Advancing Health Podcast

00:00:01:01 - 00:00:30:06
Tom Haederle
Welcome to Advancing Health. Quality and patient safety are the twin engines driving the mission of every hospital and health system, and both clinicians and board members have an important role to play in achieving these goals. Coming up in today's podcast, we hear from two experts from University of Utah Health about some of the best ways to help board members understand the critical role they play in making sure that quality and safety are always foremost in the patient experience.

00:00:30:09 - 00:00:53:15
Nikhil Baviskar
Hi, I'm Nikhil Baviskar program manager, trustee services here at the American Hospital Association. Today I'll be discussing the critical role the board plays in quality and safety. With me are Dr. Kencee Graves, who is the interim chief medical quality officer at University of Utah Health and is an associate professor of internal medicine, where she practices as a hospitalist and palliative medicine physician.

00:00:53:18 - 00:01:16:24
Nikhil Baviskar
Also with us today is David Calling, who has served on the University of Utah Hospitals and Clinics Board since 2016 and is currently vice chair and co-chair of the board Quality and Safety Committee. Dr. Graves, I'd like to start with you. You recently presented to the board at University of Utah Health on quality and patient safety, an extremely important topic now and always for board members.

00:01:16:29 - 00:01:19:18
Nikhil Baviskar
Can you give us an outline of that presentation?

00:01:19:20 - 00:01:51:22
Kencee K. Graves, M.D.
Thanks for having us. And I think this is a really important topic. So when I gave this presentation to our board, I was new in this role. And what I learned was people around me, our board, our staff, people did not really understand the nuts and bolts of quality and the details. And so one of the things I offered to do was a quality 101 session. And my intent in doing that was to make sure that the group I would be working with and I were starting on the same page, so we both knew kind of what was going on in the landscape of quality.

00:01:51:25 - 00:02:10:18
Kencee K. Graves, M.D.
So the content of my presentation really came from the questions I was being asked in my first few months in this role. And that is, what is quality? What is safety? How they are different. So what sets those apart? What are these ranking systems all about? Why do we do that? What are accreditation bodies, why do we do that?

00:02:10:20 - 00:02:22:05
Kencee K. Graves, M.D.
And then, what is a quality structure? So what are you responsible [for]? Who works for you, that kind of stuff. And so really that's what my outline was, was just the basics, what I consider the basics in quality.

00:02:22:07 - 00:02:38:29
Nikhil Baviskar
I think it's great that you, you did something where everyone starts at a level playing field. That sounds like a really wonderful way. I know that not everyone has the opportunity to do so, but definitely a good way to get everyone on the same page. Can you give us the response that you received from the board members to that presentation?

00:02:39:01 - 00:02:57:20
Kencee K. Graves, M.D.
Yeah, I do want to call out - when I started, I actually had really good support from our board members. And they told me that this is something that they wanted. And so I felt like I had an open invitation because Dave and our CEO said, hey, we really think people could use something like this. Would you be open for it?

00:02:57:20 - 00:03:15:20
Kencee K. Graves, M.D.
So they gave me the time. Many of them had been to the AHA and we used an AHA podcast by Jamie Orlikoff to kind of set the tone for that session. And so people went in with a really curious mindset. I actually did a Google survey after I gave the talk to make sure people learned and felt like it was valuable.

00:03:15:22 - 00:03:35:21
Kencee K. Graves, M.D.
The feedback I got were that people felt like they knew more about quality after this session than they did before. They loved hearing about what we did at the U. They really felt strongly about supporting quality and supporting our leadership and driving toward high quality care, and they wanted to know how they could be more involved.

00:03:35:23 - 00:03:44:27
Nikhil Baviskar
So, David, question for you as one of the University of Utah Health board members, what was your reaction to this presentation?

00:03:45:00 - 00:04:03:12
David Colling
Yeah, Nikhil, what I would say is a couple of things, a few things that Kencee mentioned. But also remember, community board members typically are not clinicians, they're not health care employees, so this is a bit of a foreign environment for them. And that's part of the point, right. To have community board members get, you know, to offer a different perspective.

00:04:03:14 - 00:04:22:09
David Colling
But what can happen is, as a board member, you can get pretty overwhelmed pretty quickly with whether it's the acronyms, the accreditation, you know, all the different things Kencee trained on can be pretty overwhelming for community board members. So, I thought it was excellent. And once again, I want to reiterate, it was really a 101. Kencee

00:04:22:09 - 00:04:40:02
David Colling
didn't take any for granted, whether it was an acronym or a word, something need to be defined. It was really quite effective in the way that she approached it. You know, the other thing I think is it helped us continue to elevate quality and safety, you know, as a really important topic for the board. Right? So this is not a sideline.

00:04:40:09 - 00:04:55:17
David Colling
This is a really, really important really the driving force behind the board. You know, maybe besides finance and some other things, you know, a really important piece of piece of the work that we do. So I think there's a couple of things, that I reacted to. And frankly, I've been a board member for, as you mentioned, almost ten years.

00:04:55:19 - 00:05:03:13
David Colling
And I learned a lot. So what does that tell you? Right. So I think it's good for existing board members and new board members.

00:05:03:16 - 00:05:14:01
Kencee K. Graves, M.D.
I think it was a really important launching point for the CMS structural measure that requires patient safety to be part of board meetings. That would have been difficult if we had not done already the Quality 101 session.

00:05:14:03 - 00:05:35:29
Nikhil Baviskar
Thank you for mentioning that. What you're referring to as quapi, we're seeing a lot of folks, other boards that are realizing this is something that has to be integral to the planning process and the strategic planning process. David, I wanted to ask you, a follow up on that. So as the co-chair of the Board Quality and Safety Committee, you said you learned a lot.

00:05:36:01 - 00:05:46:01
Nikhil Baviskar
Do you do you feel like Kencee's presentation sort of set maybe an agenda or help you and your other co-chair plan going forward?

00:05:46:04 - 00:06:02:13
David Colling
Yeah. I mean, again, it gave such a good foundation, and I liked what Kencee said about us all being on the same page. So I do, I think it's set an excellent foundation for the committee moving forward. Got us all kind of in the same spot, whether you'd been there for ten years like myself or whether you're a brand new community board member.

00:06:02:15 - 00:06:19:22
David Colling
You know, the other thing I thought it was nice to, you know, we had it wasn't just board members. It was the clinical and health care staff there as well. I think it's important for them to listen to the dialog, understand that should help them understand kind of that knowledge gap, whether it's quality and safety or whether it's other, you know, board activities.

00:06:19:22 - 00:06:32:15
David Colling
You know, the community board members do need to be constantly reminded of definitions and things that come naturally to clinicians and health care workers, that that we need to continue to, to bridge that knowledge gap. So, yeah, absolutely.

00:06:32:17 - 00:06:43:01
Nikhil Baviskar
So as you know, this podcast will be listened to, by other board members. David, can you give some nuggets of wisdom or some advice to other board members that may be listening?

00:06:43:04 - 00:07:04:06
David Colling
Yeah for sure. So again, going to reiterate 101 basics. You know, don't take anything for granted. Don't make any assumptions. Assume that you're starting with everyone that knows very little about, you know, not necessary quality and safety, but certainly quality and safety in the context of the health care environment. I'd highly recommend making it interactive, almost a Q&A ongoing, right?

00:07:04:06 - 00:07:23:12
David Colling
So in other words, and I think we did that, you know, we never have enough time in our board activities. We probably could even have allotted more time. But as opposed to a report out on a presentation with Q&A at the end, and we did some of this, I would argue we could have even done more with this kind of back and forth discussion with the community board members asking further questions.

00:07:23:16 - 00:07:41:15
David Colling
Kencee being able to elaborate a little bit more, potentially even the health care folks and clinicians in the room adding a little bit of color. And we did some of that but I would encourage that. And once again, I would make sure that you include all certainly all community board members, regardless of tenure. You know, there might be the occasional one that feels like they know it.

00:07:41:15 - 00:08:01:11
David Colling
I'd be amazed if, if a community board member, no matter how long you've been serving didn't learn something from the presentation. And once again, I would say the entire board should be included, that dialog is healthy and I think creates good understanding amongst all parties. And you know, Kencee, you mentioned the podcast that that we kind of did a pre-work.

00:08:01:12 - 00:08:20:28
David Colling
You know, we asked everybody to listen to Jamie's podcast, and I want to say that was about a 30 minute give or take podcast, excellent foundation to reinforce the importance of quality and safety, right? So before we go into the 101 and the teaching piece, get everybody on the same page of the importance of it and the role it plays with the board.

00:08:20:28 - 00:08:29:10
David Colling
So I thought that was excellent. You know, I'll call it pre-work and everyone should kind of be required to listen to that I think prior to the actual presentation itself.

00:08:29:12 - 00:08:46:16
Kencee K. Graves, M.D.
I'm really glad you called out some of the interactive stuff and the keep it fun. I don't know if there's any chief quality officers listening, I do think that's an important piece. And so a couple things that I did that I thought worked really, really well. Survey questions after sections of my presentation. So I would talk about patient safety.

00:08:46:16 - 00:09:04:11
Kencee K. Graves, M.D.
And then I would ask people what it is. And then I would give them four multiple choice questions. Put one in there that was funny. And that kind of thing kept people really engaged. I also put together a laminated front-and-back about what ranking system that we use at the University of Utah, and explained every section of that.

00:09:04:14 - 00:09:23:11
Kencee K. Graves, M.D.
I went through my office and introduced people and talk about what they did, and that's the kind of stuff that people loved. They loved getting to know who their leaders are, and they really liked the human part. And I think that's critical because we're here for humans, right? Like quality care is for humans. And so that was kind of my undertone.

00:09:23:11 - 00:09:24:29
Kencee K. Graves, M.D.
I'm glad David picked up on it.

00:09:25:01 - 00:09:42:16
David Colling
And Nikhil, I'll just add one more comment to that. Yeah, the structure within the organization where quality and safety fits, the different roles. Again, something I kind of knew but didn't know in that level of detail. There's quite a bit more to the quality and safety than many would imagine. So I thought that was know really well done.

00:09:42:16 - 00:09:58:17
David Colling
You know, Kencee, I don't know if I've mentioned it to you, but I think that presentation it's interesting is I went back and reviewed it. That almost needs to be kind of a continuous piece of reference material. I almost feel like I want to make it a little less of a PowerPoint and more of a reference piece. So there's an assignment for you.

00:09:58:17 - 00:10:16:07
David Colling
But, you know, because it is so well done. It should be a continuous reference, you know, that's almost in your little in your toolbox as a community board member, because this is how busy we as committee board members are. You know, we've got our day jobs and we get so focused. So that presentation, which was extremely effective was only a few months ago.

00:10:16:09 - 00:10:30:20
David Colling
But when I reviewed it, you know, even prior to this, discussion, I was like, oh yeah, I need to, you know, keep remembering this kind of thing. So I'm going to be referring back to that pretty regularly. So that might be another piece of advice, you know, use it as an ongoing resource for the for the board.

00:10:30:22 - 00:10:48:28
Kencee K. Graves, M.D.
That's really good advice. And I want to go back to a point you made earlier where our accreditation partner is, that Det Norske Veritas or DNV. They were on site at the end of January. And so I reported that out to the board in February, and I included what DNV stands for and what it means and what they gave us citations on.

00:10:48:28 - 00:11:07:27
Kencee K. Graves, M.D.
And I used graphics to demonstrate kind of each bucket. And I did have people that have worked at the University of Utah in leadership for more than a decade come up and tell me, thank you for doing that, because I think quality is such an alphabet soup that for those of us who work in it, it's easy to forget that it doesn't mean a lot to anybody else.

00:11:07:27 - 00:11:16:23
Kencee K. Graves, M.D.
And so I would just say, I think it's really, really important to continue to revisit those abbreviations that may not land well without an introduction.

00:11:16:25 - 00:11:35:05
David Colling
And Kencee, I would say that the entire clinical or healthcare environment, health care environment is a big alphabet soup. If I had one advice for, you know, the clinical and health care staff, beyond quality and safety, there are acronyms and short you know, wordings used for things that just don't come natural to community board members.

00:11:35:05 - 00:11:38:06
David Colling
So I think that's a good reminder beyond quality and safety as well.

00:11:38:08 - 00:11:59:03
Kencee K. Graves, M.D.
Yeah, I've spent a lot of time talking about what I think chief quality officers should do. But I'll tell you what I think has been valuable to me as interim chief quality officer with a board. The board members ask really good questions. And for me, that is my check on. Am I explaining something well? What does an average patient hear and think and see?

00:11:59:03 - 00:12:17:24
Kencee K. Graves, M.D.
And how do they perceive us through the media? And what does the community say? And that is incredibly valuable because there are not a lot of spaces in my life where I hear that because I work in health care, I work around other doctors and nurses and the community board is my window to what the rest of the world sees when they see our health system.

00:12:17:27 - 00:12:37:28
Nikhil Baviskar
That's very helpful. As you said, the board should reflect the community and that's really important. You know, Kencee or Doctor Graves, I'll ask you just one more thing. For the board members listening, I already asked this to David, but what do you think that the board member should take away when it comes to, you know, working on quality, understanding it and learning about it?

00:12:38:01 - 00:13:01:02
Kencee K. Graves, M.D.
Part of that is, is what I said in that ask questions, stay engaged. And so if you see something or hear something that doesn't make sense, ask about it. The other thing that our board has asked me to do, which I found very, very helpful, is if I bring them a problem they've also asked me to report on who is responsible for it, what is the fix and when do I report back?

00:13:01:05 - 00:13:23:29
Kencee K. Graves, M.D.
And that cadence has kept me giving them information that is meaningful. And then also they've learned to trust the information I bring them. It keeps me honest and keeps a closed loop communication. So I think that's been really good. I do think it's possible to skim over things, and I would just say, I think board members can and should ask really really good questions.

00:13:24:01 - 00:13:35:08
Nikhil Baviskar
Well, thank you both so much for your time. This has been an awesome discussion and we really do hope that you know, your quality journey just continues getting better from here on out. So thank you again.

00:13:35:11 - 00:13:36:04
David Colling
Thank you.

00:13:36:07 - 00:13:38:16
Kencee K. Graves, M.D.
Thank you for having us.

00:13:38:19 - 00:13:47:00
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:01:01 - 00:00:26:19
Tom Haederle
Welcome to Advancing Health. Ambient listening technology is coming into wider use as a way to keep accurate records of the conversations between doctors and their patients. In today's podcast, we hear from two senior executives with the Cleveland Clinic about how their integration of this new application of artificial intelligence makes for better clinical notes and leads to a better experience for everyone.

00:00:26:21 - 00:00:55:20
Chris DeRienzo, M.D.
Hi, this is Dr. Chris DeRienzo, AHA’s chief physician executive, and I am very excited for today's podcast. We get to have a conversation about AI enabled solutions in health care, and we get to have that conversation with two individuals who are leading the way at the Cleveland Clinic. We have both Rohit Chandra, PhD, executive vice president and chief digital officer for the clinic, as well as Dr. Eric Boose, he's a family medicine physician and the associate CMIO for Cleveland Clinic.

00:00:55:23 - 00:01:14:12
Chris DeRienzo, M.D.
We're going to have a broad ranging conversation today. But, folks, just before we get started, I've been out on the road a lot. And I have heard from health system after health system who is implementing this ambient listening technology about the kinds of transformative outcomes that they're experiencing. And now we get to talk to folks who are seeing that firsthand.

00:01:14:12 - 00:01:31:20
Chris DeRienzo, M.D.
And so, Rohit, perhaps the first question is to you, as the clinic begin to think about this universe of AI enabled solutions and ambient technology, what drew you to that as an offering that you wanted to get integrated into practice, you know, as quickly as possible?

00:01:31:23 - 00:01:46:27
Rohit Chandra, Ph.D.
So thanks, Chris, for the question. I think that our belief is that over time, AI has the potential to impact multiple aspects of health care all the way from clinical to back office and everything in between.

00:01:47:00 - 00:02:18:16
Rohit Chandra, Ph.D.
The thing that is particularly intriguing about ambient solutions is that they hit a critical pain point for physicians, and they have the potential to do it in a way that is safe. So ambient listening hits a pain point where physicians often spend multiple hours a day in documentation tasks. Those are obviously necessary from a regulatory and patient care perspective, but they take a lot of time. And the technology is almost perfectly suited at streamlining that burden.

00:02:18:18 - 00:02:27:00
Rohit Chandra, Ph.D.
The second part of it is it can be done safely and make sure that there is human oversight so that there is no risk of any patient harm.

00:02:27:02 - 00:02:38:21
Chris DeRienzo, M.D.
Let's talk about implementing this kind of a solution a little bit, because I couldn't agree more of the potential for safe, and better experience is huge. But this isn't the kind of thing that you can just turn on.

00:02:38:21 - 00:02:50:15
Chris DeRienzo, M.D.
And so, Eric, perhaps this one to you. When you made the decision, yes, we want to pursue this technology, we want to get it into the documentation arms of our clinicians. How did you begin that evaluation process?

00:02:50:17 - 00:03:07:03
Eric Boose, M.D.
Yeah, we know that there's quite a few of these software companies that are out there on the marketplace now. And so we want to make sure we found the right one for us. Isro had said we want to make sure it's safe, the content is appropriate. It's really helping the physicians and not being a hindrance to their day or some new technology that's being imposed on them.

00:03:07:06 - 00:03:27:18
Eric Boose, M.D.
So we actually took the route of doing several pilots. We actually worked with five different ambient vendors to see which one would work well for us. We had about 50 physicians in each of those. We kind of jokingly called it like a "British Bake Off," because we were kind of having comparisons going on between five different softwares, but we thought it was important to make sure that we chose the right one for us.

00:03:27:20 - 00:03:41:28
Eric Boose, M.D.
And just like choosing a car, you could go with that first one. It seems to work pretty good and you'll take it. Or you want to look at a variety and really make sure that the choice you're making is a good one, because it's going to be a major decision going forward. So we actually had a lot of fun with that.

00:03:41:28 - 00:04:05:15
Eric Boose, M.D.
We saw a lot of different aspects of ambient software. What's available out there on the marketplace, which ones worked well? And got a lot of feedback from our pilot users. And everybody was just so excited about this technology. The idea of going from being a lot of data entry, which was a big disruptor when the HRs came on the marketplace, to having something actually doing the work for you and doing it well was super exciting.

00:04:05:17 - 00:04:13:04
Eric Boose, M.D.
And to your point, you know, thinking about the idea of not having to spend the extra hours and all this documentation and focusing on other patient care we'd like to do.

00:04:13:06 - 00:04:22:24
Chris DeRienzo, M.D.
Amen. I imagine so five different solutions, 50-ish clinicians per solution. How did you pick where to go and who to work with and which sites to do?

00:04:22:26 - 00:04:49:09
Eric Boose, M.D.
Yeah, I mean, we had a whole evaluation process. A lot of the things you might think of when you're trying to determine if a tool like this would be appropriate for your organization. And one of them is, you know, around documentation, we want to make sure, first of all, they're not having to spend as much time documenting or getting that documentation done in a more timely fashion, getting home better, you know, in the sense of like less time after work hours or spending more time with our family or things that you want to do rather than doing all this extra work after hours.

00:04:49:11 - 00:05:06:03
Eric Boose, M.D.
But we want to make sure the quality was there. So we worked with our, you know, audit folks to make sure that the notes were looking good. We were tracking what the physicians were doing, how often they were using it, what they recommended. We did some surveys around, before and after, you know, do you feel like your cognitive load is less?

00:05:06:03 - 00:05:25:08
Eric Boose, M.D.
Do you feel a little less burnout? Basically, do you feel more comfortable and kind of enjoying medicine again, being able to sit there, not be worried about taking notes through the whole visit, but just having that face to face conversation that we all enjoy, including the patient. The patient certainly  notices, too. Everybody seems more relaxed and it's just been going so much more smoothly.

00:05:25:10 - 00:05:42:14
Chris DeRienzo, M.D.
That really hits home. I remember I had this spectacular family practice physician when I was, in western North Carolina, and he could, stay totally engaged in the entire visit while continually typing away at structure documentation. And he's sort of a unicorn. There are obviously other doctors who can do that, but most of us can't do that.

00:05:42:17 - 00:05:56:28
Chris DeRienzo, M.D.
And so, you know, hearing that you walk through this very purposeful and intentional evaluation process. Rohit, I'm curious. How did you ultimately decide on which solution to implement? And then, what approach are you taking the implemented?

00:05:57:00 - 00:06:08:08
Rohit Chandra, Ph.D.
So, a couple of comments. One, I think that traditionally humans have to overextend themselves to adapt to technology and that was sort of the journey with the EHR.

00:06:08:11 - 00:06:40:14
Rohit Chandra, Ph.D.
The thing that's intriguing about these ambient solutions is that the technology increasingly adapts to the human interaction, and that's the appeal. So just wanted to sort of get that out there. In terms of actually piloting and then deciding what technology to go forward with, we feel that this capability is the start of a transformation journey, and we hope that this is a big decision that if you make a good decision will be transformative over time.

00:06:40:16 - 00:07:02:28
Rohit Chandra, Ph.D.
What that translated into was a little bit of an approach that I have in bringing technology into the organization is "try before you buy." So that's what led us to say, hey, it's important for us to pilot something as opposed to just pick a partner based on sort of a superficial assessment. So I look back and say, I'm glad we did the pilot.

00:07:02:28 - 00:07:23:29
Rohit Chandra, Ph.D.
We got a chance to test drive multiple technologies by hand and there's no substitute for that. And at the end of it, then you're far more confident in your solution and the capability and the potential that it has. In terms of actually piloting five vendors, we piloted with what we thought were sort of key players in the space.

00:07:24:01 - 00:07:44:23
Rohit Chandra, Ph.D.
I am told that there are more than 100 different companies doing it, so. Goodness! Exactly. How many survive? How many find different variations? Time will tell. But at least we try to apply some judgment on which are the prominent ones that we should test drive. Like Eric alluded to, we looked at a few different criteria.

00:07:44:25 - 00:08:13:06
Rohit Chandra, Ph.D.
First and foremost is the product capabilities, the quality of the transcriptions, the ability to deal with multiple languages, the ability to attribute the right conversation to the right person in the room. All of that is technology capability that needs to be done right. The second part of it is the quality of the summaries that are generated, whether for the patient, whether for the physician, all of those. You need revisions...

00:08:13:06 - 00:08:23:14
Rohit Chandra, Ph.D.
how accurate and how complete is it? is a second consideration. Integration with the EMR so that the workflows are relatively smooth and not cumbersome is essential.

00:08:23:21 - 00:08:33:16
Chris DeRienzo, M.D.
Let's pause there for a second, because I know there are many different possible solutions. But as we get into sort of the next part of our conversation, which solution did you ultimately go with?

00:08:33:16 - 00:08:40:15
Chris DeRienzo, M.D.
And then what is the EMR platform that sits on top of just so listeners can have sort of a sense of, okay, this is what their environment looks like.

00:08:40:17 - 00:08:55:25
Rohit Chandra, Ph.D.
I can get some of the basics, and then I'll defer to Eric to speak to the experience. So we're an EPIC house. Our EMR is EPIC. And it was obviously essential for us that the workflows that the physicians encounter are as seamless as possible.

00:08:56:01 - 00:09:01:15
Rohit Chandra, Ph.D.
And I'll defer to Eric to speak to that part of it. But that was obviously an important part of our assessment.

00:09:01:17 - 00:09:19:00
Eric Boose, M.D.
Yeah. So in the end, when we went through our different assessments, we ended up with ambiance as our solution for our ambient AI software. I do think there's something about ease of use for the user, right? Just like any other technology, if you throw in too many barriers or make it too complicated the uptake is much lower.

00:09:19:02 - 00:09:42:17
Eric Boose, M.D.
All of these softwares in general are pretty elegant in their solutions in the sense that the listening of the visit all tends to occur on a phone that's listening through an app. But how it gets into the EPIC or whatever your EHR might be, the ease of use of having it there as a draft so that at that point can be reviewed, edited, added, subtracted before it's obviously accepted in the medical record was very important to us.

00:09:42:19 - 00:09:55:25
Eric Boose, M.D.
And so ease of use in the integration doesn't have to be fully, deeply integrated. I wouldn't say, but it has to be nice and elegant so that things go through so quickly and smoothly that the uptake is done. And it's very easy to use.

00:09:55:27 - 00:10:03:06
Chris DeRienzo, M.D.
And from the integration perspective, it's not just free text getting ported in. There are structured components to it that also have to get completed. Is that right?

00:10:03:09 - 00:10:23:04
Eric Boose, M.D.
Correct. I mean, as the recording is in the AI software is working, it will bring back the note and all the different sections that you would need. So the HPI, API and results and erroneous systems is also as patient instructions, which actually turned out to be one of the surprises that we found very valuable was that as soon as the AI was done, it created the note.

00:10:23:10 - 00:10:34:20
Eric Boose, M.D.
You could have the patient structures ready for them before they even left the exam room. Wow. And to have kind of like that written record of all the things I asked them to do, it was so nice for them as they left, having those instructions with them.

00:10:34:22 - 00:10:46:09
Chris DeRienzo, M.D.
You're about a month since announcing partnership in the move forward. How's it going? What kind of outcomes are you seeing? Well, you know, what do you what are you focusing on now that it's going live across the clinic?

00:10:46:12 - 00:11:03:25
Eric Boose, M.D.
I mean, it's been very exciting. We just started the implementation on March 10th. We did listen to our vendor ambiance a little bit, guiding us the way, you know, what's been successful for implementation across a large enterprise to start. And we work together also with our Cleveland Clinic culture to make sure how was accepted and brought forth to all of our providers.

00:11:03:27 - 00:11:20:10
Eric Boose, M.D.
There are several thousand in scope to be using the product, and so we decided to do things in waves. Ambiance gave us some advice about which they felt which specialty models were ready to go out of the box, which ones they might need about, you know, 4 to 6 weeks to get really tuned up and some other ones that took about 12 weeks.

00:11:20:12 - 00:11:40:07
Eric Boose, M.D.
So we're like, that's fine, we'll spread out the waves, so we'll launch as many as we can in wave one. And then move on from there. And we've actually within two weeks have about 1500 trained and almost a thousand using it already. We're getting feedback, you know, it's life changing. I love this product. I don't know how I survived without it.

00:11:40:09 - 00:11:41:00
Chris DeRienzo, M.D.
Oh my goodness.

00:11:41:00 - 00:11:57:09
Eric Boose, M.D.
We can all attest that it's been a struggle these days, right? We have a lot of information coming to us. We have a lot of patient expectations about getting back to them as quickly as possible. All this electronic health record and patient portals and just, you know, it's expected to be very quickly going through information and getting back to them.

00:11:57:11 - 00:12:15:16
Eric Boose, M.D.
So this really helps us in our day in the sense of things happened so quickly with it that it's really unloading the other processes that we have to do during the day. And we're feeling that relief and we're seeing some of the docs saying, you know, I don't know if I'm going to cut back my time like I thought it was going to, or I may postpone retirement for a couple more years.

00:12:15:16 - 00:12:31:00
Eric Boose, M.D.
I mean, things you would never think you would hear from physicians, right? This is like a technology they're asking for and begging for. Like, it was so interesting during the pilots. If there was a person that was in the office using it, yet three others weren't, they're all like, I want it. When can I get it? So that kind of energy has been building.

00:12:31:00 - 00:12:37:03
Eric Boose, M.D.
And so when we launched it and advertised it, everybody was very, very excited about it. So it's been it's been going very well.

00:12:37:06 - 00:13:01:20
Rohit Chandra, Ph.D.
Chris, I'll add a quick comment, which is most times technology is a little bit clunky to adopt and integrate, and understandably so. That's true for all of us as consumers. The nice thing was this technology's the integration and the ability to use it is pretty seamless. And the appetite and the enthusiasm for adopting it is unprecedented.

00:13:01:22 - 00:13:06:27
Chris DeRienzo, M.D.
It's pretty rare for me to hear a positive, life changing story from a technology implementation.

00:13:06:27 - 00:13:27:26
Chris DeRienzo, M.D.
But you've got it. And to be clear, like, this is the story I'm hearing everywhere. Health care is and will always be a uniquely human experience. And the more opportunities we have to thread our humanity back into the practice of medicine using this needle of technology, the better. We are just about out of time. As expected, this has been a fantastic conversation.

00:13:27:28 - 00:13:46:18
Chris DeRienzo, M.D.
I am curious, though, as your ambient rollout continues through its the thousands of providers who are pulling to try to get to use it. What else do you see on the horizon with this kind of potential impact? And where are you sort of looking down the road towards other potential AI enabled use cases?

00:13:46:20 - 00:14:04:10
Rohit Chandra, Ph.D.
I'll touch on a couple of things, which is we are currently rolling out ambient listening in outpatient settings. I think there's an opportunity to look at other scenarios and use cases in different settings where ambient technology can help streamline the documentation burden.

00:14:04:13 - 00:14:22:04
Rohit Chandra, Ph.D.
I think the second part of it is while today we are leading with transcription and summarization, I think there's an opportunity to bring greater clinical knowledge to bear that can perhaps serve as a physician's assistant at their elbow, helping streamline more and more mundane tasks as we go forward.

00:14:22:06 - 00:14:38:10
Eric Boose, M.D.
Yeah. And I think just to echo that, I kind of picture that as well - as sort of having this kind of copilot, you know, with you. Again, we have so much information we're trying to gather before we see a patient and deal with after we see a patient with testing, that I almost see it as like, could the AI bring everything together, like do a chart review?

00:14:38:10 - 00:14:58:16
Eric Boose, M.D.
What care gaps do they have? What are actionable findings that may need to be promoted to make sure they follow up on? Almost like a patient briefing that when I open that record, tell me what I really need to know going into this visit to make sure that I take care of that patient very well. It's personalized to their care, and we make sure that the proper follow up and everything is sort of set up before they even leave the office.

00:14:58:16 - 00:15:09:12
Eric Boose, M.D.
So I feel like there's a lot of those tasks that I think that as the AI products get better and they do a little more deep dive into the charts and help us with all that context is where I see this going next.

00:15:09:15 - 00:15:32:06
Chris DeRienzo, M.D.
Well, if that is where we are going, then to all of the young folks out there who are studying medicine and nursing and respiratory therapy at an APP school, the future that awaits you is much better than the present that the folks on this call have lived through. We've gone through the challenging ages of early stage implementation and hopefully through the work that you all are doing leading the way at Cleveland Clinic,

00:15:32:08 - 00:15:43:08
Chris DeRienzo, M.D.
we will help bring some humanity back into the practice of medicine for all those who get to follow us. It has been a real privilege to get to speak with both of you. Thank you so much for joining us today.

00:15:43:10 - 00:15:44:17
Eric Boose, M.D.
Thank you for having us.

00:15:44:20 - 00:15:46:22
Rohit Chandra, Ph.D.
Thanks, Chris.

00:15:46:24 - 00:15:55:06
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:01:05 - 00:00:26:29
Tom Haederle
Welcome to Advancing Health. There aren't enough people working in health care to meet demand, either current or projected. In today's podcast, we learn more about how the American Hospital Association's 2025 Health Care Workforce Scan has identified ways to enhance the overall workforce experience and help employers refresh, retain and recruit health care workers for the future.

00:00:27:01 - 00:00:51:14
Elisa Arespacochaga
Hello, I'm Elisa Arespacochaga, vice president for clinical affairs and workforce with the American Hospital Association. Joining me today are Joel Moore, chief nursing officer with MercyOne Genesis and chair of the AONL Workforce Committee, and Claire Zangerle, chief executive officer of AONL, the American Organization for Nursing Leadership and senior vice president and chief nursing officer with the American Hospital Association.

00:00:51:17 - 00:01:10:06
Elisa Arespacochaga
So today, we're here to talk about workforce, and we're here to talk about the 2025 Health Care Workforce Scan, which focuses on four opportunities hospitals and health systems have to really support their workforce. Because, as I have been known to say many, many times, there are no more people who are going to come work in health care.

00:01:10:06 - 00:01:29:07
Elisa Arespacochaga
We've got to keep the ones we have, and we really have to do more to encourage them to want to be in health care because there is probably a reason they started in health care. They were called to be there. Those four areas are embracing technologically integrated care models and innovation. Let's use technology as best we can.

00:01:29:10 - 00:01:53:12
Elisa Arespacochaga
The second is engaging the clinical teams in the design of those innovations. We've got to get them involved in all of those details. Third, boosting access by increasing that workforce through some innovative partnerships, encouraging more people to come into health care, who might not have thought of health care as a career and rethinking how we can engage with our workforce.

00:01:53:12 - 00:02:12:21
Elisa Arespacochaga
And I know most of the world is rethinking how they engage with their workforce in a more remote era. But we're going to talk a lot about how do we work on all four of those at the same time, while continuing to take care of the patients that come to our doors every day. Joel and Claire and I'll ask Joel - for you to start.

00:02:12:23 - 00:02:34:00
Elisa Arespacochaga
How are you seeing in your roles the field really connect these ideas together - from everything from how do we use technology? How do we bring the clinicians in to encourage more people to join health care and also really engage those we have? How do you see those threading together as you're trying to address workforce challenges?

00:02:34:02 - 00:03:04:28
Joel Moore
Yeah, it's a great question. I really appreciate what you said at the beginning about us being called into nursing. And I think that starts with the person at the bedside. And so as I've seen models of care and workforce wrap around and through these four top-of-mind ideas from the Workforce Scan, we have to really focus on the person providing care and engage them at every level of the work.

00:03:05:01 - 00:03:39:03
Joel Moore
I think some of the work from our history and from our past, how things unfolded, it was very much top down. At this era we need bedside nurses to be a part of technology innovation, redesigning the model of care, helping us establish what a healthy work environment is about. So I think we can tackle all four of these, but I think we have to have it driven by the nurse at the bedside, or from those frontline staff who are providing direct care to our communities.

00:03:39:05 - 00:03:42:17
Elisa Arespacochaga
Claire, from your perspective at AONL, how do you see this?

00:03:42:19 - 00:04:13:27
Claire Zangerle, DNP, R.N.
I think all four of these tenants for the Workforce Scan fit together very well to make a bigger picture of what needs to happen with the workforce. Embracing technology is so important because that in and of itself reduces the workload of those who are delivering care, whether they're in acute care setting, an outpatient setting, an ambulatory surgery center, post-acute care - wherever they are. Bringing those clinicians in to help make the decisions around the solution is essential to success.

00:04:14:00 - 00:04:39:22
Claire Zangerle, DNP, R.N.
There's really no way that anything technologically around the workforce can be successful without that clinician voice. Making sure that we take down some of those barriers that many are seeing as access to getting into health care so that they can become part of the health care ecosystem, I think is important, too, and it's really incumbent upon us as leaders in health care to take those barriers down.

00:04:39:25 - 00:05:01:28
Claire Zangerle, DNP, R.N.
And again, let's not forget about the people who are already here, who are already doing the hard work so that we can reengage them so that we can, you know, court them again, have them fall back in love with their jobs because we're losing them. And that's the hard part, is all of that knowledge capital and that dedication is leaving.

00:05:02:04 - 00:05:09:10
Claire Zangerle, DNP, R.N.
And those are let's solve the problems that we can solve because there's a lot of problems we can't. And that's a problem we can solve.

00:05:09:12 - 00:05:28:18
Elisa Arespacochaga
I completely agree with that. Joel, from your perspective, I know we've gotten to work together on the AHA and AONL care model learning community. What are you seeing organizations embrace in that technology space into their care models? And what do you think is really had the most impact?

00:05:28:21 - 00:05:57:21
Joel Moore
I am going to be cautious to say what's had the most impact, because I think we're still in development. We're still in the middle of the PDSA cycle. One of the first things that we stood up as a nursing profession in the pandemic and post pandemic was virtual nursing. And that's a model that does work for some. But I am unsure about the sustainability and if it really is having impact on patient outcomes.

00:05:57:24 - 00:06:40:15
Joel Moore
I think this is our era of really thinking outside the box. I'm getting goosebumps thinking about ambient listening and the forward thinking that's being done with that. Some people are labeling it AI and how that supports the lift of the workforce load. But, you know, I think about the little devices that we have in our homes and that we've had for years that we're bossing around. What can we do to develop technology with these really brilliant people that are at the bedside now to help support and engage and attract future workforce clinicians that won't ever even touch a keyboard?

00:06:40:17 - 00:06:58:00
Joel Moore
So, you know, there's so much technology  - from help that's moving pharmaceuticals from, you know, one level to another in the hospital to ambient listening to virtual nursing. There's just a long stream of technology that's helping us at this point.

00:06:58:03 - 00:07:20:04
Elisa Arespacochaga
Absolutely. And I think you are, you hit it on the head. We are very much in a phase of trying all of these different technologies to see which really, truly hit value for our organizations. And, you know, really help at the end of the day, that bedside nurse, that bedside clinician provide the best possible care for their patient.

00:07:20:06 - 00:07:30:15
Joel Moore
What's driving the outcomes? I don't think we have enough to say what has been the most successful to help drive outcomes, which is what we need to be looking at.

00:07:30:18 - 00:07:51:11
Claire Zangerle, DNP, R.N.
I think we also have to recognize the maturity of organizations around adopting technology. All organizations are on a different maturity model. Some are just thinking about it and what does it look like? And they're very scared of it. And I get that. And they're also asking themselves, do I have the money to invest in this? Because what if it doesn't work?

00:07:51:13 - 00:08:17:18
Claire Zangerle, DNP, R.N.
I'm taking a big chance. We're seeing a lot of people do pilots, and this is okay to do a pilot, to say, does this work for me and if not, I'm going to either scale fast or fail fast. And I think it's important that people realize that when they think about technology. But there's also a human side to this technology that's being adopted and that I think will come out loud and clear in the Workforce Scan.

00:08:17:21 - 00:08:51:24
Claire Zangerle, DNP, R.N.
Because just because you put technology in does not mean that you eliminate the human touch and the human aspect of caregiving. There's a lot of ways to do new models of care, including that human touch. Maybe you're using new disciplines to deliver that care, and they're infusing new technologies into using those new disciplines. We're inviting LPNs back into the acute care space when before we had somewhat dismissed LPNs to other care sites because we didn't have a place for them in acute care. Now we're rethinking that,

00:08:52:01 - 00:09:04:07
Claire Zangerle, DNP, R.N.
and that's the beauty of our being nimble in health care is to be able to rethink and reapproach for what works today and what is going to work for the future.

00:09:04:09 - 00:09:25:01
Joel Moore
Claire, I love that. I love that part too, perhaps even the people part of nursing. Perhaps we need to challenge, you know, what's our scope? We haven't revisited that for a while. You know, the scope of the RN, the scope of the LPN. It's, you know, it could be something. I've seen studies over in Europe, and we have opportunity to think about people.

00:09:25:06 - 00:09:31:07
Joel Moore
And I love the thread of people that is woven through the four core challenges brought forward in the Workforce Scan.

00:09:31:09 - 00:10:01:04
Elisa Arespacochaga
Joel, let me pick up on that. We all know that, you know, to some extent, the math doesn't work. With the retirement and aging of the baby boomers, the next generation, the staffing shortages, all of those things, they're just not going to go away. What are some of the pathways and partnerships you're seeing locally to really encourage people to not only get into health care, but now get into this, this new version of health care, this one that has the technology that is connecting to its frontline teams.

00:10:01:06 - 00:10:25:12
Joel Moore
Yeah, it's taking the message out early. You know, we have to engage what we've done here is engage in our community, even at the elementary school age level and talked about the brand image or what is a nurse now? What does that look like? We're still pretty close to the pandemic. So there's this frightening view of what it may appear to be if you were to practice nursing.

00:10:25:15 - 00:10:56:04
Joel Moore
And so taking the image of nursing and talking about the flexibility and engagement in the community that you can develop when you go into a profession like nursing, or many other professions at the bedside. So it's cultivating relationships early. I have a lot of energy focused on my partnerships with my colleges and universities that are within a 60 mile radius of the buildings. The colleges and universities know

00:10:56:04 - 00:11:21:19
Joel Moore
I'm going to say yes to every nursing student, once they get into studies to come and do their clinicals in my building. Because that's the future workforce. And there isn't enough of them. So engaging with our colleges and universities and taking the message out in places where we hadn't been before, I think there's still opportunity to perhaps persuade some people in other vocations.

00:11:21:19 - 00:11:32:20
Joel Moore
I'm a second vocation nurse, so I think we could persuade others to join the health care work environment if they really knew what fulfillment they would get practicing.

00:11:32:22 - 00:11:56:09
Elisa Arespacochaga
I always say that there are a lot of places I could earn a living with my MBA, but health care is the only place that feeds my soul. Claire, from a national perspective, we know health care works workers are...they're tired. Health care is hard. It's never not been hard. But we've been able to continue to attract a great, amazing group of people to work in health care and be connected to health care.

00:11:56:15 - 00:12:02:25
Elisa Arespacochaga
What are some of the strategies to now, given the challenges we're seeing, to keep them in health care?

00:12:02:28 - 00:12:24:03
Claire Zangerle, DNP, R.N.
The first thing we need to recognize is that the workforce is evolving. We have new generations of workers that are here in our midst, and we have to recognize that. We have to recognize the opportunity to embrace those ways of thinking. Back in the day, you would work 24/7 and not think anything about it. That's not healthy.

00:12:24:05 - 00:12:44:24
Claire Zangerle, DNP, R.N.
We have to recognize that people want to have harmony. They want to have a little bit of balance in their life. And health care is open 24/7, so we have to recognize that. And make sure that we're meeting the needs of a workforce that is before us. If we don't do that, we're not doing ourselves any favors. We're not going to grow our workforce.

00:12:44:24 - 00:13:03:00
Claire Zangerle, DNP, R.N.
We're not going to retain the people that want to work in this profession. You hear all the time, I love what I do, but I can't maintain the pace. And I think we will attract more people if we become more realistic about what people want in their work life.

00:13:03:02 - 00:13:11:15
Elisa Arespacochaga
Joel, on the ground at your organization, what some of the ways that you are really building that engagement and connection to your frontline teams?

00:13:11:18 - 00:13:39:15
Joel Moore
One of the ways is that we are building a culture of trust. You know, my visibility as CNO is really important. So our leaders are with our frontline, our executive level leaders are rounding, being with the frontline as much. So building that culture of trust, picking up on one thing that Claire had said, you know, at my organization, we are really trying to cultivate our workforce to look like our community.

00:13:39:18 - 00:13:57:25
Joel Moore
So we have a variety of cultures within our community. So we are recruiting from different neighborhoods that we hadn't recruited before. Which, you know, engages us in new ways as we're learning more about the people who may not be exactly like us.

00:13:57:27 - 00:13:59:10
Elisa Arespacochaga
That's awesome.

00:13:59:12 - 00:14:28:28
Elisa Arespacochaga
Joel and Claire, thank you so much for joining me today and sharing your views and how you're addressing this work, which are, among just some of the stories that are included in the 2025 AHA Health Care Workforce Scan, which is based on a review of reports and studies and leaders like Joel and Claire providing their input and insights and recommendations of what they are trying to really, support and retain our health care workforce

00:14:28:28 - 00:14:31:09
Elisa Arespacochaga
staff. So thank you both for joining me.

00:14:31:12 - 00:14:51:08
Tom Haederle
Thank you for joining us. If you'd like to learn more about the latest health care workforce trends and real world approaches to guide your workforce strategies, be sure to check out the 2025 Health Care Workforce scan at www.aha.org/aha-workforce-scan.

00:00:01:05 - 00:00:23:09
Tom Haederle
Welcome to Advancing Health. In the face of today's multiple challenges, every hospital needs support and buy in for its mission of great care. Storytelling - sharing the right kinds of stories with the right audience at the right time - is a great way to build and maintain that support. This is particularly important for rural hospitals and health systems, most of which have razor-thin operating margins.

00:00:23:12 - 00:00:40:10
Tom Haederle
In this month's Leadership Dialogue, hosted by the American Hospital Association's 2025 Board Chair Tina Freese Decker, we hear more about the importance of advocacy and of all team members participating in telling the hospital story.

00:00:40:13 - 00:01:07:25
Tina Freese Decker
Thank you so much for joining us today. I'm Tina Freese Decker, president CEO for Corewell Health, and I'm also the board chair for the American Hospital Association. Last month we talked about trust and how our hospitals and our health systems can strengthen that trust with our communities and the people that we serve. Our rural hospitals are uniquely positioned to do this, as they are often the largest employers in their towns and communities, and frequently the only local source of care.

00:01:07:27 - 00:01:28:07
Tina Freese Decker
Rural health care is about being a family. We take care of each other in our communities as best as possible, and we're here to provide that care close to home, no matter what headwinds that we all face. I recently had the opportunity to attend the American Hospital Association's Rural Conference and you could really feel that sense of family and community in the room.

00:01:28:09 - 00:01:59:15
Tina Freese Decker
We work in hospitals in red states and blue states all across the country, but we are all focused on the same thing: helping our neighbors in our communities to be healthier. There are some big challenges that are facing real health care, but together with a unified voice, we can get what we need. As I have traveled around our country meeting with the American Hospital Association's regional policy boards and visiting the rural hospitals and my health system and others, the number one concern that I have heard from our hospitals, our communities, is access.

00:01:59:18 - 00:02:22:28
Tina Freese Decker
And that is why it is so integral to the American Hospital Association strategy and it is why it is so important that we come together as a field and that we're united as a field, because these challenges that we are facing are real. So today, I am pleased to have a distinguished leader in rural health care with us to talk about how we can all work together to advocate for the needs of our hospitals.

00:02:23:01 - 00:02:45:09
Tina Freese Decker
I'd like to welcome Lori Wightman. She is the CEO of Bothwell Regional Health Center, a 108 bed acute care hospital in Sedalia, Missouri. Laura has served in this role since 2019, but even prior to Bothwell, she worked in real health care as the president of Mercy Hospital Ada in Ada, Oklahoma. So, Lori, welcome. Glad you were able to join us today.

00:02:45:15 - 00:02:46:17
Lori Wightman, R.N.
Thank you, Tina.

00:02:46:19 - 00:03:03:20
Tina Freese Decker
And I wanted to start out with just telling us a little bit about yourself. I know you started your health care career as a nurse and then you made the shift to administration. Can you tell us about yourself and how you see that family aspect in the hospital and the community in our rural areas?

00:03:03:22 - 00:03:30:01
Lori Wightman, R.N.
Sure. Well, my father was a hospital administrator and my mother was a nurse, so I did both. And so it was a natural progression. And I think the foundation that nursing lays gives you all kinds of transferable skills that have been very helpful as I went into hospital administration. My career and dating advice has always been, you can't go wrong with a nurse.

00:03:30:03 - 00:03:57:14
Lori Wightman, R.N.
And there's certainly served me well. And you talk about that family atmosphere. That is why I continue to choose rural health care. I've done the CEO position in a suburban hospital, and I sat at our senior leadership team meeting and thinking I was the only one on our senior leadership team that even lived in the area that we served.

00:03:57:17 - 00:04:23:24
Lori Wightman, R.N.
Everyone else lived in a different suburb, and I just thought that was strange and disconnected. And, so I returned again then to rural health care because it is like a family. And it's ironic because we just finished revisiting our mission, vision and values. And our new mission statement talks about together we work to provide compassionate and safe care to family, friends, and neighbors.

00:04:23:27 - 00:04:37:07
Lori Wightman, R.N.
Invariably, when I met new employee orientation, a significant number of people were born at the hospital. That's why I love rural. It's like that "Cheers" phenomenon where everyone knows your name.

00:04:37:09 - 00:05:01:02
Tina Freese Decker
Very true. I used to lead a couple of rural hospitals as well. And like you said, even just walking into a rural hospital it feels like family where everyone there knows your name and of course, protect things from a confidentiality and a privacy perspective, but that feeling that we're all in this together. So I love that your mission statement is about together, that you can make an impact on people's health.

00:05:01:05 - 00:05:13:28
Tina Freese Decker
I described a little bit about what it's like to walk into a rural hospital. Can you share a little bit about what is like to be a rural hospital, what it means in today's environment and why it's such a great place to work?

00:05:14:01 - 00:05:47:06
Lori Wightman, R.N.
Well, in many ways, rural hospitals are uniquely the same as our suburban or urban counterparts. Forty six million people depend on a rural hospital for their care. So we struggle with the same labor shortages, the cost of labor supplies and drugs is rising faster than our reimbursement. We have all of those same struggles. Unique is that family atmosphere, I think.

00:05:47:06 - 00:06:13:26
Lori Wightman, R.N.
And we have multiple generations working at the hospital. Now, you can't say anything bad about anyone because invariably they're somehow related. Or they were best friends in high school, or they used to be married to each other. So I mean, it's unique in that way. We have the same types of struggles that  our counterparts do.

00:06:13:28 - 00:06:18:03
Tina Freese Decker
What pressures are you feeling the most acutely right now?

00:06:18:06 - 00:06:47:09
Lori Wightman, R.N.
Well, you take all of those common challenges that I talked about, and you turn up the volume a little bit. Because for us, 78% of our patients and our volume is governmental payers, so 78% of our business, we're getting reimbursed below cost. You can't make that up in volume. So we rely on all of the governmental programs, you know, disproportionate share all of those things.

00:06:47:09 - 00:06:54:22
Lori Wightman, R.N.
And, 340B is doing exactly for us what it was designed to do, save rural hospitals.

00:06:54:25 - 00:07:11:22
Tina Freese Decker
Those areas are critical that they remain. And so that we can continue to provide that sustainable, high quality care in our communities and all of our communities. 78% being governmental. It's a huge portion of what we do and what we rely on for access and caring for people.

00:07:11:29 - 00:07:23:15
Lori Wightman, R.N.
Right. We are the typical rural hospital. We have razor-thin margins and aging plant of 18 years.

00:07:23:18 - 00:07:31:10
Tina Freese Decker
So those are challenges that you're trying to navigate right now with all of the other things that happen. And how is your staffing levels going? Are those going okay?

00:07:31:13 - 00:07:55:12
Lori Wightman, R.N.
Have the same labor shortage issues. We still have 22 traveling nurses here, but we have started being very aggressive in a grow your own program. And so as soon as the next month we're going to cut that number in half and then, within six months, we're hoping to have all of contract staff out.

00:07:55:15 - 00:08:02:04
Tina Freese Decker
Is that something that you're most proud of, or is there something else that you want to share that you're most proud of from a rural hospital perspective?

00:08:02:06 - 00:08:29:24
Lori Wightman, R.N.
I think what I'm most proud of is you get to personally view the impact of your decisions on people. I'm very proud of our all the talented people that we have here, from clinicians to community health workers. All of our physicians get to use all of the things they learned in medical school and residency, because there isn't a lot of subspecialists, so they are working at the top of their license.

00:08:29:26 - 00:08:50:21
Lori Wightman, R.N.
Just several months ago, one of our critical care physicians diagnosed a case of botulism. Now as an old infection control nurse I get very excited about that because I never thought in my career I would see botulism. But it was diagnosed and treated here and the person's doing well.

00:08:50:23 - 00:09:25:27
Tina Freese Decker
Oh, that's wonderful to hear. When you talk about all the different people that are part of health care in rural settings, or also another settings, it's quite amazing to see how many different areas we need to come together to take care of our community. When you think about an even larger scale, from rural hospitals to urban and teaching hospitals and others, how do you think about the whole ecosystem of our field and how we, you know, do we need all of us or and is there a way to form that greater fabric and social connection, or is there something else that we should be doing?

00:09:25:29 - 00:09:50:21
Lori Wightman, R.N.
We are all very interconnected and I believe we are all needed. And I especially feel that as an independent hospital, not part of a health system, this is my first independent hospital. I rely on my hospital association more than I ever did when I was working for a health system, because it all comes down to relationships.

00:09:50:21 - 00:10:18:13
Lori Wightman, R.N.
And so how do you develop, how do you get yourself in situations where you are meeting and now working with your partners around the state or the region? Because it comes down to relationships, you really need to know who your neighbors are in terms of other hospitals, who you're referring your patients to and develop that working relationship because it is all interconnected.

00:10:18:13 - 00:10:25:06
Lori Wightman, R.N.
And we rely on our partners that we refer to, and they rely on us, too.

00:10:25:08 - 00:10:43:23
Tina Freese Decker
One of the things I heard you say about the Rural Health Conference that the American Hospital Association just put on, and the value of the American Hospital Association is that we're not alone. And those values of relationships are really critical. So I appreciate that. The American Hospital Association also talks a lot about how do we tell the hospital story.

00:10:43:25 - 00:10:55:15
Tina Freese Decker
So how do you engage in advocacy to make sure we're telling that hospital story so that our legislative leaders and others know the value that we're bringing to the community?

00:10:55:17 - 00:11:22:11
Lori Wightman, R.N.
Well, we are surrounded by stories. And so the first thing is to always be picking up on what is the story that is surrounding us, and how can we capture that? Because the most effective way is to bring that patient or nurse or physician to the legislator to testify, because they are the most effective way of communicating a message.

00:11:22:18 - 00:11:49:07
Lori Wightman, R.N.
You know, the suits can go and talk about data, but nothing is more effective than what I call a real person telling their story and how a decision or a potential decision is going to impact them and how it feels. The other thing we do is every October, it's become tradition. We have Advocacy Day with our board, at our board meeting.

00:11:49:09 - 00:12:21:12
Lori Wightman, R.N.
We invite our state elected officials  - so people representing us at the state capitol - to come to our board meetings. On election years their challengers also come and I invite the hospital association and they all answer two questions: What do you hope to accomplish in the next legislative session, and what do you think might get in the way? That sets the scene for my board to understand that part of their role in governance is advocacy.

00:12:21:14 - 00:12:29:19
Lori Wightman, R.N.
And so I've had two of my board members...almost every legislative session I go and testify on on some bill.

00:12:29:21 - 00:12:50:01
Tina Freese Decker
That is really a good idea. Thank you so much for sharing that. Do you have any other final suggestions for us as AHA members, as other hospitals, whether it's rural or urban, that we should think about or do as we think about advocacy and access or also field unity?

00:12:50:03 - 00:13:22:11
Lori Wightman, R.N.
You know, having been on the board of two different state hospital associations, I get it. You know, sometimes members can be at odds with each other on a given issue. And my advice to AHA would be to play the role of convener, facilitating conversations between members to better understand each other's position. And if a middle ground can't be reached, then that might be an issue that AHA remains neutral on.

00:13:22:14 - 00:13:34:07
Lori Wightman, R.N.
But there are so many issues where we can agree on and that is very much the role and what all of us depend on AHA to play in advocating.

00:13:34:09 - 00:14:02:15
Tina Freese Decker
There's a lot that binds us together. Like you said, we're all caring for our neighbors and our communities, and that's the most critical piece of it. And we have to keep that front and center with every decision that we make and every action that we do. Well, Lori, thank you so much for being with us today on this AHA podcast, for sharing your expertise in rural health care and for talking about some new ideas that all of us can take forward to ensure that we're telling the hospital story in the best way possible.

00:14:02:18 - 00:14:21:09
Tina Freese Decker
So while I know that we have our work ahead of us, I know that I continue to be energized every time I speak with committed and passionate hospital leaders like Lori. Again, appreciate your work that you do every single day for the neighbors and for the people in your community that you serve. We'll be back next month for another Leadership Dialogue conversation.

00:14:21:13 - 00:14:23:01
Tina Freese Decker
Have a great day.

00:14:23:03 - 00:14:31:13
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:03 - 00:00:26:14
Tom Haederle
Welcome to Advancing Health. Hospitals and health systems never stop working to advance patient safety and quality. It has been and always will be our field's top priority. In today's conversation, two former American Hospital Association board chairs discuss the importance of bringing a culture of safety reporting to an organization, and how technology can't replace the human factor in a successful patient safety strategy.

00:00:26:16 - 00:00:41:04
Tom Haederle
Dr. Mindy Estes is the former CEO of Saint Luke's Health System in Kansas City and her guest, Nancy Howell Agee, is CEO emeritus of Carilion Clinic in Roanoke, Virginia.

00:00:41:06 - 00:01:06:23
Mindy Estes, M.D.
I'm Dr. Mindy Estes, and today we have the privilege of speaking with Nancy Howell Agee, CEO of Carilion Clinic. Nancy's remarkable journey began as a nurse when her commitment to patient care laid the foundation for an extraordinary leadership career. So let's just jump right in. You've had a remarkable career from nurse to CEO and long service in the field for AHA and other organizations

00:01:06:23 - 00:01:24:22
Mindy Estes, M.D.
and so, I think it really gives you a unique perspective on health care quality, safety, equity, workforce, all facets that go into a quality organization. So thinking back, what have been the most important actions you've taken as a leader to drive quality and patient safety?

00:01:24:25 - 00:02:09:21
Nancy Howell Agee
Well, you know, I'm glad you mentioned that I began my career as a nurse. And I treasure the fact that I am a nurse still. And, as one-on-one patient encounters are what have always driven me - the notion that you're caring for one person after another, and how you do that the very best of all. As I became a leader in health care about the time that I was moving as a chief operating officer and then the CEO, I was a representative from the American Hospital Association to the Joint Commission, and I was on the Joint Commission Board.

00:02:09:24 - 00:02:34:07
Nancy Howell Agee
And at that time, you know, we were beginning to talk about zero harm. And so I was hearing from the AHA in one ear: patient safety, quality; and in the other ear from the Joint Commission, patient safety and quality. So in stereo, what's really important. And I pondered that quite a lot as a leader to look at our own organization,

00:02:34:07 - 00:03:00:07
Nancy Howell Agee
what could we do differently? Not just check the box, not just meet the regulations, but really understand fundamentally what it meant to improve health care, improve patient safety, and improve quality. It seemed to me that it needed to start with the board. And so sort of a bottom up, top down conversation of education about our highest priority and what that meant.

00:03:00:07 - 00:03:31:07
Nancy Howell Agee
And when we talk about statistics, it's really important to measure quality, of course. But a statistic represents a patient. And so we began to frame how we think about quality with the patient in mind. Not the patients, but a patient. And it seemed to make a difference. At that time we reorganized the board and the board committees. And while we had a quality committee, it wasn't perhaps as robust as the finance committee.

00:03:31:07 - 00:04:00:15
Nancy Howell Agee
And it seemed like the committee that got the most airtime at board meetings was the finance committee. And educating the board about what it meant to be an integral, high integrity, zero harm organization. So we renamed the Quality Committee for the board CAPS: Clinical Advancement and Patient Safety. And now the two most important board committees are CAPS and finance.

00:04:00:17 - 00:04:27:09
Nancy Howell Agee
And our board chair sits on both. In hindsight, it was really important that our board chair began to [see] patient safety and quality is the single most important thing. I'll tell you something else we've done, Mindy. We celebrate what we call the great catch. And so the more event reporting that we do, we think that's fantastic. And so we, you know, any little thing, any big thing. Was funny,

00:04:27:09 - 00:04:51:07
Nancy Howell Agee
I was waiting on the elevator, a gurney went by and it went a little too fast around the curve. And there was a resident standing there and he said, hey, I think we need to put that in the event report. And it was, you know, just kind of an everyday encounter, but it was a great focus. The other thing we did was create a new set of values.

00:04:51:09 - 00:05:25:17
Nancy Howell Agee
Our mission is to improve the health of the communities we serve. We focused on our values and our values include courage, compassion, curiosity, commitment. And by focusing on those values,  we use those to talk and to educate regularly for new employees, as well as every year the required education for all staff include focus on our values and what that means to patient safety and quality.

00:05:25:19 - 00:06:02:13
Nancy Howell Agee
And the last thing I'd mention is that we organized everything under one umbrella. So everything from risk management to honor reporting to all the sort of things we do for preparation, for Joint Commission, for surveys from our state, patient safety, patient advocacy and our human factors team and our sim lab are all under one umbrella. And creating that real focus that's both education metrics and celebrate the good work that we do.

00:06:02:15 - 00:06:37:27
Mindy Estes, M.D.
It's remarkable. There are a couple of things that have, that have struck me. One is your point about so much time spent in board meetings on finance. And one of the things that, we did at Saint Luke's was to reorder our board agenda and have a quality close, if you will, just like we have the financial close where we are presenting the quality metrics not only on a monthly basis, but year to date basis, so that we have time on the front end of the board meeting to talk about quality as opposed to whatever time we had left.

00:06:38:00 - 00:07:06:15
Mindy Estes, M.D.
The other thing I would mention is, as you know, I'm currently on the Joint Commission Board, and we talk about innovation and quality and patient safety. And the conversations when you were on the board beginning to talk about Do No Harm. You know, today Joint Commission is innovating and innovating rapidly. So I think it really is, organizations in the Joint Commission, in this instance, marching together from a foundation that's been created over a number of years.

00:07:06:18 - 00:07:31:02
Mindy Estes, M.D.
You helped develop Carilion's innovative care model. Undoubtedly - and I've heard you speak on how that evolved - and I know you have a lot of insights for other leaders. So if you were advising a new system leader and there certainly as we've seen, movement in health care, there are a lot of new system leaders in our field. What would you tell them to do first, to set the tone for an effective culture in the organization?

00:07:31:02 - 00:07:34:04
Mindy Estes, M.D.
I think you've already touched on that, but I know there's more.

00:07:34:06 - 00:08:19:07
Nancy Howell Agee
I think creating an environment of this is our highest priority means you're using every single meeting, every memo, your social media, we have an internal social activity. We focus on that with every single communication that we have. And I think that that's critically important. But I'm glad you mentioned technology because both existing technology and new technologies, again, we focus on why we're doing this for patient safety and how it improves quality and by having that as our key priority, I think it begins to permeate the organization.

00:08:19:15 - 00:08:45:00
Nancy Howell Agee
Technology is important. If you ask me, what doesn't work as well as you thought it would when you first started? You know, I'll say introducing an electronic health record. I remember when we did that and we did it big bang approach. And I remember these words probably came out of my mouth as much as anybody. We're going to eliminate medication errors by having this technology.

00:08:45:04 - 00:09:15:24
Nancy Howell Agee
And of course that's ridiculous in hindsight. There's nothing that can completely alter the human nature of our business, thank goodness. But because we are humans, mistakes can happen. And so doing everything you can to have a safe environment, to create a culture that's a permissive culture that encompasses patients taking quality and everything that you do, I think that makes all the difference.

00:09:15:27 - 00:09:43:27
Nancy Howell Agee
You know, Mindy, you and I go back a long time. We used to think about things like central line infections and catheter infections and I don't know. It wasn't that we were cavalier about those things. I think we were just as concerned about patient safety and quality. We didn't recognize the whole milieu that it took to care for every single patient, every time, in the way that a patient should be cared for.

00:09:43:29 - 00:10:02:28
Nancy Howell Agee
And when I look back and I think about some of the things that we perhaps took for granted or didn't realize that we could change, and now I look where we are as an industry. Our whole field has improved patient safety culture, and I think there's even more that we can do.

00:10:03:00 - 00:10:26:20
Mindy Estes, M.D.
You know, to your point of change. And, you know, I think organizations like ours, we test, we pilot, we retest, and, you know, we want consensus. And if we don't like the first pilot, we do another one. And I think Covid taught us very quickly that, you know, we can innovate and we can innovate quickly. And we can learn from that innovation

00:10:26:20 - 00:10:39:12
Mindy Estes, M.D.
and if we fail, we need to fail quickly. And you touched on the electronic record and my next question, it was just going to be, what did you learn from something that wasn't as effective as you might have hoped?

00:10:39:15 - 00:11:03:10
Nancy Howell Agee
Well, I'll just echo first of all that you're right. During Covid, we learned, and I hope we continue to learn that lesson - and that is innovate, innovate quickly. You know, I think we can be accused of being way too slow and thinking through things, which is important. We have a saying here. Take risks without being reckless. After all, you are talking about a patient's life.

00:11:03:12 - 00:11:44:00
Nancy Howell Agee
The notion that we can innovate, that we can recognize and do something about that and take ownership at multiple levels. So I think one of the real lessons that began before Covid, but what really came home during Covid was a necessity for focusing on the resilience of our staff and all the things that we can do, because, you know, as a CEO, you and I are not really important to that patient interaction, that precious moment between a caregiver and a patient.

00:11:44:03 - 00:11:54:07
Nancy Howell Agee
And so all the things that we can do to support our staff so that they can give the kind of high quality, safe care that we would expect.

00:11:54:09 - 00:12:17:21
Mindy Estes, M.D.
You know, resilience continues to be important. And I think in this day and age is something that we used to take for granted as well, that the mission and the privilege to do what we do would fuel internal resilience. And I think part of this whole patient safety, quality and quality of our workforce and our workforces experience as well -

00:12:17:27 - 00:12:57:04
Mindy Estes, M.D.
that resilience and how we take care of that has become increasingly important. And Nancy, I want to thank you as always for your time, for your sharing your insights and experiences and your journey from being a nurse to an award winning CEO and your successful transformation of Carilion Clinic. It really provides powerful lessons for all health care leaders at all levels, and your commitment to quality and safety innovation, combined with your dedication to mentoring future leaders, especially women in health care, truly exemplifies exceptional leadership.

00:12:57:04 - 00:13:25:04
Mindy Estes, M.D.
And, you know, we've seen through your examples, how health care organizations can navigate while maintaining an unwavering focus on quality and safety, Because at the end of the day, that is what we do to provide the highest quality patient care and safety to our patients, first and foremost. And I really think it's important for our listeners to realize that underlying all of the success you've had is the heart of a nurse.

00:13:25:06 - 00:13:27:11
Nancy Howell Agee
Thank you Mindy.

00:13:27:13 - 00:13:35:23
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.