LEDI 99 | Patient Throughput

 

Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. The show has been with great experts who share their wisdom to help leaders navigate these changes within the industry. In today’s special episode, Dr. Roger Spoelman and Dr. Chuck Peck are joined again by Darin Vercillo and Ben Sawyer of ABOUT Healthcare for a Quarterly Co-Host Review. They talk about what they have seen going on in the environment and reflect back on some of their previous conversations with guests. Tackling issues with throughput using sports metaphors and fighter pilot analogies, this conversation will fill you with fresh insights on how to get your organization to the level of performance the health system wants. So tune in to not miss out!

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Baldridge Leader Dialogue Quarterly Co-Host Review: On Patient Throughput And Production Science

Thank you so much for joining us for another edition of LeaderDialogue. LeaderDialogue is brought to you by the Baldrige Foundation and made possible by our strategic partner, ABOUT Healthcare. Speaking of ABOUT, we have Darin Vercillo and Ben Sawyer as usual with us. They are two executives with ABOUT Healthcare. Welcome, guys.

It’s good to be on with you, Roger. Thank you.

My co-host, Dr. Chuck Peck, is also here. This is a special time. We think it’s special. We hope you do too. Quarterly, we get to have a round table discussion amongst ourselves. We’re the ones who handle the interviewing duties of our fascinating guests that we’re able to source for you. Hopefully, they provide you with a lot of information and a lot of encouragement in dealing with the challenges that you have in your day-to-day work.

We are going to talk a little bit about what we see going on in the environment, and then reflect back on some of our previous conversations with some of our guests. If you haven’t heard those, hopefully, you’ll be able to go back into the archives. First of all, let me try to set the stage here a little bit. Reading the headlines of our industry, there’s not a lot of feel-good stuff going on out there. In fact, there are some concerning and maybe discouraging things as I was reading about some of the larger health systems posting significant losses. One of the largest health systems in the country, nonprofit systems, posted a 9-month $1.1 billion loss, which was about twice what they were in 2022. This has become a pretty common story among some of the larger systems.

What happens when we have that kind of stress internally is we start making decisions. Some of them may be good decisions. Some may not be so good decisions, and time will tell whether or not it was the right approach. Certainly, all of the systems that we’re familiar with and you are all familiar with or involved in are looking for operating efficiencies and ways to reduce your expenses. I want to throw it open to my colleagues and talk about what you are hearing and seeing in the news, and what concerns you about some of the reactions and responses that we’re seeing in these market conditions.

Roger, this is Chuck. This is an interesting day for me to be talking about this because in about an hour, I’m getting on a plane to go up to a system in Pennsylvania that has never had a loss or a negative margin. I was going to say losing year, but a negative margin in its history until 2022, and 2023 is looking even worse. It’s not to the extent that you mentioned the other system of over a billion. This system is nowhere near as large as that.

What they’re focused on now is the whole issue of throughput. They’re having the same issues that other people are having. They’ve got a lot of people sitting in the emergency room. They have people sitting in the ICU that can’t go out to the floor. They’re at a stalemate with their post-acute care providers. They don’t understand or know exactly what to do about it.

Some of the things that we’ve heard on the show from our most successful organizations, almost everybody now is moving to multidisciplinary rounds. This system tried it and did it, but they didn’t do it long enough to get the behavior changed. That’s obviously a problem. This system also has another issue that we talked about with our friends in Northern Arizona, which is the whole cultural issue of the hospitals. I’m sure Darin will have something to say about this.

The hospital is still having the feeling that they’re the ones who make the final decisions on these patients, as opposed to a team approach, which is what multidisciplinary is all about. Everybody is involved in rounds early in the morning if possible, and making sure everybody is on the same page about what the patient needs and when they need it. They are starting to talk about discharge planning even before the patient hits the floor almost.

This whole issue of collaboration amongst the different folks. A lot of frustration among nurse practitioners who are not being utilized up to their full license by a lot of the physicians. This seems to be a common problem of lack of coordination of care of the patient by all the people who touched the patient during hospitalization. Lack of teamwork and collaboration among all the people providing the care. Poor communication among everybody providing the care. Having an organized way to meet with your network of providers in the community or community providers. Not just post-accused providers but home and hospital-at-home providers. Having an organized way to think about the processes involved.

Having a system or a technology that I know of about providers where all of these different pieces and parts can be linked so that everybody has an understanding of what the plan is and they can be ready for it. I think that’s the major obstacle that’s facing most of these systems. We haven’t even talked about behavioral health, which is a whole other major problem we discussed an episode or two ago.

Thank you for that, Chuck. We could mine that and talk for hours just in your comments. You said something that made me think, and I would love to hear from Darin. Darin, you spend a good share of your time practicing medicine still. With what Chuck was talking about, it occurred to me, who’s in charge? The level of frustration that physicians have. We’re just on the heels of Nurses Week. Shout out to all of our nurses and nurse leaders. They’re absolutely essential to our healthcare system, but who’s in charge? Do you get a sense of greater control or less control? I wonder who’s in control.

Control is an illusion. First of all, thanks, Roger and Chuck. What a great summation of many of the things that are going on that are so interdependent in the hospital environment. Certainly what I’ve been seeing is no different. Interestingly enough, the organization where I practice here in the Salt Lake City area was just the five hospitals here that were part of that network. Were just acquired by another network. We’re making a shift from being a for-profit organization to a not-for-profit religious-based organization, which is going to be a fantastic shift in experience for all involved.

It is definitely “roll up your sleeves and think outside of the box” time for administrators across the country in organizations. Whether you’re acquiring a new set of hospitals or merging together and bringing cultures together, or you’re just looking at your own organization trying to fix the issues. A lot of it is throughput based on the hospitalist and intensivist work that I do. It’s a daily question. This idea of being nurse full as opposed to bed full is pretty much the common thing in all hospitals these days.

It is definitely “roll up your sleeves and think outside of the box” time for administrators across the country in organizations. Click To Tweet

As a physician, attending to your patients, especially as a hospital-based physician, the same question is still being asked. Where do you start on a particular day? You come in and you have critically ill patients in the ICU. You want to get to them first because they demand your attention. They’re complex, and they need decisions made right off the bat. You’re supposed to have those discharge orders written by 11:00 so they can make the decision and start getting them out the door by the time the nursing shift change happens. What are you doing with patients that are backed up in the ER that can’t be transferred out? They can’t be transferred in. They can’t be moved from level to level. It’s a pervasive issue.

I like some of the things that I’m seeing happening. Chuck mentioned this idea of MDRs or Multidisciplinary Rounds. Everybody is very purposeful in the movement of patients through their stay, rather than just letting things unfold. We can make better decisions. We can make more purposeful decisions. Granted, things are going to come up. Patients are going to throw curve balls at you. Their health status is going to change.

Things are going to get delayed the more purposeful we are. I don’t think that physicians should look at this as control being taken out of their hands with respect to the decision-making with their patients. We should look at these as more tools in our tool belt to get things done and get them done correctly so we can move patients through the experience. That’s one thing.

Secondly, with the float pool nurses, agency nurses, and expenses. We know we had our little chat before this talking about some of the things that we’re seeing there. We may have to reverse some of the things that we’ve seen. We got rid of all the LPNs out of the hospitals because they’re coming back. Necessity is the mother of all needs and decisions. We’re there. We have to staff. We have to bring back people in.

Many of these were great experienced people. Let’s leverage that talent rather than spending ten times more than we normally would to get other talents through the door. These are just a couple of examples, and there are many more. The relationships between organizations and making sure continuity of care is there so we can make sure patients move to a place where they can be successful. Don’t bounce back and don’t readmit is a very important part of this as well.

Thanks, Darin. Let me just summarize though. I want to clear that. You, as a physician, still feel like you are the decision-maker. The responsibility for that patient’s care while they’re in the hospital, readiness for discharge, and meeting the criteria are firmly in your court. You rely on the help of all these other ancillary people. I’m sure there are more frustrations than perhaps in the past, but it still is very clear. You are in charge.

That will continue to be the case. That being said, there are lots of different ways to help incent to drive the outcomes that you’re looking for. Ultimately, the physician has to make the decision, “My patient is ready for discharge based on my clinical acumen and judgment.”

We’ll get to that discussion that you and I had with Tricia Baird about preventing re-admissions. Ben has a question or comment, and then Chuck.

With the physician as the captain of the team, the team needs to work off a script. One of the things that are coming forward again as we’re looking at patient throughput is this whole notion of production science. In other words, what is the important variable that you’re trying to drive, which is a high-quality and healthy discharge? What is that date? What’s authorized? What are the obstacles? Anticipating that as early in the stay as possible. They have underway the post-acute care referral process to be able for patients that need that kind of care. Get that transition of care buttoned up as soon as possible so that discharge becomes a little speed bump instead of a big obstacle that creates all kinds of extensions.

The context for that is hospitals in these big loss scenarios that you describe, Roger, are getting erosion in direct-to-consumer markets from outside competitors. That’s cutting into their bottom line in significant ways. They clearly have to do extremely well in the business that they own exclusively, which is the acute care medicine business, particularly inpatient stays. This science of patient throughput optimization has to become a superb skillset for them, which we’ll talk more about. That is a thread in all of this that we’re talking about.

Thanks, Ben. Great point. Chuck?

Darin, I just wanted to ask you a question based on what you said. I totally agree with everything you said, but I’m wondering. I believe it’s now in your state, Utah, where nurse practitioners were granted the same abilities to do whatever as physicians. Maybe I misunderstood that. Has that caused more communication issues or more confusion around who’s in charge, and that sort of thing? How is that going?

We’re 1 of 26 states now that have that designation for nurse practitioners. There are some physicians who might feel threatened by that. In our particular practice, interestingly enough, in a hospital’s practice, we are a group of physicians that have physician assistants and nurse practitioners that work with us and alongside us that make decisions that we support. For us, it has not been a confusing state. We are all comfortable in the environment that we’re working in with autonomy, support, and the tools that we need to get the work done and do what’s right for the patient. We work as a team. There’s no pulling power away. There are no power struggles or boundary issues because we’re firmly planted as a team together.

Ben, you talked about the need for a plan. The physician is in charge. There has to be a plan. It takes me back to a comment that Dr. Tricia Baird made when Darin and I had this fascinating conversation with her about this notion of a whole-person approach to preventing re-admissions. It’s interesting. We got to read the paper to get the full impact of this, but she talked about football and she used a football analogy. It occurred to me when you said, Ben, talking about the need for a plan.

In football, you got the quarterback who’s theoretically calling the plays. Actually, it’s the coach more often from the sidelines calling the plays or the offensive coordinator up in the press box or whoever is calling the plays. The important thing about that is everybody on the team and everybody on the field knows the play. The quarterback may be the one who executes it, or it may look as though they have responsibility for the execution of the play, but everybody on the team knows the play. They know the script. What do you think about that analogy? That’s pretty interesting.

It’s a viable analogy. It cuts to the heart of the siloization of healthcare. I’ll give you a simple example. Many hospitals have limited diagnostic resources. Radiology, for example. If they’re seeing a lot of outpatients on inpatient MRIs, etc., it compromises their ability to expedite the care for the inpatient. That would be similar on a football field to the wide receiver not just listening to the quarterback but they’re taking passes on the side.

How could they even possibly work? In your analogy, everyone has to be dialed into that particular play and the execution of it. In healthcare though, because of the nature of complexity, siloization, and lots of different things that we’re trying to accomplish, we can often run across purposes. Another good example is you have physical therapy up in the patient unit doing ambulation with a patient. They didn’t know that radiology was trying to bring the patient down. The radiologist shows up, “Where’s the patient?” “Physical therapy is down at the end of the hall walking them.” That’s incoordination.

LEDI 99 | Patient Throughput
Patient Throughput: In healthcare though, because of the nature of complexity, siloization, and lots of different things that we’re trying to accomplish, we can often run across purposes.

 

It’s wasted time.

When you’re talking about going after it, it’s a production mindset. You have to understand what’s important, which is this intersection of quality and logistics. The logistics are you have an authorized length of stay. The patient has to get out at a particular time unless their condition changes. Otherwise, you’re going to get into avoidable days. That’s going to go right to the bottom line in terms of lost revenue.

Quality is how you make sure that the patient gets exactly what they need so that they have a high-quality discharge. They’re not coming back in for avoidable re-admissions because you didn’t somehow get done what you needed to get done, or they didn’t have the home instructions, or whatever the case may be.

Those two things, quality, and logistics, come together in a production mindset. It then has to be a well-coordinated team approach. More health systems can pursue that, which also incorporates their technology. Not all technologies support that flow because they’re built modularly. You have a module for diagnostics, physical therapy, or whatever.

Plug and play.

You have reports and analytics for each of those areas, but it doesn’t mean that they actually support your flow. They’re supporting documentation and billing, but they’re not necessarily supporting your production flow. All of those things are things that health systems are going to have to take a hard look at and make sure they do that well so no one can intrude in that space for them because that’s their bread and butter. They then can go out and more effectively compete in the market outside of that acute care medicine space.

Roger, let’s talk about that one last comment, the elephant in the room, based on what you were using as your football analogy. It’s not just that the offensive coordinator sends the play down, and everybody knows it. If the wide receiver decides to go and do his own thing, it’s not 1 or 2 plays that they’re yanked out of the game, and a new person is put in their place. It goes right to communication and collaboration as well. It’s not just getting the play in, it’s assuming and insisting on the accountability of everybody on the team following that play. They may not necessarily like the play or think it’s the wrong play for third down, but they’re going to have to follow what’s called. Otherwise, there’s total chaos.

Not to torture the metaphor too much, but there’s film day. That’s something that we don’t typically do. The same thing with fighter pilots. I don’t know what the ratio is in terms of the flying hours versus doing the recap. We should do more of that in healthcare. Don’t you think? See what worked, what didn’t, and let’s make sure we’re not going to do that again. Darin, go ahead.

This is a fantastic conversation. The fighter pilot analogy is great. Early in my career when I was practicing right near an Air Force base, I pulled a fighter pilot inadvertently out of the rotation because he had a DVT. I told him he had to be on Coumadin, and then he couldn’t fly. I thought I had committed treason against the country because I was taking him out of the rotation. That being said, imagine the team analogy and you just had a 22% turnover in your team. We are facing that across the whole industry where we have new nurses and new staff members coming in across all of our areas. That’s expensive to do all that recruiting, hire all that people, and deal with that turnover. Not to mention the limited capacity by having reduced numbers.

It’s so important to take a look at what we’re talking about, making sure that people can be on the team, understand the plays, and train them. I get back to this whole idea of rolling up our sleeves and thinking outside the box. We don’t have to think that far outside the box because we’re just getting people to do the things that we know work. We have to get a lot of new people so we can play as a team together and get that coordination and effectiveness.

Darin, you bring up an important point. The increased percentage of contract labor has a direct impact on cultural alignment. These people are in to do a job contractually. They don’t necessarily know the culture. They’re not bought into the culture. They can miss the place whether intentionally or unintentionally. It’s harder for the C-suite, like Chief Nursing Officers and so forth, to be able to call the place and make sure that things are being conducted the way they need to. The resolution of that probably still has a tail from the pandemic that’s going to continue for some time. It’s the part where production science and logistics have to come into play. Those kinds of variables have to be handled and addressed to be able to get to the level of performance that the health system wants.

The unfortunate opportunity for mistakes, errors, medical errors You’re taking a player who’s been playing on another team and then dropping him into this team. They don’t know the playbook. They said, “This is how we ran this playbook at home. Now, I’m dropped into your team and thinking that I’m doing what’s right.” Think of the opportunity for errors and the inefficiency that occurs. Back to my original question, we think we know who’s in charge but I still say, who is controlling this? I don’t think we know for sure who owns all of this that we’re talking about.

Roger, I think you bring up a good point because even though as a physician, I may think I’m in charge of making the decisions and captaining the ship. How much is the tide dragging us in the direction that it wants to take us? We need to be purposeful so we don’t get dragged from one place to the other just because that’s the motion of the ocean.

We need to be purposeful so we don't get dragged from one place to the other just because that's the motion of the ocean. Click To Tweet

Darin, if you’re assigned one hospital of 30 patients, you’re going to get what you paid for. It’s not the doctor’s fault.

That’s true.

Even if they’re in control of the patient, they’re not necessarily in control of the assets. That’s the problem. When you’re designating what your patients need, that could be directly in conflict from an asset utilization standpoint with what a surgeon needs, for example. Therefore, somebody has to call the play to be able to say, “No, we’re going to prioritize this over that.”

It ultimately comes back to leadership. Roger, you brought up in our prep discussion that there have been some changes in some of these organizations where they’re taking out Chief Operations Officers that historically would be the role that’s responsible for making sure that all of these assets and all of these different things work well together. That may be a short-term staffing decision that may make sense but could be a long-term disaster. Depending on whether this is impacting your logistical capability and our production science.

What I want to do for the remaining few minutes we have because I don’t want to drive more people out of healthcare because we’ve just made them more frustrated. Let’s give them a little encouragement. Let’s see if we can do this in 2 to 3 minutes. Darin, could you talk a little bit about our discussion with Tricia Baird about making sure that we can avoid re-admissions? Just your recollection from that conversation. Chuck, you had a great conversation with K.C. about behavioral health. Let’s give our audience a little bit of encouragement.

Going back to the conversation with Tricia, she’s a fantastically dynamic leader and she just has done such great things. The thing that impressed me the most with what she described was how they crossed the traditional boundaries of bringing people together and rally around the patient. Whether you’re already in an IDN or you’re creating relationships with your preferred partners and other providers in the area, they had created a great model to make sure that everybody is working together for the betterment of the patient.

It’s patient-centric, rally around the patient, and communication. I love what I do as a physician. I love what we do, especially bridging barriers of communication and getting organizations so they can work together in a more streamlined and efficient way. I would throw that out there that there are some wonderful models, great tools, and fantastic technology that allow us to bridge those barriers and make sure that we can address larger cohorts of patients and larger groups of our affiliated providers in a way that gets everybody on the same page for the betterment of the patient and the organization.

We want to drive our audience to that episode if you haven’t heard it. If you have, listen to it again because there’s so much there. One could argue that as the physician responsible for the discharge, my job is to throw it over the wall. They’re out of the hospital. I’m done. I’m onto the next job and my next patient. She absolutely did not do that. That’s what their paper talked about. They went so far as to mapping the State of Michigan. When the schools were closed, they mapped each part of Michigan and some of the rural areas that simply did not have the bandwidth to teach remotely.

They had to put on school buses. They drove paper packets around to some of the kids. They used that data and they found out where were the gaps in health disparities and where the issues are. We refer you to Dr. Tricia Baird. It was a great conversation. Darin had some great questions. Onto you, Chuck. What do you think about behavioral health, and how do we encourage our audience in dealing with that?

K.C. runs a shared services organization that’s focused on behavioral health and crisis care. He’s been doing this for many years in several large health systems before becoming the CEO of his company. He emphasized a few important things. I think we all agree, and he certainly agrees that we have a mental health crisis in this country. It’s focused severely on kids and adolescents, but it’s also a problem and was a problem way before COVID for the adult population.

A few of the takeaways were the emergency room is probably one of the worst places in terms of the environment to put a behavioral health patient. Working more closely and collaboratively with your community resources or pharmacies, it’s trying to find better ways to maintain drug utilization and compliance and keep the folks out of the emergency room if possible. That was one issue.

LEDI 99 | Patient Throughput
Patient Throughput: The emergency room is probably one of the worst places in terms of the environment to put a behavioral health patient.

 

Another issue was when they come into the emergency room, it was a very loud and chaotic environment. Having a separate space just for behavioral health away from the main ED is probably a very good thing to do. That may involve keeping some beds open for patients. Having a separate unit or area near the emergency room, but completely apart from it, with mental health nurse practitioners taking care of the patient in a quiet environment would also be helpful.

This is very important that he said. Many times, these people come to the emergency room. They’re there for very extended stays that we’re all aware of, but they’re not continued on their meds. Whether that’s a question of them that the people in the ED not knowing what meds they were on, and not knowing where to call to find what meds they were on. If all possible, keep them on the meds that they had been taking that may have stopped or they may not have. Maintaining those medications is the third important point.

We then talked about potentially some innovative things to think about. I’ll give one example that I did when I was a CEO in a high behavioral health area. We actually leased some beds at the behavioral health center. Even though very occasionally they were empty, we had access to a few beds. We weren’t in the situation of having to spend 3 to 4 days sometimes calling around trying to find a bed. Sometimes you’re overwhelmed with behavioral health people, and you just can’t do much else other than try to find a bed. For the days when you can, having those beds available is helpful.

It was a great conversation. I listened to it myself. It was very interesting and a lot of practical tips there. Thank you, guys. Ben, we’ve got to wrap up. Any last comments from you?

For the audience, we will continue to have practical episodes around these kinds of themes that are helpful to healthcare leaders. This also includes webinars where we take a topic in for an hour. We have round table discussions on that. We have one coming up on May 23rd. There’s going to be another one in August. We do have planned in October a round table discussion with CEOs to get them aside for a day and tackle some of these things together where there’s a lot of sharing of peer information and some best practices from Baldrige and so forth.

That’s some great times. Very good. I enjoy these times, guys. You guys are smart. You have all the answers. Chuck, you’re going to go fix some hospital system, so safe travel to you. As Ben said, we want to do what’s practical and helpful to you. Please let us know. Go to our website and let us know if there are topics you would like us to discuss or give us some of your feedback. We’d appreciate that. Thank you for tuning in. Thank you to my friends here. We’ll be back with another episode. Stay tuned, and thank you for tuning in. Talk to you later.

 

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