LEDI 92 | Hospitalist-Based Leadership

 

Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. Sharing his perspective as both a Physician Executive and Hospital Board Chairman, David Sailors, MD of the Piedmont Athens Regional Medical Center joins us in this episode. Dr. Sailors takes us deep into how Piedmont is managing the changing and complex healthcare system landscape today with their hospitalist-based medical program in their leadership structure. He shares the best ways doctors, administrators, and other healthcare professionals can work together to provide the best standards of care for their patients. All of these in the midst of seeing through various challenges that include bedside care and staffing shortages as well as financial issues. Tune in to find out how healthcare practices can be made better for the benefit of patients and the community around you.

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Why You Need To Consider A Hospitalist-Based Leadership Structure With David Sailors, MD

This show is brought to you by the Malcolm Baldrige Foundation and our strategic partner ABOUT Healthcare. I’m joined by Ben Sawyer and Darin Vercillo, both of whom are executives at ABOUT Healthcare. For those of you who are regular readers, you know that we’ve been focused a lot on leadership challenges and change management topics. We’ve been discussing these over the past several episodes. We’ll be continuing these discussions with both CEOs and other healthcare leaders who have had to lead their organizations through these challenging times.

In this episode, we’ll be expanding on those themes and discussing the challenges of leading through adversity and all the other things that are going on in healthcare with our special guest, Dr. David Sailors. David and I have been colleagues. David is a good friend. Most importantly for all of you to know, David is one of the team physicians for the National College Football Champions, the Georgia Bulldogs.

David is also the Chairman of the Department of Surgery at Piedmont Athens Regional Medical Center in Athens, Georgia. He’s a vascular surgeon and a member of The American College of Surgeons, the Southeastern Surgical Society and several other surgical societies. There’s a reason that I wanted to have David on because he’s in a unique position. He’s a physician executive but he’s also the Chairman of the Board of Directors at Piedmont Athens Regional Medical Center. In addition to having that chairmanship of the board of the hospital and health system, he also is on the Board of Piedmont Healthcare.

For those of you who don’t know, Piedmont Healthcare is the largest integrated healthcare system in the State of Georgia. I thought it was very important to have somebody with the perspective of David Sailors, a physician executive who also is a board chairman and on the board of a very large healthcare organization. He’ll have some perspectives that maybe we haven’t considered as we’ve been discussing all of these challenges. David has also published a large number of articles and is a very well-respected member of the physician community in Athens and Piedmont Healthcare. Welcome, David. It’s great to have you. Thanks for coming on.

Thank you, Chuck.

Let’s start with a question. As a physician executive and hospital board chairman, you do have a unique perspective on what’s going on in healthcare. I’m curious what do you see as the biggest challenges going forward in 2023 and the next few years, not just for Piedmont Athens but for healthcare, in general?

There are 2 or 3 things that jump out of my mind to me. One that we all battle both practitioners who are in their local practices, as well as healthcare systems and local hospitals, is reimbursement. Reimbursement is a major challenge that we’re dealing with, especially given the role that government insurance or government carriers play in the healthcare market. The cuts that you’ve seen certainly on the physician side over the last couple of years have been fairly tough. It was 4% in 2022. It was 4% this 2023 but they cut it to 2% and that’s an across-the-board cut.

Most businesses would have a hard time tolerating that cut. Practices are taking pretty good hits. The other thing is there were more cuts than just that 6%. There were individual cuts to specialties, especially in the procedural area that were on top of those cuts you could see certain specialties had across-the-board cuts that hit double digits. Reimbursement is certainly one that jumps out to me.

The second one is something we dealt with throughout the pandemic that we still can’t seem to recover from and that’s staffing shortages. Those are huge issues that we’re constantly facing. I have some ideas or opinions about that and I’ll be happy to expand on that if you like. The third one for me, which hits home is the chase to zero harm. There’s a constant chase to eliminate adverse events in the healthcare setting and inside your hospital. Those are the three things to me that will highlight 2023 and beyond.

There's a constant chase to eliminate adverse events in the healthcare setting and inside your hospital. Share on X

In your board position, you’re discussing a lot of the challenges. As a board member and a physician, your perspective may be a little bit different than some of the board members’ perspectives. What conversations are you having about these issues with the board? What are some of the things that you see the board addressing to try to obviate some of these things?

The conversations generally from the administrative leadership team that you’ve sat in are from the data and information that we’re getting. If you look at staffing shortages, we’re getting the data and information to the board members so that they understand exactly what it’s costing the institution or facility or in the Piedmont setting, the total system, what’s it costing. At least your board, which may also have some laypeople on it so they understand the financial situation that you’re faced with.

The other thing is we’re discussing what people’s thoughts are as to how to move forward. Anyone that has ideas as well as the administrative team, we’re having a constructive debate about it. I’ll give you a good example. During the pandemic and even to this day because of staffing shortages, there’s this conversation of the poor term, “Stop doing elective surgeries.” I don’t think there’s any such thing as elective surgery. No one walks in off the street and says, “I got up this morning and I decided I wanted my knee joint changed so I’d like you to put a ball and socket joint in my knee because I felt like it.” It’s not elective, maybe non-urgent.

These are people that have problems. They’re having symptoms that are needed to be addressed. It’s not life-threatening. In Athens, when we went through that conundrum a lot of facilities were shutting down those surgeries but we didn’t shut them down. We recognized that we played a role in the community and we had to figure out how to make sure that all of our patients got access to care if they needed the care. We figured out ways to make sure that those individuals were able to access the healthcare system throughout a time when a lot of places were shutting down. It’s because of how we looked at those patients is why we were able to do it that way.

The other thing is staffing shortages in particular. I hearken it to NIL in college football. You can’t chase the money. It’s hard to constantly raise the bar financially. It’s unsustainable like the NIL situation that we’re seeing in the nation in college football because each year the dollar figure goes up, it doesn’t go down. At some point, you have to recognize there are things we can’t pay for. If the personnel is chasing dollars elsewhere, then that’s a real conundrum if you’re not going to be able to constantly raise the dollar bar inside your facilities.

LEDI 92 | Hospitalist-Based Leadership
Hospitalist-Based Leadership: If the personnel are chasing dollars elsewhere, then that’s a real conundrum if you’re not going to be able to constantly raise the dollar bar inside your facilities.

 

Where does that come out? The conversations with legislative help, “Do you have the ability through legislation or some governmental assistance where you can either access money or can they give you some ability to work and collaborate with hospitals in your region where you’re not constantly chasing each other trying to raise the dollar figure?”

You bring up some incredible points when you talk about government involvement. I think back to the State of Arizona, interestingly enough, where we did some collaborations with them during the peak of the COVID time. They were suffering from nursing and staffing shortages. They had their influx and outflux of people in Arizona. The state government got very involved in recruiting and helping to fund the recruitment of 500 or 1,000 nurses from out-of-state to bring them in to meet the need. They didn’t leave all of the hospital systems on their own.

To your point, they saw the need in the community, addressed it and were proactive in it. As we look at this nursing shortage issue and the problem that it’s creating like having to downsize the number of people that hospitals can take and shifting people all over the place in transfers, where’s our solution there? Where’s our solution to bringing more nurses but also making better use of what we have?

One of the things that I see, the use issue jumps out to me. The traditional role of nursing at the bedside seems to have gone by the wayside. The traditional role that we see, if you walk a floor of a hospital with a nurse, they’re computer charting because that’s all they’re doing. They’re constantly charting. For those of us who work inside of the electronic medical record, it does not increase efficiency. You cannot see more patients by using EMR. It decreases your efficiency and sees fewer patients by using EMR.

If you talk to a nurse, they will tell you that it takes so much time for them to do their electronic health record charting. It dissatisfies them because it takes away from their ability to be at the bedside with patients. From a nursing shortage standpoint, we have to recognize that nurses don’t go into the field to stand in front of a computer screen and chart into the record. We have to figure out how we’re going to get them back into that role that they played at the bedside with the patients in a little more of a traditional nursing matter that is not there.

LEDI 92 | Hospitalist-Based Leadership
Hospitalist-Based Leadership: From a nursing shortage standpoint, we have to recognize that nurses don’t go into the field to stand in front of a computer screen and chart into the record.

 

If you don’t mind me asking, has there been feedback from patients in that regard as well? Have you seen a trend in data as it relates to patient satisfaction? What have been the responses to try to fill in that gap in terms of bedside care?

Patient satisfaction scores are part of any healthcare system’s rating. The patient satisfaction component is a big deal both on the physician’s side and the nursing side. If you looked across the board, they’re generally pleased with the care they received but if you look at that interaction, the verbal communication between the physician and the nurse, it’s not what it needs to be. That’s probably a low point. It may not be the lowest point it’s ever been but it’s still a low point when you look at a patient’s comments about their care when they’ve been in a healthcare setting.

It indicates that there’s a need for you to address this.

That’s a huge opportunity. That problem we have though is the EMR monster perpetuated the healthcare system to where we’re like, “How do you turn that back?” I don’t know how you turn it back. I don’t know if there’s additional technology that allows for an automatic population of data into the records so that nurses aren’t there clicking and there’s data that will automatically populate. I’m sure that technology’s out there but then you get into the concept of you’re trying to figure out how to pay your nurses and then you’re trying to figure out how to buy the latest piece of equipment so you can free the nurses up. It’s a never-ending battle, which is why reimbursement is a big deal.

It’s a conundrum.

When you look at reimbursement, CMS’ latest numbers are about 18% and 18.5% of the GDP is spent on healthcare. Why not 20%? That’s the most important thing we can do is take care of our constituents and the people in our community. Why does it have to be cut? Why does somebody not stand up and say, “It needs to be 21% of our GDP?”

What’s more important than the healthcare of the people who live in this country? There’s nothing more important than that. There’s a little bit of a mind shift that has to take place at the leadership level with when state capitals and national capitals when they’re looking at these numbers and understand that funding the health of the people of the nation is not a bad way to spend your money.

If you put on your Piedmont Healthcare System board hat for a second, Piedmont is well over fifteen hospitals throughout the State of Georgia with over 3,000 physicians. Unlike many other hospitals, both independent as well as hospitals that are part of systems across the country, the number that is doing well in terms of their financial position has been dwindling but Piedmont has seemed to continue to do very well.

If you can give our readers some ideas of the things that you’ve seen Piedmont do, both in terms of Piedmont Athens as well as the system as a whole that’s allowed it to maintain its positive financial position and very high regard by patients in all the communities that they serve. What do you see as some differentiating things that Piedmont Healthcare has been able to do, particularly as you see that rating over the last few years where everybody’s been struggling?

First and foremost, there are two types of leadership and you’re aware of this. There’s your executive leadership and your individual facilities. There’s an executive leadership and the health system. There’s your local physician leadership. They’re not all the same. They don’t all have the same skillsets. They don’t all bring the same thing to the table when you’re on a boardroom or in a meeting room.

What Piedmont has done a great job from the administrative side is hiring good chief executives starting at the system level with Kevin Brown whose Q scores are off the charts. Kevin does a great job. On top of that, at the local facilities, there are 19 acute care hospitals and 6 additional. That’s a total of 25 facilities. It’s a large healthcare system. They’re able to generate profit margins that most people are having a hard time generating.

It’s the governance structure. I’ve watched it and become well aware of how boards have operated but if you look at your board structure or strategies inside your boardroom when you’re talking about big health systems and local hospitals, traditionally we think about physicians on boards with expertise, complex clinical outcomes and data that are being shared and add to the boards, we’ll say cognitive diversity. That’s how you look at docs on a board.

We also tend to understand the facilities’ strengths and weaknesses. That’s by virtue of our daily presence in the emergency departments, on the floors, in the ICUs and the operating rooms. We have an understanding of what’s going on inside the hospital and sometimes maybe even a little more than a chief administrator whose focus may not be always inside the hospital or the clinical setting. Those are the politically correct answers as to the model of a board and how physicians interact.

I’ve seen the way Piedmont does things and I like the way they do it. We have a parallel system. Piedmont has a system of clinical governance councils that are physician-led. It’s a Piedmont clinic. It’s a clinically integrated network of physicians involved with the majority of the Piedmont hospitals. As you stated, there are over 3,000 physicians. We have clinical governance councils involving every specialty that you can have. Each clinical governance council is led by a physician. We drive the goals towards evidence-based medicine, making sure we’re doing the right thing and using the right equipment. We hold the health system accountable for doing things for budgetary means.

For example, if it’s a piece of equipment that you may not like and there are some potential problems with it. The CGC has the ability to interact with the administrative side in those regards. At the same time, the administrative side holds the CGC accountable by saying, “Make sure you’re doing this with evidence-based information. Also, we’re going to hold you all accountable by getting your physicians to buy in throughout the whole system.” In other words, not just in one hospital or one group but we want 100% physician buy-in. That’s the right model.

You know better than I do what boards need. In a boardroom, you need a doctor or two in there but you don’t. What you need are finance expertise, real estate expertise, IT expertise, regulatory expertise, compliance expertise and human resources expertise. Physicians need to be leading the clinical side and inside the hospital. They need to be communicating with the board about things they need to do their job at a high level. The board needs to work hard to help them get it.

You’re using Piedmont as an example of what you’re trying to say. Piedmont as a system leads with the Piedmont Clinic. It doesn’t lead with the hospitals within the Piedmont Healthcare system. Maybe you can say a little bit more about this but the reason I’m saying it that way is because what you’re saying is the key appears to be a true partnership between clinicians and non-clinicians.

Clinicians have their voice through the clinical governance councils. The administration has its voice through some of these other entities and the boards. That seems to be a differentiating factor that you’re talking about the importance of this partnership. The administrators realize that they don’t understand clinical medicine that well and that doctors understand that they don’t understand administrative medicine that well. “Let’s work together to make this as good as we can for our patients and communities.” Is that a fair way to put it?

That’s a perfect synopsis. That’s exactly what’s taking place and what we’re striving to achieve. The other thing we want is whether you go into one facility, another facility or a third facility, your standards of care, your level of care and the outcomes of care are going to be equivalent. All the facilities are going to have clinicians at least involved in the decision-making as it relates to how we’re going to provide care throughout their local communities and for the system as a whole.

The goal here is zero harm. You may know better than me about the latest number. I was at a meeting where it was something like $500 million a month in the United States is what it costs for adverse events. Chasing zero harm is both economically advantageous for your healthcare system and more importantly, it’s better for the individual patient.

Chasing zero harm is both economically advantageous for your healthcare system and more importantly, it's better for the individual patient. Share on X

This initiative started sometime around ’99. I’m quoting from a meeting I was at. It was around 44,000 to 98,000 adverse events in the United States at that time. There was a publication in 2010 that said 27% of Medicare patients have an adverse event while they’re hospitalized. That includes things like low blood pressure or something even more serious like delay in care as far as procedural based, sepsis or something along those lines that develops as an inpatient. Fast forward to 2020, they took a look again and we had dropped from 27% to 25% of patients that are Medicare beneficiaries still have that same risk.

There’s a lot of opportunity here for us. That’s a big one. The way you do that is by creating evidence-based care and a lot of times that involves standardization of order sets, which is a huge one. Whether it be in surgeries like total joint order sets, colon order sets or robotic urologic order sets. You can go through each specialty and come up with standardizations that could be uniformly adopted throughout a system. Frankly, they ought to be uniformly adopted throughout the country because whether you’re getting your colon operated on in Athens, Georgia or Los Angeles, it ought to be the same evidence-based care that’s done both preoperative, intraoperative and postoperative.

Those are the things that as an administrator are happy to hear there’s a doctor who says, “We want to chase that,” because you all talk about it but the reality is physicians are the drivers of it. We drive it. You as a CEO could talk to doctors all day long trying to get them to come up with a standard order. If you can get your doctors to buy in or create governance structures where your doctors lead themselves, then that’s when it happens.

This is a great insight. We started the conversation with a top concern that you articulated that every health system is articulating, which is the bedside care and the staffing challenge. How has Piedmont used this skillset that you have of the clinical governance council combined with the boards to start looking at that problem? What are some of the innovations that you guys are identifying because of that collaborative look?

From the bedside care standpoint, we’re looking at standardizing a lot of care that goes on at the bedside. We’re doing that through standardization with an evidence-based order set. We have them for the things that I was mentioning. We have sepsis alerts and sepsis-based order sets. We have requirements where those alerts go off. There has to be some documentation in the chart usually within a timeline period as to whether this was truly a sepsis potential problem or not. Those are the things that we are trying to integrate.

It’s not easy because when you start systems like this aren’t perfect. We’ve had to troubleshoot but our goal is the right goal which is to come up with a system that minimizes the risk of any adverse event to one of our patients. We have someone from the internal medicine hospitalist arena. Chuck gave me a forum so you’re going to get it. The role of the hospitalist-based provider in your leadership structure is not uncommon. If you look at leadership structures throughout these hospitals, the hospitalist service line is not represented. Sometimes it’s your superstar specialty people and some of your hospitalists are not represented.

LEDI 92 | Hospitalist-Based Leadership
Hospitalist-Based Leadership: Our goal is to come up with a system that minimizes the risk of any adverse event to one of our patients.

 

Three-quarters of the patients in the healthcare system during the pandemic were cared for by hospitalists. They are the leaders inside of a hospital when it relates to documentation, which also helps your reimbursement. They’re making sure that you’re getting everything documented on a patient the way it needs to be documented to submit a bill.

I’ve become a real advocate over the last couple of years for our hospital-based medical program and for them having leadership positions inside of the system i.e., division chiefs, chairs of departments and positions on boards. They need to be there. They’re probably the biggest medical driver of quality because they’re there all the time. They’re not in the hospital for a half day or a day and then not back at the hospital for the next two days because they’re in their office setting. They’re there every day. That’s a huge deal as well. I’m interested to hear what my hospitalist colleague thinks.

It’s music to my ears and I owe you a steak dinner for that advocacy there. That’s been my experience as well. Back to the first time that I took a hospitalist position, the hospital that I was working with and the medical staff coordinator and the CEO of the hospital was very strongly advocating what you mentioned of having those positions on the medical executive committee, working towards the board and having that representation. To your point, it permeates all aspects of the hospital practice and having hospitalist representation on not only the executive committee but all of the subcommittees and the decisions they’re making with regard to rules, regs, policies and procedures is crucial.

I applaud you for your recommendations despite the fact that many hospitalists work for large hospitalist employment organizations and sometimes they’re commoditized because of that. They still need to have that relationship and advocate that relationship within the hospitals they have of leadership positions and not just sit back and consider themselves a shift employee that doesn’t have a say in their surroundings. It comes from both sides. The administration needs to recognize the value. The hospitalists also need to step up and grab the bull by the horns.

You made the reference to the whole NIL thing and that’s something that they’re chasing there and isn’t sustainable. Not to put healthcare systems in the same situation but there’s something that hospital systems are chasing a lot in the acquisition, growth of brand and recognition. Those aren’t necessarily bad things. Don’t get me wrong.

You mentioned creating this system or approach with respect to your opinions, your visibility of the industry and what you’re doing at Piedmont, talk to us about that growth initiative and how are you leveraging your system for all of the resources that it has across in your many hospitals. Load balancing or resource balancing, where does that play the role in your board’s decision-making and the targets that you look at as a senior administrator within Piedmont?

The horizontal integration that’s going on in healthcare has certainly taken place inside the Piedmont system over the last several years. Acquiring light facilities that provide the same care is something that has been taking place throughout the country. The most important thing to me is how you manage it from a system level. There are always struggles when you get inside a big system with the ask or the needs because the system needs to look at local facilities as well as looking at the system as a whole.

They’re always going to have the issue where you have to recognize there’s a discussion, negotiation and prioritization that takes place with your needs on your local level when you’re a healthcare facility inside of a large system. At the same time, the most important thing we’ve been able to impart as physician leaders to the system is that you’re a system only because of your local facilities. Without the local facilities, you’re not a system. If we weren’t there, you’re not there.

We have to provide a level of care inside our communities. Certain things are expected inside of our communities. Everybody understands that if your local facilities are doing well, your system is doing well. If your local facilities are not doing well, your system will reflect that same bottom line. That’s a reality. Here in Athens, starting with Chuck when he came in and led us through a bad time, getting us out of a negative and turning it into a nice positive and then handing off the reins to Michael Burnett, who’s done a great job taking and managing it through the pandemic. We were very fortunate.

At the end of the day, that comes down to the executive. I’m a surgeon. We call it as we see it. Reality is like anything else there are master chefs and people who grill in their backyards. Some CEOs excel and are phenomenal. Some struggle. At the end of the day, administrative talent is a big deal. Good administrators are worth every penny because they can manage you at times when it’s difficult. Administrators who are not quite of the same abilities may struggle when things get tough. To me, that’s the human capital side.

Administrative talent is a big deal. Good administrators are worth every penny because they can manage you at times when it's difficult. Share on X

David, this has been a great conversation. As a physician as well as a former CEO, this whole idea about the true partnership is key to the whole thing. You’ve done a great job of talking about that. We appreciate your insight and perspectives. You’ve done a great job on the sidelines based on the results that the Dogs got as well. Congratulations on that. Have a great year and thanks again for joining us. It’s been a great discussion.

Dr. Sailors, thank you so much again for being on. It’s great to see you again and go Dogs. For the readers, we have a webinar coming up on Tuesday, February 21st, 2023 at 12:00 Central and 1:00 PM Eastern. The title is The Leadership Challenge: Managing and Innovating Through Change. It’s a lot of what Dr. Sailors has been talking about. It’s going to be a round table discussion. You don’t want to miss that.

We also are taking on a very practical-themed approach this 2023. It’s like a day in the life of leadership like what David has talked to us about and addressing hot topics that leaders are dealing with. We’ll be working on those in various episodes as well as events like webinars and so forth. We hope that this is helpful for you as healthcare leaders and physicians that are navigating through this challenging time.

 

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About Dr. David Sailors

LEDI 92 | Hospitalist-Based LeadershipDr. Sailors received his medical degree from the Medical College of Georgia, completed his residency in general surgery at the University of Tennessee College of Medicine in Chattanooga TN. He then completed his vascular surgery fellowship at the University of Arkansas in Little Rock, Arkansas.

He is a Fellow of the American College of Surgeons and an active member in the Southeastern Surgical Society, Society of Vascular Surgery, and the Peripheral Vascular Surgery Society. Though interested in all aspects of vascular surgery, he brings special expertise in the field of endovascular surgery.

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