Advancing Health Podcast

00;00;00;20 - 00;00;26;05
Tom Haederle
Many hospitals and health systems will attest that building a culture of safety is a foundational mindset. It cannot be an adjunct mission or simply on a list of to do's. Case in point: Emerson Health of Concord, Massachusetts. Adopting an approach it calls equity informed high reliability, Emerson has conducted trainings on driving quality and safety for all stakeholders: board members, organization leaders, front line staff...
00;00;26;09 - 00;00;42;24
Tom Haederle
really, everyone. One Emerson executive calls it "singing from the same hymnal," and it's made a difference.

00;00;42;26 - 00;01;13;24
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this Safety Speaks podcast series hosted by Kristen Preihs, AHA's director of clinical quality, we hear how Emerson Health has achieved increased buy-in and measurable success in building a culture of safety across the organization. A key factor has been building psychological safety for its staff by shifting to thinking about how to improve systems, rather than blaming individuals if something is amiss.

00;01;13;26 - 00;01;36;26
Kristin Preihs
Hello and welcome to Safety Speaks, brought to you by American Hospital Association's Patient Safety Initiative. I'm your host, Kristen Preihs. And today, like every day, we're dedicated to empowering patients and health care professionals alike. Our goal is to foster engagement in patient safety initiatives, bolster public trust in hospitals and health systems, and promote evidence-based strategies to ensure the highest quality of care.

00;01;36;28 - 00;01;59;03
Kristin Preihs
Joining us today for Safety Speaks to discuss building a culture of safety is Christi Barney. Thank you, Christi, for being with us today - vice president of quality and patient safety and chief health equity officer at Emerson Health, located in Concord, Massachusetts. Christi, welcome. I'm looking forward to exploring your journey and discussing the impactful work you've been able to achieve in patient safety.

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Christi Barney
Thanks, Kristin.

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Kristin Preihs
Emerson has been on a high reliability journey for several years. What shifts have you seen the greatest impact on patient safety?

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Christi Barney
That is a great question, Kristin. I think some of this is changing a mindset around high reliability. I've worked in other organizations and certainly had a chance to share patient safety work, across the country as well as locally. And I think one of the pitfalls is when we think about high reliability as another project that we're going to graft on top of the work that we're doing in the hospital at any one time. And really changing that mindset and thinking about high reliability as truly the foundation of all the other work that we're going to do, begins to create a different kind of dialog and a different expectation.

00;02;47;01 - 00;03;23;02
Christi Barney
And that has been very exciting as we sort of embarked on that, embraced it in that way. As a result, we then really dedicated ourselves. Two and a half, three years ago, we began really, truly embarking on what we were calling equity informed, high reliability. So also pulling in the pieces every single time we look at it to think about our own cognitive bias, the bias that we might bring from our experience to also think again about the equity principles of the patients or families that are involved in the care and our own backgrounds that influence the way that we think about things.

00;03;23;04 - 00;03;49;03
Christi Barney
We rolled all that up, and we did a lot of training, making sure that every single one of our leaders were trained at the same high level about the content that we had. And we train the board and we train the frontline staff and making sure that, again, once we were all, as I like to say, singing from the same hymnal - once we really had the same language, we could then again have this foundational understanding and use that approach then to drive safety and quality throughout the whole organization.

00;03;49;06 - 00;04;00;29
Kristin Preihs
Wow, I love that and it sounds like your organization has gone through so many changes from training board to bedside. Can you talk a little bit about some of the greatest impacts you've seen in some of the shifts that you've moved forward with?

00;04;01;02 - 00;04;26;21
Christi Barney
I think some of this really gets down to, again, how we begin to build up psychological safety for the staff. When you begin to really embrace high reliability and the way that we're thinking about it, and in some ways that is different than, say, some of the traditional methodology that we use about, say, root cause analysis. The downside to a root cause analysis is there was often the idea that at the bottom, we're going to quote, get to the root of this, right?

00;04;26;21 - 00;04;55;24
Christi Barney
And then that often meant that there was a human at the bottom of that that had made an error, either intentional or unintentional. And instead we really begin by thinking about systems. So our work and thinking about systems helps shape the way that we pull apart cases. We certainly look at the human factors as well. But when we start with systems and we really allow ourselves to begin there and work together, what we find in these, these are interdisciplinary, collaborative case reviews.

00;04;55;24 - 00;05;16;03
Christi Barney
We bring the whole team together. We have on occasion brought in even the patient and family into that analysis, or at the very least reflected the work of having talked to them and getting their perspective, because we really do want a shared understanding again of the systems and what happened during the course of the events.

00;05;16;05 - 00;05;49;06
Christi Barney
That allows, I think, the team to operate from a different space where instead of feeling blamed for what happened, we really allow them some safety to mull over the impacts. So for example, one of the ways that this has really been enriching is when we find out that, say, the person forgot to do a step that we had assumed was a known safety step, taking it a step back and saying, well, what was our system for training that staff person and having that staff person tell us

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Christi Barney
but then turning to the rest of the crew and saying, did that work the same way for other people? Was everybody present when we did that training? Keep incrementally thinking differently about the way that we intended to communicate the priorities around safety to the frontline staff, and to find what we would call the risk points in there. Because otherwise, the downside is we often got to this point where we decide, well, the human was the risk. And more often it is not.

00;06;16;12 - 00;06;34;16
Christi Barney
I really, truly believe that the people who choose to work in health care are doing so because they really want to make a difference. They want to provide the very best care every single time to every single patient. So the interesting thing is, where did we not build systems around people so that they're able to do the very best every single day?

00;06;34;24 - 00;06;54;20
Christi Barney
And where can we equip them differently to make sure that their training, their orientation and that the systems themselves lend themselves for them to cognitively remember the things that they need to do? Certainly a lot of the work then that we do is around system redesign and making things better and safer in the hospital as a result of that.

00;06;54;22 - 00;07;22;16
Chris DeRienzo, M.D.
Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, the AHA’s chief physician executive and a champion of the AHA Patient Safety Initiative. AHA’s Patient Safety Initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

00;07;22;18 - 00;07;54;15
Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1500 other hospitals already involved, visit aha.org/patientsafety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA’s Patient Safety Initiative.

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Chris DeRienzo, M.D.
Remember, together we can make health care safer for everyone.

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Kristin Preihs
That's such incredible work. And I want to say too, you went through such a huge transition as you really shifted the mindsets of those you are working with from something that it's much more expectation to be more punitive and how you're looking at things like root cause analysis to really a much more positively focused effort. So could you talk a little bit about how you supported that transition and mindset with those you were working with?

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Christi Barney
Yeah. Great question Kristen. You know, some of this is I think...when we convene these collaborative case reviews, we really start by trying to set that framework to help people. I always give the caution, I want everybody to just stay curious. Often when we're unpacking these situations, people understandably feel passionate about the thing that didn't go to plan. People

00;08;47;10 - 00;09;07;12
Christi Barney
you know, it really, I think, pains health care workers when a med error is made or again, a patient gets an infection. And so there's a lot of passion in the room and there's a lot of energy. People feel badly sometimes about the role that they may or may not have played in it. And what we want to do is turn down the volume.

00;09;07;12 - 00;09;34;08
Christi Barney
One of the things that we talk about in the high reliability is, again, that idea of just stay curious. You can't be curious and angry at the same time, right? You don't find a curiously angry person in your life. So really being in that mindset of continuing to feel like you're safe enough to ask yourself questions and ask other people questions, and we mind the emotional temperature of the CCR in that way

00;09;34;08 - 00;10;01;16
Christi Barney
the collaborative case review. And really try to create an environment where we can keep asking those curious questions. Once we have enough space, then we're like, off to the races, it's really fun. And it often leads to a deeper conversation that I think we were having previously. You know, unfortunately many's the time I've sat in root cause analysis and everybody just struggles over the timeline, the sequence of what was happening.

00;10;01;23 - 00;10;30;01
Christi Barney
And we can't step away from that to really, again, think big picture, systems thinking. Where were the risks in what we had designed? Where did the things go wrong? This really I think has changed the dialog. The other thing that we've tried to intentionally put into the design is that very naturally, often, near the end of the collaborative case review, we start to talk about an after the event happened or after this came to light, how were people doing?

00;10;30;04 - 00;10;50;09
Christi Barney
What did we do next? Did we take good care of each other? Was there a debrief at the end of this? If we did a debrief, what was working and not working about it, what would you have liked to do differently? Letting ourselves really think about how we take care of each other, and whether or not that too is highly reliable, that we're making sure that that gets wired in.

00;10;50;12 - 00;11;09;11
Kristin Preihs
That's such a significant achievement. And again, I just think it's so incredible, that you've changed hearts and minds with this approach and acknowledge that these changes likely took time in many instances. So could you talk a little bit about how you led the staff through kind of this transition, and then what the impact of all of this incredible work was

00;11;09;11 - 00;11;11;22
Kristin Preihs
as you move from one model to the next?

00;11;11;24 - 00;11;37;02
Christi Barney
You know, I think it is a journey, right? Every day I think is an opportunity to learn something new and to approach something, from a fresh perspective. Part of the work that we have done is to, again, use that same model to apply to any number of things. I think traditionally, again, sometimes that root cause work would tend to be for a serious reportable event or a sentinel event.

00;11;37;05 - 00;12;02;15
Christi Barney
And so the only time that people convened in that space and work together and thinking about it in this particular, methodology might be again, those things that again, really you were fighting outcome bias, to a certain extent. Instead we can review anything. So an example, we knew that we had more CAUTIs and CLABSI's than we felt comfortable with because in an ideal world, we would have none.

00;12;02;23 - 00;12;27;03
Christi Barney
And so what we began to do was, every single time we had a CAUTI or CLABSI, we would have a collaborative case review. And we started out in that case by knowing again, what's the system design, is that first question. We used, some of the ARC framework, some of the best practice documents, and we had a standardized set of questions that we were going to look at ahead of time to help people think through again:

00;12;27;05 - 00;12;47;23
Christi Barney
did we do the bundle as we truly intended? You know, were there things that fell out of that? But then use that as the beginning of - once we had done that, the springboard of, again, thinking about both the system that the humans... that led to a richness of dialog that over time we began to find certain things that were falling out.

00;12;47;23 - 00;13;19;27
Christi Barney
So again, this using this concrete example for our CLABSIs, lo and behold, we found out sometimes patients were refusing a CHG back. Again, this interdisciplinary group gathered, it was our patient care technicians, our PCTs who were right at the bedside. They were able to say, well, it's sticky. The patients don't like it. It's really sticky. And that led to this great opportunity to then take that information and think about using, again the quality improvement principles.

00;13;19;29 - 00;13;48;06
Christi Barney
So now we can take that. We can begin to think of interventions. We can test out those interventions. And in the end we had to build way back. We realized way back before for elective surgeries, we needed to talk to people about why the sticky bath matters and have education going right from the get go. So people had the expectation there is going to be this important bath that helps decrease my risk of infection because I'm going to have a central line

00;13;48;06 - 00;14;16;18
Christi Barney
so I need to be able to be prepared to do that. Having done that, we've now gone over a year with no CAUTIs and no CLABSIs. And again, it was this standard work of coming together every single time. But we've done collaborative case reviews for when the tissue freezer went out of range in the O.R., and why alerts failed to be signaled in an appropriate time frame.

00;14;16;18 - 00;14;41;08
Christi Barney
And again, really thinking about again. And that's situation how all of the team fits together. The bio-med people and the again, some of our supply chain folks with staff in the O.R. and how all the systems work together and how we, again, alert and respond. We've had collaborative case reviews where we looked at escalation pathways. When what happens when we have a disagreement?

00;14;41;08 - 00;15;03;24
Christi Barney
And do we have a standard way that we work through a disagreement and use our escalation process? All of these different things, you can hear could be, very different content wise, but it's that same methodology. And then taking that step back and saying, okay, at the end of the day, how do we do together? How does it feel to be together in the room?

00;15;03;25 - 00;15;24;25
Christi Barney
How are people feeling? Those kinds of questions, again, mattered a lot. And from that then we began to have, you know, exponential growth. So we had four times as many safety reports as when we started three years ago. We have staff who will seek us out or seek their leaders out and say, I'd like to have one of those collaborative case reviews.

00;15;24;29 - 00;15;42;04
Christi Barney
This thing happened on the shift last night and it just didn't go right. And I want to understand more about it. so you're really watching people embrace together this spirit of curiosity and a methodology for then, figuring out how to do things better.

00;15;42;06 - 00;16;04;16
Kristin Preihs
Christi, I think your journey again is just one that we all have so much to learn from. And, you know, just like sticky bath matters, everyone's voice matters when it comes to patient safety. So really appreciate you, being on this podcast today and sharing your valuable insights and experiences in patient safety. I hope we hear from you many, many more times because I think you have a lot to teach us

00;16;04;18 - 00;16;23;23
Kristin Preihs
really, in your experience. And from, you know, transitioning system wide improvements in quality, improvement in patient safety all the way out to things like burnout and how do you get people to try things that are new, an environment where that can be really difficult to know what to start and how to create that, psychological safety that you mentioned in our current workforce is just so key.

00;16;23;24 - 00;16;43;05
Kristin Preihs
So I truly applaud you and your efforts. To others that are listening, if you want to have conversations with Christi or learn more about the Patient Safety Initiative, I highly encourage you to join us so we can hear your voice as well. By becoming a member of the Patient Safety Initiative, you gain an access to a wealth of resources, collaborative opportunities and killer expertise

00;16;43;05 - 00;16;55;05
Kristin Preihs
Just like Chrisi who can support you in your journeys. We're very fortunate to have this initiative and hope others to sign up as well. And Christi , I just want to say thank you again for your time today and look forward to continuing the conversation.

00;16;55;08 - 00;16;56;22
Christi Barney
Thanks, Kristin.

00;16;56;25 - 00;17;05;07
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.

00:00:00:18 - 00:00:20:26
Tom Haederle
Experts say at least one in five children or adolescents in a pediatric waiting room is dealing with a significant mental health problem — everything from serious eating disorders to suicide attempts. Nationwide, there has long been a critical shortage of trained care providers to meet the needs of kids struggling with these issues. And the problem is especially acute in rural areas.

00:00:20:29 - 00:00:42:06
Tom Haederle
So it's encouraging to see that the most rural academic health system in the U.S., New Hampshire's Dartmouth Health, has created one of the most innovative and effective programs anywhere to provide the tools to help.

00:00:42:09 - 00:01:09:27
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Sitting near the border with Vermont, Dartmouth Health serves a population of nearly two million people across many small towns in northern New England. Backed with a federal grant, Dartmouth has created a five-part virtual behavioral health training program for children and adolescents that offers care providers effective tools to engage and help guide young people through their challenges.

00:01:09:29 - 00:01:37:00
Tom Haederle
The program is called Keeping Students Safe: Supporting Youth in Mental Health Distress. In dialogue about the program with Jordan Steiger, AHA senior program manager for clinical affairs and workforce, are three experts from Dartmouth Health. Dr. Julie Balaban, child psychiatrist, Jackie Pogue, research project manager with the Dartmouth Institute for Health Policy and Clinical Practice, and Barbara Dieckman, director of Knowledge Map and patient education.

0:01:37:02 - 00:01:53:18
Jordan Steiger
Julie, I'm wondering if you can kick this off being that you are a child and adolescent psychiatrist, but we know it's been all over the news that since the start of the pandemic, a lot of children and adolescents are really struggling with their mental health. So could you kind of just paint the picture for us of what that's looking like right now?

00:01:53:25 - 00:02:21:09
Julie Balaban, M.D.
Yeah, I think there's actually been a problem with meeting the needs of children and adolescent mental health for a long time, because there's always been a critical shortage of mental health providers in general, and specifically for children and adolescents in that area of specialty. And then the pandemic really highlighted that the kids that were coming into the emergency room were seriously ill.

0:02:21:11 - 00:02:43:17
Julie Balaban, M.D.
Significant eating disorders, very serious suicide attempts. That's what was showing up during that time. And I think that really brought to light that this was an area of great need for a long time. So it's been well known that historically, that one in five kids in a pediatric waiting room, for example, will have a significant mental health problem.

00:02:43:17 - 00:03:10:14
Julie Balaban, M.D.
That number may now be higher, maybe one in four. And depending on what region you live in of course. The other piece that the pandemic played into is of course the general workforce shortage. So nursing shortage, for example, is a problem that's been affecting things like inpatient beds for kids who might need a psychiatric hospitalization. So hospitals have had to decrease their bed size.

00:03:10:14 - 00:03:34:05
Julie Balaban, M.D.
And so that led to a backlog for kids who were seriously ill, having to be in emergency rooms or even waiting at home. At Dartmouth, we had the luxury of being able to put some of those kids, at least up on a pediatrics unit, so they were around other kids and not in a general emergency department, which can be a scary place for a kid.

00:03:34:07 - 00:03:58:09
Jordan Steiger
Absolutely. And I mean, I know that this is a problem that is affecting communities, hospitals, health systems across the country. We hear it all the time at AHA. You know, we need to provide support to children and adolescents. I know you mentioned some pretty severe things like suicidal ideation, you know, severe and persistent mental illness that we know can continue to get worse when they are not treated.

00:03:58:11 - 00:04:14:27
Jordan Steiger
What I love about the work that you all are doing is that you're not just sitting back and saying, this is bad, what are we going to do? You've taken the steps to do something about it, and kind of brought your entire community and state along for the ride with you. So I would love to hear kind of what you're doing.

00:04:14:27 - 00:04:25:11
Jordan Steiger
I know that you have a virtual behavioral health training program for children and adolescents, and teaching people how to respond. Is that correct? Jackie? Can you tell us a little bit more about it?

00:04:25:11 - 00:04:49:09
Jackie Pogue
Sure. So we received a grant from HRSA around training rural behavioral health workers, very broadly defined. And we knew we wanted to focus on youth mental health. But, you know, we can't, like, grow a bunch of new psychiatrists in three years or, you know, things like that, we're trying to think creatively about where might be points of intervention that could have a bigger impact.

00:04:49:12 - 00:05:32:04
Jackie Pogue
So we met with a lot of different stakeholder groups, a lot of people from schools. So school counselors, school principals, other folks hearing about how youth mental health was impacting kids at school. So it could be things like really disruptive classroom behavior, kids who are kind of languishing, like just showing up but not thriving, right. A lot of kids wandering the hallways and hearing some of those stories, and also educators and people on the school staff, like really trying to work together for the increased severity and number of kids who were in having mental health challenges.

0:05:32:05 - 00:05:55:22
Jackie Pogue
So through those conversations, we developed, five-series training called Keeping Students Safe: Supporting Youth and Mental Health Distress. And we designed the program so that way to kind of fill some of these gaps that we heard from the schools. So they're like, well, they said they're very sick, but they went to the hospital and they sent them home.

00:05:55:24 - 00:06:17:06
Jackie Pogue
Like, why didn't they admit them? They're still so sick, or, oh, they went to the hospital and they came back and they're still really having problems, like what's going on. And so we realized there were, there are these kind of siloed systems, and to be able to share information and, you know, sort of promote more collaboration and give people more tools.

00:06:17:09 - 00:06:45:11
Jackie Pogue
What's been interesting is sort of helping people learn about all the skills they already do have, you know. I think there's a lot of fear from people that they're gonna say the wrong thing or that they don't have the tools, and not everybody is going to administer like a Columbia scale around suicide severity, right. But like especially school staff, I mean, they're amazing, you know, they're like, yeah, I talk to this kid every day.

00:06:45:11 - 00:06:55:27
Jackie Pogue
We do a check-in. We do these things like so just helping them feel more confident and that there's more details on it left out. Julie or Barb, what what else would you add?

00:06:56:00 - 00:07:26:16
Julie Balaban, M.D.
I think you did a great job, Jackie, of describing. I think what I would add is each time that we do the program, we learn from what our experience is, so that we can fine tune the content to better address what's coming up from the participants as what their needs are. And I think the other really nice aspect of the way the program runs through the I ECHO format is this all teach, all learn model.

00:07:26:19 - 00:07:55:04
Julie Balaban, M.D.
So not only, as Jackie said to people already innately have a lot of skills that they can bring. They just don't realize that it's useful. But they also all have a lot of help and support for each other and very practical resources. You know, we'll hear schools from the northern part of the state talking about something that they're doing, and then someone in the southern part of the state will connect with them offline to find out how they could implement the same thing in their school.

00:07:55:10 - 00:08:17:04
Julie Balaban, M.D.
So it's just been a wonderful way to build connections and networks that otherwise would never have happened, and all in the name of supporting youth in their schools. And our hope being that with those added resources and support, that kids will do better sooner and won't get to that severe level where they need to go to the emergency room or need to access things.

00:08:17:12 - 00:08:23:21
Julie Balaban, M.D.
But we also tell them how to handle that and what they have available to support them if they should need to.

00:08:23:23 - 00:08:52:06
Barbara Dieckman
I would agree with both of you. You know, I think that the ability to intervene in a kid's life earlier or in their where are you beginning to see some problems at school and having people that have those natural relationships with kids actually do something or be able to reach out and touch them is really helpful. I think just to decrease the demand on the whole acute care system.

0:08:52:08 - 00:09:17:26
Jordan Steiger
Absolutely. And I love, you know, through this program, you've kind of addressed some of those workforce issues that we hear about, maybe not directly, you know, but bringing people in like a coach, like a school nurse, like a principal, people like you said, Barb, that have contact with these children every day, that know them, that know their lives and can intervene, I think, takes so much stress off of the local health care system, as you all have mentioned.

00:09:17:29 - 00:09:37:07
Jordan Steiger
And I think that's so important because as you said, Jackie, we can't grow psychiatrists on trees. That's going to take a little time to build the workforce. So this is, I think, just such a great example that others can emulate and really implement in their own states. But I'd love to hear a little bit, maybe about some of the positive outcomes that you've seen.

00:09:37:15 - 00:10:21:23
Jackie Pogue
So we've done this five, it's a five-session one hour Zoom like every couple weeks. Usually. So we've run that five times. We've probably had 500 total people participate. It's been very, very popular. And some of the outcomes that we've heard, we do a pre/post course survey and we do a follow-up three months later. So things that people talked about are feeling more confident that they could intervene with a student in distress, that they knew the resources that were available and that they felt more confident interacting with youth's families as a resource and also other community resources.

00:10:21:26 - 00:10:57:29
Jackie Pogue
One outcome that we're really proud of is that, like 100% in every session, people talk about having a decreased sense of professional isolation. And so that is really powerful for us, knowing that people are, you know, just like in health care, school staff are very stressed. They've had a really hard time from the pandemic and now, and to be able to provide an opportunity for people to connect, to not feel so alone, right, that there's resources and there's hope has been really very meaningful I think for our team.

00:10:58:01 - 00:11:15:28
Jordan Steiger
That's great. I think, you know, sometimes we all get in our own bubbles and lanes and think, oh, we are the hospital. We can only solve problems for patients and families once they walk through the doors. But I think this proves that there are a lot of ways to partner with your community and to really improve the way that we respond as a whole.

00:11:15:28 - 00:11:28:20
Jordan Steiger
And I think that's really, really powerful, especially when we're talking about maybe smaller rural communities that we do know have some issues sometimes with workforce, with access, with things like that. I think this is just such a great example.

00:11:28:23 - 00:11:56:13
Jackie Pogue
Yeah. With youth mental health, it's just, it's such a crisis, right. And it's really an all hands on deck situation. And there's so many areas where people can act. And so that's really you know, when I think about the stats, it's really sobering. And then I think about all the caring school staff and community youth supporters and other folks that I have, that we've met through our Project ECHO.

00:11:56:15 - 00:11:58:09
Jackie Pogue
It really gives me a lot of hope.

00:11:58:11 - 00:12:19:09
Julie Balaban, M.D.
Yeah, I think one of the things that was an unexpected outcome for me, anyway, was hearing from the community, you know, we know this is a crisis and I come at it particularly from a clinical perspective. And what are we doing and how are we seeing these kids, and what kinds of things can we do to increase access to specialty care and all of that?

00:12:19:12 - 00:12:45:19
Julie Balaban, M.D.
And then talking to not just the schools, but particularly when we did the community programs, town libraries, we had a lot of librarians participate, and the stories that they tell about what they're doing and how they're trying to hold these kids together and what they have to manage in their setting with even less support than a school setting would have

00:12:45:21 - 00:13:09:21
Julie Balaban, M.D.
for example, it really opened my eyes to how this problem is just not just pervasive, but is really affecting people in the community so strongly, even if it's not the family member of the kid or the school trying to educate the kid. Like everybody is experiencing it, everybody is struggling. It was really something.

00:13:09:24 - 00:13:16:22
Jordan Steiger
That is. What other types of professionals were involved in that community ECHO that you ran?

00:13:16:24 - 00:13:57:03
Julie Balaban, M.D.
So we had some faith leaders from the community. We particularly ended up with our panel trying to include more of the community members for that reason, because we previously had had a lot of school people because we were dealing with school. And then of course, the hospital psychologists and myself and the typical sort of providers for kids. But we've very much have learned that if we're doing a program for a particular group of stakeholders, you need to have representation from that group on your panel, or you'll miss the boat in a number of things, even if it's just like when to schedule the sessions.

00:13:57:05 - 00:14:12:07
Julie Balaban, M.D.
So we had faith leaders, we had the coaches, we had rec department people, we had a daycare provider participate. People from some of the like, family support centers throughout the region. Those kinds of people.

00:14:12:09 - 00:14:37:15
Barbara Dieckman
You know, I would add to that, what is so good about doing this in a virtual way is that people didn't have to come to a meeting, central location. We've got mountains and you know everything else, right? And like every other rural community, there's distance, right? And there is hardship in terms of transportation and getting time off. None of that had to happen.

00:14:37:23 - 00:14:53:13
Barbara Dieckman
I mean, what we were able to do is to bring these people together from very disparate areas geographically to talk about something that they all cared about, and they all had very similar themes of need and solutions for each other.

00:14:53:15 - 00:15:12:10
Jordan Steiger
I think that's really powerful and especially like you mentioned, just, you know, addressing some of those, you know, transportation, some, you know, that distance between people, I think is something that I think many people will resonate with that are listening, you know, finding easier ways to connect people. And I think you guys have done that really, really well.

00:15:12:12 - 00:15:22:20
Jordan Steiger
As we wrap up, if you maybe have inspired somebody that is listening to, you know, implement something like this at their own hospital or health system, what advice would you give them?

00:15:22:23 - 00:15:49:00
Julie Balaban, M.D.
I would say do it. You know, we used a particular program that I ECHO program because Dartmouth has joined that group. But you can do this without any sort of a formal program. In our presentation, in our handouts, we particularly put a lot of that information because we want people to be able to emulate it within their own setting with whatever they can do and whatever resources they have, and it doesn't have to be costly at all.

00:15:49:03 - 00:16:14:16
Julie Balaban, M.D.
So I would say just jump in and do it. And I think, again, I think the important pieces are to go to the group you're trying to reach and hear from them. As Jackie talked about what they see as their needs, because we had guesses about things. But I think we did a better program because we worked from their perspective and what they were telling us.

00:16:14:19 - 00:16:24:18
Julie Balaban, M.D.
And then also to keep that good representation on your planning committee and on your panel so that you're really keeping a nice, well-rounded group going.

00:16:24:20 - 00:16:29:12
Jordan Steiger
Great, thanks Julie. Barb, Jackie, any advice you'd want to share?

00:16:29:14 - 00:16:43:01
Barbara Dieckman
Know that you can make a difference. Know that you can make a difference and just keep keep doing it. Keep improving. Keep looking for ways to hear from the people that are your audience. You can do it.

00:16:43:04 - 00:17:05:29
Jackie Pogue
I would add, you know, I think Project ECHO is a really great training platform and format, but like Julie said, you don't need to do Project ECHO to do a good program. And the things that I really value about ECHO and what we've been doing is you don't need to have a bunch of fancy experts like talking, talking, talking, right?

00:17:05:29 - 00:17:33:11
Jackie Pogue
The beauty of a more interactive, all teach, all learn there is the sense that you're relinquishing some control over your program, but it ends up providing space and being more powerful, I think. And that is, that's just how adults learn, right? Like giving each other advice and ideas and stuff that you can apply right away. So, you know, I've facilitated all the sessions.

00:17:33:11 - 00:17:52:11
Jackie Pogue
It's super fun for me to just, you know, don't know what people are going to say. And, in that way, yeah, it's just it's really rewarding. So I would say even if you're not going to use Project ECHO, I would encourage you to if you're going to do a session, have half of it be something where the audiences interacting and sharing with each other.

00:17:52:14 - 00:18:10:20
Jordan Steiger
I love that all teach, all learn model. I think that is so effective and just want to thank all of you again for joining us. I think the work that you're doing across your state is truly phenomenal. And like I said, something that others can really learn from. So we appreciate you sharing. And Julie, I know you mentioned you put some notes in your presentation.

00:18:10:20 - 00:18:17:03
Jordan Steiger
We can make sure maybe to add those to the podcast description so others can also learn from that. As long as that's okay.

00:18:17:03 - 00:18:18:01
Julie Balaban, M.D.
That would be great.

00:18:18:01 - 00:18:21:12
Jordan Steiger
Wonderful. So thank you so much again.

00:18:21:15 - 00:18:29:23
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.

00:00:00:18 - 00:00:31:20
Tom Haederle
Many Americans believe that the world's most elite law enforcement agency, our own Federal Bureau of Investigation, has a purely domestic charter and operates only within the borders of the United States. That's not completely accurate. While it's true the FBI cannot issue subpoenas, conduct investigations, or make arrests overseas without consent from the host country, it does have an international operations division of nearly 100 offices around the world that monitors and works to mitigate the kinds of crimes and threats that don't respect borders.

00:00:31:23 - 00:00:46:00
Tom Haederle
And in this age of rampant cybercrime, their presence is more important than ever.

00:00:46:02 - 00:01:26:02
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. The rise in devastating cyber attacks directed against hospitals by state-sponsored bad actors remind us that America's interests can be assaulted from anywhere and must be defended everywhere. In this podcast hosted by John Riggi, AHA’s National Advisor for Cybersecurity and Risk, we hear from an Oliver Rich, assistant director for the FBI's International Operations Division about the unique ways the Bureau operates in host countries and the essential role that diplomacy and cooperation play in working together to block or deflect criminal activity.

00:01:26:05 - 00:01:52:03
John Riggi
A.D. Rich, Oliver, if I may. You've had a very interesting and highly distinguished career in the FBI, and many young men and women still dream of becoming an FBI agent. Could you tell us your path to the FBI? What drew you to the FBI in a career in law enforcement? And how did you prepare yourself for the highly competitive process for selection to the most elite law enforcement agency in the world?

00:01:52:05 - 00:02:09:18
Oliver E. Rich, Jr.
Again, thank you very much for the opportunity. Good to be with you. And thank you for the question. You know that it's never lost on me, that you know the incredible opportunity that I have working for the FBI. I can say that, you know, I've met some people in my career that have thought about being an FBI agent their entire life.

00:02:09:18 - 00:02:35:10
Oliver E. Rich, Jr.
Right? And that's always been their dream. That's not particularly my story. When I was a kid, my father was in the Air Force and he was an Air Force mechanic. And he used to talk about all the planes and the aircraft and the jets and things like that when I was a kid. And so as a kid, I grew up wanting to be a pilot, and that's pretty much was my dream until I went off and joined the Navy and became a pilot in the Navy.

00:02:35:12 - 00:02:52:06
Oliver E. Rich, Jr.
When I left the Navy, my wife was in the military as well. And when, you know, we had kids and, you know, life was changing and those kinds of things. I did happen to meet a guy one time when I was stationed in Memphis, Tennessee. He was an FBI pilot, and he started talking with me about the FBI.

00:02:52:06 - 00:03:08:12
Oliver E. Rich, Jr.
Took me over to the FBI building. Showed me around. And, you know, we talked about it, and I was like, man, that'd be an interesting career. As I was  getting out of the Navy. I ended up going to the airlines. And then 9/11 happened, and I didn't forget about my experience and my exposure to the FBI.

00:03:08:13 - 00:03:28:20
Oliver E. Rich, Jr.
But also, you know, being an airline pilot. Great job. I mean, it really is a great job. You know, you can have a lot of fun, go all over the world and stuff like that. A really, really enjoyable job. I just thought that there was more service to be done and I reflected on my conversations with not only that FBI agent, but another FBI agent that I met when I was in the Navy.

00:03:28:20 - 00:03:49:01
Oliver E. Rich, Jr.
And so they talked with me about, you know, the amount of service or the kind of service that I could have as an agent. And it really just piqued my interest. And particularly after 9/11, you know, I talked to my wife and I said, I think, I think I want to do this. So I reached out to an agent that I knew from the military, and, he helped to recruit me and get me into the FBI.

00:03:49:01 - 00:04:14:00
Oliver E. Rich, Jr.
And so it's been a it's been a great career. I think, you know, that a lot of the things that in my past and in my, in my career before coming into the FBI kind of fit well with, with the FBI, the military background, it's not just about military folks. I was really proud of our class that we had so many different people with backgrounds from a range of industries, including banking and finance and accounting and teachers.

00:04:14:00 - 00:04:37:11
Oliver E. Rich, Jr.
And so it wasn't just, you know, military guys that was there. But I think what we were looking for is a kind of person that really wanted to serve. And, you know, we were I came in 2004. So there's a lot of us that looked at what happened on 9/11 and wanted to make a difference and wanted to serve, and felt like we could in a way that would allow us to be part of a team and allow us to be a part of something bigger and support the nation.

00:04:37:11 - 00:04:55:00
Oliver E. Rich, Jr.
And I think that was the backbone of really most of us and why we did that. I'll tell you when I took the test, when I took the test for the FBI, you know, I thought I failed it. It was a lot of math on that test. And I was like, there's no way I passed that test. I'm just going to go back and take my airline job.

00:04:55:02 - 00:05:07:24
Oliver E. Rich, Jr.
But it really made me want it more. I am that kind of person that if you tell me I can't do something, then I'm like, I would double-down and I want to do a lot more. So when I thought I didn't pass a written test, I was like, oh my gosh, you know, I could not fail this test.

00:05:07:26 - 00:05:26:18
Oliver E. Rich, Jr.
But I got the letter. I found out later that they didn't care about the math. They're really just trying to work me up to, you know, for the really important part, which is what kind of person are you, what kind of character you have? Are you driven? Also just being that, you know, type A personality, a lot of us are where we want to get 100% on everything.

00:05:26:25 - 00:05:37:00
Oliver E. Rich, Jr.
You know, I think I was ready for the academy, I think I was ready for the career. And, you know, I was very, very pleased to be able to work with some of the some of the best people that I've, I've got a chance to meet in my lifetime.

00:05:37:02 - 00:06:01:12
John Riggi
Thanks for that background, Oliver. It's interesting how you talk about one meeting with someone who takes an interest in a young person to help mentor and guide them can change their entire lives. In the fact that you, being present in the Bureau has helped the Bureau become better as well. So these, you know, as I've learned, you know, I spent 28 years in the Bureau, you know, and been out for a retired eight years now.

00:06:01:15 - 00:06:26:19
John Riggi
And I think back of, all the folks that helped me and mentored me in my career and steered me in the right direction. And there is a personality type goes to the Bureau. Be the best - as soon as you attach elite to anything, that's what we want. But I realize now, at this stage in my life, that some of the most important things that I do involve mentoring young folks, helping them realize their fullest potential.

00:06:26:19 - 00:06:52:16
John Riggi
And thank goodness that person - thank goodness for the nation and the FBI - they took that time with you, Oliver. Let's talk current tense right now. Tell us about your current role. Extremely fascinating that most folks don't realize the FBI has an international mission. You're not just a domestic law enforcement agency and domestic, national security agency. The FBI absolutely is international in scope.

00:06:52:18 - 00:07:07:23
John Riggi
Talk to us about your global responsibilities as head of the FBI's International Criminal National Security Investigation and Operations that you oversee. And, maybe you can talk to us about what authorities the FBI does or does not have overseas as well.

00:07:07:25 - 00:07:30:24
Oliver E. Rich, Jr.
The kinds of issues and threats that we deal with as a nation today obviously do not respect borders, right? And so the FBI, many, many years ago saw this as something that we you know, saw the international, aspects to crime and to national security as something that we needed to be able to have a presence and be able to work from overseas standpoint.

00:07:30:24 - 00:07:51:21
Oliver E. Rich, Jr.
So as far back as in the 40s, I think our first office that the FBI established was in, Bogota in Colombia. And then we set up some additional sites in Mexico. And the program sort of expanded. But today, International Operations Division, we have about 65 legats and another 30 legal attache offices offices.

00:07:51:21 - 00:08:30:13
Oliver E. Rich, Jr.
where we have a senior FBI agent assigned along with the team, as well as we have some offices around 32. So we have about 98, you know, 90, 97, 98 offices around the world. The staff with about 350 people. And we cover about 180 countries, in international operations division. And our goal is to be a good partner with our foreign partners, with our international partners, to help mitigate threats of national security, to help mitigate threats of, from a criminal aspect, whether it's transnational organized crime or crimes against children.

00:08:30:16 - 00:09:03:24
Oliver E. Rich, Jr.
We have agents stationed all over the world to help mitigate and manage these threats and risks. For the most part, 99% of the time we don't have any authorities overseas to act except for the authority and the power of our foreign partners. So, so much of what we do is just based on relationships. It's based on the fact that we are talking with like minded countries, for the most part, to have an interest in mitigating the same types of threats that we have an interest in.

00:09:03:27 - 00:09:37:24
John Riggi
So, Oliver, fascinating what you're describing here, how many different countries that you cover. And I think one of the key points you mentioned is that everything that is a national security threat or internet organized crime, major crimes are international in scope these days. And certainly part of the reason for that is the internet. People are able to including the bad guys, communicate much more efficiently and develop global relationships, which unfortunately is turned into global criminal and national security threats.

00:09:37:26 - 00:09:55:11
John Riggi
As you indicated, the FBI has no unilateral authority. You just can't handle a agency or a foreign entity, a subpoena or a search warrant you've got to work at through cooperation. So that's really what I found amazing when I was dealing with the legats when I had the privilege to be overseas for a little bit as well.

00:09:55:13 - 00:10:25:17
John Riggi
Speaking about being overseas: recently I had the opportunity to provide a keynote presentation at a very large European cybersecurity conference with the head of your FBI Rome office, your legal attache, Chris Flowers, just did an amazing job. We discussed recent joint international cyber law enforcement disruptions. Could you briefly tell us about some of those, such as the Lockbit in the hive ransomware group disruptions and how you work with allied foreign law enforcement agencies?

00:10:25:19 - 00:10:29:04
John Riggi
Finally, does the private sector play a role in those disruptions?

00:10:29:06 - 00:10:47:13
Oliver E. Rich, Jr.
Yeah. Thanks again, for your question, and thank you for attending the event over there. I mean, I know there was a there was a lot of people are huge event. And, we were very fortunate to be able to, take part in, with, with our, our legal attache, Chris Flowers over there, who's representing the Bureau extremely well in Rome with all our partners.

00:10:47:15 - 00:11:06:05
Oliver E. Rich, Jr.
Look at, you know, cyber is one of those things like I said earlier, there is no borders here, right? And, so these are huge problems that we face within our cyber division. In the FBI in general, you know, part of our strategy is to one: identify and disrupt cyber networks wherever they are in the world.

00:11:06:05 - 00:11:31:28
Oliver E. Rich, Jr.
And so we have to work very closely with our international partners, and also with, with our domestic partners as well. To do this is I mean, these are, very challenging threat actors. They present numerous, numerous areas where we have difficulty in tracking and figuring out who they are. But we are working very hard to, number one, remove their anonymity of these actors.

00:11:32:01 - 00:11:54:03
Oliver E. Rich, Jr.
So, you know, remove that cloud that they have around them and who they are and identify them and publicly name them through indictments and things like that. And so we want to do that. We want to be able to get onto their networks. We want to be able to disrupt their networks, and then we want to be able to impose consequences where a lot of these folks are working in terms of, ransomware, you know, the money, the financing, how do we get that?

00:11:54:06 - 00:12:17:11
Oliver E. Rich, Jr.
Can we get into their wallets? And can we can we take that, take those funds back and make this a game that is not necessarily one that they're willing to take the chances enacting. And so, Lockbit and HIVE are two examples of that, where the FBI and other partners around the world have been really successful in taking down infrastructure, getting on infrastructure, identifying who the actors were and imposing consequences

00:12:17:11 - 00:12:56:12
Oliver E. Rich, Jr.
in terms of the financing. When you mentioned the private sector and how they might be engaged and how they might help. Number one, we really, really need to continue to need the private sector to come forward and to share information about when they're hit with ransomware attacks, to help identify the threat actors tactics, their procedures, and also sort of what they're looking for and in terms of where the ransoms are being paid. We need that information it helps us conduct our investigations, and it also helps us to do joint and sequence operations with our partners around the world, identifying crypto wallets and working through these chains to see where the

00:12:56:12 - 00:13:19:24
Oliver E. Rich, Jr.
money actually lands. We have some very, very smart people that work on that. And we, you know, our cyber division, along with, the other agencies we work with in that space, you know, they're working very hard to impose consequences on these threat actors in that area, but super, super excited about what we did with Lockbit and HIVE to take down Lockbit ransomware as a service and malware as a service.

00:13:19:29 - 00:13:39:22
Oliver E. Rich, Jr.
If you got briefings on this, you'd be surprised about how easy it is to deploy some of this ransomware as a as a service or malware as a service to, to deploy this material. And it is a problem that is going to continue to grow, which is why we have to work internationally with partners. All around the world to combat it.

00:13:39:25 - 00:14:07:27
John Riggi
Certainly, we understand from the hospital perspective the threat that ransomware groups pose to us and as a nation. Ransomware attacks on U.S hospitals and health systems continue to disrupt and delay healthcare delivery, posing a risk to patient safety. And, we've had hospitals from very large systems experiencing attacks currently to very small, remote rural hospitals that serve 500 square miles.

00:14:07:29 - 00:14:32:28
John Riggi
And suddenly they have to go on ambulance diversion. These are just truly life-threatening issues. And we're glad to see the FBI attempting to impose risk and consequences. Take the money out of the equation. Help them - the bad guys - understand that ultimately if you the attack a hospital, it's not an economic crime, it's a threat to life crime and that they face serious risk and consequences for that. Oliver from all of from Europe

00:14:32:29 - 00:14:45:03
John Riggi
global law enforcement intelligence perspective, what do you see as the emerging global threats, cyber and otherwise? What should we be watching for in health care and in general here in the US?

00:14:45:06 - 00:15:09:22
Oliver E. Rich, Jr.
So I look, I think that, you know, the problems that we've seen in the past are still with us. Right? And so if you think about transnational organized crime, those problems are still with us, and they're going to remain a problem for us for quite some time. Counterterrorism, you know, those problems still with us, but technology and sort of changing methods and tactics and these kinds of things make these challenges a lot more difficult.

00:15:09:27 - 00:15:31:03
Oliver E. Rich, Jr.
Let's talk about CT, for example, I'll go back to the medical system in a minute. But from a counterterrorism perspective, if you think about the ease with which people move around the world today and how that might create additional risk for terrorism to act, or the widespread use of drones and those kinds of things, and what a drone can be used for today.

00:15:31:10 - 00:15:53:04
Oliver E. Rich, Jr.
Years ago, you know, we didn't have to worry about drones so much. Now, what someone can do with a drone and how drones are used and automation and these kinds of things are present much more of a challenge. And so as technology continues to move and create the different ways for people to deploy criminal and national security threats, we still have to keep watching out for that, right?

00:15:53:06 - 00:16:30:28
Oliver E. Rich, Jr.
When it comes to fraud. And if you look at health care and these kinds of issues, so fraud, ransomware attacks, we just talked about how ransomware as a service was going to continue to be a problem. Malware, these kinds of cyber threats are going to continue to be a problem. Fraud itself and the ability for people to use computer generated images and messaging in order to commit fraud, whether it's healthcare fraud or, or just, you know, stealing money from people who have saved, spent their entire life saving up a nest egg.

00:16:30:28 - 00:16:53:05
Oliver E. Rich, Jr.
And now somebody comes along and uses AI generated technology to commit fraud. So these are all problems that I think are just going to require us to be a lot more vigilant, a lot more understanding of what these trade issues are. Gonna require a lot more outreach and engagement, which the FBI is doing, a whole lot more outreach and engagement to educate people.

00:16:53:05 - 00:17:09:08
Oliver E. Rich, Jr.
So we're trying to stop crime and events from happening in the first place before we ever get to the investigation piece. How do we help people identify threats on their own and so they become less vulnerable? And how do you identify risk for hospitals? And so you become less vulnerable.

00:17:09:13 - 00:17:37:28
John Riggi
And as you mentioned, technology is the great enabler. However, it is an enabler for criminals as well. And as technology continues to evolve, so will the attack vectors, whether it's national security threats, criminal threats, and of course cyber threats as well. AI of course, we're watching that very closely in health care, the use of artificial intelligence in health care holds tremendous hope and promise to the point where AI may be used to discover cures for cancer, so forth.

00:17:38:01 - 00:18:05:16
John Riggi
As you mentioned, we're also seeing our adversaries use AI to generate highly effective malware to target hospitals and health care. So it's a double-edged sword at the moment. And again, clearly the cooperation, as you mentioned, between private sector and the FBI, especially in cyber matters, is vitally important. The evidence and intelligence related to cyber crimes lies on private sector networks, which comprise about 85% of all the networks in the United States.

00:18:05:19 - 00:18:20:17
John Riggi
And contrary to popular belief, and correct me if I'm wrong, Oliver, I don't think so, that the FBI just can't see into private sector networks without a warrant or cooperation. And, so the government doesn't see all that they need private sector cooperation.

00:18:20:20 - 00:18:44:15
Oliver E. Rich, Jr.
No, you're absolutely right about that. We definitely need the private sector to cooperate with us. We need the public in general. And this has been the lifeblood of the FBI for many years. Is is having the public help law enforcement help us in our national security mission to protect the United States. I mean, it is a whole of society, whole government approach to defend ourselves against the threats that we face.

00:18:44:17 - 00:19:13:17
Oliver E. Rich, Jr.
I mean, a wise person said, hey, you know, it might have been a general or famous general, but it takes a network to defeat a network, right? And so we have to build stronger networks and stronger partnerships and stronger relationships to work against the adversaries that we have in all of these different spaces. I mean, the one thing about the FBI and, you know, just go back to the first question you asked and what's attractive about the FBI is we work in so many different areas. So many different responsibilities in our portfolio, but it creates a challenge for us.

00:19:13:17 - 00:19:35:17
Oliver E. Rich, Jr.
Right? And we absolutely need the public. We need private sector partners. We need our law enforcement partners domestically and international to work with us, to make us more effective at addressing all these different, different issues that we have to face every day. In order for us to be the most effective and most capable as we can as a nation and as a global community,

00:19:35:17 - 00:19:54:26
Oliver E. Rich, Jr.
we have to be able to work together. We have to be willing to share information with one another that will help us. Number one, identify areas where we're vulnerable. And number two, come up with ways of hardening or mitigating those risks to us, either as an industry, as a community and as a nation.

00:19:55:02 - 00:20:16:12
John Riggi
Thank you, Oliver. I think you summed it up quite nicely. It's not just dependent on the private sector or the public to defend ourselves against these threats. The government can't do it without our cooperation. Whole of government is great. Absolutely. But as you said, it's a whole of nation approach, private sector, working with the government to defeat our common adversaries here, cyber and otherwise.

00:20:16:15 - 00:20:40:05
John Riggi
Thank you for being here with us today. Appreciate everything you do and all the men and women of the FBI to defend the nation against all physical and virtual and counterterrorist and all types of international crime. And thanks to all our listeners for tuning in and thank you for all our frontline health care heroes, for everything you do every day to care for patients and serve your communities.

00:20:40:12 - 00:20:46:06
John Riggi
This has been John Riggi, your national advisor for cybersecurity and risk. Stay safe everyone.

00:20:46:08 - 00:20:54:19
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.

00:00:00:12 - 00:00:35:02
Tom Haederle
The federal public health emergency for Covid 19 officially ended 15 months ago, but any health care provider will tell you the official date means little because the pandemic's repercussions for hospital and health system workforces lingers on. It's felt every day, while the great migration out of the health care profession has slowed. It's not over. Nonetheless, caregivers are finding ways to cope and continuing to deliver great patient care.

00:00:35:04 - 00:01:01:16
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Corewell Health, which provides care to a large section of Michigan, also faced a shrinking workforce during the pandemic, as so many providers did. In this podcast, we learn about its response, which can be summed up like this. Instead of saying we'll do more with less by making people work harder, we said, how do we do more with less?

00:01:01:16 - 00:01:06:02
Tom Haederle
By thinking outside the box and reinventing some of the things we did.

00:01:06:04 - 00:01:30:03
Elisa Arespacochaga
Thanks, Tom. I'm Elisa Arespacochaga, vice president of clinical affairs and workforce, and today I'm really excited to have a conversation with Dr. Darryl Elmouchi, Chief Operating Officer of Corewell Health, where he leads strategy, operations and clinical care delivery across 21 hospitals and is dealing with all sorts of challenges related to the workforce and really supporting the teams that, he gets to lead.

00:01:30:05 - 00:01:46:18
Elisa Arespacochaga
And I'm excited to have him share with this group some of the amazing work that they are doing and piloting and innovating to really support their workforce. So to get us started, Darryl, can you tell me a little bit about your background and sort of how you came to this role, from your clinical work?

00:01:46:20 - 00:02:07:20
Darryl Elmouchi, M.D.
Sure. So thanks so much for having me. I'm excited to be here. I am what's called a cardiac electrophysiologist. So a cardiologist who did very specialized procedures for heart rhythms, and never, ever intended to be standing here talking to someone like you. But over the course of many years. And you'll see a theme here when we talk about some of the work we've done.

00:02:07:23 - 00:02:29:10
Darryl Elmouchi, M.D.
I came to see, not only caring for patients being important, but for caring for people that care for patients to be important and really saw a need to make systems better. And so started down that path well over a decade ago and over the course of many years took on different jobs trying to do that. And over the last few years have been really leading all care delivery for Corewell Health.

00:02:29:12 - 00:02:36:03
Darryl Elmouchi, M.D.
if you recall, Corewell Health has actually two health systems emerged about two years ago, Spectrum Health and Beaumont Health, in Michigan.

00:02:36:06 - 00:03:03:27
Elisa Arespacochaga
You're covering not only the entire state, but really trying to make sure you're supporting, to two different teams and bringing those cultures together. So that's, definitely a challenge. And I know we've talked about this. You're facing the same workforce shortages and challenges with turnover and the overall impact on that care team. So not only are you trying to support them, but you're trying to support a team that maybe tired and worn out and needing some, extra supports.

00:03:03:27 - 00:03:17:05
Elisa Arespacochaga
And quite honestly, they're fewer than maybe they were before. So what are some of the biggest challenges you've been seeing? And some of the drivers of dissatisfaction that you really wanted to tackle as you started thinking about this work?

00:03:17:07 - 00:03:47:29
Darryl Elmouchi, M.D.
Yeah, you know, I think you kind of hit it very well. And I'd say a couple of things. Obviously, I think for everyone coming out of Covid, it was just a year or two plus that was incredibly challenging emotionally, physically in every possible way. For caregivers. And then coming out very specifically, we saw, like everyone else, this migration of folks that were no longer in the workforce, whether it was early retirements of nurses or people that came into the workforce and pretty quickly said, I can go do something else that's easier.

00:03:48:01 - 00:04:06:27
Darryl Elmouchi, M.D.
I don't have the calling that I used to have. And so we were trying to do the same amount of work or more with less people. And ultimately that just is a recipe for burnout, and it doesn't work. so we took a multi-pronged approach, and I want to preface this by saying we're on a journey. There's nothing that's perfect.

00:04:06:29 - 00:04:25:21
Darryl Elmouchi, M.D.
But, I really like to pride our teams and some of our leaders because instead of saying, how do we do more with less? By making people work harder, we said, how do we do more with less? By thinking outside the box and reinventing some of the things we did. And I'm really proud with some of the pilots that we've been now starting to scale.

00:04:25:21 - 00:04:27:29
Darryl Elmouchi, M.D.
And I'm happy to share a lot of them, if you'd like.

00:04:28:06 - 00:04:48:12
Elisa Arespacochaga
Absolutely. I know one of the areas you've really, sort of double clicked on is looking for ways to incorporate technology, which is not something that clinicians have, you know, had a real good track record with, let's just put it that way. But looking for ways to incorporate that technology that can reduce the burden, particularly that administrative burden.

00:04:48:12 - 00:05:03:28
Elisa Arespacochaga
That is not why you went into health care. You went into health care to help people. And, you know, typing up their complaint list is not doesn't feel like it's helping them. So what are some of the ways that you have been using technology to really augment the ability of the team?

00:05:04:00 - 00:05:25:08
Darryl Elmouchi, M.D.
Maybe I'll start with nursing because I think probably across the country, that's been the area that's probably been the most challenging in terms of workforce and how hard it is to both hire and continue keeping nurses, as well as attracting new nurses into the field. You know, we've done a lot of things, like many other working on pipelining, partnering with universities and so forth to try to increase the number of nurses in the state.

00:05:25:10 - 00:05:42:11
Darryl Elmouchi, M.D.
But in addition, we had a team that looked at what are our nurses doing, particularly in the hospitals on the floor. What are they doing minute by minute? And how much of that work is really not value at it's not what they went to nursing school for. It's not what we really intended to hire them to do, but they're doing.

00:05:42:11 - 00:05:54:18
Darryl Elmouchi, M.D.
And maybe I'll turn and ask you just a quick question. What percentage of what a nurse does every day in the hospital do you think is really kind of clinical, needing a nurse versus anything else?

00:05:54:20 - 00:06:06:05
Elisa Arespacochaga
Well, I only know the answer because I've heard you talk about this, but I was shocked because I would have thought it would have been in the 70 to 80% range before I heard your, what your study showed.

00:06:06:08 - 00:06:33:07
Darryl Elmouchi, M.D.
So we did very detailed pilots looking on different nursing floors to understand what nurses do. And as it turns out, direct patient care is about 44% of their time, meaning 56% is something other than direct patient care. And even within direct patient care, a large percentage of that is documentation. And that's not necessarily truly direct patient care. But you'd argue that a nurse probably has to document.

00:06:33:09 - 00:07:01:12
Darryl Elmouchi, M.D.
So there's a huge amount of other work. And the hard part about this is that as we learn and we dove into this, that other work isn't work that doesn't have to be done. It absolutely is. It just might not have to be done by a nurse. And so what I would share with you is this if you start thinking about what a nurse does, aside from going in and adjusting medications, giving medications, assessing patients, checking vitals, all the things that clearly are part of a nurse's toolbox.

00:07:01:15 - 00:07:21:20
Darryl Elmouchi, M.D.
There are so many other things that happen that are really challenging for nurses. So think about everything as simple as, you know, a patient wanting a glass of water. That's really important for that patient, for the nurse, probably someone else can do that is going to find supplies on the floor. So many other things that they're coordinating and trying to do that really aren't that helpful.

00:07:21:27 - 00:07:44:10
Darryl Elmouchi, M.D.
So what we ended up doing, and this is a really interesting way that it was piloted, we said, well, is there a way for patients to let us know what they want in a room that uses technology? And by use of that technology, can we use another workforce to do some of that work? And we started this pilot now about two years ago in one of our smaller rural hospitals, and we actually had an Alexa.

00:07:44:10 - 00:08:07:24
Darryl Elmouchi, M.D.
So an Amazon device and a created an interface in an app on Alexa where the patients could talk to that. And the first thing we learned was it totally didn't work. It just didn't work well. Patients, really, it couldn't understand them. The patients themselves really couldn't figure out how to use them very well. So we scrapped that. And we partnered with a local entrepreneur and actually created an app.

00:08:08:01 - 00:08:30:10
Darryl Elmouchi, M.D.
That app can go on a iPad or type a tablet device in a room. The app also we put on nurses workstations and their devices. They carry it around the hospital. And what we learned is that there was a ton of requests or there are a ton of requests, for these nurses. Through this app, we started adding more requests that someone else could do.

00:08:30:12 - 00:08:53:19
Darryl Elmouchi, M.D.
So the second thing we did was we temporarily hired a distinct workforce where we more or less, and for lack of a better term, gamified or Uberized, what they did relative to these other tasks. So if a patient needs a blanket, the patient clicks on the app. They need a blanket. Someone else in the hospital who's hired to do this brings them a blanket, and they could be coming from another unit.

00:08:53:24 - 00:09:15:25
Darryl Elmouchi, M.D.
And that person gets incentives to do more over the course of time. So almost like an Uber driver gets incentive to drive. We started working on this more and more, and we realized that actually the most clicked from the app came not from the patients, but from the nurses themselves when they were tasked with something, when they came by a room, they saw something was needed or asked, and they can actually ask someone else to do it for them.

00:09:15:27 - 00:09:27:23
Darryl Elmouchi, M.D.
And we have now scaled this across multiple, nursing units at large academic thousand plus bed hospitals and in smaller hospitals. And it has been incredibly effective.

00:09:27:26 - 00:09:49:18
Elisa Arespacochaga
I just love this idea. And I especially love that you went back to it. Even after the first version. Didn't quite, do what you needed. I just love the idea of being able to really look for ways to create that delegation chain in a way that doesn't feel like you've got to, you know, then train another workforce and pull them in.

00:09:49:20 - 00:10:14:00
Elisa Arespacochaga
This is work that can be done in a way that that really doesn't put another burden on the nursing team to figure out how to get it done. So can you tell me a little bit about what you're doing to bring some of those teams together, so that you can reduce some of the frictions? I know we often set workflows in health care, and then they are set in concrete and we never move them.

00:10:14:03 - 00:10:25:17
Elisa Arespacochaga
but to try to make the teams more efficient, especially when you're working with maybe people you haven't worked with before or you're trying to do different things with that smaller team.

00:10:25:19 - 00:10:49:10
Darryl Elmouchi, M.D.
Yeah, I love the question. And I say that, you know, if you think about kind of some of the universal challenges in modern health care delivery, one of them is everything's become so big that it becomes more impersonal. Humans are we're just tribal. We like to be around people that we get to know. We understand how they work, how we work, and large hospitals, large clinics, large systems.

00:10:49:15 - 00:11:10:04
Darryl Elmouchi, M.D.
That becomes increasingly challenging. So I'd point that is just one underlying problem that really takes away from the family feeling of things. Number two, as a health system, we had issues with our length of stay. We wanted to work on making our length of stay better. I firmly believe a shorter length of stay improves the patient experience, because they're not waiting for things in the hospital.

00:11:10:04 - 00:11:28:03
Darryl Elmouchi, M.D.
They can be home and not lying in a hospital bed, and it allows us to use our resources more effectively. And as we were looking at both of those problems, we had different teams kind of looking at them. We realized there's a very simple solution, which quite honestly, it's quite possible many of our members have done years ago or never went away from.

00:11:28:07 - 00:12:00:01
Darryl Elmouchi, M.D.
But we started realizing that particularly in our larger hospitals, we had people all over the hospital and very few areas where there were kind of similar people that were working together all the time. And very specifically, this has to do with the move to hospitalist and physicians. So we have large hospitalist program, and we had hospitalist that were in our largest hospitals, you know, over a thousand beds going to 6 or 7 nursing units in a given day around because they were caring for a patient here or a patient there and so forth.

00:12:00:03 - 00:12:32:29
Darryl Elmouchi, M.D.
And as we started working on length of stay and doing what we call care progression rounds, where you have a case manager assigned to a floor, a nursing unit manager assigned to a floor, you realize they'd have to call in the doctor who's running from somewhere different, and that just didn't seem to make sense. And when we started thinking of both of those problems together, we said, you know, the more we can try to cohort patients, doctors, nurses, care managers in the same area, the same unit, the same floor, the more they can work together, not only in this shift or for this week when they're working.

00:12:32:29 - 00:12:49:18
Darryl Elmouchi, M.D.
You know, doctors are often seven days on, seven days off in these areas, but over time, they can develop long term relationships that really help strengthen that bond and have people work together well. And it's been incredibly positive, both from a well-being standpoint and from a length of stay standpoint.

00:12:49:21 - 00:13:07:26
Elisa Arespacochaga
That's awesome. It's, reminds me of one of potentially the Hocus movies that I am a big fan of. But the Apollo 13 and where, you know, Tom Hanks starts talking about, wait, you want to change one of my team members when you know, we know the way, you know the sound of each other's voice, the tone of our voice, how we react and all of those things.

00:13:07:26 - 00:13:33:01
Elisa Arespacochaga
And it's so important to not underestimate the value of that teamwork and that connection among our clinicians, particularly when they are dealing with much more stressful times, patients who are sicker, all of those things that we're seeing now, I think it's really a great approach and, you know, always nice when it also helps reduce length of stay and make the patient experience better.

00:13:33:01 - 00:13:38:24
Elisa Arespacochaga
But I can't imagine it doesn't really make the team members feel really unified as a group.

00:13:38:26 - 00:13:55:24
Darryl Elmouchi, M.D.
Absolutely. And it's such a much more cohesive feeling. And, you know, and I'll be very honest and say that if we look at our particular larger hospitals, somewhere between 50 and 80% of the units were now able to do that. We call it Co-horting. We were 0%, you know, a few years ago. So we've made a lot of progress.

00:13:55:24 - 00:14:05:02
Darryl Elmouchi, M.D.
But there's probably a limit to what you can do just based on the nature of variability within health care. But even that 50 to 80% has made a huge difference.

00:14:05:04 - 00:14:23:15
Elisa Arespacochaga
As you starting to think about this, in especially going into the future and starting to change workflows in the work environment and thinking about the team a little bit differently. I don't know if you've guys coined the term, but I love the idea of someone being an in-box ologist, and I'd love for you to share a little bit about that.

00:14:23:17 - 00:14:41:01
Darryl Elmouchi, M.D.
Yeah, so this one could be one of my favorites. I'm a little biased, as you know, a former practicing physician. So when I started in clinical practice, you know, about 20 years ago, there were no EHRs, at least where I was. and so I was so used to you work, you go home, you work, you go home.

00:14:41:06 - 00:15:04:00
Darryl Elmouchi, M.D.
And when you're home, you could be on call, but you're not finishing notes at 2 a.m.. you're not jumping in the inbox because of alerts and so forth. And nowadays, anyone who works in electronic record, regardless of what it is, is inundated with inbox messages. and that essentially is like your email in basket. But for clinical issues, some of those are very important.

00:15:04:02 - 00:15:25:15
Darryl Elmouchi, M.D.
Some of those are more informational and less important. And it becomes truly overwhelming. And so we started looking and many of the modern EHR vendors, we have to have epic, can give you all sorts of data on what we call pajama time. So how much time clinicians are spending after hours generally when they're home in the in basket.

00:15:25:15 - 00:15:52:15
Darryl Elmouchi, M.D.
And you can look at how much time during say a clinic day they're spending doing things in the, in the in basket and in the E.R.. And it is mind numbingly frightening where we've come. So you talk about burnout amongst the physician and app workforce. It is completely understandable. And you even go a step further. And you say in the beginning of Covid, electronic messages to providers were common, but not commonplace everywhere, all the time they've skyrocketed.

00:15:52:15 - 00:16:11:22
Darryl Elmouchi, M.D.
If you look at data across the country, anywhere from 3 to 6 fold post-Covid. So and that's just new work. You're not getting necessarily paid for it. It's and you're not allocating time for it. So we started looking at what can we do to make life better. And we took it on two paths a technology path and just a rethinking the workflow path.

00:16:11:22 - 00:16:31:06
Darryl Elmouchi, M.D.
And I'll start with the letter first. And we said, you know, there's a lot of stuff that comes to us in basket that absolutely needs a clinical eye on it, but probably can be addressed without the top of license. And our workforce physician looking at each of these. And so we decided to create a pilot. We call this the inboxologist.

00:16:31:06 - 00:16:59:21
Darryl Elmouchi, M.D.
And I'm pretty confident, I don't know that we're the first person to think of this, but we're definitely, I think, the one to coined the term. We actually have a publication coming out, relatively soon on our data for this, for the inboxologist, which is what we call an app, a physician assistant or nurse practitioner specifically hired to manage the inbox of a number of clinicians started with just physicians, but they actually could be managing the inbox of other apps that are in the clinical workforce.

00:16:59:23 - 00:17:25:18
Darryl Elmouchi, M.D.
And the goal was to see, can we decrease the amount of burden on the physicians and apps that they're doing this work for? Can we decrease their pajama time? And our hope was and we this was kind of our underlying assumption that this would improve productivity enough without us asking for anything in return, that it would at least break even and pay for itself, because you have to find something sustainable in this world.

00:17:25:21 - 00:17:42:26
Darryl Elmouchi, M.D.
The second big issue we had with it was, would anyone want to do this? If we're going to advertise for this role, would anyone want to be in the in basket all day as part of their job? Well, we started probably a year and a half ago and I can tell you it has been amazing. So first of all, would anyone want to do this?

00:17:43:02 - 00:18:06:00
Darryl Elmouchi, M.D.
I think I recall us having somewhere like 2 or 3 dozen applicants for the first two open positions. it turns out that, there are a lot of apps that really like this work. They can do this from home. The hours are pretty flexible, and so it's a pretty nice lifestyle work and it's still important work. The second part of it was, can we scale this and make it work?

00:18:06:00 - 00:18:24:10
Darryl Elmouchi, M.D.
And we had a lot of learnings to do because we didn't know. Do you say that one app covers ten doctors, covers five doctors, and it turns out you really have to adjust this based on the panel size of the physician or app, the type of work they do. We really started in primary care thinking that's where the biggest burden was.

00:18:24:12 - 00:18:52:14
Darryl Elmouchi, M.D.
And I can tell you that the data has been absolutely spectacular. I'm going to actually share you our most recent data, which came out about a month ago. So the average physician who is enrolled in this meeting, they have an inbox ologist, spends an average of 77 minutes during daytime hours, less in their invested each day. So an hour and a quarter and 95 minutes less each night of pajama time when they have an inbox.

00:18:52:21 - 00:19:18:07
Darryl Elmouchi, M.D.
Just the work life balance of these providers went from on a scale of 0 to 5, five being the best one from a three to a 4.25, with this being the only intervention. And we've seen a 41% in basket reduction volume. So either it doesn't come to them because it's something the app can be address or when it gets to them, there's a narrative around it where it's very clear kind of where to look and what to do.

00:19:18:14 - 00:19:20:24
Darryl Elmouchi, M.D.
It has been spectacular.

00:19:20:26 - 00:19:23:28
Elisa Arespacochaga
You've given the most of a day back in a week.

00:19:24:03 - 00:19:46:20
Darryl Elmouchi, M.D.
Could you imagine? And I'll share. And so the big thing for, you know, my CFO colleagues, is when you look at this, we also had that idea like, what will happen? How will this work? And so we have now determined that just about everybody who goes through this has enough time on their day where they will see an extra patient in the clinic every day, every few days, what have you.

00:19:46:24 - 00:19:54:03
Darryl Elmouchi, M.D.
And when you add it all up and you also look at decreased turnover, it actually pays for itself and a little bit more.

00:19:54:05 - 00:20:14:03
Elisa Arespacochaga
I love talking to you because you give me so much hope for the work we do in healthcare. Darryl, I can't thank you enough for sharing these great highlights that you're working on, and I hope we can revisit sort of where core well, Health is taking this into the future. I'm super excited. for all the work you're doing and the ability of the rest of the field to, to try taking these on.

00:20:14:07 - 00:20:15:11
Elisa Arespacochaga
Thank you so much.

00:20:15:13 - 00:20:17:27
Darryl Elmouchi, M.D.
Thanks so much for having me. It was a pleasure.

00:20:18:00 - 00:20:26:10
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00;00;00;21 - 00;00;28;18
Tom Haederle
America's very first hospital opened its doors in Philadelphia in 1752. And in that first model the hospital's board members or overseers were responsible for its finances, while doctors and medical staff were charged with issues of quality and safety. That set the pattern for the next 200 years. It wasn't until the advent of Medicare in the 1960s that hospital boards were assigned primary responsibility for quality and safety as a condition of participation in the program.

00;00;28;21 - 00;00;42;19
Tom Haederle
Today, those responsibilities have only grown in size and scope.

00;00;42;22 - 00;01;10;14
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this Safety Speak series podcast hosted by Sue Ellen Wagner, vice president of Trustee Engagement and Strategy with AHA, she speaks with Jamie Orlikoff, National Advisor on Governance and Leadership to the American Hospital Association and one of the nation's leading experts on the role hospital boards can play in supporting quality and safety efforts within their organizations.

00;01;10;16 - 00;01;28;07
Tom Haederle
As Orlikoff notes, the basic question hasn't really changed much since that first hospital took in patients so long ago. Now, as then, the challenge remains: how can laypeople who are not nurses or clinicians get comfortable with their roles on the board and actually improve quality and safety?

00;01;28;09 - 00;01;52;19
Sue Ellen Wagner
Thanks, Tom. I'm very happy to be with Jamie Orlikoff today, who's going to be talking to us about laying the foundation for the board's role in quality and patient safety. Jamie Orlikoff is president of Orlikoff and Associates Incorporated, which is a consulting firm that specializes in health care governance and leadership strategy, quality, patient safety and organizational development.

00;01;52;19 - 00;02;00;26
Sue Ellen Wagner
And he's also the national advisor on Governance and Leadership for the American Hospital Association. Jamie, thank you for joining me.

00;02;00;29 - 00;02;03;03
Jamie Orlikoff
My pleasure. Well, I'm happy to be here.

00;02;03;05 - 00;02;10;08
Sue Ellen Wagner
Would you tell folks a little bit more about a lot of your accomplishments that you've had over the several years?

00;02;10;08 - 00;02;33;01
Jamie Orlikoff
Accomplishments I don't know if I'll emphasize, but I'll talk a little bit about my engagement in this topic. You know, the board's role in oversight and quality. I'm doing a little research and prep for this podcast came across a book that I and a colleague of mine wrote, Mary Totten is her name - back in 1991, which was called the Board's Role in Quality of Care, and it was the very first book written about this topic that we're going to discuss.

00;02;33;02 - 00;02;58;27
Jamie Orlikoff
And in looking over it, I didn't know whether to be horribly embarrassed or, you know, shocked at how naive much of the content was. But some of it is still right on track. The essential concept that the board bears the responsibility for quality, which we can chat about if you're interested. So I would just mention that and then that I've spent, you know, a good, good portion of my career addressing this challenging issue.

00;02;58;28 - 00;03;25;25
Jamie Orlikoff
You know, how can a board that is composed primarily of lay individuals, i.e. people who are not clinicians, they're not physicians, they're not nurses. How can they, first of all, get comfortable with their responsibility to oversee the issues of safety and quality and then to effectively improve, you know, act as a board to effectively improve the quality of care that's provided in their organizations and the safety profile within their organization?

00;03;25;25 - 00;03;38;22
Jamie Orlikoff
And so I've been approaching that from many different perspectives for 40 years. I don't know if you'd call that an accomplishment. Sometimes I feel like Don Quixote tilting at windmills, but that's all I'll say on that.

00;03;38;24 - 00;03;45;13
Sue Ellen Wagner
Well, and also, you get to practice what you preach. You've been on boards, you've chaired a couple of boards. You just want to mention that.

00;03;45;15 - 00;04;05;14
Jamie Orlikoff
Yeah. Well, right now I just stepped down as board chair of the Saint Charles Health System at the end of 2023. I'm still on the board, and I am chair of the board's Safety and Quality Committee. So I'm still very, very engaged in this particular issue and specifically in the interface of the board and the organization in terms of its oversight and quality.

00;04;05;14 - 00;04;19;14
Jamie Orlikoff
So I will tell you, being a consultant to boards and also being a board member, it's much easier to be a consultant than it is to actually be a board member. It's very challenging, very difficult. It really gives you a very good perspective on the issues and the challenges.

00;04;19;17 - 00;04;38;26
Sue Ellen Wagner
Good. Well, again, very happy that you're here with me today. So can you provide some background for the board's responsibility and role in quality and patient safety? And can you specifically speak to the CMS requirements of the governing body? I think this will be a really great foundation for some new board members.

00;04;38;28 - 00;05;10;27
Jamie Orlikoff
I think the question you're asking is a really important one. And that notion is who is responsible for quality? And in the last it's really well understood. The default perspective and the incorrect perspective is the board takes care of finance and the medical staff takes care of quality. And that's not true. It used to be true. And that's the problem: is for many, many years, going back to the founding of the nation's first hospital by Ben Franklin in 1752, the role of the board was primarily raising money, and then later on managing that money.

00;05;11;03 - 00;05;40;06
Jamie Orlikoff
The responsibility for quality, such as it was, rested with the medical staff, and they typically then just deferred that to the individual physician. That didn't change until the 1960s, as a result of a series of malpractice cases, the most famous one being from Illinois, the Darling vs.Charleston Memorial Hospital case, where the hospital was sued by the plaintiff, saying the hospital made some errors in failing to effectively oversee the physician and allowed the physician to injure

00;05;40;06 - 00;06;03;23
Jamie Orlikoff
you know, the patient who became a plaintiff. And that was upheld at the Supreme Court level, where the court basically said that modern day hospitals do more than simply furnish facilities for treatment and very specifically said when a patient avails himself of the services of a hospital, he expects, at a minimum, that the hospital will endeavor to protect him from injury and more importantly, the hospital will attempt to keep him well.

00;06;04;00 - 00;06;33;16
Jamie Orlikoff
And then here was the line that began to change everything: the public must be protected. From whence does this protection come? It comes from the Board of Trustees. Boom! That suddenly changed everything. Now, the case law was still kind of inconsistent with the state hospital licensing statutes. And remember, this is 1965. So Medicare legislation had just passed. But because of this case, it sent reverberations through the American health care system.

00;06;33;16 - 00;07;09;00
Jamie Orlikoff
And within three to four years by 1969, all hospital state licensing statutes had been changed to say that the board bears the ultimate responsibility for quality. That the board oversees the medical staff and the medical staff reports to the board. So they're not separate, co-equal authorities, but there is a hierarchical relationship. And then to your point, you know, Medicare legislation passed in 1965 and then became effective in 1966 or right around that time, the kind of worker bees of government, the non-elected people had to write the Medicare regulations.

00;07;09;02 - 00;07;24;24
Jamie Orlikoff
They said, you know, we're spending all this money. It's going to cost a lot of money. How do we oversee quality? How do we make sure there's good quality? Who is in charge of quality at the hospital? And they basically said, oh, look what just happened in Illinois. Look at the Darling case and look what state statutes are doing.

00;07;25;02 - 00;07;51;28
Jamie Orlikoff
So they put into the very, very first Medicare rules, conditions of participation, which is basically a contract between a hospital and the federal government. They said the board bears the ultimate responsibility for quality. So that didn't change legally until 1965. Since then, it has become more codified in the law. In case law, and the Medicare regulations have become much, much more specific.

00;07;52;01 - 00;08;14;23
Jamie Orlikoff
So now if you take a look at the conditions of participation, you go to their section 482.11 and 422.22. And they very specifically say, number one, there must be an effective governing body that's legally responsible for the conduct of the hospital. And then they immediately go in talking about it is the board who oversees the medical staff.

00;08;14;25 - 00;08;43;29
Jamie Orlikoff
The board ensures that the medical staff is accountable to the governing body for the quality of care provided to patients. So right now, the Medicare regs make it very, very clear that it is the board that bears the ultimate responsibility for quality and more specifically, when a hospital gets in trouble with the federal government, when the government issues a what's called a 23-day letter, you know, basically saying you're out of compliance with the conditions of participation, you have 23 days to fix it.

00;08;44;01 - 00;09;15;26
Jamie Orlikoff
And if you don't, if your remediation plan is not sufficient, you could lose your status to be eligible for Medicare reimbursement. Which is basically a death sentence for a hospital, because all of their commercial contracts specify that in order to be eligible for commercial reimbursement, they must be in good standing with the Medicare program. But whenever Medicare does this, and they do it more frequently than many hospital board members think, the number one citation when they say it was determined that you continue to be out of compliance

00;09;16;01 - 00;09;40;17
Jamie Orlikoff
is that a regulation that I quoted to you, 482.12, the governing body that the board failed to fulfill its obligation to effectively oversee quality of care or oversee the medical staff in the provision of the quality of care. So that's a little bit of the history. And that's also kind of an emphasis that, you know, from a legal and a regulatory perspective, it is the board.

00;09;40;18 - 00;10;00;12
Jamie Orlikoff
They bear the ultimate responsibility for quality. But yet many board members don't really understand that. Many medical staffs don't understand that. I'm amazed. Just within the last two years, the chief of the medical staff of a fairly, you know, decent-sized system told me the medical staff is responsible for quality. Wow. And I said, no, no, no, it's the board.

00;10;00;13 - 00;10;25;07
Jamie Orlikoff
He said, no, no, no, no, it's the medical staff. So that is a factual issue which should not be open for debate. Now the other issue which we'll talk about, you know, perhaps later in this podcast or another podcast, is once that's understood, how does the board then effectively oversee quality? But in order to do that, everyone in the organization needs to understand that the board is responsible for quality.

00;10;25;09 - 00;10;47;23
Jamie Orlikoff
What that means. And then you need to start to overcome some of the conceptual barriers to effectively being able to have governance oversight of quality. Don't you have to be a physician to understand quality? It's amazing how many board members kind of retreat to that defensive perspective. No one - you never hear anyone say, don't you have to be a certified financial professional to understand finance?

00;10;47;23 - 00;11;00;18
Jamie Orlikoff
You never hear anyone say that, but you will frequently hear board members say, no, no, you've got to be a doctor or a nurse to understand quality. So the first step is really understanding that the board is.

00;11;00;20 - 00;11;28;11
Chris DeRienzo, M.D.
Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, the AHA’s chief physician executive and a champion of the Patient Safety Initiative. The AHA patient safety initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

00;11;28;14 - 00;12;00;14
Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1,500 other hospitals already involved, visit aha.org/patient safety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA’s Patient Safety Initiative.

00;12;00;16 - 00;12;07;10
Chris DeRienzo, M.D.
Remember, together, we can make health care safer for everyone.

00;12;07;12 - 00;12;31;14
Sue Ellen Wagner
So when you're a hospital CEO and you know you have your board chair, you have new board members coming on. They should be explaining all of this to the new board members so that they understand that they're accountable, that they're responsible, that they don't need to be a physician, correct? So there needs to be some great lines of communication that come through so that new board members understand what they do.

00;12;31;17 - 00;12;41;06
Sue Ellen Wagner
And it's probably not a bad idea for the CEO and board chair to remind the medical staff of the requirements too, that who's responsible and why.

00;12;41;08 - 00;13;03;04
Jamie Orlikoff
Great points, Sue Ellen.  And what you're really talking about is one of the characteristics of effective governance is a really good mandatory new board member orientation process where this issue is discussed, you know, in some detail. And the same thing is true for a new orientation process for elected medical staff. So everyone understands it. And I'll give you a point.

00;13;03;06 - 00;13;25;27
Jamie Orlikoff
I was facilitating a board self-evaluation session in the last six months, and one of the board members said, well, I'm really concerned because I think we're a micromanaging board. We spend all this time on medical staff credentialing, on approving the privileges of individual physicians. We shouldn't do that. That's management's job. Oh, man. So it's like, whoa, wait a minute now, how long have you been on the board?

00;13;25;27 - 00;13;45;19
Jamie Orlikoff
And this person had been on board three years. Wow. How can you be on a hospital board for that length of time and not understand one of the basic concepts that the medical staff does not report to management. It reports to the board. That management doesn't make decisions or even recommendations regarding medical staff credentialing. And that's a board decision.

00;13;45;19 - 00;14;08;23
Jamie Orlikoff
So that really emphasizes your point. You don't want board members to hopefully, you know, pick this up, you know, organically by going to meetings. You want to really emphasize this in the orientation process, because this is a responsibility of a board, which is unlike any other governance responsibility in non-health care organization. So there's really no equivalent to it.

00;14;08;26 - 00;14;12;05
Jamie Orlikoff
And so that's where it really needs to be emphasized as you smartly point out.

00;14;12;07 - 00;14;19;05
Sue Ellen Wagner
Great. Thank you so much. Any lasting comments Jamie on the history of quality and what boards should know.

00;14;19;08 - 00;14;54;02
Jamie Orlikoff
Yeah, I would say if you really want to go back, you know, because I'm kind of a nerd on this topic, you know, and you want to take a look at origins of the interest in quality and safety. It goes back to ancient Babylonian in 2000 B.C., or about 4000 years ago. And, there was an emperor named Hammurabi who's famous for codifying the first set of written laws after cuneiform writing, the first written form of language came about. And one of the laws that he passed was a law establishing avenues for patients to redress grievances for perceived acts of malpractice against physicians.

00;14;54;04 - 00;15;13;06
Jamie Orlikoff
And the law basically said, and this is a quote, if the physician has made an incision in the body of a free man and so has caused the man's death, or has opened a carbuncle in the man's eye, and so destroys the man's sight, they shall cut off the physicians for him, you know. So boom, there's a big problem there for several perspectives.

00;15;13;06 - 00;15;40;09
Jamie Orlikoff
Number one, you see the punitive aspect that has been in existence for so many years. If there's a problem with quality or safety, that means someone did something wrong and they should be punished. And it's taken us years to get past that thinking and move into the concept of systemness and a just culture where we now begin to recognize that the majority of issues which cause injury to patients, preventable injury,

00;15;40;09 - 00;16;10;11
Jamie Orlikoff
you know, that that cause less than optimal quality, are not individuals doing something wrong. There are problems in systems and systems which make it either impossible or very difficult for, you know, a provider to do the right thing. So that's one thing to take from that. And that's also a very important concept for boards to understand, because it helps them understand, oh, I get my job as a board to oversee a system and to look for levers which will improve a system.

00;16;10;14 - 00;16;36;17
Jamie Orlikoff
So that actually is very helpful for many board members to get more comfortable with their responsibility for quality and safety. Now, the other really important issue in this law which we still deal with is these two different terms, safety and quality. And what's the difference? Boards really need to kind of understand this difference because they're related but different. Safety basically is not injuring the patient or the or a staff member, "doing no harm."

00;16;36;21 - 00;17;06;06
Jamie Orlikoff
So safety equals the absence of injury. Quality, on the other hand, is doing all and only the care that we know will help the patient. So they're related but different. How? Just because you are not injuring patients does not mean you have good quality care. But if you are injuring patients, you cannot have quality care. So a good way of thinking about this is safety is like the floor, you got to have safety.

00;17;06;09 - 00;17;37;29
Jamie Orlikoff
Quality is the ceiling. So it's important for board members to understand the difference because frequently this responsibility is integrated. Look at the name of the board committee that I chair, the safety and quality committee. So the board is responsible for both. But it has to be very, very cautious to make sure it understands both the relationship between these two very important concepts, but also how they are different so that they can work very effectively to say, okay, do we have safe care?

00;17;37;29 - 00;18;04;12
Jamie Orlikoff
Because the answer is no. That's where the board's going to spend most of its attention until they get safe care. And then once they get that to a level where there is no or very, very low levels of, you know, preventable patient injury or preventable patient mortality, when they get to that point, then they can start to focus on making certain that they're providing all and only the care that, you know, science shows will benefit the patient.

00;18;04;18 - 00;18;24;01
Jamie Orlikoff
So that's a little bit of the more of the background and the nuance and the history. But it also points out that, you know, going back to Hammurabi, you know, this law is 4,000 years old, and that was before there were hospitals. So the concern, society's concern for quality, for safety has been evident in every civilization since that time.

00;18;24;09 - 00;18;32;10
Jamie Orlikoff
And board members are kind of the linchpin between the concern for society and the expression of it in their individual hospital.

00;18;32;12 - 00;18;42;16
Sue Ellen Wagner
Well, thank you so much, Jamie, for joining us. Really appreciate it. That great background. And hopefully folks will be able to use this as a good part of their orientation.

00;18;42;19 - 00;18;50;29
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.