Advancing Health Podcast

00:00:00:06 - 00:00:18:22
Tom Haederle
Welcome to Advancing Health. Now in its 10th year, #HAVHope Friday is a national day of awareness to end violence, both in communities and in the hospital workplace. In this podcast, we get a progress report on how one health system is meeting that goal.

00:00:18:25 - 00:00:39:25
Jordan Steiger
Hi, my name is Jordan Steiger and I'm the director of Behavioral Health and Violence prevention at the AHA. We're here today to talk with Sarah Hunter, the president of Gottlieb Memorial Hospital, about AHA's #HAVHope day, which is happening this year on Friday, June 5th, and some of the work she and her team are doing at their organization to support workplace violence prevention.

00:00:39:26 - 00:00:41:21
Jordan Steiger
So, Sarah, welcome to the show.

00:00:41:24 - 00:00:43:18
Sarah Hunter
Yes. Thank you for having me. Excited to be here.

00:00:43:19 - 00:00:48:09
Jordan Steiger
So tell us a little bit just about who you are and where you come from.

00:00:48:12 - 00:01:04:16
Sarah Hunter
I am Sarah Hunter. I am the president at Gottlieb Memorial Hospital, which is a part of Loyola Medicine in the Chicagoland area. Our parent company is Trinity Health, based out of Michigan. So I've been here for just over six months, but have been in the area in healthcare administration for a long time.

00:01:04:17 - 00:01:10:10
Jordan Steiger
And I'll add, you are a member of AHA's Hospitals Against Violence Advisory Group.

00:01:10:10 - 00:01:15:08
Sarah Hunter
I am, it's a great honor to be a part of that advisory group. It's been a lot of fun and interesting so far.

00:01:15:12 - 00:01:32:18
Jordan Steiger
Yes, we love having you. So, and I mean to mention that you are so passionate about improving outcomes around workplace violence. And so we wanted to get you here today to just tell us a little bit about some of the work that you're doing at your own organization and how you're supporting your workforce.

00:01:32:25 - 00:02:00:03
Sarah Hunter
Yeah, I am very passionate about this topic. I find that supporting and building a safe environment for our healthcare workers is one of the top callings that we have in healthcare today. At Loyola Medicine, we've been really focused on building the environments that really care for our caregivers in all ways, and that includes avoiding workplace violence, supporting them if an incident happens, and really making sure that we build the right type of awareness around the issues that are facing our healthcare workers today.

00:02:00:03 - 00:02:03:09
Jordan Steiger
And tell us what you think some of those big issues are.

00:02:03:12 - 00:02:24:13
Sarah Hunter
So, you know, I think, you know, the world has changed. You know, and healthcare in particular, has really changed over the last decade or so. And the people that we are seeing in our within our walls are becoming more and more complex. And that lends itself to some situations that can sometimes get dangerous. There are a lot of different factors that influence how we care for a patient and their mental health.

00:02:24:13 - 00:02:49:09
Sarah Hunter
Their ability to escalate can really be something that takes its toll on our colleagues that are here within our system. So for me, you know, in leadership and administration, it is really our job to build good processes that support our colleagues, to make sure we're mitigating risk, to provide education, to build awareness both inside the hospital, outside the hospital, and to make sure that we're offering meaningful support and intervention when necessary.

00:02:49:12 - 00:02:52:02
Jordan Steiger
What does that look like, like in the day to day?

00:02:52:09 - 00:03:09:21
Sarah Hunter
Part of why I have so much hope, you know, for where we are going with reducing workplace violence is it's really about listening to the colleagues who do the work. Here at Loyola Medicine, we have really strong interdisciplinary support from our frontline colleagues about the things that make a difference to them day to day. I'll give you one example.

00:03:09:26 - 00:03:28:12
Sarah Hunter
Across our system at all three hospitals, we instituted what we call a buddy system, which is a really simplistic way of looking at a process that we've really used to improve the safety for our colleagues. It really involves starting at the front door of our hospital and making sure that we are assessing patients for their risk to escalate.

00:03:28:13 - 00:03:51:13
Sarah Hunter
We use a standardized tool, which is very common in healthcare, but we've applied it to behavior as well to know if a patient could possibly escalate to aggressive situation. From there, we mitigate the situation with a number of things, including, you know, making sure there's a visual cue for staff that this person could be somebody that would escalate, making sure that we're respectfully searching any belongings and being mindful of visitors that come into the space.

00:03:51:13 - 00:04:20:10
Sarah Hunter
And really, what's been the most impactful part of this process is that for these patients, in these situations where there might be a danger, our colleagues never enter those rooms alone. And so our public safety team, who's a great partner with us here for our clinicians, goes into those rooms with our clinicians, with our EDS personnel, with food and nutrition to make sure there's a second person in that room that could be a potentially, you know, bad situation for those moments that could escalate.

00:04:20:10 - 00:04:33:08
Sarah Hunter
And that has led to increased trust. It's safer for the patients, it's safer for our colleagues, and really, most drastically has reduced any sort of adverse outcome, any workplace violence towards our clinicians in the last year.

00:04:33:10 - 00:04:52:18
Jordan Steiger
I love that everything you just mentioned doesn't cost a ton of money. Building that trust through having support, you know, having a buddy person to come with you, you know, in a room or those visual cues. Those are all things that I think lots of different organizations could do. You mentioned some of those evidence based tools that you can use to assess risk.

00:04:52:20 - 00:05:03:20
Jordan Steiger
And those are out there. You know, those are out there for anybody to use. And I know a lot of our members are using those already, but I think there's still opportunity to kind of think about how we can use those resources that are available to us.

00:05:03:22 - 00:05:34:08
Sarah Hunter
Yeah, absolutely. And I think you hit on it just there to that trust is really the biggest part of this equation. It's amazing what people do when they start to have trust with one another across disciplines in a hospital setting, or every spoke of that will really matters for patient care. And when you introduce complex situations like a potentially aggressive or violent or dangerous situation that could result in harm, that trust becomes very, very critical and really is the cornerstone, I think, of healthcare and where we need to go.

00:05:34:15 - 00:05:51:10
Jordan Steiger
Absolutely. And you know, when you're talking about trust, too, I think about the community and, you know, the patients and families coming into your organization to get care that's going to enhance trust with them, too, if they know that they're going to be safe and get the care they need without having all of these kind of external factors.

00:05:51:12 - 00:06:18:03
Sarah Hunter
Absolutely. And I also just to add, the patients that come in that need our care sometimes are not at their best state, often are not in their best state, right. And so this gives our caregivers the latitude and the space to connect to their purpose of why they're here in the first place. They are here to take care of patients, to make sure they're giving that life saving care, whether it's an emergency room or a labor and delivery unit or an inpatient unit, wherever that might be, an ambulatory setting.

00:06:18:03 - 00:06:41:02
Sarah Hunter
And these types of factors are worrying about what could happen, really can get in the way of that good care. And so the processes like the ones that we've developed here, and we've seen great success in really help navigate that. So caregivers can do their jobs and feel like they can go home and stay safe and feel like they've done a good job that day, and they've cared for the people that they came to care for.

00:06:41:04 - 00:07:02:12
Jordan Steiger
Absolutely, absolutely. I think that's just so important for mental well-being, for, you know, feelings of psychological safety, for wanting to come to work and feeling good being at work. And like you said, just being able to deliver the care that they need to deliver, whether that's clinical care or, you know, providing care through administrative work or EDS or I mean, there's a million different ways.

00:07:02:18 - 00:07:20:24
Sarah Hunter
Yeah. So I think, you know, for us it is about continuing this good work. We want to make sure we continue to develop processes that we get the right people around the table to have conversations about workplace safety, continuing to really monitor and adapt and evolve to the communities that we serve into the situations that we might be in.

00:07:20:26 - 00:07:46:13
Sarah Hunter
You know, I think workplace safety really expands not only from the hospital setting, but to the larger community, to the ambulatory network, to home health and hospice, making sure that we're developing, again, the right processes, the protocols, the right training, the right education. There are a lot of really phenomenal tools out there that we can use to keep our workforce safe, and it is the future for us to be able to use those in a way that really makes a difference.

00:07:46:15 - 00:08:24:01
Sarah Hunter
I think beyond that, our community partnerships are becoming more and more critical. We partner very closely here at Loyola Medicine with our local public officials, with public safety officials, with our elected officials, to make sure that there's a mutual understanding of the priorities of both parties so we can align and work together. The critical partnership locally in each of our hospitals communities is our local police department, fire service, our local first responders. Police department in particular, has been really beneficial for us because we can partner on safety drills, on making sure that they understand the inner workings of places like our emergency room

00:08:24:01 - 00:09:03:08
Sarah Hunter
so if there is an incident, they can respond. I think getting to know our team, our leadership style also helps because when they come into a difficult situation, they already know how we operate and how we work, and it's much easier for them to support our teams if we've built up that relationship. I think the second really influential partnership that we have is with advocacy groups and organizations like the Illinois Hospital Association and the American Hospital Association, who gives us a plethora of resources to make sure that we are implementing best practices, that we're thinking really strategically about workplace safety, that we're looking meaningfully at trends in the industry.

00:09:03:08 - 00:09:09:08
Sarah Hunter
And that is something that we utilize often to help our conversations and our advocacy efforts.

00:09:09:10 - 00:09:27:08
Jordan Steiger
Absolutely. I'm glad you brought up the advocacy piece. That's such an important part of this conversation, and it's something that everybody can do, and AHA has a ton of resources to help you do that. But yeah, I'm glad you brought that up. I think the community partnership piece is also so important. Just acknowledging that we don't have to do this alone

00:09:27:08 - 00:09:34:18
Jordan Steiger
as hospital leaders. There are a lot of people in the community that we can work with and partner with to make our hospitals safer, but also our community safer.

00:09:34:22 - 00:09:48:25
Sarah Hunter
Safe hospitals, safe healthcare is a key part of safe communities, right? They go hand in hand. And so to think that we are in it alone would be foolish when the best thing that we can do is partner and find those partnerships that can make a lasting impact.

00:09:48:25 - 00:09:54:15
Jordan Steiger
And last question for you today. How are you spotlighting #HAVHope Day on June 5th?

00:09:54:18 - 00:10:11:14
Sarah Hunter
So we are going to spotlight it by really talking about it. So we want to talk to our colleagues about why they have hope, what they've seen change in their work environment, really talk about the processes that we've implemented that have kept them safer than they have before, than they've been before. That'll be a big part of what we do.

00:10:11:14 - 00:10:27:21
Sarah Hunter
And I think, you know, even beyond that, you know, we'll be partnering with the AHA. We also want to take part in having a strong presence on social media and public facing to talk about why we have hope in the organization and what we are doing about workplace violence and how what we are doing to address it.

00:10:27:24 - 00:10:43:20
Jordan Steiger
Sarah, thank you so much for being here today and sharing a little bit about the work you're doing. I think this really does spread great knowledge and great hope to our other members, and maybe gives them some ideas of things that they can do on Friday, June 5th for #HAVHope Day. So thank you for being here.

00:10:43:27 - 00:10:46:08
Sarah Hunter
Thank you again for having me.

00:10:46:10 - 00:10:55:04
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;10 - 00;00;19;03
Tom Haederle
Welcome to Advancing Health. The demand for behavioral health services continues to grow, and providing the necessary resources can be a challenge. In this Leadership Dialogue podcast, we learn how a New England health system is navigating these issues and delivering for its patients.

00;00;19;06 - 00;00;52;06
Marc Boom, M.D.
Greetings and thank you everyone for joining me today. I'm Marc Boom, the president and CEO of Houston Methodist and the board chair of the American Hospital Association. As we continue this set of discussions, we're going to focus today's conversation on the very critical issue of behavioral health. Behavioral health has long been, unfortunately, both stigmatized and underfunded. And yet, with the mental health crisis in our country worsening, the hospital field should innovate and advocate for solutions to help both patients and families, as well as our own caregivers, who have seen increased rates of anxiety and burnout.

00;00;52;07 - 00;01;16;11
Marc Boom, M.D.
I know at Houston Methodist, as with many other organizations, we are very dedicated to caring for our patients overall health, their physical and their emotional well-being. We've embraced a holistic, collaborative approach to incorporating behavioral health services into the organization and offer both inpatient and outpatient programs and services. Our caregivers work collaboratively in a team based structure that allows them to draw on clinical expertise and medical innovation.

00;01;16;13 - 00;01;38;16
Marc Boom, M.D.
So today, I am pleased to be joined by Dr. John Santopietro, an expert in the field. Dr. Santopietro is currently the senior vice president and physician- in-chief at Hartford Healthcare's Behavioral Health Network. Before that, he was president and medical director of Silver Hill Hospital and had served on the AHA's Committee on Behavioral Health and the Regional Policy Board.

00;01;38;17 - 00;01;46;18
Marc Boom, M.D.
So let's jump into our discussion. John, I look forward to learning from your expertise and hearing about the opportunities innovations you're seeing. Thanks for joining us today.

00;01;46;20 - 00;01;56;20
John Santopietro, M.D.
Well, thank you for having me. And thank you for centering behavioral health. And it sounds like you guys are doing amazing things in your system to make sure you're giving excellent care. So I'm honored to be here.

00;01;56;23 - 00;02;06;16
Marc Boom, M.D.
Well, fantastic. Well, I'd love to hear a little bit more about the Hartford Health Care Behavioral Health Network, what it encompasses, what's led to your current structure and approach?

00;02;06;19 - 00;02;30;21
John Santopietro, M.D.
Yeah, so not unlike your system, at Hartford Healthcare, we are very focused on behavioral health. So just briefly, I'm a psychiatrist. I took a course on Freud when I was a sophomore in college, and that was it. I loved doing the clinical work, but my first job was in an inner city hospital just outside of Boston about 26 years ago, and I saw how broken the system was, and I couldn't stay out of the fight to make things better.

00;02;30;21 - 00;02;55;28
John Santopietro, M.D.
So that's sort of my leadership journey. I've been in a number of systems, always focused on bringing the best care to the most people. I've been at Hartford Healthcare for going on seven and a half years now. So Hartford Healthcare is about a $7.5 billion integrated delivery system, not for profit in Connecticut. But even for a system that size, we have a almost an outsized engine of behavioral health.

00;02;55;28 - 00;03;24;19
John Santopietro, M.D.
So we have 4,000 people working in behavioral health in our system. We do about going on 700,000 outpatient visits a year, going on almost 200,000 inpatient days a year. We have education, we have three residencies, we have fellowships. We actually have a fair amount of research for an organization like ours. So since 2007, we're upwards of $100 million worth of behavioral health research just in this system.

00;03;24;19 - 00;03;33;14
John Santopietro, M.D.
So it's an incredible chassis, so to speak, for what I'm trying to do in my leadership and behavioral health, again, which is the best care to the most people.

00;03;33;20 - 00;03;38;19
Marc Boom, M.D.
That's amazing. So $100 million in research, where is that funded from?

00;03;38;19 - 00;04;09;09
John Santopietro, M.D.
Mostly places like NIH and NIMH, but also substance use agencies and local foundations. And we do also have some industry sponsored drug research going on from time to time. But primarily it's from NIH and NIMH. We actually just got an $8 million grant from NIH to enhance our research facilities. We're working in this one laboratory on what's called bio typing.

00;04;09;09 - 00;04;32;25
John Santopietro, M.D.
So, as you may know, in psychiatry, we're really good at what we do, but we're not precise. There's no blood tests that you can give somebody that says they've got PTSD or bipolar. But bio typing is a way of using a variety of different biomarkers to be able to identify populations outside of the normal way that we do it, to be able to classify them and figure out who's dealing with what.

00;04;32;27 - 00;04;49;28
John Santopietro, M.D.
Under the leadership of Godfrey Pearlson, who's been leading our neuroscience lab here for 20 years, he's one of the primary researchers in something called BESNET. And especially these days, to be getting that kind of funding from NIH is fantastic. So very, very proud of that.

00;04;50;02 - 00;05;11;21
Marc Boom, M.D.
That's quite amazing. Everything you've been able to accomplish and really the how robust the program is...really very multifaceted. So I know part of what you do then to build such a robust program is recruiting behavioral health care givers, which we know are in shortage across the country. So you must struggle with that even in an institution like yours.

00;05;11;23 - 00;05;16;14
Marc Boom, M.D.
I'd love to hear some advice and some steps you take to address those issues.

00;05;16;19 - 00;05;36;06
John Santopietro, M.D.
Yeah, it's a great question Marc. And we are not immune from, you know, having to deal with the job market. And there is an undersupply of the workforce in behavioral health, everything from psychiatrists, PRNs, to social workers to psychiatric nurses. You know, I have to say, first of all, being in a place where you're doing amazing, innovative things is very important, right?

00;05;36;09 - 00;06;00;15
John Santopietro, M.D.
That obviously helps. And we have a fantastic talent acquisition department, which we couldn't work without. Some of the other things that I've found in recent years that are very important and working for us. One is to recruit fantastic psychiatric leaders, because if you recruit great leaders, the people will come. And we've had an academic system, but we're not a medical school, so we're still community oriented.

00;06;00;16 - 00;06;28;03
John Santopietro, M.D.
This is a place where people can come and do what they want to do to make a difference and have impact, without necessarily having to jump through as many hoops as they would in an academic system. So we have this nice, sweet spot for recruiting psychiatric leaders. And that's one of the things that's been important. Another thing is that our HR department and talent acquisition have worked on some very innovative programing. For instance, social workers.

00;06;28;03 - 00;06;52;23
John Santopietro, M.D.
So these days, and you probably know for the work that you do and just the market, it's hard to compete with online virtual, you know, therapy organizations that, you know, I commend because they're getting out there, you know, needed treatment for people that have no treatment. But it's hard for folks like us working in systems to compete with some of the flexibility around, I can just work virtually and that sort of thing.

00;06;52;23 - 00;07;21;11
John Santopietro, M.D.
So one of the things that they have done is they've started a mentorship program for therapists and social workers. And they have events throughout the year, including now what's become a fairly sought after summit. There's like a summit for the interns that we have in social work and some of the trainees that we have, and we set aside a day and we invite people from the community, and it's become an incredible event.

00;07;21;12 - 00;07;47;16
John Santopietro, M.D.
Also, things like there's one called Coffee and Careers, and I think that's specifically focused on women who are in positions of leadership and inspirational, really making themselves accessible on a regular basis. So lots of things going on. I can't say enough about having your own training programs. In addition to we have internships for psychology and for social works, we now have three -

00;07;47;23 - 00;08;12;09
John Santopietro, M.D.
I may have mentioned - adult psychiatric residencies, and we have, you know, fellowship in addiction medicine and consult liaison psychiatry. So not only does that mean you'd be graduating young doctors who know your system, but you're also creating the kind of workforce that you're going to want in your system. So that's very helpful.

00;08;12;11 - 00;08;25;24
Marc Boom, M.D.
It's fantastic. I want to ask a question about innovating and transforming and says, I've heard a lot about that already, but one of your programs I know is a radical recovery program, which is something you all have done on a very innovative front. Tell me more about that.

00;08;25;25 - 00;08;47;26
John Santopietro, M.D.
Yeah, well, I'm so glad you found that. And you asked that question, and it's a catchy term and I wanted to catch on. Those listening who know about behavioral health know the term recovery. That term has been sort of an industry term for, you know, maybe 20 years for us. And that term itself came out of the movement of advocates for patients, basically.

00;08;47;27 - 00;09;12;22
John Santopietro, M.D.
And they stood up and said, when you build systems, we need to be at the table and we need to be part of this emerging movement of recovery. So radical recovery is a concept that was originated by one of these amazing psychiatric leaders that has come here named Dr. Javid Sukhera. And you can Google him and you can look for him on X and social media.

00;09;12;23 - 00;09;42;04
John Santopietro, M.D.
He's a thought leader that came out of he was in Canada, up in Toronto, and he's an educator. You know, some of the research that we're doing out of some of his research here at the Institute of Living - which is our flagship psychiatric hospital in the system, we have four behavioral health campuses, but that's the largest - is taking down the walls, so to speak, reaching into the community, co-designed programing and research with people with lived experience in the community.

00;09;42;06 - 00;10;11;16
John Santopietro, M.D.
One of the things that's falling under this umbrella of radical recovery is the notion of deprescribing. Again, that might be an industry term in behavioral health. What that means is an acknowledgment that even with all we know, we still over prescribe medications. We also under prescribe them, by the way. So it's not only that we over prescribe them, but the psychiatrists out there will be familiar with, you know, when you're picking up a patient and you see that they're on a list of 11 medications, and what is this about?

00;10;11;16 - 00;10;26;01
John Santopietro, M.D.
And this steps back and says, okay, wait a minute. Let's not just be reactive. Every time somebody has a symptom, we're going to put them on a medication. Let's try and understand what's going on with them and their families. Who is this human being within the patient, so to speak?

00;10;26;04 - 00;10;58;08
Marc Boom, M.D.
I'm actually geriatrics-trained. So we do a lot of deep prescribing in the geriatrics realm as well. Honing in and really focusing on medications, so that makes a lot of sense. In 2026, I can't ask a question without bringing AI into the mix, of course, right? So it seems to me AI has incredible promise. We heard a little bit about technology and virtual and things, but where's the promise of AI for both health care delivery in behavioral health, but also the operations part of that, and then also some of the treatment of the mental illness and addiction?

00;10;58;11 - 00;11;21;14
John Santopietro, M.D.
Yeah. And I imagine, you know, many are familiar or tracking formally or informally this idea about AI, you know, therapy. And so that's one thing it's probably worth touching on. But also even before that, you know, practically what we are using now with AI and many systems I think are thankfully is a way to transcribe, you know, notes.

00;11;21;14 - 00;11;44;20
John Santopietro, M.D.
We don't do a lot of procedures, we do some in psychiatry. But one of the things that slows us down in our day to day operations is doing notes. So we are currently engaged with a company that has a product that we use to transcribe notes. And so you can stay focused on the patient. Imagine in psychiatry and behavioral health and therapy to be on the computer and not making eye contact.

00;11;44;20 - 00;12;04;26
John Santopietro, M.D.
So that practically is something we are already using. To talk for a minute about the AI therapy, I think all of us in the field are tracking that very carefully. On the one hand, there's a part of us that has some healthy suspicion about some of the things that can go awry with having therapy with an AI agent.

00;12;04;29 - 00;12;25;14
John Santopietro, M.D.
People are seeing in the news reports with some regularity, but not every day about some kind of bad outcome. And these patients come to us opening up in their deepest moments of insecurity and suffering and doubt and thoughts of not being around. And sometimes it can be made worse. So I don't think anything is ready for mainstream there.

00;12;25;14 - 00;12;46;15
John Santopietro, M.D.
I will note though, and I do track it and have friends that are very involved in it. Some of the studies are showing that the AI relationship is tracking well as compared to human relationships, and when you measure things like therapeutic alliance, it's very interesting to follow that. I think first of all, we need to learn from that,

00;12;46;16 - 00;13;08;14
John Santopietro, M.D.
what does that mean? What does that mean about what we can do in our work better? And let's track it carefully. The system, however, is off and running outside of behavioral health. You know, with AI, including having recently launched our own, working with another company, basically like a chat GPT for patients. I think the name is Patient GPT, and it links even into the medical records.

00;13;08;14 - 00;13;31;01
John Santopietro, M.D.
So it's a personalized experience with agentic AI and the person who leads innovation for our system, Dr. Barry Stein, is just astonishing in what he has done in the last decade or more to build an ecosystem that is attracting incredibly innovative companies that want to do work with us. So we're very excited about a lot of those things going on.

00;13;31;01 - 00;13;49;23
John Santopietro, M.D.
But in behavioral health, outside of the dictation and of course, we should mention virtual. It's not AI, but it is technology. We were at least over the hump now after Covid and using that with much more regularity, which is fantastic for making our care more convenient to patients.

00;13;49;26 - 00;14;03;05
Marc Boom, M.D.
A lot of mind boggling things there. You know, I think there's a real role in loneliness and coaching and sort of longitudinal things that just are not achievable with a health care professional. What do you think about that comment?

00;14;03;07 - 00;14;28;11
John Santopietro, M.D.
Yeah, I agree, I remember hearing this term about the "white space" in between, right? You know, I'm still seeing patients and I luckily have some flexibility in my schedule where if I need to see somebody in a week, I can see you in a week. And sometimes I don't see somebody for three months. Their life happens in the white space in between appointments, and we don't effectively reach them in that space.

00;14;28;12 - 00;14;52;12
John Santopietro, M.D.
And that can be everything from, you know, wearables that track passive data and feed that into algorithms that might suggest some of the organizations we have been thinking with look at that. Is there some way that you could predict that somebody is headed toward a mood episode based on what time are they going to sleep, and what's their heart rate and maybe even galvanic skin stuff or tone of voice.

00;14;52;12 - 00;15;13;15
John Santopietro, M.D.
So there's a lot of really interesting stuff going on in that area. And I'm not the expert, but somebody within the system looking at this and seeing many organizations, companies and startups come in with great ideas that only sort of have an arc, and then it doesn't work out. I'm not sure that anyone's figured that out yet -

00;15;13;17 - 00;15;33;18
John Santopietro, M.D.
the white space problem in behavioral health. But I think we will. What they have figured out, the market has, is this virtual therapy, virtual psychiatry. Again, I think that is really filling a need in the community and the market and challenges us in systems to keep pace with the convenience of it.

00;15;33;23 - 00;15;53;26
Marc Boom, M.D.
Well, I want to thank you. It's been a fascinating conversation. I want to wrap up with one brief question, give you a chance to toot your horn a little bit, but also question that really gets right to the core mission as hospitals are delivering safe, high quality health care to the patients and human beings we serve. I know you all received the Quest for Quality award last year, and that's really about you

00;15;53;26 - 00;15;59;15
Marc Boom, M.D.
advancing high quality, evidence-based behavioral health programs. Could you give us just a little snippet about that.

00;15;59;16 - 00;16;24;09
John Santopietro, M.D.
Yes. And Jeffrey Flaks, our CEO, will be very glad that we've mentioned that. He's so proud of it. And Dr. Ajay Kumar, who was central to that in his physician leadership role in the organization. Yeah, very proud of that. And, you know, as you as you know, in behavioral health because it's not precise, one of the challenges for us is the quality measures that we have to work with right now that are reportable.

00;16;24;09 - 00;16;46;06
John Santopietro, M.D.
And all this tend to be more process measures at this point. Right? So if somebody comes in with a concurrent tobacco use disorder with their bipolar, did we offer them treatment for tobacco? Or what's your readmission rate and what's your seclusion and restraint rate? Those are all incredibly important by the way. And we work on them and we drive them in the forward direction.

00;16;46;06 - 00;17;12;15
John Santopietro, M.D.
Our teams are doing that. But at this point, because of the under utilization of behavioral health, because 1 in 4, 1 in 5 people have a behavioral health issue today in the country, less than half of them make it to treatment. First of all, access is quality. So getting people into care is quality. They're getting no care. And we really boy, in terms of pride, it is not easy to fill every bed in psychiatry.

00;17;12;15 - 00;17;43;20
John Santopietro, M.D.
In behavioral health we have limitations with physical plant. There's behavioral issues. Our teams have worked extraordinarily hard over last several years. Increased access by 20 to 30%. But one other thing I will mention is that we find this very effective quality tool that Dr. Kumar has used across the system. We call them clinical councils. So it's a group of experts and interested, passionate people within the system, different disciplines that get together to work on a clinical problem and drive it forward.

00;17;43;20 - 00;18;06;16
John Santopietro, M.D.
We have several in behavioral health. One of them is on psychosis. So we've been focusing on psychosis. Why psychosis? Well, among other things, it's more discreet than some of our other disorders, a little bit easier to identify. But more importantly you can have huge impact if you intervene early. If you detect it early, intervene early with evidence based practices.

00;18;06;16 - 00;18;32;23
John Santopietro, M.D.
And if you reduce what's called the duration of untreated psychosis - the DUP. Studies are very clear the impact on that human beings life is incredible. So we have Dr. Tobias Wasser, another one of these incredible leaders that's come here is leading that clinical council. And that's what they're focusing on. They have work groups working on early detection, early intervention, clinical pathways, drug dosing algorithms, wraparound services.

00;18;32;23 - 00;18;55;10
John Santopietro, M.D.
And they're beginning to put things into place and beginning to set the standards. And if we do this well, there is some possibility that we could reduce the incidence of schizophrenia, say, in our population. And so it's a bold, audacious goal and lots of energy going into it. Lots of pride. So very happy to be able to talk about it.

00;18;55;11 - 00;19;19;20
Marc Boom, M.D.
That's a very welcome big audacious goal. Wouldn't that be a fantastic thing? Well, thank you very, very much for your time today. It's been a fascinating conversation. I've learned a ton. I know our viewers will have learned a ton as well. So huge thanks for being here today. And thank you to all of you as viewers for taking the time to watch and listen, and we'll look forward to seeing you next month for another Leadership Dialogue conversation.

00;19;19;22 - 00;19;28;16
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;04 - 00;00;22;28
Tom Haederle
Welcome to Advancing Health. How can we make sure that everyone benefits from the efficiencies and improvements to healthcare that are expected from artificial intelligence? In this podcast, we hear from a theological ethicist who says the guiding principle should be this: all efficiency should serve compassion.

00;00;23;00 - 00;00;46;29
Joy Rhoden
Joy Rhoden here with the American Hospital Association, where I serve as the senior vice president for the Division of Health Outcomes and Care Transformation. And I'm joined today by Daniel Daly, who's the executive director for the center for Theology and Ethics in Catholic Health at the Catholic Health Association. And it's a pleasure to have you here with me, Daniel.

00;00;47;02 - 00;01;11;26
Joy Rhoden
We're going to be diving into a topic that sits at the crossroads of evolving technology and healthcare, and that is the rise of artificial intelligence in healthcare. But specifically, given Daniel's role as a theological ethicist - and I'm going to ask you to explain to our listenership what exactly is that and what do you do in your day job -

00;01;11;27 - 00;01;41;02
Joy Rhoden
but we're going to be talking about essentially, how do we think about AI from through an ethical lens? What are those considerations as healthcare leaders are really launching these tools? And because I sit and lead the division of Health Outcomes and Care Transformation, I also want to talk to you about some concerns that have surfaced about maybe unequal access to AI driven benefits.

00;01;41;02 - 00;01;56;04
Joy Rhoden
And so with that, I'm going to give you the opportunity to do a better introduction of your work at the Catholic Health Association. So what is a theological ethicist? Who is that? What's your role?

00;01;56;06 - 00;02;15;19
Daniel Daly
Well, first, Joy, thank you for having me. I'm excited to be with you today to talk about this really important topic. So as you said, I'm a theological ethicist. I also teach at Boston College. And a theological ethicist looks at goodness and rightness in light of theology. When we think about this in terms of healthcare, you know, I'm a Catholic theological ethicist.

00;02;15;19 - 00;02;38;25
Daniel Daly
As our listening audience knows, Catholic healthcare is throughout the world, but you know, a lot of it here in the United States. It basically emerges from this understanding of who we're called to be, which is to care for the suffering, the sick, the poor, the forgotten. So an ethicist, the theological ethicist is looking at that tradition. You live out your faith through healing the sick.

00;02;38;26 - 00;02;49;20
Daniel Daly
And so we need to, you know, how do we do that? How do we do that? Well, we need people to be thinking about that. And that's essentially the role of an assist in this kind of Catholic healthcare space.

00;02;49;27 - 00;03;17;20 
Joy Rhoden
Very unique role. Thanks for sharing that. So many of our organizations, our hospitals and health systems are really excited about the efficiency gains that AI can bring them. In a field where folks are called to care for others, how should leaders think about balancing the efficiencies that they can gain from AI with compassion and responsibility?

00;03;17;22 - 00;03;43;02
Daniel Daly
And Joy, it's a great question, and I think the way that I look at this is that it's not so much that we're balancing efficiency against something like compassion or responsibility, but rather all efficiency should serve compassion. It should serve responsibility because, as you rightly noted, the goal of healthcare is to care for, to provide healing and health and even enable human flourishing for patients.

00;03;43;08 - 00;04;08;28
Daniel Daly
Really, the threat of AI, one of the one of the threats is that we turn more to kind of optimized care that the focus is on efficiency for efficiency sake, and that would get us away from person centered care. So efficiency has its place, but its place it's not the final goal of healthcare. And so what we have to be careful as we bring in these tools that help us be more efficient.

00;04;08;28 - 00;04;22;16
Daniel Daly
And that's great. We don't let the means drive the end. The end is always going to be person centered care for human health and well-being. And I think this is a critical, critical point as we as we take up AI.

00;04;22;19 - 00;04;51;19
Joy Rhoden
You've surfaced a few key concepts and constructs, and I want to go a little bit deeper around person centered care. So many of the use cases thus far in healthcare for AI are around admin processes, right? But as AI becomes more integrated into the care delivery space, how might providers leverage AI in support of person centered care?

00;04;51;26 - 00;05;19;12
Daniel Daly
I think the first thing is, is that we need a culture that emphasizes the importance of person centered care, the importance of that professional patient relationship. These should be sacrosanct in healthcare. They should be untouchable, and the team needs to know when that leaders value person centered care, that the leaders value the relationship of the professional and the patients.

00;05;19;17 - 00;05;41;24
Daniel Daly
We're certainly going to be integrating this in clinical settings. But, you know, I was at a conference last year, and in the room there was basically this this adage that we need to fall in love with the use case, not the technology. That's right. And I had to push back on that. The use case is valuable only insofar as it helps us to heal and care for patients.

00;05;41;24 - 00;06;01;03
Daniel Daly
So we shouldn't be falling in love with the technology, nor that specific use case. But all of our evaluation of AI and healthcare has to be in light of human well-being, human flourishing, whether it's the flourishing of patients or as we think about, you know, we're also concerned with the flourishing of professionals.

00;06;01;04 - 00;06;02;21
Joy Rhoden
That's right. The workforce. Yep.

00;06;02;23 - 00;06;27;12
Daniel Daly
Yeah, exactly. We need to be concerned not just because they're the ones who provide the care, but because they have intrinsic value themselves. They are human beings who deserve to be treated with respect and dignity, and that the AI shouldn't be changing their work to the point that they are not respected as healers, as carers, as professionals in what they do.

00;06;27;13 - 00;06;33;28
Joy Rhoden
To think about how to leverage the technology to strengthen those relationships.

00;06;33;28 - 00;06;57;01
Daniel Daly
That's exactly it. It can be leveraged. I think it has been. You can think about something like ambient listing technology, which the early returns are pretty strong, if not little mixed, but that ambient listening technology, you know, that famous AMA study from a couple of years ago that it really reduced pajama time for professionals. It leads them to be less burned out, have greater job satisfaction.

00;06;57;04 - 00;07;18;04
Daniel Daly
But patients early reports are that patients like it as well because they get that eye contact. They feel listened to, they feel seen where the iPad is not the fixation of the professional, but rather the person. Now that's a huge win that promotes the professional patient relationship and makes care more person centered.

00;07;18;11 - 00;07;59;14
Joy Rhoden
That's really all exciting and sounds directionally correct, but we know that technology has the potential to exacerbate disparities if it's not deployed in a responsible manner. And so some patients may benefit more from AI driven tools than others, particularly those with access to digital devices and Wi-Fi, broadband and other technologies. What do you see as the responsibility or the role that hospitals and health systems play to ensure that while they're moving forward with these advancements in AI, that they are not leaving some patients behind?

00;07;59;16 - 00;08;18;29
Daniel Daly
You know, Joy, it's an incredibly important question, and I think it's underappreciated, under discussed, so I really appreciate you bringing it in. I think systems have a mission. I think their mission is if you if you ask them and they is to provide care for all in a community, they're not making distinctions between who should be cared for and who shouldn't be or who doesn't deserve care.

00;08;19;04 - 00;08;52;22
Daniel Daly
They're looking to reduce those inequalities. Or they at least they should be, and I believe they are. However, as you noted, the well-resourced are positioned to benefit the most from AI. So what does that mean? I think it means we need to really focus on the kind of tools that we adopt and use, and to test them and to monitor them for the expansion of access that they benefit, not just the well-resourced, but they benefit everyone who is coming into the medical setting.

00;08;53;00 - 00;09;09;00
Joy Rhoden
You said health system leaders should actually maybe think about how they can influence the development of new AI tools, right? What are some practical steps that you would give to health system leaders on the development front?

00;09;09;02 - 00;09;30;15
Daniel Daly
So yeah, on the development front, I think what we need is we need strong governance structures here to evaluate and monitor AI across its life cycle in the in the system. So I think we need people in policy. We need committees. We need groups, interdisciplinary groups that are that come together, that are evaluating regularly. And they need to be diverse.

00;09;30;16 - 00;09;35;03
Daniel Daly
Right. You need to bring in multiple kinds of people with different backgrounds to do that.

00;09;35;04 - 00;09;42;04
Joy Rhoden
It sounds like we should actually be moving upstream and working with the vendors in the development phase. Correct?

00;09;42;05 - 00;10;01;09
Daniel Daly
Well, I mean, ideally, yes, that does happen and it can happen. I've talked to many people that it's often the vendor coming after the product has been developed. There can then be modifications that happen in light of the values that maybe I have as a system, but certainly, yeah, I mean, the earlier you get in  - ethics by design is a best practice.

00;10;01;10 - 00;10;20;00
Daniel Daly
Exactly. And I think if we can make that normative in the in the field, we'll go a long way to avoiding more surprises that happen as these tools get deployed. And often there are surprises. You can you can cut off those problems by invoking ethics by design.

00;10;20;03 - 00;10;32;03
Joy Rhoden
As AI is introduced across care settings, you know, to really think about that alignment that you spoke about with mission and ethical commitments.

00;10;32;05 - 00;10;51;18
Daniel Daly
I think when you think about making ethics more than lip service, because it often is, and it needs to be, it needs to be more than that. It's about getting it into the structure and the culture. What are the ideas that we endorse? What are the ideas we support, and then what structures have we put in place to ensure that we are aligned with those values that we have?

00;10;51;20 - 00;11;15;09
Daniel Daly
So things like performance reviews or the way the organizational chart is set up. Position descriptions, all of that has to have those things embedded, because we reward what we value and we value what we reward. And if we value the ethical use of AI, we need to reward that in our associates, in our workers, in our professionals, in our administrators.

00;11;15;09 - 00;11;23;25
Daniel Daly
And that's the surest way to get those values to be lived out on the ground in the care for the patients and communities.

00;11;24;01 - 00;11;44;21
Joy Rhoden
Well said. Thank you so much, Daniel, for being with us today and for really helping our audience think about the both and how might we pursue potential efficiency gains leveraging AI without compromising person centered care and improving health outcomes for all. Thank you.

00;11;44;25 - 00;11;46;07
Daniel Daly
Thank you. Joy.

00;11;46;09 - 00;11;55;02
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;01 - 00;00;19;04
Tom Haederle
Welcome to Advancing Health. Many a parent has wondered what's really going on inside the head of their beloved teenager. As we hear in this podcast, a new predictive tool helps answer that question and can flag teens at elevated risk for developing a psychiatric illness in the near future.

00;00;19;06 - 00;00;41;25
Jordan Steiger
Hi everyone, and welcome to the Advancing Health Podcast. My name is Jordan Steiger, and I'm the director of Behavioral Health and Violence Prevention at the American Hospital Association. I'm joined today by Dr. Jonathan Posner, who is the J.P. Gibbons Distinguished Professor of Psychiatry, and Dr. Matthew Englehard, the assistant professor of biostatistics and bioinformatics, both at Duke University School of Medicine.

00;00;41;26 - 00;00;46;11
Jordan Steiger
So, Dr. Posner and Dr. Englehard, thank you so much for being here today.

00;00;46;14 - 00;00;47;18
Jonathan Posner, M.D.
Thanks for having us.

00;00;47;20 - 00;00;48;29
Matthew Engelhard, M.D., Ph.D.
Yeah, thanks for having us.

00;00;49;05 - 00;01;07;02
Jordan Steiger
We're really excited to talk about the work you're doing. This is a little bit different of a topic that I think we usually have on our Advancing Health podcast, more kind of focused on the research and what could be coming down the pike in terms of behavioral health. So I'm really, really excited to share everything with our membership today that you've been working on.

00;01;07;02 - 00;01;25;23
Jordan Steiger
I would love for you to just tell the audience a little bit about what you do, the Duke predictive model of Adolescent Mental Health, or we'll call it the Duke PMA. To shorten that a little bit on this podcast and just tell us what this tool is, who it's for and what it can do. Dr. Posner, why don't you get us started with this one?

00;01;25;29 - 00;01;54;27
Jonathan Posner, M.D.
So we designed the Duke PMA to be able to automate the assessment of psychiatric risk in teenagers. So essentially what the tool does is it can identify which teenagers are most likely to develop a psychiatric illness within the next 12 months. And it does that by using pretty standard questionnaires that can easily be collected in a primary care setting.

00;01;55;02 - 00;02;15;13
Jonathan Posner, M.D.
And then not only does it tell you who's at risk, but it also tells you what's contributing to that risk. So as an example, let's say I am a pediatrician and I'm about to evaluate a 14 year old. I might only have 5 or 10 minutes with that kid, and it's not enough time to do a thorough psychiatric assessment.

00;02;15;15 - 00;02;42;19
Jonathan Posner, M.D.
But the Duke PMA will automate that for me, and it will tell me that the kid that I'm evaluating who seems stable today, actually has an 80% chance, or a 90% chance of developing a psychiatric illness in the next year. And a key contributor to that might be poor sleep. So as the pediatrician, if I can get that kid sleeping better today, I might be able to prevent him from ever developing a psychiatric condition.

00;02;42;21 - 00;02;58;01
Jordan Steiger
Wow. So that could be transformative for adolescent behavioral health. That's really incredible. You mentioned sleep is maybe one of the predictors. And I know in our conversations you've said that's a pretty significant predictor. What are some of the others?

00;02;58;03 - 00;03;25;22
Jonathan Posner, M.D.
So we looked at a bunch of different factors that relate to psychiatric risk. And so some of the other contributors are things like conflict within the family, the school setting, some demographic features, a history of childhood adversity and family history of psychiatric illness. So some of them are things that we could - that are modifiable, that a physician could say, okay, I'm going to try to intervene on that.

00;03;25;25 - 00;03;30;29
Jonathan Posner, M.D.
Other things, like family history of psychiatric illness are more challenging to intervene on.

00;03;31;02 - 00;03;40;00
Jordan Steiger
Absolutely. But that does give the clinician a great opportunity, at least to get ahead of it and start intervening early. And it sounds like that really is the goal of this work.

00;03;40;05 - 00;03;48;02
Jonathan Posner, M.D.
That's right. Yeah. The goal is really to move psychiatry into a model that's much more proactive and preventative.

00;03;48;05 - 00;03;58;14
Jordan Steiger
Dr. Englehard, tell us a little bit more, just why AI tools? What is the most transformative thing about using AI tools like this to predict mental health before symptoms appear?

00;03;58;16 - 00;04;22;04
Matthew Engelhard, M.D., Ph.D
Yeah. So I think I think AI tools are really good at figuring out what in a specific type of information ends up being predictive. So compared to more traditional models, I think of them as being able to, you know, extract all of that signal. And when you couple these tools with a really large data set like the one we've been working with, which is coming out of the Adolescent Brain Cognitive Development study, it really enhances our ability to do that.

00;04;22;04 - 00;04;51;19
Matthew Engelhard, M.D., Ph.D
So first and foremost, it's about just sort of being able to pull as much predictive power as we can. At the same time, AI tools are really good at being able to combine different types of information together to say sort of what is what is shared between this questionnaire and this questionnaire and this questionnaire, and what is distinct between them and being able to draw on those individually and together again, to enhance our ability to make the best predictions that we can.

00;04;51;26 - 00;05;05;12
Jordan Steiger
That makes total sense, and I think it would be great - I probably should have started with this. Can we tell the audience a little bit about where you're at in your research and just this whole work? It sounds like you've done quite a bit already to show that this model is really impactful.

00;05;05;15 - 00;05;29;16
Matthew Engelhard, M.D., Ph.D
So we've already developed our model, and it's a matter of making sure that this model, that we have everything in place so that this model can reach as many people as possible. So we're really careful about making sure that our model is what we call generalizable, that we've built it in this this study, which is intended to be which is nationally representative, but it doesn't include everyone.

00;05;29;18 - 00;05;52;01
Matthew Engelhard, M.D., Ph.D
Right. We want to make sure that we've built it in this particular study, and now we have a system that we're confident is going to be able to work for everyone across the United States, regardless of what region they're part of,  regardless of their demographic background, and even regardless of some of the specific data collection practices that might be in place where they receive their care.

00;05;52;01 - 00;06;08;18
Matthew Engelhard, M.D., Ph.D
So right now, we're in a phase where we're getting ready to take our model that we've built and to validate it in a bunch of different rural communities and in several states. But before we do that, we're making absolutely sure that it is going to work effectively for everybody.

00;06;08;26 - 00;06;27;25
Jordan Steiger
That makes total sense. And I think going into rural communities, you know, presents such an opportunity to expand access to care, make sure that we're focusing in on that prevention aspect a little bit. But tell us a little bit more about that, Dr. Posner. Maybe just why you're starting to test in these rural areas and what's next in terms of that?

00;06;28;01 - 00;07;07;05
Jonathan Posner, M.D.
Yeah, I mean, one of the key motivators in developing the PMA was to try to make psychiatric assessment much more efficient by automating the process. The availability of mental health providers across the boards is extremely limited. But then if you go into rural areas, the problem is even more severe. So the reason why we wanted to bring the Duke PMA to rural communities is for exactly that reason, that that the availability of providers is so limited in those communities that we thought the Duke PMA could be particularly helpful in that setting.

00;07;07;13 - 00;07;26;12
Jordan Steiger
I was thinking about the workforce aspect as you both were talking about this, and just how that can, I'm sure, really, really help clinicians in these areas that maybe don't have the time, you know, to spend with the kids that really need the help and the mental health support, you know, or they might not catch something that's happening because they don't have the time.

00;07;26;15 - 00;07;42;24
Jonathan Posner, M.D.
Yeah, I think that that is really a huge factor in that we're not making the claim that the Duke PMA could do an assessment better than a trained professional, it's just that it can do it much more efficiently. And those trained professionals aren't available in lots of settings.

00;07;42;26 - 00;08;02;14
Jordan Steiger
Absolutely. It's an additional tool for trained professionals to use. Thinking about how this is going to play out in a real world clinic setting in some of these rural communities. What do we think? I know we just talked about workforce and expanding access, but some of those other big opportunities and maybe some of the challenges that might arise in practice.

00;08;02;17 - 00;08;32;22
Jonathan Posner, M.D.
One of the big opportunities that I would see is for this to become a standard part of a pediatric assessment. So the comparison that I like to use is with cardiac risk. So essentially all adults in the US get screened for cardiac risk, for cardiovascular disease. And then the risk gets tracked over time. And the goal is to intervene well in advance of anyone ever having a heart attack for example.

00;08;32;24 - 00;08;51;01
Jonathan Posner, M.D.
And so we would we would love to see something similar to that with mental health risk, so that kids are identified as being high risk before the conditions have really taken root. And the earlier we can intervene, our chances of being able to help these kids is substantially higher.

00;08;51;07 - 00;09;06;22
Jordan Steiger
Absolutely. And, you know, walk me through before we go to maybe some of the challenges, say a child is identified as having a risk for sleep. Let's use that as the example because we brought it up earlier. What happens after that? Just tell me kind of walk me through the clinical process after that.

00;09;06;25 - 00;09;29;04
Jonathan Posner, M.D.
So fortunately with sleep, we have really good evidence based interventions that can help kids sleep better. So depending on the setting and the community and the availability, being able to refer that child for a psychotherapy to address poor sleep would be one natural route to go.

00;09;29;06 - 00;09;41;14
Jordan Steiger
The reason I'm asking that, I guess, is I'm thinking about these rural communities that might not always have the resources available to kind of refer to those additional services. So I'm, I guess thinking about challenges and maybe some of that.

00;09;41;22 - 00;10;08;08
Jonathan Posner, M.D.
Yeah, I think no, it's a great point. One of the things that that Matt and I have talked a lot about is we would ideally love to be able to bring the Duke PMA to schools, because that's where kids are. But one of the challenges of that is that, you know, the last thing we want to do is identify a child at being high risk, but then not having any resources for them, not being able to refer them to a provider.

00;10;08;09 - 00;10;30;03
Jonathan Posner, M.D.
So by working within primary care settings, they'll at least be partnered immediately with a medical team. And some of the interventions can be pretty straightforward. So for example, with sleep, talking to the child and talking to the family about better sleep hygiene, better sleep habits that could actually go a long way and doesn't require a separate referral.

00;10;30;06 - 00;10;35;18
Jordan Steiger
No, absolutely. That's a great point. Dr. Englehart, what do you think about challenges and opportunities?

00;10;35;20 - 00;10;57;05
Matthew Engelhard, M.D., Ph.D
Gosh, we have so many opportunities to make an impact here and so many opportunities to get more and more sophisticated in our ability to perform this work. So I think being able to connect with the schools is a tremendous opportunity. We also see there's an opportunity in being able to understand the device use component of the picture here.

00;10;57;07 - 00;11;23;24
Matthew Engelhard, M.D., Ph.D
How do you how do adolescents use of their digital devices? How does that contribute to some of the development of mental health distress that we're seeing? And then how can we in turn interpret information coming from those devices to help us intervene again? Another opportunity that we're really excited about is that as part of the work that we're working on now, we're going to be collecting information about home environments as well.

00;11;24;00 - 00;11;58;20
Matthew Engelhard, M.D., Ph.D
So this is drawing on research that we've been engaged in for a while now to understand relationships between different personal environments over the course of the day, and different health risks that individuals might be exposed to. And it's known that there are relationships between aspects of home environments and adolescent mental health. But we have the opportunity to work with adolescents and their parents to document different components of home environments and understand again how that relates in turn to the mental health picture, and maybe to make recommendations along those lines as well.

00;11;58;21 - 00;12;18;28
Matthew Engelhard, M.D., Ph.D
I think I would also add one more, which is that we've mentioned the importance of sleep, which has already come up, and I think we're very excited about the opportunity to put that knowledge to use and understand whether we can, in fact, use our model to identify children that are at high risk of worsening mental health because of their sleep, at least in part.

00;12;19;04 - 00;12;29;13
Matthew Engelhard, M.D., Ph.D
And to see if intervening on sleep, giving them some actionable recommendations to change sleep patterns, as I think Jonathan mentioned, whether that can indeed move the needle for those kids.

00;12;29;15 - 00;12;50;26
Jordan Steiger
That makes total sense. And, you know, thinking about teenagers to in the home environment, I feel like that's really, really important, thinking about mental health. And, you know, you bring up your personal device used to and I think that's another fascinating thing. I'll be curious to follow your work and see what comes of that, because we know that's a huge component in the way mental health kind of manifests for kids these days.

00;12;50;28 - 00;13;06;24
Jordan Steiger
Tell me a little bit more about what the Duke PMA can be used for. Like, is this a universal tool to predict mental illness kind of across the spectrum of different disorders that children can experience? Or is this really focused in on just a few different things?

00;13;06;26 - 00;13;35;04
Jonathan Posner, M.D.
Yeah, it's a great it's a great question. And what it actually predicts is something called a P factor, which is a global measure of mental illness. So it essentially encompasses risk for the full spectrum of psychiatric disorders. And one of the reasons why we chose the P factor is because if it was specific to a predicting risk for one disorder, its utility would be much more limited.

00;13;35;05 - 00;14;00;12
Jonathan Posner, M.D.
So, for example, if it predicted development of bipolar disorder, that would still be useful. But the number of teenagers that you could use it with would be also very limited. By using a global measure, it can be applied essentially to all kids. We're working to make it as user friendly as possible, so the entire battery of questions are being put onto an iPad.

00;14;00;20 - 00;14;21;11
Jonathan Posner, M.D.
So in theory, a family comes to their primary care clinic, and while they're in the waiting room, they could be handed the iPad, answer all the questions, and then the risk prediction and the profile would then be fed forward to the clinician who's about to see them. In the current version of the tool to complete all the questions,

00;14;21;12 - 00;14;41;15
Jonathan Posner, M.D.
it probably takes about half an hour. And that's one thing that we're really focused on, is to try to get the assessment down to as short as possible so that families could complete it in say, ten minutes, rather than 30 minutes. And so what we're trying to do is to limit the number of questions while still maintaining the predictive power.

00;14;41;15 - 00;14;44;07
Jonathan Posner, M.D.
And that's an active area of work for us.

00;14;44;10 - 00;15;06;26
Matthew Engelhard, M.D., Ph.D
And I would add that from the AI perspective, I think one of the reasons we've been so successful in doing something that is, is new here is the fact that in focusing broadly on all these different pathologies, we've really enhanced our ability to learn about relationships between general psychopathology and all of these different types of predictive features that we've talked about.

00;15;06;28 - 00;15;19;05
Matthew Engelhard, M.D., Ph.D
So, you know, it puts us in a position to give people the help they need. It's also enhanced our ability to understand what risk factors contribute.

00;15;19;06 - 00;15;43;02
Jordan Steiger
So I know we all are in the world right now where everybody is talking about AI constantly. And I think AI and mental health is a really hot topic right now. I know a lot of our members at the AHA are really kind of trying to understand and consider how they can incorporate more AI, you know, predictive models and all sorts of different things that you all know much more about than I do.

00;15;43;02 - 00;16;00;03
Jordan Steiger
But a lot of the audience on this podcast is hospital leaders. So if they're listening and thinking, how can I do this at my organization? How can I get something like the Duke PMA in, you know, for my primary care clinics or psychiatric clinics for kids? What would you tell them?

00;16;00;06 - 00;16;23;11
Matthew Engelhard, M.D., Ph.D
Well, first, first I would tell them, we're always happy to engage with folks that are interested in getting connected on this. So happy to talk to specific individuals who might like to adopt some of this technology. Thinking about interest in AI broadly, AI is so many different things. I mean, I think we're in an era where people think of ChatGPT and other chatbots as being synonymous with AI in some ways.

00;16;23;11 - 00;16;51;06
Matthew Engelhard, M.D., Ph.D
And I would say that this is a little bit different. I mean, when we talk about AI, we're thinking more broadly about systems that are used to make sense of data to understand patterns and data, in this case, patterns that help us understand, again, who's at greatest likelihood of being in mental health distress. So we're thinking of sort of AI in a broad versus a narrow sense here, and how to get this kind of technology up and running at a particular institution.

00;16;51;09 - 00;17;15;11
Matthew Engelhard, M.D., Ph.D
There is institutional know how that is, that is required. But we are doing everything we can to make this tool as broadly accessible as possible. Our model is in fact available in a public repository right now, and we are happy to work with folks to think about how they might take the publicly facing resources that we've made available and put it to work toward a specific use case.

00;17;15;14 - 00;17;34;18
Jordan Steiger
Thank you both so much for being here today. I think this is such a great opportunity just to share some of the really innovative work that's coming out of Duke right now and, you know, spreading across the country. I think this is just an incredible example of how we can kind of get ahead of the mental health crisis that we are all hearing about and experiencing every day.

00;17;34;18 - 00;17;40;03
Jordan Steiger
So thank you both for the work that you're doing to make mental health care better for people all across the country.

00;17;40;11 - 00;17;43;28
Jonathan Posner, M.D.
Absolutely. Thank you for having us and for your great questions.

00;17;44;02 - 00;17;46;04
Matthew Engelhard, M.D., Ph.D
It's been a pleasure. Thanks for having us.

00;17;46;07 - 00;17;54;29
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;09 - 00;00;17;07
Tom Haederle
Welcome to Advancing Health. Members of hospital boards have a wide portfolio of responsibilities. Still, there are five things every board member should know about quality and patient safety, and we hear what they are in today's podcast.

00;00;17;10 - 00;00;49;21
Rebecca Chickey
My name is Rebecca Chickey and I am the vice president of Behavioral Health and Trustee Services at the American Hospital Association. And it is my honor today to be joined by Dr. Elizabeth Mort. She is the vice president and chief medical officer for the Joint Commission. In this role, Liz serves as a primary voice for patient quality and safety, and as a key liaison between the Joint Commission and the health care quality and safety community, and works closely with health care organizations on accreditation processes.

00;00;49;21 - 00;01;12;26
Rebecca Chickey
Dr. Mort is also the editor in chief of the Joint Commission Journal on Patient Safety and Quality. Prior to joining the Joint Commission, she served as the senior vice president of Quality and Safety and the chief quality officer at Massachusetts General Hospital for ten years, and she's also served on AHA's Committee on Clinical Leadership. Dr. Mort, thank you for being here today.

00;01;13;02 - 00;01;15;28
Elizabeth Mort, M.D.
Rebecca, it's a pleasure. Thank you so much for having me.

00;01;15;29 - 00;01;47;17
Rebecca Chickey
Well, I also want to thank you not only for the time you're going to spend with us today on this podcast, but you've just recently written an article that's going to be featured in the May edition of AHA's Trustee Insights newsletter. In that article, you really described what a board, an overall board, the full board needs to know about running a quality committee. And you provided five recommendations to elevate the impact of the quality committee, particularly during times of financial and operational challenges.

00;01;47;22 - 00;02;03;15
Rebecca Chickey
So the focus of our podcast today is really going to be on those five things that all board members need to know about quality and patient safety, including how that relates to Joint Commission surveys and resulting reports. Are you game?

00;02;03;23 - 00;02;05;06
Elizabeth Mort, M.D.
Game. Game on.

00;02;05;07 - 00;02;24;20
Rebecca Chickey
Wonderful. So we'll start with this. If you can simply list the top five things that you think all board members should know about quality and patient safety. Give maybe a high level 1 or 2 sentences about what that means. And then we'll go back and dig into each of those five.

00;02;24;22 - 00;02;51;24
Elizabeth Mort, M.D.
Absolutely. You know, just to reinforce what you said, Rebecca, a focus on quality is more important now than ever during these difficult times. There are so many competing demands for boards to focus on. It's a great time to think, how are we focusing on quality and how can we even do a better job? So the five things that I've outlined for that charge really, focus on quality, is to really own the charter.

00;02;51;24 - 00;03;18;25
Elizabeth Mort, M.D.
And what do I mean by that? Boards have charters. If you have a quality committee, it likely has a charter. And what we need these individuals to do is realize that they can move from generally understanding quality, thinking about quality as an abstract fiduciary, going from that stance to being more active, really put that quality committee to work.

00;03;18;27 - 00;03;48;20
Elizabeth Mort, M.D.
The second one is really the board needs to understand what the organization has as an operating system to ensure the quality assurance and performance improvement is happening. So many of you are probably familiar with the fact that the Centers for Medicare and Medicaid Services refer to this as quality assurance and performance improvement. For board members listening, you've probably heard that acronym.

00;03;48;23 - 00;04;12;06
Elizabeth Mort, M.D.
You've probably seen org charts, but do you really know how it works? And it's often a committee that goes parallel to an operational org chart. And it's more than just looking at the org chart and seeing various things in boxes. Now is the time to really understand its function. Is it functioning well and is it getting the results it should?

00;04;12;12 - 00;04;31;17
Elizabeth Mort, M.D.
The third thing I would say is that you really need to know your quality metrics and then ask what's missing? Quality measures over the last 20 years have escalated at a very, very rapid pace, and many board members are accustomed to looking at financial reports and looking to the bottom right and seeing whether things are positive or negative in parentheses or not.

00;04;31;20 - 00;05;00;10
Elizabeth Mort, M.D.
Quality measurement, unfortunately, is not as easy to summarize. So orgs make choices about what they put on the reports that they show the board. And you have to understand what those measures are and probe. But you also need to ask, what aren't you measuring? What are you worried about? So it's really being much more involved, I would say, and understanding and helping to support choice of measures and improvement of measures.

00;05;00;14 - 00;05;27;27
Elizabeth Mort, M.D.
So the fourth one is this: make risk decisions explicit and transparent. What do I mean by that? Organizations have lots of things that they might want to implement, they might want to resource. Even if they had all the resources you can't implement everything all at once. So whether it's because of bandwidth resources, both organizations are constantly making decisions about, go with this one,

00;05;27;28 - 00;05;51;18
Elizabeth Mort, M.D.
don't go with that one. I would encourage boards to think, particularly during this time when resources are constrained to find out what wasn't put on the list, why it wasn't put on the list, and that what risks patient safety risk, quality risk are associated with delays or discarding things. That isn't often done, and we call that transparent risk assessment.

00;05;51;18 - 00;06;15;27
Elizabeth Mort, M.D.
It's really very important. And I think it's particularly important when clearly resources do not allow organizations to do everything they want. It just simply not possible in today's world. The last one relates to accreditation. I would say boards really need to lean more into accreditation, and they should expect continuous readiness. Accreditation organizations come into your organizations on a periodic basis.

00;06;15;29 - 00;06;48;12
Elizabeth Mort, M.D.
They give you some feedback, and those organizations expect you to be monitoring that, managing that, improving that continuously. And I have seen boards be disappointed when they weren't really aware of that obligation. And a survey might be every three years; I work at the Joint Commission. Our standard surveys are every three years. But the point is that even though you may be only visited on site on a periodic basis, you are responsible for fixing things that were cited.

00;06;48;12 - 00;06;59;19
Elizabeth Mort, M.D.
And if they come back, it bounces back to the board. So you really have to understand your accountability for accreditation. You're not going to get quarterly measures unless you do something yourself. So we'll talk more about that.

00;06;59;21 - 00;07;35;09
Rebecca Chickey
Thank you. Liz I'm going to go back up to number one, which you said is called Own the Charter. Really own it. The question I'd love you to dig into a little bit more there is,  governance... there's always a balance between for governance roles to be ensuring organizational health and not getting into the day to day operations. Give an example of something that would be on the ensuring organizational health as it relates to patient safety and quality, but that can be active without getting stepping over that line into operations.

00;07;35;15 - 00;07;57;11
Elizabeth Mort, M.D.
It's a fine line, obviously, and one that, you know, governance and management - that fine line needs to be walked carefully. I do think being a more active quality committee or being having the board being more active in a quality capacity in these times can be done without getting into management. And it's really about in general surfacing where the issues are.

00;07;57;14 - 00;08;23;26
Elizabeth Mort, M.D.
So, you know, find the issues, have management share the issues. Don't tell management how to solve the issues, but expect management to come back with progress. So it's more of a, you know, what's going wrong? How can I help? Expect that from your management teams and then have them be accountable for reports and tracking the improvements. So you know, oftentimes what boards will get in their quality committee are report outs.

00;08;23;27 - 00;08;45;23
Elizabeth Mort, M.D.
Here's how we're doing on med errors. Here's how we're doing on infections here. Here's how we're doing on falls. And I think then the more active board stance in times like these is, well, you're doing well in these metrics. These are these are not doing well. What's your plan? What's your time frame? Do you have the resources you need? If the answers are we have a plan.

00;08;45;23 - 00;09;11;29
Elizabeth Mort, M.D.
We have a timeline. We have the resources. Then say, well, when will you be back to show me, show us the results? So it's really being more active and supporting them. And some of that is actually asking why they're not where they want to be on a performance metric. So the leaning in of the board is really about activating and encouraging improvement, trying to get take barriers away rather than solve the problems tactically or from a management perspective.

00;09;11;29 - 00;09;35;11
Rebecca Chickey
And that leads me into - because I think all of these are interconnected. As they are asking these questions, do you see that as a way for them to better understand the quality operating system or the copy? Is that really a way of being active, is a way of, you know, rolling up your sleeves and understanding better how the quality process works at their organization?

00;09;35;16 - 00;09;56;15
Elizabeth Mort, M.D.
Well, it could be certainly, depending upon what the report out comes back at and who gives it. I think that's a really interesting question, is that could you ask a board member, committee member? Could we could we say, you know, when you come back, I'd really love to know how you collaborate. It could be a quality leader, for example, or a chief nurse or a chief medical officer giving a report out at a board meeting.

00;09;56;22 - 00;10;18;29
Elizabeth Mort, M.D.
But it might have something to do with medication errors, or it might have something to do with high level disinfection. And to really understand how the leaders of quality who are often in that space. CNO, CMO, CQO, regulatory leaders, those are the people that often show up at these meetings, but the people doing the work are the ones who are in operations.

00;10;18;29 - 00;10;33;00
Elizabeth Mort, M.D.
And how does that all work? So one thing to consider would be a board member could say, when you come back with the report, I'd love you to consider bringing those folks who are actually on the front lines and hearing from them as to what the barriers are.

00;10;33;07 - 00;10;58;00
Rebecca Chickey
That's excellent. I'm going to ask you for the third measure, or the third recommendation that you noted, and that is to know the quality metrics. Then ask what's missing? I think for all of us not knowing what we don't know, that is one of the biggest concerns, because there's always something that we don't know. So what are some questions that they might ask beyond what's missing?

00;10;58;00 - 00;11;05;27
Rebecca Chickey
Or are there any things that you've seen over the last many years in quality and patient safety, where things get left off?

00;11;06;03 - 00;11;35;09
Elizabeth Mort, M.D.
Yeah. You know, it's an interesting history over the last 20 years. You know, if you think back, we used to just have Medicare mortality rates, and now we have so many measures that span impatient. There are a lot of ambulatory measures now. And the whole concept of a dashboard is not to flood it with so many measures that it becomes an eye chart and you lose the forest through the trees. But find measures that are important to the organization's health, to monitor the health and make some choices about that.

00;11;35;11 - 00;12;03;23
Elizabeth Mort, M.D.
People do it different ways. Organizations do it different ways. But no organization would put every measure on a dashboard. What I might do is if I were, you know, designing a sort of an approach is I would have boards get some basic information about what we can measure in health care and who's asking organizations to measure it. Because, you know, there's government, right?

00;12;03;23 - 00;12;26;02
Elizabeth Mort, M.D.
There's CMS, commercial payers are asking to be measuring a lot of things. There's groups like Leapfrog. There are groups like, well, Joint Commission. We ask for some measures. We try to align very closely with CMS for reduced burden. US News is out there. We have Newsweek, but there are lots of things out there. And my goodness, how are you going to decide what's important.

00;12;26;06 - 00;13;01;08
Elizabeth Mort, M.D.
So I think educating boards about what's out there, then putting out for the boards, even recommendations, these are the things we think are most important, but also committing to monitor what's not being shown. So that you have sort of a sort of behind the scenes detail list of measures that are being tracked. Because some of those measures are presented to the organization, some have to be collected by the organization, but somebody should be tracking the other measures that aren't on the dashboard.

00;13;01;10 - 00;13;09;02
Rebecca Chickey
It just doesn't have to always be reported out to the board unless a certain threshold is reached where it has risen to a level of concern.

00;13;09;03 - 00;13;22;27
Elizabeth Mort, M.D.
And then the board should say, well, listen, you know, if you watch those others, you know, and if one is one is a trigger, I want to hear about it. So that's one way to do it. There are just so many measures right now, and there's a lot of conversation in the industry about, do we have enough measures?

00;13;22;29 - 00;13;41;17
Elizabeth Mort, M.D.
Are we doing the right thing? And I imagine that this will evolve. There is not one good solid, you know, bottom line measure, unfortunately. That would be very, very nice. Many people have asked me, you know, inpatient mortality adjusted for risk and all these things. It just doesn't cut it as an overall measure like in a financial report.

00;13;41;17 - 00;14;03;24
Elizabeth Mort, M.D.
So boards need that education. And I think it's education that's worth taking time to provide. There are things that we worry about in health care that don't have measures despite all these measures. So another question I would suggest boards ask their staff, the management is,  okay, so we got the measures. We see where you're doing well. We see where you're not.

00;14;03;24 - 00;14;23;22
Elizabeth Mort, M.D.
You're going to watch these other measures and escalate problems. We've got that covered. What else keeps you up at night? Because not everything that's important from a patient safety risk perspective actually has a measure. And those risks need to be transmitted and talked about not on a dashboard, but they need to be talked about. So I just didn't want to leave that out.

00;14;23;22 - 00;14;24;25
Elizabeth Mort, M.D.
That's super important to.

00;14;24;26 - 00;14;52;02
Rebecca Chickey
That is also related to your fourth recommendation around making risk decisions explicit and transparent. You're making decisions and not reporting those out may have risks that need to be understood. And that's where I circle back to your point about continuing to educate the board members about this whole process. I'll tell a quick story about my own two children.

00;14;52;02 - 00;15;10;04
Rebecca Chickey
When I would pick them up from school, I would always before they wanted to game or start talking about something. They had to say, what was one good thing that happened today, and what was one bad thing that happened today? It has brought them into adulthood. And somebody else told me this. This was not an original idea, but it's brought them to adulthood.

00;15;10;05 - 00;15;34;19
Rebecca Chickey
Being able to share with us the bad things that happened in their life. And that's not easy. And I think enforcing and strengthening the importance of being transparent with the decisions that are difficult, that are complex, that have to be made to let the board know what the risks are. Because they may have a perspective that is different.

00;15;34;21 - 00;15;56;01
Elizabeth Mort, M.D.
Yeah, that's a great story. And I think it relates also to the tracking of the metrics. I've seen organizations, they get some scores on something. The scores aren't good. They think, I'm going to fix this before I share it. Not the way to go. I think, you know, you need to be you need to be monitoring metrics and you need to be on top of them.

00;15;56;01 - 00;16;12;21
Elizabeth Mort, M.D.
But oftentimes if things are not going in the way you want, it can't be fixed by one person. It needs a team. And that you know what you had your kids do, which is you know what didn't go well, that gave them the muscle memory and the comfort and the reflexes to be able to say, hey, I need help.

00;16;12;21 - 00;16;24;10
Elizabeth Mort, M.D.
So, you know, never worry alone is something that I've heard said by lots of people. And I would just say, don't, you know, encourage your management, staff, board members to not sit on things. We're here to help.

00;16;24;16 - 00;16;38;06
Rebecca Chickey
As we come to the fifth one, which specifically, you said the committee should lean into accreditation and expect continuous readiness. Can you help the listeners know what is continuous readiness? What do you mean when you say that?

00;16;38;10 - 00;17;05;25
Elizabeth Mort, M.D.
So continuous readiness is a term in this case that is referring to the next patient getting high quality, safe, compassionate, appropriate care, continuously being ready for that. But it also can be referring to being ready for the next time somebody comes to your organization to make sure that you're providing for the next patient, for every patient, safe, high quality, continuous, compassionate care.

00;17;05;27 - 00;17;36;09
Elizabeth Mort, M.D.
With respect to accreditation and the Joint Commission, I'll use that as the example. That's my organization. Our traditional surveys are every three years. We go into hospitals every three years. And as I mentioned in my opening comments, there are options for more continuous touchpoints. But the survey itself is sporadic. And what I would encourage and what I did in my old organization is set up a surveillance program so that you're monitoring all the things that CMS and your accrediting organization -

00;17;36;09 - 00;18;00;24
Elizabeth Mort, M.D.
in our case, it was the joint Commission - you're monitoring to make sure those things happen every day for every patient. So continuous readiness for all patients, continuous readiness for the next survey. That's extremely important. And I'll just share that you all remember Covid. And you know when Covid happened at its peak some things had to get back-burnered while we just struggled to make sure that we could get a bed for every single patient and needed one.

00;18;00;24 - 00;18;22;04
Elizabeth Mort, M.D.
We all did that. We all remember that. And as things quieted down, the very first thing I said we needed to put back in our armamentarium of tactics to provide high quality, safe care. The very first thing I said we needed to do is put back that surveillance of continuous readiness. And it's a monitoring system. And basically teams go and they use tools.

00;18;22;05 - 00;18;55;08
Elizabeth Mort, M.D.
Joint Commission has a great tool, a tracer tool, and they're going through the hospital and they're looking for things. They're looking for evidence of infection control, medication management, clean environment. Safe environment. Are your emergency equipment... are your cold carts ready? Are timeouts being done? And those things are being done in a continuous way. Surveillance. And you get the data. I think boards should expect that their organizations are not just waiting for the next survey, but they are ready for the next patient.

00;18;55;14 - 00;19;25;08
Rebecca Chickey
That helps tremendously. Your recommendations are own the charter, really own it. Be active, not passive. Understand the quality operating system and your organization's approach to QAPI, know the quality metrics and then ask what's missing. Make risk decisions explicit and transparent, and the board and the quality committee should lean into accreditation and expect continuous readiness as you just described.

00;19;25;10 - 00;19;51;10
Rebecca Chickey
Liz, Dr. Mort. Thank you so much for sharing your time, your expertise, providing guidance. Health care is complex, but the mission is health care, and that involves being able to deliver high quality care for each and every patient we serve. And the words you've shared here with the listeners today will inspire others to take a more active engagement if they're serving on a board.

00;19;51;11 - 00;19;52;24
Rebecca Chickey
Thank you so much.

00;19;52;26 - 00;19;54;27
Elizabeth Mort, M.D.
My pleasure. Thank you.

00;19;55;00 - 00;20;03;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.