to this conversation to not miss out!
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Focus On Expanded Care Settings: Reimagining Patient Flow With Dave Willis
My friends and esteemed colleagues who are both executives at about health are joining me again in our discussion. They’re no strangers to you, our faithful readers. They are as you know Ben Sawyer and Dr. Darin Vercillo. Welcome back, folks.
Rog, good to be here.
Good to have you with us. We are very pleased to have as our guest, David Willis. Dave is a graduate of Carnegie Mellon, the Wharton School at the University of Pennsylvania. He earned an MBA at Yale School of Management. The IQ in our group went up, the average, so thanks Dave for that. Dave served as Senior Vice President for the Center for Transformation at the Health Management Academy. He’s had various positions at the advisory board Think Tank that we’re all familiar with.
He’s an independent consultant and we are going to let you know how to connect with Dave as you may want to reach out to him to speak to your leadership team or board. Maybe a board retreat or something like that. You’ll soon discover that he has some unique and very helpful insights for all of us. Dave, welcome to the show. Thanks so much for taking the time to chat with us.
I couldn’t be happier to spend the time with you, Roger. Ben and Darin, thank you for the invitation. I appreciate it.
Good to have you here.
It’s going to be a good one. Our audience is in for a real treat. With the topic that we’re talking about, Dave, we’d like to have you help us think differently about patient flow and how we can help our readers maybe achieve some efficiencies that they didn’t think were possible as they steward their resources. Let’s talk about that at the beginning here. Why do organizations need to reimagine their patient flow? What’s the benefit of doing that?
I love the framing of reimagining patient flow because patient flow is certainly not a new issue. Anyone who has been involved in patient care for decades would’ve had this as an issue on their radar screen for any number of reasons. As we think about coming out of the pandemic, the financial and operational challenges that provider organizations, especially larger health systems are facing, there are at least three reasons why we are seeing a renewed focus on this.
Hopefully, we’ll have a chance to talk about all of them. One is a shifting set of patient preferences for where care is delivered. There’s so much going on there. We could probably spend our entire time together talking about that. Second, an enormous issue in almost every organization is the challenges around staffing and the general health and stability of the workforce. That’s intimately tied to the issues of patient flow.
The third is the issue of margins and general financial health. You can’t talk to too many health systems that are doing astonishingly well financially, to say the least. Anything that they can be doing to pull levers here that have an impact has to be part of their playbook and that relates to patient flow also. Three big reasons why we’re seeing a renewed focus on this.
If I could jump in on the first one that you mentioned, patient preference, this is a common theme. We’ve talked about this before and I want to remind all of our healthcare brothers and sisters out there. This is a situation that we’ve created by trying to deal with the pandemic and keep people away from our campuses and our facilities, and said, “Don’t come in unless you’re dying or unless you’re severely seriously ill.” When things settled down, we said, “It’s time to come back. It’s safe.” By that time, everyone had figured out new ways to take care of themselves and some other options. There are many more preferences now than there were before. People have discovered options.
Roger, that’s a great point. One of the things that happened was a trend that was already in motion prior to the pandemic but the pandemic certainly accelerated it for the reasons you described. Whether we like it or not, we forced, in many cases, patients to get comfortable with accessing care in virtual or remote settings. Amazingly, it turns out that they often like it. That’s been true across all age groups. This isn’t Millennials like my daughter. Patients of all age groups found out that there was a lot of benefit to having care outside of a traditional acute setting.
Care on my terms. Not maybe care always on the terms of the provider. These are such great reasons, Dave, for thinking about patient flow. Staffing the workforce clearly is something that all health systems are dealing with. We talk often about how it’s not bed availability. It’s staffed bed availability. I was chatting with the Dean of Health Sciences at a major university in Michigan. He was talking about the fact that for the first time in history, their nursing program does not have a waiting list. While that might sound good for those who want to become an RN, it’s bad for the whole environment because the quit rate of nurses is so much faster than the replacement rate, isn’t it?
What you’re alluding to is such an important phenomenon that is happening now. We have a structural imbalance between the supply and demand of caregivers at all levels of the healthcare delivery team. Nursing is often where we feel it most acutely but this is true in general across the clinical workforce. That’s a phenomenal data point that you shared. Even if that’s one, I bet there are a number of your readers that are saying the same thing. They’re seeing not just in their school programs but in their markets. They cannot hire or build the pipeline for nursing talent faster.
I’ll tell you, Roger. I was in the ICU on call and chatting with one of the nurses as we were nursing full with only two-thirds of the beds in the ICU, staffed and full at that time. I said, “There’s a solution to this. Either we can clone the nurses or do 3D printing of nurses,” but they didn’t have an option for either one.
Dave, I’m interested in your thoughts as to why there has been such a profound shift. I know you had talked a little bit about that in our prep but can you give some insight to our audience as to why that might be occurring? Why people are self-selecting out of going into nursing and/or staying in the profession? What are the circumstances in your opinion that are creating that environment?
Ben, it’s such a multifactorial problem. This part of what makes it hard is there isn’t one root cause that you can point to, tackle that, and try to solve it. Without putting these in any preferential order of importance, you’ve got some or all of the following. One is burnout. We put the clinical workforce through such tremendous trials over the past years. Analogies to soldiers coming back from armed combat are potentially overused but they are reflective of the reality. These are individuals who saw unprecedented levels of trauma and death and difficulty on their job.
The long hours, which traditionally we’ve seen as part and parcel of the nursing conversation, are butting up against changing preferences for work-life balance and other dynamics. We certainly have seen a rise in workplace violence. This saddens me tremendously. Any chief nursing officer that you talk to will say it’s unusual for them to go a week, maybe sometimes a day without there being some issue in one of their sites of care, whether it’s a disgruntled patient, a family member, or something else exploding either into physical violence or mental abuse.
Nobody got into nursing to deal with that. There are other reasons as well but all of these have created an environment where many of these individuals are saying, “This is no longer the career that I want or if I do want to remain a nurse, I’m less interested in spending all of my time in an acute setting. I’m going to look at alternatives.” There is certainly no shortage of alternatives for those who want to continue practice nursing but perhaps, in a different setting of care.
The nurses are at the point of this situation. It’s a well-worn thing but it’s so important. I had coffee with a hospital CEO friend of mine. To double down on presence, there’s a tendency to hide in our offices and not want to put ourselves out there in an environment where we may not have all the answers for people but I encouraged him. We talked about him being present, being out there, walking around, and being available. You may not be able to help or do anything. Your presence there is so important, recognizing how difficult a job we’re asking our nurses to do.
I’d like to make sure for our audience that we differentiate a couple of things here. One, I’m aware that many organizations they are no longer quite facing the radical increase in the amount and expense of temporary or agency labor that they were many months ago. To some extent on that level, things have stabilized but we shouldn’t miss that underneath that. There is this deeper problem and it’s reflective of the conversation you had with the director of health sciences at the university, which is nursing engagement is lower than it has been in a long time.Nursing engagement is lower than it has been in a long time. Click To Tweet
To pick one data point, healthcare does an annual survey of nursing engagement and their numbers in 2023. This is recent data. Dramatic engagement, we attribute that to the accumulated effect of all of these things that have happened in years. There is a long-term challenge here. As many of us who have managed the workforce in any field know, you don’t solve an engagement challenge overnight. It’s going to take a long time to turn that around. We’re going to have to think very differently about what it means to be a nurse, especially in an acute care setting.
Ben, you were trying to jump in there.
I was going to ask Dave about that engagement statistic because that is significant. One of the dynamics that was happening, Dave, during the pandemic is a lot of experienced nurses left because they had opportunities for early retirement. It left a lot of new people in the toughest of environments. I’m wondering if you think that may have had any impact on these engagement scores because experienced people can sometimes blunt the impact. They’ve had that experience and they can adapt. Whereas, if you’re a newbie and you’re coming in into tough circumstances. It seems on the surface it could have a bigger impact.
A couple of years ago, when I was still on the advisory board, my colleagues who ran the nursing workforce program were doing some pretty in-depth research. Again, because some of these trends predate the pandemic. This is not all as a result of the COVID-19 situation. They coined the term the experience complexity gap. That gets to exactly what you’re talking about.
At the same time, as we have this long-term trend to higher acuity, more complex patients in the inpatient setting, that’s a trend that’s been happening for years. We’ve had this wave of retirement as a large percentage of the nursing workforce ages out or gets to a home where they’re cutting back. It’s not a one-for-one trade-off. You trade off an experienced nurse with years of Med-Surg or ICU bedside under his or her belt. You trade that off for a person who’s in their early twenties and it’s their first time dealing with some of these situations. That’s not 1 for 1 even if the FTEs are the same. The capability to deal with it is often quite different.
Dave, it’s interesting that you bring that up because as a physician practicing in a hospital, I’ve seen the downstream effect on two levels. One, as a physician, when you are dealing with inexperienced nurses. Some of the things that get overlooked or aren’t paid attention to or they don’t have on their radar that a nurse with 20- or 30-years’ experience knows, “This is a red flag. I need to contact the physician. We should be making an adjustment here because that’s what makes sense.” That’s one of the downstream effects. The other downstream effect that I see as a physician and that we work with, at ABOUT Healthcare, as we’ve talked about, is the patient flow issues.
We have self-selecting, in some ways, high-acuity patients in the ERs that need to get beds in the hospital. We talk about acuity levels going up in hospitals. Partially, maybe patients are sicker but when we look at the average patient that’s going into a hospital, they’re sicker because some of the other not-so-sick patients that we used to admit to the hospital are now going home or to other venues of care. Everybody that comes into the hospital is sick.
When you have a reduced nursing force, you’re filling up every single possible bed that you can staff with a sick patient. Now you’ve got a nurse on Med-Surg taking care of 6 patients or on telemetry, taking care of 4, in the ICU taking care of 2 and every patient they have is 4-plus sick. Lengths of stay go up. It’s this cascading effect. What are the things that our administrators should be doing to address this issue, take care of their staff and their patients, and make sure it’s successful?
I love where the conversation is going. Roger, if I may, I’m going to tie this conversation now directly to patient flow because what Darin has said is so important. Let’s stipulate for a minute that there is a long-term supply problem in the clinical labor force that we’re not going to be able to solve easily. If I’m an administrator, if I’m running an inpatient facility or an ICU, or what have you, that means I have to think about working on the demand side for clinical labor. That means I have to take a hard look at things like my bed utilization, my length of stay, why this ties to patient flow, and why it’s so important.
We have to begin asking ourselves, are there any patients whatsoever under our purview who don’t need to be in the bed that they are in? Where can we put them? Could they have been deflected from an inpatient bed if we had a robust acute care at-home program and our ED was prepared to admit the patient to that? Could they have been discharged 1 day or 2 earlier if we had better visibility into our PAC network and our post-acute care network, and could see where the resources were there? Could they have been discharged earlier? Perhaps there was an issue across their care where we didn’t plan the discharge with the family or early enough.
Grandma Smith is ready to go home but Grandma Smith’s caregivers aren’t ready to take her home until the beginning of next week. Some of this is blocking and tackling length of stay tactics but I would challenge organizations to say, have you given the same focus in recent years that you would have historically? I say that not from a point of criticism. I say that from the experience of speaking with a lot of chief nursing officers and chief operating officers over the past years.
Two things are almost always said to me. One, our length of stay has gone up in some cases by a day or more compared to pre-pandemic levels. Some of that is related to acuity but not all of it. In their very next breath, they will say something like, “We’ve taken our eye off the ball on some of the operational disciplines that we used to bring to this.”
It’s probably time to take a fresh look at that. It’s probably time if you have a performance improvement, a lean, or a performance excellence team to deploy them again and start asking, “Do we need to revisit some assumptions? Do we need to up our game on some of the traditional tactics or consider new ones?” That’s a bit of a long-winded comment but it’s an important one because if we can’t solve the supply side, we better be willing to take everything in our toolkit and address the demand side.
David, that’s such an important point. Being the lean black belt in the conversation, I want to encourage the audience to look at every single detail. For example, when you’re looking at a timely and effective discharge, even things as simple as reliable transportation from the hospital to wherever they’re going next are huge. You can wait an entire day for something like that.
Not having automation in terms of what your discharge planners are doing so that they’re not able to function at the top of the license and instead they’re doing faxing or other types of things. Early identification of patients that need a packed plan and being able to jump on that early. Also, prior authorization can often be poor prior authorization processes can extend links of stay. Anything that is driving the avoidable day, which hammers the bottom line. No matter what the detail is, re-looking at those things is what you’re speaking to. Correct?
That’s what I’m speaking to. This is going to be an area where those organizations are able to bring that level of operational discipline, that level of critical thinking. Root cause analyses are going to find significant benefits. The other thing that is important in what you’re saying, Ben, is when we look at the way the market has changed here.
There are so many more tools, capabilities, and organizations stepping in to provide them that make the ability to discharge a patient. Perhaps a few years ago, we would’ve said, “We’re not comfortable with that patient getting their follow-up care in the home.” We may think about that very differently now given the expansion of tools, internet access, and companies that are designed to support that level of care. Again, we ought to revisit some of our assumptions here.
It’s almost Care Orchestration V2.
That’s a good way to put it. That’s right. We’re going to have to figure out the next level of this. Some of this is doing the same things that we might have done before but better or getting back to baseline. Some of it is also going to be recognizing the reality that we are in a different market than we were pre-pandemic and there are opportunities here that there might not have been available to us a few years ago.
Before we end this point, Darin, I want to refer back to a previous episode of the show that we did with Dr. Tricia Baird from Corewell Health. The topic there was preventing preventable readmissions. She was talking about some of these same things that you’ve brought up, Dave, reexamining the proper care setting. Could this patient be discharged a day early?
If so, what do we do to prevent a readmission? What do we do to ensure that it’s not an early, appropriate discharge and some of those things that need to be focused on? I know you have an opinion on this but my question always goes to the pragmatic, who owns this process? Have we identified the right person to own this? It’s wonderful for us to talk about this and share our ideas but who’s responsible for this?
I’m sure that Ben and Darin have no shortage of thoughts on that. From my perspective, Roger, I don’t know that there’s one universal right answer for that. Typically, you’re going to find that if it’s at an executive level, that’s going to roll up to either the chief operating officer or the chief nursing officer. Possibly the chief medical officer in some cases but you’re going to see the CNO or the COO with a lot of purviews there. Again, Ben and Darin, you may have specific examples that are similar or that disagree with that.
Dave, I’m glad you brought this up and it goes back to what you mentioned before as far as leaders being present. This is a cultural shift that we’re seeing in the industry. Make a comparison, for instance, to the airline industry when fuel prices went up and costs went up. They had to streamline the number of planes. Every seat is filled and they had to change the culture of how they operated down to every single person who moves people on and off the plane and the speed at which they fill in every seat.
There can’t be any slack anywhere. There can’t be any wiggle room. You had to trim everything out of it. They even moved the seats closer together and made them smaller. We’ve experienced all of that. The same thing to your point is happening and has to happen in the hospital industry. To throw a couple of things out there, you’ve got, for instance, some organizations that, to cut costs, got rid of their entire COO level and put all those responsibilities on the CEOs.
There has to be that top-down cultural change. There has to be the presence, the engagement, and the interest of the leaders so their organizations know that this isn’t them throwing out work that other people have to suck up in the end. As we look at it, this becomes even more critical towards the weekends. If you don’t get things right on a Thursday or Friday, that one-day extra length of stay becomes three days extra length of stay because nothing happens on weekends.
My father is sitting in UCLA Hospital on about day 62 of his stay. He got an LVAD put in. It’s an unusually long stay and it’s supposed to be his move-day out to cardiac rehab and he still hasn’t heard as to when he’s going to move. Again, this whole pre-pandemic or the old methodology that we used of not having a tight methodology of all of this has to go away. We’ve got to get tight on this and make sure that we are paying attention to the details and executing them in a rapid fashion.
Darin, that was a lot of great stuff. I want to pull out a couple of things. One is, it is very easy for health systems to do a knee-jerk reaction to cutting costs.
We’re seeing it all over the place.
Let’s tell all COOs because they’re expensive but the question is unless you understand where the handoffs are, what the necessary processes are, and the roles and competencies of those, you will make a miss and the delays will be built into your system. In terms of process optimization, handoffs are always the first place you want to look because typically there are delays associated with that.
Whoever is handling it within the organization, before you knee jerk and cut people out and cut costs, there has to be a great deal of clarity to your point, Darin, around what’s the process, how do we optimize it, and let’s make sure that whoever’s owning it is on top of understanding that to drive the demand side of the equation, to your point, Dave.
This is such a rich conversation that’s happening now. To put a point to it, Ben, let me suggest the following. This is not news to any of your readers how challenging the financial environment is now. Kaufman Hall’s report on margins, March 23, 2023, was the last one that I have. The median operating margin for health systems in the US is -1.1%. That’s down a little bit from where it had been earlier in the year. There are a lot of root causes for that. We’re not going to unpack all of them. Not all of them are tied to patient flow but if you go to what Darin suggested, which is if our operational processes are not good and it’s leading to length of stay creeping up. A couple of problems with that.
In a DRG or case-based system, those extra days of the length of stay, which are unfunded, by the way, are just eating up cost. Assuming all else being equal, assuming clinical efficacy, would you rather have in that bed a Medicare patient on day 8 or 9 of their length of stay for a medical admission or a short-stay surgery patient where you’re being paid surgery rates? At a time when staffed beds are your critically constrained resource, that becomes an important trade-off that you have to be able to operationalize.
I share your concern, Ben, that the trend towards eliminating COOs. I’m not going to be so bold as to say that’s not a good idea or that organizations have to make their own decisions but I do worry that is exposing or creating risk for us at a time when we need to be doubling down on operational efficiency and operational performance.The trend towards eliminating COOs is exposing or creating risk for us at a time when we need to be doubling down on operational efficiency and operational performance. Click To Tweet
In my own experience, I was a CEO for 34 years, and for a brief time, I was a COO in just a minute and I wasn’t very good at it. I was so much better as a CEO than I was as a COO. I never survive what’s going on now. Dave, I’m going to give you a second to think about this. As predicted, this went so fast. There’s so much there and a lot of unfinished business. We don’t leave our readers on the brink of despair, we got to pull them off the ledge. What are 1 or 2 things that they could do, questions that they could ask, or something that could give actionable that they could take hold of from this discussion and maybe implement?
I’m glad that we’re circling back on this, Roger. I always like to leave any conversation with what are the takeaways or what are the next steps. We’ve covered a lot of ground. If I can be bold and ask your readers to consider a couple of recommendations. 1) Regardless of whether you have maintained the COO role or not, I’m going to make the assumption that you have a performance improvement team in the organization. Probably their top 1 or 2 priorities should be looking at the length of stay at your institutions, doing the root cause analysis, understanding what has driven that up, and being very cautious about relying on old assumptions. Again, the world has changed and we need to be taking a fresh look at that.
2) During the height of the pandemic, organizations got good at using some form of weekly or, in some cases, daily huddle to get visibility across their system. Not just their owned assets but often the broader network. Where do we have availability? Where do we have scarcity? Where could we potentially be shifting patient flow or volume?
You probably included your post-acute care network in that because it was so critical, you needed to free up that ICU bed with a ventilator, and as soon as you had a place to put the patient who was stable, you wanted to move them there. Is it time to think about bringing that back or bringing back some version of that? If you don’t have visibility into what the available beds are in your network and that, by the way, might include a bed in the patient’s home, I’m not sure you can solve the problem.
The next thing that I will suggest is something I alluded to earlier. 3) Recognize that the market is evolving to help us meet this need. Is it time to inventory or re-inventory the potential partners in your market and the capabilities they have for caring for higher acuity patients in other settings? This could include everything from their acute care at-home companies. There are technology partners. No favoritism here but to pick one, it’s interesting what Best Buy is getting into here. Bringing some of their in-home capabilities.
I’m increasingly seeing organizations turn to community paramedics as a way to offload some of the burdens of caring for patients in the home. You probably should do a market scan here and understand who these players are. Maybe do a little bit of a SWOT analysis, Strengths, Weaknesses, Opportunities, and Threats, to understand whether they are a good potential partner for you. A couple of things that I would recommend organizations take away and think about if they’re going to revisit the challenge that’s in front.
Dave, I love the things you just mentioned. I would hone in on a couple of things that you said about the tools and the technology and the processes that people are putting in place as we go around the country with ABOUT Healthcare. Talk about how we can enable case management staff and leaders and visibility and those partnerships, those close relationships with their post-acute providers.
In the past, they thought of those as endpoints that they could leverage if they were available. For us, it’s all about tying these together better with technology and visibility. Also, the process to make those relationships stronger, so they’re more responsive so we can optimize that patient flow both from a technology and a process side. Honestly, you hit a nail right on the head there. That’s very practical.
Thank you so much, Dave. That was a great prologue to our conversation and a great value there for our readers. Thank you so much for taking the time with us to chat about this challenge. That’s a pretty universal challenge but also give some encouragement at the end. We encourage you to think about how you might contact him and use this information for your senior teams or your boards.
Ben and Darin, thank you so much for another fascinating discussion. Great questions and great insight. To our readers, thanks for spending time with us. There are a lot of shows out there. We hope to bring you some value as you read this. We also look forward to hearing your questions and comments. Until next time, we’ll see you next time on the show.
- David Willis – LinkedIn
- ABOUT Healthcare
- Health Management Academy
- Dr. Tricia Baird – Previous Episode of LeaderDialogue
About Dave Willis
Dave is an experienced general manager, strategist, thought leader, speaker, facilitator. He has deep expertise in experience in strategy, organizational change, and executive and board effectiveness.
Most recently, Dave served as the SVP, Center of Transformation at the Health Management Academy, having worked previously as the VP, Service Delivery and Health System Strategy at The Advisory Board. He is now providing strategic consulting services to health systems.
Dave will share his perspective and insights on this important theme and topic, providing practical suggestions that can be applied immediately.
David Willis holds a Master of Business Administration from Yale University, a certificate in Operations Research from The Wharton School, and a BS in Mechanical Engineering from Carnegie Mellon University.