Advancing Health Podcast

00:00:00:09 - 00:00:36:07
Tom Haederle
Clean air, peace and quiet, and quick access to outdoor activities are among the draws of practicing health care in a rural setting. On the flip side, issues such as housing, transportation and affordable childcare remain challenges for all rural hospitals and health systems, and affect their ability to attract and retain top talent. Stay with us to hear how the leader of the most rural academic medical center in the country has faced those issues and produced solutions that work.

00:00:36:09 - 00:01:01:06
Tom Haederle
Welcome to Advancing Health, the podcast of the American Hospital Association. I'm Tom Haederle with AHA Communications. Dr. Joanne Conroy is CEO and president of Dartmouth Health in New Hampshire, and the 2024 chair of the AHA Board of Trustees. In this podcast hosted by Shannon Wu, director of payment policy with the AHA, we learn more about Dartmouth Health's winning recipe for hiring and keeping talented health care professionals.

00:01:01:13 - 00:01:05:29
Tom Haederle
Ideas that could work just about anywhere. Now to Shannon.

00:01:06:01 - 00:01:21:26
Shannon Wu
Joanne, thanks so much for joining us on the podcast today. Before we get into the topic of rural health care delivery, please tell us a little bit about yourself and your journey to becoming the CEO and president of Dartmouth Health and the 2024 board chair for the AHA.

00:01:21:28 - 00:01:45:09
Joanne Conroy, M.D.
Thanks, Shannon, and it's great to be here. I've been at Dartmouth Health since 2017, and my path here was a little bit circuitous. I started my career in South Carolina at the Medical University of South Carolina, where I spent about 21 years. After that, I went to Atlantic Health in northern New Jersey and spent about eight years there.

00:01:45:09 - 00:02:17:09
Joanne Conroy, M.D.
And that was actually a great experience, kind of contrasting academic medicine in a kind of a regional institution, to going to northern New Jersey, where you had all the influences of metro New York. After eight years at Atlantic, I went to the AAMC, the Association of American Medical Colleges, where I was their chief health care officer. And that was really great because I really got to see policy and the impact of policy on practice, and I was actually there,

00:02:17:16 - 00:02:47:29
Joanne Conroy, M.D.
I started in the fall of 2008, just as Obama was getting elected, and all the buzz around Affordable Care Act and the contributions that many organizations had to drafting, that was really, really fascinating. After six years, I took a role at the Lahey Clinic. I was the president of the Lahey Clinic, and it had just become part of a larger organization called Lahey Health.

00:02:48:01 - 00:03:15:18
Joanne Conroy, M.D.
And you know, I actually love the clinic model where everybody's paycheck is written by the same person. It's a real great way to really align across the organization. But I was contacted about the role at Dartmouth, which again is a Clinic member, the Hitchcock Clinic has been in place for close to 100 years. I interviewed and they offered me the job, and I came up in 2017.

00:03:15:20 - 00:03:34:17
Joanne Conroy, M.D.
I've had the opportunity to have really a great kind of experience in almost every different type of health care system. And then when I was at the AAMC, I got to look under the hood of 185 teaching hospitals, which really gives you a perspective about the differences across the country.

00:03:34:24 - 00:03:49:18
Shannon Wu
Yeah, you're right. That is such a varied set of experiences you've had. I understand that you are one of the most rural academic health systems in the country. Please tell us a little bit more about Dartmouth Health and the rural population specifically that you serve.

00:03:49:20 - 00:04:15:17
Joanne Conroy, M.D.
You're right. We are the most rural academic medical center in the country. And people say, well, how do you know that? They actually see how many people live within 30 miles of the academic medical center. And we have only 170,000 people within 30 miles of Dartmouth Hitchcock Medical Center, which is our academic site. And the next most rural is Mayo, which has about 230,000 people.

00:04:15:19 - 00:04:54:25
Joanne Conroy, M.D.
And then you have a number of organizations like University of Virginia, Carilion Clinic, that actually have small city populations. I would say, Dartmouth Hitchcock, when you kind of think about how did we get here? And really we sit on 200 acres, and you wouldn't even be able to see us from the highway. And yet, when you turn down the roads that bring you to the institution, all of a sudden you have over two million square feet of research infrastructure, clinical services, outpatient services, as well as the Hitchcock Clinic offices.

00:04:54:27 - 00:05:34:23
Joanne Conroy, M.D.
And, you know, people drive two, three hours here to get their care. Rural health care in New England is probably different than rural health care in the Midwest, which is different from rural health care in the Southwest. They all have a little different flavor, but they all share many of the same challenges. When you think about the importance, however, 20% of people in the U.S. get their care from rural hospitals, and we have made a commitment to actually supporting what we call the rural safety net, which bridges New Hampshire and Vermont.

00:05:34:25 - 00:05:46:23
Joanne Conroy, M.D.
That's been the focus of not only the hospitals that we bring into our network, but also the services we invest in to allow care to be delivered locally and for people to stay in their communities.

00:05:46:25 - 00:06:11:15
Shannon Wu
Yeah, that's great. And let's dig into some of the challenges, that comes with serving patients in rural communities. We know that health care workforce has experienced many challenges, especially during this past few years. There's both a nursing and physician shortage, and it must be very tough to recruit and retain the clinical workforce that you need, in such a rural footprint.

00:06:11:17 - 00:06:15:16
Shannon Wu
What have you done at Dartmouth Health to address some of these staffing challenges?

00:06:15:18 - 00:06:38:18
Joanne Conroy, M.D.
So, yes, and no. So yes, it's a challenge, but there is a certain type of person that actually wants to live and work in a place like Dartmouth Hitchcock. So let me first talk about our attitude towards remote work. We took all of our jobs at the academic medical center and decided which ones were going to be permanently remote.

00:06:38:21 - 00:07:01:11
Joanne Conroy, M.D.
This was probably a year, a year and a half into the pandemic, and we have close to 2,500 people that are permanently remote. We employ people in 35 states, which makes some of our tax people a little bit crazy because we have to, you know, make sure that we adhere to the employment law in every single state and file all the forms.

00:07:01:14 - 00:07:24:05
Joanne Conroy, M.D.
But what it does allow us to do is actually find talent all across the country and actually leverage that talent. So our performance network is scattered across the country, but we have incredibly talented people that we could not recruit if they actually had to be within, you know, 45 minutes of Dartmouth Hitchcock in order to be on site.

00:07:24:08 - 00:07:45:24
Joanne Conroy, M.D.
And another thing we found out is that often we have professional marriages, and in rural America, it's not just the person you're recruiting, it's their partner as well. And they have to find gainful employment. So a lot of this is solved by really remote work and really getting good at remote work. The second thing are nurses and physicians.

00:07:45:27 - 00:08:08:03
Joanne Conroy, M.D.
And, you know, people love working up here. I mean, if you love really being in the outdoors, we are literally 15 minutes away from a ski slope, and in five minutes you could be on your bike mountain biking, and a lot of people do ride to work, and a lot of people have kayaks on the top of their car.

00:08:08:03 - 00:08:33:12
Joanne Conroy, M.D.
And, you know, it's less than 10 minutes and you're flipping that into the water, so you can actually really enjoy the outdoors here and don't have to travel two or three hours to do that. You're actually living in this wonderful place. Unfortunately, our issues are the same across the country. Housing, transportation, childcare services, all the things that are less of a challenge in the city.

00:08:33:15 - 00:09:00:08
Joanne Conroy, M.D.
We actually are subsidizing housing for our clinical frontline providers. And we've been talking about building housing. It's just it's that bad. Now, we know that once we start doing it, everybody else in the community is going to say, that's not a bad idea. How can we actually use the same approach to actually developing workforce housing? I would say that we invest in transportation.

00:09:00:11 - 00:09:27:08
Joanne Conroy, M.D.
We know that not everybody wants to drive to work, so we actually support a lot of our local transportation systems from our small city hubs where most of our employees come from. And finally, childcare. You know what distresses me the most is 10% of all the women that left the workforce during the pandemic have not come back. For many of them, it's a lack of affordable and accessible childcare.

00:09:27:10 - 00:10:01:26
Joanne Conroy, M.D.
So we've invested a tremendous amount of time and effort to actually educating more early childhood educators so they can either participate in the large centers we have, and we have a number of them, and or start small businesses in their home where they can take care of kids in their home. And, you know, my hope is this way we make it easier for women to come back into the workforce because we're 85% female, and we know that having 10% of that workforce not be available is a huge issue for us.

00:10:01:28 - 00:10:07:09
Joanne Conroy, M.D.
But, you know, those are the challenges that they face in many other rural areas of the country.

00:10:07:12 - 00:10:35:00
Shannon Wu
As you alluded to, social drivers of health have also become more recognized as a major contributing factor to overall health. And as you've just mentioned, as really Dartmouth Health as the anchor institution for your community. Like many other hospitals and health systems, it is committed to promoting well-being and addressing societal factors that influence health. You had mentioned, you know, your investments in transportation and childcare services and housing.

00:10:35:03 - 00:10:46:19
Shannon Wu
How are hospitals and health systems working with community partners to address these social drivers of health in Dartmouth in particular, and other conversations you've had with other rural health leaders?

00:10:46:22 - 00:11:14:23
Joanne Conroy, M.D.
Well, we have a Center for Advancing Rural Health Equity, which is really focused on operationalizing how do you improve health? Over half the people on the board are actually community health organizations, housing authority, food banks, you know, people that are living every day trying to actually improve the conditions in which people live that are critical to maintaining their health.

00:11:14:25 - 00:11:51:08
Joanne Conroy, M.D.
They actually did a really interesting study about three or four years ago, where they identified the decrease in average lifespan from Hanover to Lebanon to Grantham to Newport to Claremont, and the difference between Hanover and Claremont, which are probably only separated by 20 miles, is about 15 years. When you look at the, you know, the drivers of health, they're actually very different in those communities.

00:11:51:10 - 00:12:20:09
Joanne Conroy, M.D.
The Hanover community is populated with a lot of professionals from Dartmouth Hitchcock, and also professionals from the college. And Claremont, it's an old mill town, and a lot of people that get the work done every day, but often in blue collar jobs or jobs that don't pay as much. And we look at the correlates between income, education, access to care.

00:12:20:12 - 00:12:55:27
Joanne Conroy, M.D.
There's a huge difference. What's great is today we actually celebrated the fact that that hospital in that community is actually joining us. And our hope is that that hospital that's anchored in the community and using all of our resources in terms of expertise, our telehealth, our back office resources, so that organization can actually have a greater return on the community investment and then reinvest it in their facilities and programs, will ultimately improve the health of the community at large.

00:12:56:00 - 00:13:20:01
Shannon Wu
That's great to hear. The next question is going to be a two-part question and how we talked about some of this, but what are some of the other challenges you see that face rural hospitals and providers, in delivering care to their patients? But then, hopefully to end on a positive note, what innovations and opportunities are you seeing in this space as well?

00:13:20:03 - 00:13:46:19
Joanne Conroy, M.D.
We have actually looked at hospital at home frequently. It is hard to do it in a rural community when internet is spotty, questionable, consistent electrical and water sources. We talk about how do we deliver care in the homes differently. We do have a visiting nurse and hospice association, and I've actually gone on a lot of their intakes.

00:13:46:19 - 00:14:15:26
Joanne Conroy, M.D.
And I'm so impressed how they just kind of take the patients where they are and say, how can we actually appreciate this environment so this patient can get better and will no longer need our services. So those are some of the really unusual challenges. On the flip side, we have some remarkable innovations. We have a super strong, telehealth program.

00:14:16:01 - 00:14:50:02
Joanne Conroy, M.D.
It's interesting, it’s provider to provider. So we actually provide the care to outpatient clinics, to hospitals, to physicians’ offices. And a lot of that is so people don't feel like they have to refer everybody to the academic medical center. But if they have a simple question or want some guidance in terms of how to deliver care to that patient in their rural office or in their rural hospital, that we can actually give them the answer right away, and that patient can have some resolution of what their care plan is going to be.

00:14:50:04 - 00:15:26:13
Joanne Conroy, M.D.
We also have a lot of physicians that do a lot of traveling. They get in their cars and they work in clinics. Often our emergency room physicians travel all over our rural network, and that actually allows for a great exchange of ideas between the physicians that are at those facility, interacting with physicians from the academic medical center. And, you know, it's an incredibly positive relationship that actually enhances the systemness that we have, and actually improves the ability of people to actually keep people in their community.

00:15:26:15 - 00:15:55:00
Joanne Conroy, M.D.
And finally, we used ECHO, the ECHO program a lot during the pandemic, not only to educate people about COVID, but we actually have used it on all the specific disease challenges we face in the communities: substance use disorder, stroke, cardiovascular disease, liver disease. So people in the community feel like they get the resources they need to care for patients.

00:15:55:03 - 00:16:27:16
Joanne Conroy, M.D.
And, you know, after the Dobbs decision, we're offering ECHO programs through emergency rooms across the country because with the diminution of women's reproductive health services and maternity services across the state, we know that many of these patients are going to be going to emergency rooms. And those emergency room providers are ill equipped necessarily to take care of women in active labor, or a woman whose pregnancy is at risk.

00:16:27:18 - 00:16:41:20
Joanne Conroy, M.D.
So we have an OB kind of Maternity 101 for our emergency rooms. And our hope is this will help people stabilize those mothers before they needed to be transported to the academic medical center.

00:16:41:22 - 00:17:13:09
Shannon Wu
Well, thank you very much for sharing what you and Dartmouth Health are doing in providing care, for patients in your rural communities and sharing some of the innovations and opportunities you see that other providers, can take on as well. Before we wrap up, Joanne, I wanted to mention to our listeners that you and the CEOs from MaineHealth and the UVM Health Network will be presenting at the AHA Rural Health Conference in February 2025, in San Antonio, Texas.

00:17:13:11 - 00:17:32:03
Shannon Wu
We're very thrilled that you'll all be there to discuss the topic of rural health delivery. So thank you for your time, Joanne, in joining us in San Antonio. And we hope everyone who is listening will also consider heading to Texas for that event. So once again, thank you very much, Joanne, for being there. And thank you to our listeners.

00:17:32:05 - 00:17:34:26
Joanne Conroy, M.D.
Thank you, Shannon. It's great to be here.

00:17:34:28 - 00:17:43:10
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.

00:00:00:14 - 00:00:37:28
Tom Haederle
It's been noted before that 1999's groundbreaking report, "To Err is Human - Building a Safer Health System" was, frankly, a punch in the gut to American health care. The Institute of Medicine's account of preventable deaths due to medical errors ignited today's sharpened focus on patient safety, now considered a core competency that drives everything we do. While patient safety has made great strides over the past 25 years, some caregivers worry it has come to a standstill.

00:00:38:01 - 00:01:03:20
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Every hospital and health system in America is committed to the mission of patient safety, and its measurable improvement has been encouraging. But can it be sustained? In today's podcast hosted by the AHA’s chief physician and executive, Dr. Chris DeRienzo, we explore the past and future journey of patient safety and grapple with the big questions:

00:01:03:25 - 00:01:10:18
Tom Haederle
Are we improving fast enough, and can the current reality of health care be improved? Here's Chris.

00:01:10:20 - 00:01:43:15
Chris DeRienzo, M.D.
Thank you, listeners, and welcome to this episode of our podcast. I'm Dr. Chris DeRienzo, AHA’s chief physician executive, and I am incredibly excited to bring a conversation to you all today that I've been looking forward to a long time. Because our guest is Dr. Oren Guttman, and he is a practicing anesthesiologist, the enterprise leader in safety and high reliability at Jefferson Health, in addition to several other titles that might actually take the full 15 minutes of our podcast together to get through because his leadership in the field is simply unparalleled.

00:01:43:23 - 00:01:58:27
Chris DeRienzo, M.D.
And we get to spend a little bit of time today talking about the journey that we've taken as a field around patient safety over the last 25 years, and where Oren and colleagues like him are leading us to go towards the future. Oren, thank you for joining us.

00:01:59:00 - 00:02:22:28
Oren Guttman, M.D.
Hey, Chris, thank you so much. Thank you for that overly charitable introduction. It's really a privilege and a pleasure to be here with you. And really just to reflect with you on patient safety. I think for most of us, you know, patient safety is really the mission driven piece. It's the core competency of really everything we do in quality and safety and health and equity access.

00:02:23:01 - 00:02:49:10
Oren Guttman, M.D.
I think we just need that moment of reflection on safety. And I'm just so excited that we get to do that today. I think it might be fair to start by saying that, many of us and I'm here giving voice to a growing chorus, kind of feel like the patient safety movement for all the good that it's done, has probably come to a little bit of a standstill.

00:02:49:13 - 00:03:19:22
Oren Guttman, M.D.
And, you know, if we if we were to say that differently, we're not improving fast enough. When we started this, we started in a world where, you know, the public really created an outcry an appropriate outcry over, over safety and the safety of our patients and our hospitals that do no harm focus. And they called our attention. And we used social systems, systems of individual accountability, like just culture systems like, you know, teamwork and team training.

00:03:19:24 - 00:04:01:14
Oren Guttman, M.D.
We looked to other safety industries like the airline industry, and we said, what are they doing to focus on their-quote unquote- mistakes? And they did a lot of resource management. They did a lot of simulation. But what we've kind of learned is that all of that, if we can wrap it up in the bubble of a culture of safety and some of those things being tactics that we use to create a culture of safety, if we're going to be honest and have some courage, we would be forced to the conclusion that they were really expensive, they were not sustainable, and the results they produced when they produced them were not uniformly produced and

00:04:01:14 - 00:04:02:28
Oren Guttman, M.D.
they didn't last.

00:04:03:01 - 00:04:26:13
Chris DeRienzo, M.D.
And when I reflect on what we may call sort of the first 25 years of the patient safety movement in, in American hospitals and health systems, and that was a fairly seminal report back in 1999 that, as you've indicated, really opened our eyes to, some opportunities that previously we were sort of blind to in, in American health care.

00:04:26:15 - 00:04:49:12
Chris DeRienzo, M.D.
And over the course of that 25 years, no question, we've made incredible strides across numerous axis within patient safety. And I think about in just our practice career, that when we were in medical school, that was the very first literature that was published around...you can actually reduce CLABSI and or eliminate CLABSI or central line infections.

00:04:49:15 - 00:05:18:25
Chris DeRienzo, M.D.
That was not a thing that that the folks who were teaching us in medical school thought about. And now, you know, 25 years hence, we have lots of great bundles of work around that. But what I'm hearing you say is all of that really built a foundation for now where we are today, which because we have built in a number of ways to drive safety improvements, we can now think slightly differently about, what are the next steps that we get to take?

00:05:18:27 - 00:05:49:26
Oren Guttman, M.D.
Yeah. Chris, thanks for really giving voice that way to this. I think that that's absolutely true. And I would invite us to consider, is there an opportunity for us to reflect on the sustainability and whether the current reality of care delivery would still be improved by those foundational tenants? And so I would point our attention to maybe the safety moment of the century, which was the Covid 19 pandemic.

00:05:49:28 - 00:05:56:29
Oren Guttman, M.D.
Health care is a complex, irreducibly complex system. We're not complicated. We're actually complex.

00:05:57:01 - 00:06:04:21
Chris DeRienzo, M.D.
Take us deeper on that, because I remember the first time you described that, I was trying to think in my head what is irreducibly complex actually mean?

00:06:04:24 - 00:06:53:12
Oren Guttman, M.D.
Complicated systems are systems where there are cause and effect relationships, where the realities of the processes are very linear. There's a good sense that things are knowable and you can break things down. It's a macroscopic view of the world. Complexity and particularly irreducibly complex systems, they're very much non-linear. The reality of how you would classify AI or the taxonomy of a irreducibly complex system has to do with the fact that pieces of the system are interacting in ways that are totally unpredictable, that risks in those systems have a probability of risk, and that they're additive in nonlinear ways, that even the barriers can actually introduce risk themselves.

00:06:53:14 - 00:07:07:13
Oren Guttman, M.D.
And, you know, in that regard, sometimes there aren't causes, there are probabilistic contributions. I'm reminded of our my time in pre-med work in quantum mechanics and thinking about Heisenberg's uncertainty principle.

00:07:07:13 - 00:07:10:12
Chris DeRienzo, M.D.
Oh, man, you're bringing me way back.

00:07:10:19 - 00:07:46:16
Oren Guttman, M.D.
You know, I thought I'd never have to remember that again. But the reality is, is that, you know, the same events that interact today and produce success can interact tomorrow and produce failure. I think part of where we've maybe gone a little bit the wrong way is that we've focused a lot on the human contribution to safety. So again, thinking that, you know, we would culture our way to safe, that if we were able to have just better functional teams with higher teamwork scores, then ultimately, you know, we would be able to really become safer as an industry

00:07:46:16 - 00:08:09:03
Oren Guttman, M.D.
and that's probably, I would say, arguably not true. The reason is, is because, remember and when the patient safety movement started, you know, we had about 10% of health systems with an EMR. Today it's ubiquitous. The complexity of technology and how it interfaces with safety. And, you know, the work that we do is socio-technical work.

00:08:09:03 - 00:08:34:26
Oren Guttman, M.D.
You cannot move left or right in health care delivery without being engaged with tools and technology, software and hardware workflows and processes. And we don't have design moments for those things. We generally kind of get those things from industry. We put them into our system. We don't do prospective risk assessments on how we incorporate them, and then we sort of work through that.

00:08:35:03 - 00:08:46:06
Oren Guttman, M.D.
And when things don't go well, we don't redesign value streams with the right lenses. And this is where I would point to maybe a further opportunity for us.

00:08:46:08 - 00:09:09:18
Chris DeRienzo, M.D.
You're making me think back to in the old days of aviation, there was both a cultural problem. So they had to build a different culture within those cockpits. But there was also a cockpit problem that the system in which the people operated was not optimized. And I think in health care, we have spent a lot of time and energy

00:09:09:18 - 00:09:38:29
Chris DeRienzo, M.D.
and you've written extensively on this, on trying to improve the relational culture. And I think what we're what we've come to appreciate is that is necessary and insufficient for driving the kinds of transformational patient safety outcomes that we know every hospital is striving to achieve here in the 21st century. And perhaps this is a good time to talk our listeners through, you know, we hit on the Heisenberg uncertainty principle there for a moment.

00:09:38:29 - 00:10:08:12
Chris DeRienzo, M.D.
And so for those of you who weren't forced to take physics in premed, you know that that is a you can't actually measure certain particles in physics without affecting the measurement that you're taking. Even more fascinating concept to me in this construct is, the way that I've heard you talk through the difference between reliability or, again, we have spent a lot of energy building highly reliable organizations and adaptive resiliency.

00:10:08:14 - 00:10:20:29
Chris DeRienzo, M.D.
But let's go there for a moment, because I think our listeners would really benefit from hearing how you've taken that concept, from frankly other fields and are now applying it in health care.

00:10:21:01 - 00:10:57:16
Oren Guttman, M.D.
I would call our listeners attention to this idea, which has been really transformational for Jefferson Health. I think that for a long time we have focused on high reliability organizing as a health care, as a framework to get to safe, right? We want to have highly reliable, we want six Sigma failure rates. And what's really interesting, actually, is when you look at the other industries from which these studies are originated from and how we are able to try and adapt those concepts in high reliability organizing into health care,

00:10:57:18 - 00:11:26:21
Oren Guttman, M.D.
there's some really interesting observations, right, about trying to make processes more reliable. The challenge is that in a lot of those other organizations - and industries, I should say - there's a lot more knowable about the inputs. There's a lot of more control over some of the foundational elements that are then being focused on, with a preoccupation for failure and a reluctance to simplify and a deference to expertise, etc..

00:11:26:23 - 00:11:56:29
Oren Guttman, M.D.
Health care is orders of magnitude more complex than a lot of those other industries. And so in that space, you know, we recognize the resilience engineering world offers us something, I think, a lot more pragmatic. And it's basically, in a nutshell, this idea that not every error is failure and that we have to almost have a predictable unpredictability, that things are actually going to have errors all the time.

00:11:57:01 - 00:12:22:09
Oren Guttman, M.D.
And rather than try and error proof a process  - work as imagined would be that we would actually error proof a process perfectly - it's a more honest view of what happens at the sharp end of care. At the sharp end of care is that errors happen all the time, but better organizations are able to detect those errors, and they're able to rescue those errors from turning into failure.

00:12:22:12 - 00:12:48:29
Oren Guttman, M.D.
Dr. Amrika Ferrie published a really nice article in New England Journal about 15 years ago or so. Don't quote me on the exact time, but it was basically, a review of the surgical administrative claims data where they had, you know, the same complication rates between hospitals, but they actually had different outcomes. And, you know, he attributed it through some abstraction work that they did to actually the ability to actually detect errors early on and rescue them from turning into failure.

00:12:49:01 - 00:13:09:10
Oren Guttman, M.D.
That concept is a resiliency engineering idea. We have to have better mechanisms in place to detect errors and actually be able to rescue them from turning into failure when failures already happened, at least contain them. We need a different model in health care. We have to have the ability at the unit level to detect errors that have not yet become failures.

00:13:09:10 - 00:13:26:15
Oren Guttman, M.D.
I'll give you just a demonstrated example. Think about CLABSIs for a minute, right? Classically, how have we thought about CLABSIs? We thought about a bundle. We thought about not putting into many lines. We've thought about ensuring that, you know, we don't put in femoral lines, for instance. And when we do it, when we put them in, we have to put them in sterile.

00:13:26:18 - 00:13:48:24
Oren Guttman, M.D.
And there are various other things that we put in bundles. A resiliency engineering approach to this looks a little different. And it looks like, you know, we don't want to put in femoral lines. But the reality is, is that people are going to come into the emergency room all the time. They're going to be emergencies. They're not going to have time to drop in sterile necklines, and they're going to put in femoral lines.

00:13:48:27 - 00:14:10:05
Oren Guttman, M.D.
And what we need to do is be able to detect those things at a unit level and get them exchanged out really, really quickly. Another good example. You know, we expect our CHG bathing to keep our lines clean to happen every day. We want reliable processes to make sure that we do that reliably. We want to have reliable ways of changing dressings.

00:14:10:07 - 00:14:30:16
Oren Guttman, M.D.
The challenges is that care at the unit level is not always perfectly reliable. And that's the work as it's actually done. On any given day, you know, there could be a call on the unit, there could be students observing that are creating distraction, you know, necessary learners. But you know, it can be a cognitive overload situation. We could have new orientees coming on, too.

00:14:30:17 - 00:14:58:27
Oren Guttman, M.D.
It could be a shift change. There could be team changes. And all of those things together create stresses in the system that may in fact create the error of the 12-hour shift went by, and we did not, for good reasons, potentially have an event called CHC math. But if we create a process at shift change where we have a detectability of that error and we can get it reassigned, we can rescue that in a reliable way.

00:14:58:29 - 00:15:11:23
Oren Guttman, M.D.
We will then prevent failure. Resiliency engineering is constantly looking to try to find errors and actually prevent them from progressing into failure.

00:15:11:25 - 00:15:32:04
Chris DeRienzo, M.D.
If I am listening in from, a hospital, say not part of a larger system, hearing you describe this concept of resilience and saying, great. You know, I, I want to both be able  to continue the work that we're doing. But I also want to focus some energy now on taking the first steps towards becoming a more resilient.

00:15:32:04 - 00:15:41:04
Chris DeRienzo, M.D.
And, as you described it, a more adaptively resilient organization. What is your guidance to that quality and safety leader? What is step one?

00:15:41:06 - 00:16:05:06
Oren Guttman, M.D.
I'm going to give you a top three. I'm going to break down adaptive resiliency into human resiliency, process resiliency, and training resiliency I think very pragmatically, our humans are sources of resiliency in our system. One of the most misunderstood ideas that I think we've sort of lived with in the patient safety movement is this idea of a human error.

00:16:05:09 - 00:16:29:22
Oren Guttman, M.D.
The truth of the matter is, is that we have operator errors, because we have a constant focus on thinking that human capability capacity failed. And so it was a human error. But we failed to ask the question about how the system facilitated and contributed to those errors. So here's a very pragmatic approach to increase your human resiliency: turnaround your Great Catch program.

00:16:29:24 - 00:16:52:18
Oren Guttman, M.D.
We actually took the vantage point of saying, we're going to ask the people in our system who hold themselves to really high professional standards, to tell us anytime they see a broken process, broken technology, broken tools, or those tools are not supporting the people who use them in the way they need to be supported, and actually report that when you do, we'll give you a Great Catch award.

00:16:52:20 - 00:17:14:29
Oren Guttman, M.D.
We're not going to give you a great catch award anymore for just getting in the way of harm. We actually segmented that off for extraordinary human vigilance and call that a Great Save Award. That's important. We want to honor people for that contribution. But what that doesn't do is ask the harder question of why did it take more human vigilance to actually get in the way of harm?

00:17:15:01 - 00:17:40:26
Oren Guttman, M.D.
What happened all the way upstream of these events? What processes and systems in the sociotechnical system did not facilitate the best care experience for the patient and their family? What can we do there? And so we actually completely changed around Great Catch reporting and started honoring when people gave us system failures that we then put through a process of fixing and shared back, you know, really the highlights of those of those fixes.

00:17:40:26 - 00:18:12:00
Oren Guttman, M.D.
And I'll tell you what happens. When you do that, people report more harm because you're fixing stuff that's really been difficult for them. See, the truth is, is that they've been making all these little micro adjustments all the way around. An old frame of safety called safety one, we used to call that normalization of deviance. The reality is, the safety sciences tell us is that actually those folks are making micro adaptations on a daily basis to actually not let the system catastrophically fail.

00:18:12:02 - 00:18:34:03
Oren Guttman, M.D.
And if they're elevating that to us and we can actually focus on system improvement, then we'll actually make our humans much more resilient. And they're really great sources of resiliency there. So that's an example of human resiliency. I would say for process resiliency I think your shift changes, you know, creating a focus on ensuring, you know, just old school paper and pencil, right?

00:18:34:10 - 00:19:01:06
Oren Guttman, M.D.
Making sure that a part of the handoff is any omission errors that have occurred over the shift and getting them reassigned as it relates to safety critical processes. We happen to have a dashboard that does this, but frankly, it's just as easy to just make sure that you're centralizing that information on a shift report that would be overseen, for instance, by a charge nurse, so a lot of success with that.

00:19:01:06 - 00:19:45:10
Oren Guttman, M.D.
And, you know, finally, I would just invite us to thinking about training resiliency. You know, we train task oriented things like bag mask ventilation. And we trace, you know, we train adaptive things like handoffs. What's really important in training classically is we've taught it from an error avoidance perspective. Here's how you do this correctly. What's super important is in all of our training modules, a resiliency approach would invite us to include at every step how that step could fail and include that in the actual training, because by priming people and helping them understand the errors that could lead to failure, and then also teaching them how you rescue the error from the coming failure,

00:19:45:12 - 00:20:09:16
Oren Guttman, M.D.
you make that process more resilient. And so that's called an EMT training model, error management theory training model. And you know, it's really not complicated to do. We've done this with iPhones. Just straight simple videos. We put it even in our S-bars and show examples of, you know, this is how you don't want to send test tubes down, you know, various you know, forms of misapplied labels, for instance.

00:20:09:16 - 00:20:14:17
Oren Guttman, M.D.
Right? These are that we sensitize people to errors so they can rescue them before they send them down incorrectly.

00:20:14:20 - 00:20:40:07
Chris DeRienzo, M.D.
Such practical advice, and I was rounding with a team in a hospital earlier this morning. And this is exactly the conversation we're having there. Step one is trying to optimize their hand off because they knew they were some opportunities to ensure we had some structured communication and got that part right. And then step two is how do you make the handoff process itself resilient to what inevitably happens in health care, which is all of a sudden there's a code in room 12.

00:20:40:07 - 00:21:02:27
Chris DeRienzo, M.D.
And so the handoff is going to get interrupted. How do we make sure that the end outcome at the transference of all the right information to the next person gets there, recognizing that it's not going to be perfect 100% of the time, or if you are leading the field in this space. This is one of the longer podcasts I've gotten to do, and I could go another three hours on this topic.

00:21:03:00 - 00:21:31:24
Chris DeRienzo, M.D.
We are so grateful that you spent the time with us. And to listeners, thank you all for joining us on the podcast today. If your organization is not yet signed up with AHA's Patient Safety Initiative, I highly encourage you to join us. And by becoming a member, you not only gain access to a wealth of resources and a collaborative opportunities, but you also get access to a community of folks just like Dr. Guttman, who are lifting up their innovations.

00:21:31:24 - 00:21:48:25
Chris DeRienzo, M.D.
And this kind of innovation is one that I am confident over the next 25 years, patient safety leadership, we are only going to see become exponentially more important. We thank you all for listening and hope you continue to stay engaged. Stay tuned for more episodes and be well.

00:21:48:27 - 00:21:57:09
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 - 00:00:29:06
Tom Haederle
Experts acknowledge that mental health has a strong correlation with maternal morbidity and mortality. Indigenous women are more likely to experience complications from pregnancy and childbirth, so higher rates of anxiety and depression are of special concern in this community. But it is a problem that care providers can recognize and address.

00:00:29:09 - 00:00:59:18
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Different cultures have different traditions surrounding birth and motherhood. And providers may not be aware of their indigenous patients' cultural and spiritual practices. In this podcast hosted by the AHA's Julia Resnick, director of strategic initiatives, we hear from two experts about the role that culturally safe care can play in mitigating perinatal mental health conditions and other challenges that indigenous women face.

00:00:59:21 - 00:01:15:10
Julia Resnick
So, Dr. Crawford and Dr. Richards, thanks so much for being here. To kick things off, I'd like each of you to introduce yourself to our listeners. Can you tell us a bit about your personal professional background and what communities you and your organization serve? So, Dr. Richards, I'll start with you.

00:01:15:12 - 00:01:38:06
Jennifer Richards
Good morning. (First introduces herself in her native Navajo). So I'm Jennifer Richards, I'm an assistant professor at Johns Hopkins Bloomberg School for Public Health, The Center for Indigenous Health. What I said in my Navajo language is that I'm Salt Clan, which comes through my mother's line.

00:01:38:09 - 00:01:56:22
Jennifer Richards
My father is Oglala Lakota from Pine Ridge, South Dakota, and my maternal grandfather is Taos Pueblo from northern New Mexico. And I have worked at our center for almost 12 years now. And I'm a community based participatory researcher primarily focused on maternal and child health initiatives in the southwest, but primarily the Navajo Nation.

00:01:56:24 - 00:01:58:20
Julia Resnick
Wonderful. And Dr. Crawford?

00:01:58:23 - 00:02:17:28
Jennifer Crawford
I'm Jennifer Crawford, I'm a clinical psychologist and assistant professor in psychiatry and behavioral sciences here at the University of New Mexico School of Medicine and Health Sciences Center. We serve New Mexico here, with our hospital and our School of Medicine and a lot of other training programs and services. And happy to be with you this morning.

00:02:18:00 - 00:02:37:03
Julia Resnick
Happy to have you here and looking forward to getting into it. So let's start by talking about maternal mental health in indigenous communities. So what is the scope and prevalence of perinatal depression and anxiety among indigenous women, and how does that compare to other races and ethnicities? Dr. Richards, I can start with you on that one.

00:02:37:06 - 00:03:03:05
Jennifer Richards
Yeah. Thank you. There are over 575 federally recognized tribal nations in this country, and everyone is very different. So we have approximately 70% of our population is urban and the rest are living in rural areas, including their home tribal nations. So it is hard to kind of put a number on that. I will say, depending on the region, it is 3 to 4 times the rate of non-Hispanic white women for perinatal mood and anxiety disorder.

00:03:03:10 - 00:03:23:27
Jennifer Richards
And we know that that's already a problem throughout, regardless of race and ethnicity, that perinatal depression occurs in approximately 1 in 7 women, while perinatal anxiety ranges from 11 to 21%. And so, depending on where you're at, it could be much higher. In Arizona it's 4 to 7 times higher. So it just depends on what Indian Health Service area you're looking at

00:03:23:27 - 00:03:36:04
Jennifer Richards
and we have various throughout the country and what, urban area you're looking at. But regardless, it is much higher and we'll kind of get into why that is and how our mental health status might differ from other races and ethnicities.

00:03:36:07 - 00:03:38:15
Julia Resnick
Dr. Crawford, anything you want to add?

00:03:38:18 - 00:03:58:24
Jennifer Crawford
I think I'll just add that the data sort of lags the lived experience, I think, in this area. And so especially for indigenous women, the data I think it's safe to say doesn't capture the full extent of the problem. And I think when we look at international data on indigenous maternal mental health, the numbers are even bigger.

00:03:58:24 - 00:04:14:28
Jennifer Crawford
And so we would expect some of that to play out in the U.S., too, as the data catches up. I think there's been some strong efforts to try to improve that process, and there are some challenges to it that are likely to continue. And so I think we just can't always rest on just the data to understand what's going on in communities.

00:04:15:00 - 00:04:28:11
Julia Resnick
So thinking about those individual experiences that you see in your practice every day. What aspects of maternal mental health are you seeing that are unique or specific to Native American communities? Dr. Richards, we can start with you.

00:04:28:14 - 00:04:45:29
Jennifer Richards
The aspects that are very unique to native women are definitely lived experiences, and I agree, I think it's really hard to kind of capture that in the data. What we do know in the data is mortality, unfortunately. So maternal mortality, for example, in my state of Arizona is four times higher for native women than non-Hispanic white women.

00:04:45:29 - 00:05:08:29
Jennifer Richards
So that's one statistic that would kind of reflect. And we know that mental health is strongly correlated with maternal mortality. In terms of how we might differ, experiences of historical trauma is the first thing that we should talk about. There was a time in history when there was forced sterilization of native women, and even though that might be a long time ago to many, for many of our women, that is we're only 1 or 2 generations removed.

00:05:09:01 - 00:05:35:23
Jennifer Richards
And that is still a very traumatic experience for our families. Another one is rurality. A lot of our native women, especially the ones with some of the higher inequities, are living in very rural and remote tribal communities. Sometimes the transportation isn't there, the quality of the roads isn't there. And then, of course, we have some of the same factors as other women with childcare, you know, trouble having childcare to attend prenatal care appointments and postpartum appointments.

00:05:35:25 - 00:05:44:12
Jennifer Richards
We also have cultural barriers, language barriers, and we have a lot of protective factors as well. But off the top of my head, those are the three main areas.

00:05:44:17 - 00:05:47:24
Julia Resnick
Before we move on, can you talk about some of those protective factors?

00:05:47:26 - 00:06:09:03
Jennifer Richards
Yeah, yeah. So in my work I'm a researcher, I'm not a clinical provider. So I try to work upstream, ideally with young women before they become pregnant. So preconception health. But in doing all the work that I do, we also do home visiting. And it's really interesting when best practices or evidence based practice comes out and it's oftentimes things that we've been doing since time immemorial.

00:06:09:05 - 00:06:31:12
Jennifer Richards
For example, for a while there, the Back to Sleep campaign was going very strong. And in our tribal communities, you know, we already did that. We already did separate but proximal. We were doing cradle boards. Many tribal nations were doing the swings, which inherently were protective. We were also very big on breastfeeding. Culturally, we had always promoted breastfeeding.

00:06:31:15 - 00:06:51:27
Jennifer Richards
We also had a social structure net. So, you know, the whole coining of it takes a village. That's something that we've been doing for a very long time. And then even the role of the doula, which is the research that I'm focusing on right now, we've always had that role of a doula or women especially, who've helped other women during labor delivery and really the whole perinatal process.

00:06:51:27 - 00:06:58:06
Jennifer Richards
So those are just a few examples of some inherently protective practices that we've had embedded within our culture.

00:06:58:08 - 00:07:15:10
Julia Resnick
That's wonderful. And I want to pick up - I think there's a link there between the generational trauma and the cultural safety and how women engage with the health care system. So can you talk a little bit about what culturally safe care means, what it looks like when it's missing, and then what it looks like when it's present?

00:07:15:12 - 00:07:44:26
Jennifer Richards
Yeah. So I really like that the term cultural safety is really picking up lately. It's something that had really originated in - I believe it was, Australia, New Zealand and, you know, some of the among the nursing community in those areas. And we're starting to see it more, which is great. It differs from cultural competency. And I've I must say, I've never really cared for the term cultural competency, because as someone who's not from that community, you're never going to be, you know, checking a checklist that we're thereby competent now that we took this class.

00:07:44:29 - 00:08:18:14
Jennifer Richards
But cultural safety is a feasible goal to have. And what that means is it shifts the provider/patient experience to whether or not the patient determines if that clinical encounter is safe. And so that means it acknowledges the power imbalance that's there between the provider and the patient. It rejects the notion that health providers should focus on learning cultural customs, but rather seeking to just achieve better care by being aware of, you know, implicit bias, power imbalances, historical trauma, colonization, what all of that means on that environment between the patient and the provider.

00:08:18:14 - 00:08:25:03
Jennifer Richards
So it's really a shift in looking at the quality of care focusing on the patient's experience.

00:08:25:06 - 00:08:36:03
Julia Resnick
So for people who are less familiar with that concept, can you talk about, you know, what care would look like if it wasn't culturally safe versus like what culturally safe care looks and feels like?

00:08:36:06 - 00:08:57:03
Jennifer Richards
Yeah, well, one example is I come from the Navajo Nation and we're a tribe that has a lot of natural laws throughout the perinatal period. Some people would say taboos. I call them natural laws. One example is women don't tie knots and we have a reason for that. You know, there's a really big emphasis on thinking positively during that pregnancy period.

00:08:57:06 - 00:09:20:16
Jennifer Richards
The husband or the partner, he has a lot of things that he has to do, a lot of natural laws. There's not supposed to be any hunting. There's not supposed to be any talk of death. In fact, as a people, we're really careful in how we talk about that. So for a woman who's in pregnancy and she's Navajo or Dine, and she is going to a provider who might not know that, and they immediately start talking about, let's say, stillbirth or miscarriage.

00:09:20:19 - 00:09:40:14
Jennifer Richards
That can be really upsetting for a Navajo woman. And that's something that may be no fault of the provider. Maybe they didn't receive the training. They don't know that it's not polite or it's not proper. It's not traditionally appropriate to talk about that right off the bat. And there are ways to go around it. And I'd like to think that if they're working in a tribal clinic, they're going to receive that information.

00:09:40:14 - 00:10:09:22
Jennifer Richards
But that's just an example. Versus a culturally safe, environment is where the provider understands these natural laws. They don't have to understand why, they don't have to believe in them, but they have to be aware of them, and how that can be really upsetting for the patient. Appointment like that would be, you know, the women going in and the provider really taking the time to listen to them and to understand, you know, their traditional background, their beliefs and really working around those kind of boundaries, those cultural boundaries for the woman. In our tribal communities

00:10:09:22 - 00:10:27:19
Jennifer Richards
a lot of times we do view the doctors and the nurses as healers, and it's a really revered role. But I also think that when you come on to a tribal community, you're not from there, it's really important to take the role of a student and listen, and take the opportunity to really understand, you know, what are the concerns that they have?

00:10:27:19 - 00:10:48:03
Jennifer Richards
What is the background? What was forced sterilization? Why did it happen? You know, what was the boarding school and forced relocation? Why is this hesitancy there? Because on paper we just see, you know, x percent of Native women have a lack of prenatal care or lack of adherence to prenatal care. I think truly understanding why that is, is really important.

00:10:48:06 - 00:11:08:05
Jennifer Richards
I think also providers who work with large tribal populations can really leverage our community health workforce. We have community health representatives, we have doulas, we have home visitors, we have public health nurses. They're an amazing workforce that speak the language. They're from the community. They understand that, you know, you're not from here and it's okay to not know.

00:11:08:05 - 00:11:21:26
Jennifer Richards
And they're a huge source of information. So I would say for providers working in tribal communities or with a lot of women from tribal communities, to really take the time to, to learn and understand, it's a huge difference. It'll really help in creating a culturally safe environment.

00:11:21:28 - 00:12:03:26
Jennifer Crawford
Could I just chime in a little bit with that? I think it's such an important point to really drive home those sort of holding both things, the knowing and not knowing. So you should be informed and you should learn and you should do some of that work yourself and in your teams and in your systems and institutions, while also being very open and curious and making sure that when you're thinking about how you individually provide care and how care feels to be provided in your immediate clinic or in your hospital, how do you make sure that there's space for respecting indigenous patients agency, and respecting that the way that they make choices may not

00:12:03:26 - 00:12:25:00
Jennifer Crawford
fit the way you like to make choices in that system. Not assuming that you know so much that you can handle any given thing that comes your way, but really being open to asking and being curious and respectful for not just agency, but the power of someone's own way of looking at the world and their truth.

00:12:25:02 - 00:12:41:12
Julia Resnick
Dr. Crawford, I want to bring this up to the hospital perspective, because I know University of New Mexico works closely with their tribal populations, both in the urban and rural setting. So can you talk about what you're doing around perinatal mental health to provide more personalized, culturally safe care?

00:12:41:14 - 00:13:14:13
Jennifer Crawford
One thing I'll add first is that when we think about the maternal mortality and morbidity rates that Dr. Richards mentioned, the I just want to mention that one of the top contributors to pregnancy related death, especially among indigenous women, is mental health and substance use disorder. And so when we talk about what can hospitals do to help with those particular challenges, I think it's really important to remain oriented to cultural safety in terms of what are the strengths of the communities you serve already have, right?

00:13:14:13 - 00:13:39:21
Jennifer Crawford
Like not assuming that everybody needs a hospital or system to jump in with the correct or, or perfect ideas, but really that it's about, a commitment to long term relationship building and listening over time that helps build those programs. And so the University of New Mexico, we're really proud to have our Native American Health Service, which is a longstanding office here.

00:13:39:21 - 00:14:08:14
Jennifer Crawford
You know, the UNM hospital actually started out as an Indian health hospital. And when the School of Medicine identified that as its teaching hospital, there was a commitment to maintaining access to indigenous patients, both urban and rural, to be able to receive care there. And so that office does a lot of work in coordinating care to outpatient services and inpatient services at UNM and our, you know, outlying clinics and outreach clinics.

00:14:08:16 - 00:14:42:02
Jennifer Crawford
But also, more importantly, even than just the care coordination piece, which could be quite complicated. But I would say even more importantly, has a long term commitment to this sort of community liaison. New Mexico's has 23 sovereign nations within the state lines and the Native American Health Service goes out and just listens and asks, how can we help? And that has been really formative, I think, across our system over time in identifying processes, programs, initiatives, ways of making sure that we're meeting the needs of those communities as identified by those communities.

00:14:42:04 - 00:15:01:18
Jennifer Crawford
And certainly there's a lot of expertise and skill and knowledge that's held at the university. And also, I will say, University of New Mexico, we're...I think we're very lucky that a lot of that skill and knowledge actually comes from our own communities in New Mexico, people that stay here and serve their communities that they're from.

00:15:01:21 - 00:15:22:29
Jennifer Crawford
But that's not all of the knowledge, right? And so really going out into communities to ask and listen I think is really important. And something that I would encourage other hospital systems to consider: how might they build that commitment to a long term relationship that really is built around cultural safety, both knowing and not knowing and listening?

00:15:23:02 - 00:15:32:18
Julia Resnick
Absolutely. So I'm just going to wrap this up with a lightning round for each of you. If there's one key thing you want our listeners to take away, what would it be? Dr. Richards.

00:15:32:21 - 00:15:52:08
Jennifer Richards
I would say taking on the role of someone who's learning, a student, a lifelong learner, I think is critical. Also building trust. And people don't really talk about it. But I will say with a lot of the women that we work with when they trust in their provider, that's all the difference in the world. And that means different things for our tribal communities.

00:15:52:10 - 00:16:08:24
Jennifer Richards
It means showing up, you know to the tribal affairs, to the feast, to the you know community events, the game, showing that you're there, you're part of the community. I think that's really critical. But I think just listening to the stories, understanding where they're coming from, I think that will make a huge difference.

00:16:08:27 - 00:16:38:06
Jennifer Crawford
Yeah, I think that's such a great take home. And I think from, sort of a systems hospital perspective, I would really want people to consider the strengths and expertise that they may hold within their system, but really think creatively about how to find out how that body of expertise and service could be helpful to the communities that you serve, and be it sort of a willing helper.

00:16:38:08 - 00:16:56:00
Jennifer Crawford
But always listening first at the same time, right? So that knowing and not knowing at the same time. You don't have to be perfect at cultural safety. You just have to always be working on it. And I think being creative and considering your strengths, but also the strengths of the communities we serve is really important.

00:16:56:03 - 00:17:11:13
Julia Resnick
Yeah, I think listening and learning were really a key theme to this conversation. So Dr. Richards, Dr. Crawford, thank you so much for sharing your expertise with us. Thank you for the work that you do every day to support women in your communities. Really appreciate you being here with us.

00:17:11:15 - 00:17:19:26
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 - 00:00:36:09
Tom Haederle
The Age-Friendly health systems movement began in the United States in response to our growing aging population and the need to improve health care for older adults. The basic idea to care approach is to ask older adults a simple but critically important question: what matters to you? Participation in the Age-Friendly model has grown dramatically, with the U.S. Department of Veterans Affairs aiming to become the biggest and most influential member of all.

00:00:36:11 - 00:01:05:27
Tom Haederle
Welcome to Advancing Health, the podcast of the American Hospital Association. I'm Tom Haederle with AHA communications. Nine million military veterans receive their health care through the Veterans Health Administration. Nearly half of them are 65 or older. In this podcast hosted by the AHA's Raahat Ansari, senior program manager for Population Health with the AHA Center for Health Innovation, we hear how the VA is weaving the four foundational Age-Friendly principles into its care for veterans nationwide.

00:01:06:00 - 00:01:14:05
Tom Haederle
Our guest is Kimberly Wozneak, national lead for Age-Friendly Health Systems with the U.S. Department of Veterans Affairs. And now, here's Raahat.

00:01:14:07 - 00:01:24:12
Raahat Ansari
Thank you so much, Kim, for joining us and taking time out of your day to be here with us today. Let's just jump right in. How did your Age-Friendly journey begin within the VA?

00:01:24:14 - 00:01:54:16
Kimberly Wozneak
Well, thank you, Raahat, for having me join today's podcast. My Age-Friendly journey began in 2020. I was a Presidential Management Fellow with the Department of Veterans Affairs (VA), and I joined the Office of Geriatrics and Extended Care (GEC) in January of 2020. My very first week with the office included a strategic planning meeting where we set up what we called the Geriatrics and Extended Care Transformation Plan.

00:01:54:18 - 00:02:25:04
Kimberly Wozneak
This is a plan to improve how we provide care to older veterans, really looking at expanding our services so that we can honor veterans preferences to age in place in their homes and in their communities. And really, what we're talking about is what matters most to many older adults - staying independent. And so we saw this really fantastic synergy between our goals nationally and the Age-Friendly Health Systems movement.

00:02:25:06 - 00:02:38:08
Kimberly Wozneak
So following that strategic planning meeting, I met with the Institute for Health Care Improvement (IHI) and we set the aim for VA to become the largest integrated, Age-Friendly Health System in the US.

00:02:38:15 - 00:02:40:04
Raahat Ansari
That is no small feat.

00:02:40:06 - 00:02:58:19
Kimberly Wozneak
Yeah, I know, we've been doing this work now for over four and a half years, and the movement is so critical now for VA more than ever, because we have 9 million enrolled veterans that receive their health care through VA, and nearly half of those veterans are age 65 and older.

00:02:58:22 - 00:03:06:02
Raahat Ansari
That is a huge number and such an opportunity. So that's amazing that you're trying to, you know, incorporate that population into your strategy.

00:03:06:09 - 00:03:27:20
Kimberly Wozneak
Yeah. And you know, by 2035, veterans age 85 and older are expected to increase by 73%. Since 2020, we now have over 400 VA teams that have created a plan to implement the 4Ms. And they've earned recognition as an Age-Friendly Health Systems participant from the Institute for Healthcare Improvement.

00:03:27:22 - 00:03:47:05
Raahat Ansari
That is amazing progress in such a small amount of time, and I think that just is a huge testament to the work that is being done and to the drive that folks have when they're when they're being brought this opportunity. That's amazing. And one thing that I loved hearing you talk about was aging in place and aging at home

00:03:47:07 - 00:04:06:14
Raahat Ansari
and how that up almost always is a huge part of what matters to each older adult. So I love that you're highlighting that and how that typically is something that older adults are hoping is a part of their goal and their plan, but also really important for us to ask that what matters questions so we can understand is this actually your goal as well?

00:04:06:14 - 00:04:20:20
Raahat Ansari
And do you have additional things that you wanted to add to what matters most to you? Can you talk a little bit about what strategies, some of your top strategies that you implemented to see the success in spreading this to all of the VA sites in VA?

00:04:20:21 - 00:04:48:09
Kimberly Wozneak
VA is really focused on the people side of change, where anyone can become an Age-Friendly champion. When we talk about Age-Friendly care, we are talking about the 4Ms that are driven by the what matters M's. And so the 4M's are what matters, medication, mentation and mobility. And so when we're joining or, you know, a national movement, an initiative or doing anything that feels new, it can be kind of overwhelming.

00:04:48:11 - 00:05:17:06
Kimberly Wozneak
And so we encourage teams to start with small tests of change, particularly around about what matters M. And so if that just means asking one "what matters"? question to one veteran today, and that could be as simple as "what matters most to you?" And from there learning, scaling up and spreading so that we're incorporating these what matters questions into our daily practice to reach more and more veterans over time.

00:05:17:09 - 00:05:25:25
Kimberly Wozneak
I think it's also really helped that we have very active and visible leaders in the movement, communicating at all levels.

00:05:25:28 - 00:05:39:08
Raahat Ansari
That's so important. And one thing that we do hear from our participants quite regularly is it is so key and so impactful to have our leaders engaged in this work. So I love that you're highlighting that for our listeners.

00:05:39:10 - 00:06:01:15
Kimberly Wozneak
Yeah. These messages about the importance of the Age-Friendly Health Systems movement, helping us provide the soonest and best care possible to veterans have come from Dr. Elena Hall, our undersecretary for health, who gave opening remarks at our 2023 Age-Friendly summit, as well as a virtual event that we hosted over the summer that we call the state of Age-Friendly Health Systems in VA.

00:06:01:16 - 00:06:36:22
Kimberly Wozneak
This is really a forum of celebration to celebrate our accomplishments over the last year. So having those messages come from leadership as well as folks who are champions themselves. We have an incredible coalition of champions, people who I can turn to at any time to join me on a national call to share their Age-Friendly story. And I mention those national calls because I think frequent communication about what the purpose of this movement is, how it aligns with our goals for VA is really important.

00:06:36:25 - 00:06:53:08
Kimberly Wozneak
Over the last year, our team presented on over 50 national calls, conferences, presentations to over 9,500 attendees. So we are getting the message about Age-Friendly Health Systems out to anyone who will listen to us.

00:06:53:11 - 00:07:16:03
Raahat Ansari
That is fantastic impact. And one thing that I really liked hearing was about the small test of change, and something that we also teach in our action communities - the seven month long Virtual Learning collaborative. That is one of the ways that most teams engage in this work of implementation. So this is one thing that we teach is you don't have to do and implement all 4M's tomorrow.

00:07:16:06 - 00:07:41:02
Raahat Ansari
Start small, start doing one thing every day. Start doing consistently and you're driving that home by sharing. You know, you can ask one what matters question to one veteran one day, every day. And that will be get enough to get you started on your journey. So love, love hearing that. And the other thing that I wanted to just share was how impactful it is and how you mentioned there are so many champions.

00:07:41:04 - 00:08:04:03
Raahat Ansari
Anybody can have a connection to this work, and I love that you have identified so many champions and so much support that you've got. So moving on. I know you talked a lot about the amazing spread that you've had, and what I want to take a moment to speak about is how you handled any resistance to this change as you implemented it and what you might suggest as ways to overcome those challenges.

00:08:04:06 - 00:08:32:13
Kimberly Wozneak
Yeah, I sometimes hear a lack of time to just start something new and also competing priorities, right? Our clinicians are asked to do a lot. And so what we try to do is reinforce that the 4M's aren't adding work. They're actually streamlining and improving our processes and building on the fantastic evidence-based practices that we already have in place in VA.

00:08:32:14 - 00:09:16:03
Kimberly Wozneak
Right. And we're not adding staff to teams. We're leveraging existing resources and there's no cost to participate in the movement, right? Recognition from the Institute for Health Care Improvement is free. So we should celebrate the great work that we're providing and doing in VA. I mentioned, you know, communicating often. So storytelling has been incredibly impactful for getting those maybe slightly resistant teams on board by hearing from someone else working in a similar care area about their journey and how Age-Friendly care and the 4M's have been valuable to veterans, their families, and caregivers.

00:09:16:06 - 00:09:37:16
Raahat Ansari
That is really helpful and great points to share. And the one thing actually that really stuck with me was about how this all is free and want to highlight that and share that. Definitely, this is something that folks should be taking advantage of. And one thing hearing Dr. Terry Fullmer speak firsthand about this, that really stuck with me

00:09:37:16 - 00:09:57:12
Raahat Ansari
as I as I share about this opportunity, she was laughing. When folks say that this is free? Because the Johnny A. Hartford Foundation is underwriting all of this. And so, you know, it does take the IHI and your team and the AHA team time and money and staff, time to have all this programing up and running.

00:09:57:14 - 00:10:15:05
Raahat Ansari
And it is it is a very generous of the John A. Hartford Foundation to be providing us those funds to see this work forward. So that is money that we don't want to leave on the table, and we don't want any organizations to leave on the table, which is all the more reason to participate. And, you know, leverage that support that is being given.

00:10:15:08 - 00:10:23:05
Raahat Ansari
So, moving on. Do you want to talk a little bit about how have you been able to maintain that level of engagement?

00:10:23:07 - 00:11:02:19
Kimberly Wozneak
We also talk in VA about being on the journey to become a high reliability organization. And we know that high reliability organizations, HRO's, experience fewer events of harm despite operating in highly complex environments. And care for older adults is often complex. Something that I've learned from the Institute for Health Care Improvement and participating in past action communities with the American Hospital Association is taking this all teach, all learn approach that is built on a just culture. And in a just culture

00:11:02:21 - 00:11:27:11
Kimberly Wozneak
people are empowered to share safety stories so that we can learn from them. So the example that I want to give is actually from, you know, our VA action community, as we are now getting ready to launch our third national VAH friendly action communities. And we have those monthly webinars that take us into a deep dive where we learn about the 4M's followed by monthly coaching calls.

00:11:27:13 - 00:11:53:06
Kimberly Wozneak
And these are a forum for teams to bring those safety stories, share them with other teams, share challenges, barriers, but also successes. And ask these questions freely because we all have the opportunity to learn from one another and continuously improve as we improve how we document 4M's care in the electronic health record, how we leverage data through national dashboards.

00:11:53:08 - 00:11:56:28
Kimberly Wozneak
It's all for this continuous process improvement.

00:11:57:00 - 00:12:05:04
Raahat Ansari
And that is so amazing to hear. I love how you're collecting all of that data and those stories. I wonder if you have a story that you'd like to share for our listeners today.

00:12:05:06 - 00:12:37:10
Kimberly Wozneak
Well, I've heard this story from several teams now, but in particular our VA community living centers. These are our VA nursing homes, and we have great interprofessional teams in VA. And we found that the 4M's provide a really nice framework for those interprofessional team meetings and huddles, so that when we have different members of the team incorporating what matters questions as part of their practice, they can bring that information back to the team.

00:12:37:14 - 00:13:02:19
Kimberly Wozneak
And we've actually learned that depending who ask the what matters question, the response from the veteran might be a little bit different depending on if it's the, social worker or their physical therapist who's asking. And so, a story I'll share from one team is that when they joined the movement, they realized that they thought they were doing a really good job asking what matters.

00:13:02:19 - 00:13:30:08
Kimberly Wozneak
And what they found was that they were often documenting what they thought mattered to the veteran, and they saw this incredible shift, so that when they joined the movement, they actually started documenting what matters in as close to the veterans own words as possible. Bringing that information back to the team and having all team members contribute to the care plan to make it really focused and aligned with what matters to the veteran.

00:13:30:10 - 00:13:53:13
Raahat Ansari
That is incredibly interesting to hear, and I have heard one other time that what matters question and that answer changes based on who is asking the question. That is an amazing tidbit to understand and learn about, is that it matters who asks the question and where it's coming from. And with that, we're just about to wrap up, so I'll just pause here and ask if you have any last thoughts that you want to share with our listeners today.

00:13:53:15 - 00:14:19:17
Kimberly Wozneak
Really, anyone can be an Age-Friendly champion and do this incredible work in their hospital or health system. I highly encourage you to consider enrolling in a future action community. There is one coming up this spring with the Institute for Health Care Improvement. I love the structure that action communities provide and I love hearing from all the different hospitals and health systems that are doing this work.

00:14:19:19 - 00:14:29:02
Kimberly Wozneak
The Institute for Health Care Improvement has now recognized more than 4,500 participants in the movement, which is really incredible. So get started on your journey today.

00:14:29:07 - 00:14:33:22
Raahat Ansari
That's fantastic. Thank you so much for joining us today, Kim. It was a pleasure.

00:14:33:25 - 00:14:36:01
Kimberly Wozneak
Thank you for having me.

00:14:36:03 - 00:14:44:13
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.