DiscoverThe Healthcare Leadership Experience
The Healthcare Leadership Experience
Author: Lisa T. MillerSubscribed: 9Played: 22
© The Healthcare Leadership Experience Radio Show 2021
Healthcare management is ever-changing. Join Lisa Miller and Jim Cagliostro where you will hear from innovators and leaders within healthcare and from other industries. Lisa and Jim will bring you topics on the business and clinical sides of healthcare on strategy, finance, managed care contracting, nurse engagement, physician engagement, new patient care models, patient satisfaction, innovation, leadership, communication, marketing, plus much more.
This show will challenge you to think differently through proven strategies and innovative approaches that will help you to elevate your healthcare management and healthcare leadership performance for the ultimate goal of providing exceptional patient care.
Enjoy diverse and thought-provoking conversations. Lisa and Jim will present best practices, new strategies, and ideas for you to think about and to implement in your career and your healthcare organization. To contact Lisa Miller, please email: email@example.com and on linkedin at https://www.linkedin.com/in/lisamiller/ .
To contact Jim Cagliastro, please email: firstname.lastname@example.org and on linkedin at https://www.linkedin.com/in/jimcagliostro/
This show is sponsored by VIE Healthcare Consulting; https://viehealthcare.com
This show will challenge you to think differently through proven strategies and innovative approaches that will help you to elevate your healthcare management and healthcare leadership performance for the ultimate goal of providing exceptional patient care.
Enjoy diverse and thought-provoking conversations. Lisa and Jim will present best practices, new strategies, and ideas for you to think about and to implement in your career and your healthcare organization. To contact Lisa Miller, please email: email@example.com and on linkedin at https://www.linkedin.com/in/lisamiller/ .
To contact Jim Cagliastro, please email: firstname.lastname@example.org and on linkedin at https://www.linkedin.com/in/jimcagliostro/
This show is sponsored by VIE Healthcare Consulting; https://viehealthcare.com
Healthcare’s Leadership Gap with Ronnie Kinsey | E. 72
As healthcare continues to move through a challenging transition, Ronnie Kinsey explains to Jim Cagliostro how he works with healthcare leaders to surpass their greatest goals and resolve leadership gaps. Episode Introduction Ronnie highlights the importance of exposing clinicians to the business side of healthcare, how ‘’one to one to one up’’ leadership can lead to multiple gaps of ‘’abyss potential’’, and why people must prioritize behavior and check things at the door. He also explains why all leaders should consider an outside resource for support, why coaching is not therapy, and how attitude is key to successfully nurturing leaders. Show Topics Healthcare has to incorporate the business side The challenge of one to one to one up leadership Promotion can result in leadership gaps Behavioral procedures take priority in healthcare The impact of culture in filling gaps Developing leaders comes down to personality and attitude Frontline employees can resolve hospital painpoints 04:19 Healthcare has to incorporate the business side Ronnie said that clinicians must be prepared for the business side of healthcare at an earlier stage. ‘’There are so many people who got into healthcare with the idea of delivering care. They wanted care. But then you and I have had conversations. You're doing the business side of healthcare now as well. There is the whole business side of healthcare, which cannot be ignored. I think that clinicians schools could probably potentially do a better job of preparing clinicians for the business side of healthcare. Because …..if the bills aren't paid and if there's not access to plan for growing for the future, we've got a problem. So that's got to be there, but I think that it has to be really ingrained into the clinician earlier on. That would be one of my big asks for the new educational shift is that clinicians just be much more attuned to the business side of healthcare. Definitely don't lose the caring side, but be aware of the business side.’’ 07:30 The challenge of one to one to one up leadership Ronnie explained gaps happen when people leave as most hospitals only have one leader on the frontlines. ‘’You on average have one leader per category of management. So the front lines, whatever, until you get up to the C-suite and it's divided other ways. So say you have one leader that you report to, then that's at one level and that leader reports up to another leader at another level. So it's generally a one to one to one up. Well, what if that chain breaks and one of those ones goes out? There's a break. There's no extra time to fill in for that missing person per se. And again, remember we just said it takes about four months to replace them. Well, how to bring the next person up to speed, how to even try to get them close to knowing the personalities that play on that particular whatever we want to call it, the ward, the unit, the floor, the department, service line, you can name that. So look already where the gap comes in. So then from the front line, some people are wondering, "Well, who do I go to?" Okay. We can give them names, we can give them a title and that's fine. That person doesn't have extra time for you. They already have their financial responsibilities because they're in leadership…. So now are they short of resource? Where do they go? There tends to not be just so many extra hands sitting around waiting to help out because systems are really under constraints overall, especially after COVID, right? We're under a whole new redefinition of the healthcare system. It's been coming, I'll say it's for sure been coming since EHR. Well, it became no exception after COVID. … I can make that example at every level, all the way up.’’ 10:12 Promotion can lead to healthcare leadership gaps Ronnie explained why promotion can result in a cycle of resentment and resistance if clinicians aren’t prepared. ‘’And again, leaders aren't necessarily born, but leaders can be developed. So then their lies the gap. There lies the gap. So often it happens in healthcare, somebody did so well in the clinical side, they're going to get promoted. Well, guess what? They like the idea, sounds good. They want to grow. They'd like to do something new and at another level. But boom, what if they're not prepared for the business side? What if now they're not prepared to hold somebody accountable. A, they didn't show up on time. B, didn't say the right thing. C, didn't have the right thing and you know where that goes? Then there's the accountability and the disciplining that takes place. Well, then you have resentment. Then you have resistance. Are you following me on the gap yet? Do you see where this turns into a huge cycle? And then at the same time, you need to be delivering care and healthcare efficiently, appropriately, timely and properly all the rights. Right person, right time, right thing, right place, right outcome, right? Applying all of those things, but your time factor doesn't increase. People don't have extra time to work on these things.’’ 14:28 Behavioral procedures take priority in healthcare Ronnie said people have to check certain things at the door, set expectations and hold others accountable in the working environment. ‘’I'm going to share with you part of why I'm a coach now. I hired my first executive coach when I was working with a large pharmaceutical company to give a presentation overseas to our sales team and it had to do with behavior. And the executive coach says, "You can have your thoughts. You're entitled to your thoughts. You should have your thoughts, you're a human being. On the job, in this role, these are the behaviors that we'd like to pay you to perform." Boom. Cleared the sky like I'd never seen before. When I heard him say it the way he said it, he said, "You're entitled to your thoughts. You should have your thoughts. You're very welcome to have your thoughts, but on the job, please follow these behavioral procedures that we're asking you to follow."… The new phraseology seems to be like, "Bring your whole self to work." Well, you are anyway. And we are human, we have needs, we have issues. There's a time and there's a place for certain things you may or may not agree. And as adults, as professionals, as mature people, we do learn to check certain things at the door while we perform other things. It's just kind of understood. You'll be able to do that if you are a well trained, good intending, well hired professional. ….We have to set expectations and we have to hold people accountable. We know this is not ideal. We know that it'd be easier to be at the beach with ice cream right now or something like that. But we're now at work and we're doing this and we plan to do this throughout the next eight hours or the next 10 hours, 12 hours for the next three months, for the next three years, whatever it is, are you the right one to carry this behavior out with us during this time?’’ 20:53 The impact of culture in filling gaps Ronnie explained why bringing in people short-term can create more gaps down the line. ‘’It's going to take six months to a year before trust develops really, really developed. Because every place of work has the stuff that people do not want to publish and talk about immediately. Every place, anytime you put two people together you have a culture. And we know that culture is important in every place and cultures are unique. Not to say that one is so one off like none in every other place, but every place will never have exactly the same personalities, exactly the same dynamic, exactly the same location, et cetera. So if you're bringing someone, say, who's temporary. Okay, you're here for three months. They have already checked your due date at the door. Okay, welcome. You're here in June, so see you later in September. You're three months. So they've kind of like got that circle around you we're just going to be nice for three months, sometimes. People can work well together. But also for the people who are staying, that's not their long-term solution. There lies another gap. Who's going to be here in October for them? Whether it's an option that that person could get hired on long-term or not, you're still in test phase. People may be withholding what are the real issues? Because what's going to get done about them anyway? And then some people worry, did I say too much? Did I reveal too much about what's really going on? Is it going to look bad on me? Because remember, it's easy to shoot the messenger.’’ 25:20 Developing leaders comes down to personality and attitude Ronnie said that the right attitude is essential in leadership, but not everyone can be coached. ‘’So if we took two terms to work with, let's talk about, okay, there's personality. That's one thing. And then there's attitude. I want to go with attitude. I want to put weight on attitude. The right attitude can take you very far. So then there's kind of the innate attitude. Some people just have that bright shining sun in the sky attitude and they can weather the storm, what have you. Some just truly have that. Some can be shown to look at the sun rather than the mud. Okay. I like that. I heard a quote recently. "Two prisoners looked out from the prison bars, one saw this mud, the other saw the stars." What's your takeaway from that? Exactly. Yeah. You get to choose what you see. One saw a dirty, dismal, hopeless situation and the other one saw hope and aspiration. So attitude can be nurtured and developed, but it helped a whole bunch. If you already bring it, if you already bring it, the nurture curve is shorter. And by the way, as coaching goes, not everyone can be coached. Not everyone is willing to be coached. It's a possibility. It's not a guarantee.’’ 32:18 Frontline employees can resolve hospital painpoints Ronnie said that frontline employees can offer viable solutions for the C-suite. ‘’How can you be the sol
Healthcare marketing has seen a shift from ‘’patient’’ to ‘’consumer’’ in recent years. Doug Pohl explains to Jim Cagliostro how a focus on heart and emotions can help to reconnect hospitals with their patients. Episode Introduction Doug explains why hospitals need to prioritize ‘’humanity’’ over the bottom line, how to become a two-way mirror to build patient relationships, and why Business 101 is all about listening. He also shares how his experience as a singer/songwriter helped him to understand the power of storytelling, and why true leadership is about helping people climb the ladder. Show Topics Hospitals need to focus on humanity in marketing Losing the community connection Healthcare marketing is a two-way mirror Business 101: It’s about listening Tapping into the power of storytelling Leadership is about helping people climb the ladder 06:54 Hospitals need to focus on humanity in marketing Doug explained why the shift to ‘’consumers’’ from ‘’patients’’ creates a deeper problem. ‘’I feel like a lot of them are doing a decent job, in that there's been this shift to people, you can't necessarily even call them patients yet, but to view them as consumers. So, they market to us as consumers. And I get that, and I think it's effective in some ways, but my personal view is if we're treating people as healthcare consumers, there's a deeper problem that we're not addressing. And I think to ignore that is a long-term mistake. So, I think it's really important that we focus on people's humanity and do it in some powerful ways. You and I talked previously, there's some commercials out there that tap into the emotions of what people are feeling when they go into a hospital, whether as a patient or a loved one or whatever the situation is, a clinician, whoever. Everyone has these strong emotions that come with them into a healthcare facility. And understanding those, having genuine empathy, feels like a weak word these days because we use it so often. But genuine concern for those feelings and for those people and wanting to help in real ways, even if it means less efficient business or a lower bottom line, but focusing on the heart and the emotions, I think is really the best path forward for marketing. And in my opinion, for operations in general.’’ 09:13 Losing the community connection Doug said the acquisition of a smaller hospital by a larger system pushes patients aside. ‘’ I think it sort of starts in-house with a disconnect with the clinicians and administrators and everybody who works in that system at that regional hospital, where they feel less of a connection with their organization, they feel like things are being imposed on them by the mothership, and all of a sudden everything's changed. They feel a disconnect. They feel pushed aside. They feel like they're not as important as they should be, and perhaps as they used to be. And I think there's a trickle-down that comes from that. They pass on those feelings to the community, whether in the hospital or outside in their personal lives. It does change how people feel subconsciously, at least. I live in a small community, and we do have a small regional hospital that's connected to a larger one, but we're friends with the nurses and the doctors. We see them out in town and at the gym, and we talk to them, we hear their struggles, and we hear how tough it is for them. And so, these feelings are being shared in the community, and it does impact you as a patient that when it's your turn, you go and you know what people are going through, and there's this sort of inherent disdain for the organization as a whole because of it.’’ 12:36 Healthcare marketing is a two-way mirror Doug explained why every brand needs to reflect the audience back to themselves. ‘’In marketing, our job as a brand, any brand is to be a mirror, but it's sort of a two-way mirror. So, we want to reflect the audience back to themselves. The things that bother them, their challenges, their pain points, whatever you want to call it, we acknowledge those. We say, "Here's what’s going on with you, we understand your situation." So, we reflect that, and we can do that not just by saying it, but we have to say it in the right way. So, we also reflect their exact words. That's why getting those videos, those voice recordings are important. Hear that, get that voice of customer data, in this case patients or whoever it is, but get their actual words and use it. As an organization, you might call a certain program, you might have an in-house name for it. Let's just use our imaginations here. But when you start marketing, people don't understand that. And maybe you're doing your research with your audience and you realize they're actually using a different name for it. Well, name, use what people say and give it back to them. That helps them feel more connection, that sort of subconscious connection that we can't measure, but it makes a difference. It really does. Once you have that and you genuinely understand, then you're able to present your solution or offer it in a way that feels natural. It doesn't feel salesy, it just feels like an extension of that connection.’’ 16:31 Business 101: It’s about listening Doug questioned exactly how much the needs of the patient are being heard today. ‘’How much listening is going on? Are organizations not just listening, but actually hearing and absorbing and really taking patient's needs to heart? Yes, there has to be a balance with operations and with the financial concerns and all of that. I get it. But at the end of the day, none of that matters if patients aren't happy. And I'm going to go back to the beginning here. There's this trend of calling patients consumers. If your consumers aren't happy, you need to change something. That's the whole point of the business. You have to have people happy to get them to spend money, otherwise they're going to go somewhere else, right? Business 101. So, I think the most effective way is to look at how we're listening. What are we doing? Where can we improve to listen better? And once we listen, then what are we doing with that information? Are we genuinely being that mirror? Are we giving people what they want? Or are we just putting on a light patina onto what we wanted to do anyways?’’ 18:15 Tapping into the power of storytelling Doug said overlooking the human experience leaves out 80% of the marketing story. ‘’This is something I've been thinking a lot about lately. Stories are so powerful. It's incredible. And back in my songwriting days, it was always about the story. I'd make a point to go talk with whoever I could, wherever I was at. I wanted to go talk with strangers and just get them talking, just hear their stories. And it's amazing, people almost always want to share. I would write songs based on their experiences, based on what they told me. And those are the songs people love the best. They were real. They were actual stories that had a beginning, a climax and an end. And it was similar to their own lived experiences. So, again, it was taking people's stories, hearing their own words, and feeding it back to the audience. And so, it's the same thing that we can do with our marketing. We tell those stories. It's not just a disease. It's not just a treatment or a condition or whatever. It's a real person, who has parents and children and jobs and concerns and bills and whatever. That's all part of it. And to neglect all those different aspects of who they are, of what makes them human, that's to leave out 80% of the story or more. That's the meat that's really going to help connect with people, because everybody has those things. Not everyone has... pick a condition. Not everyone has diabetes, but everybody has bills and parents and jobs or whatever. So, that's how we connect, is by telling the whole story. It has to be a 360 view. And when we do that, I think it really opens up some amazing possibilities for what we can do, not only to create successful marketing, but to actually help and do what we're trying to do with healthcare.’’ 27:28 Leadership is about helping people climb the ladder Doug said leading by example and turning to help others means everybody wins. ‘’My first management experience came from my job as a lifeguard in college in the summers. And my first year, I started off with a great manager who led by example. He never asked us to do anything that he wouldn't do himself, and he made sure we all saw him do it first. And then when it was my turn to be manager, I didn't do that. I was lazy, and I would just assume people knew that I could do things. And I learned very quickly that that was a big mistake. Now, what I try to show my team is, not only can I do it, but I can probably do it better than you because I have done it. I did it for years, and now I want to help you get to my level. So, then we can all grow, we can all benefit. Everybody wins. So, I think my leadership advice that I try to remind myself all the time is, lead by example and then turn around and help the next person up the ladder.’’ Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Doug Pohl on LinkedIn Check out VIE Healthcare and SpendMend You’ll also hear: ‘’Everybody has a different story.’’ From professional country music singer/singwriter to healthcare content marketer. Listen to Doug’s unique journey. Following your instincts and avoiding ‘’normal’’, how going with gut instinct was Doug’s trajectory. ‘’I've never wanted to be normal. In high school, that was my only trajectory, was just to do something different and just go with my gut.‘’ The power of storytelling: Why listening to people’s stories is the first step to connecting with your patients. ‘’Not because we have a particular end in mind, because we want them to support an idea or to reinforce something that we might already know, but genuinely because w
Lauren Pasquale Bartlett is the first Chief Marketing Officer at Ingenovis Health, healthcare workforce solutions providers. Here, she shares how hospitals can benefit from a clear purpose, and how to achieve it. Episode Introduction Lauren discusses how purpose is every organization’s North Star, how it creates passion and reveals the survey that shows people prioritize purpose over profit She also shares Ingenovis’ ACT (Advocacy, Careers, Tools) program, discusses the rationale behind ‘’building a home for healthcare talent,’’ explains why support from the C-Suite is vital to achieve purpose, and outlines how leading by example can impact an entire organization. Show Topics The purpose of Ingenovis Health Highlighting the human element of healthcare Bringing your purpose and mission statement together The common challenges of achieving buy-in How to bring purpose to life Leading by example and leaning into purpose 01:54 The purpose of Ingenovis Health Lauren explained how Ingenovis Health became one of the largest healthcare staffing companies. ‘’… I'll start with Ingenovis Health because it's kind of new to the market. Ingenovis Health was founded in early 2021 with the merger of four leading healthcare talent providers, and at the time, that was Fastaff and U.S. Nursing, Trustaff Travel Nursing and CardioSolution. So those four companies came together in the early of 2021, and we've since acquired three more. So now Ingenovis Health is one of the largest healthcare staffing companies in the industry. We're about a $2 billion company placing around 10,000 doctors, nurses and allied professionals in positions nationwide. They're mostly travel positions, Jim, temporary positions, some permanent, but really, really large reach in who we place in our clients nationwide. As Chief Marketing Officer, I'm responsible for the marketing, the brand, the communications, and as the first chief marketing officer of Ingenovis Health, I also had the unique opportunity to contribute to the development of the purpose and the mission for the new organization.‘’ 04:04 Highlighting the human element of healthcare Lauren said we need to be aware of the impact of ongoing trauma on frontline employees, especially after the pandemic. ‘’…we have to just keep the human element at the core of it. And you know better than anybody, when you think about how much the nurses are dealing with from long shifts to understaffed units, lack of PPE during COVID, I think you could easily disassociate yourself from the idea that those are real people with their own lives and families, and they're dedicating so much of their energy and their attention to their patients. So it really is a very human industry, and you have to, again, keep them at the core of it. One of the things about our nurses, our doctors, our allies, is that they're just experiencing stuff that other people don't experience in their jobs. So they're seeing a lot of death, particularly during COVID. They're experiencing traumatic events along the way, and oftentimes they're called to come back in on days off, even though they haven't really had a sufficient break just because there's not enough help. So you really have to keep thinking of them as you define purpose in anything that impacts the healthcare industry.’’ 10:34: Bringing your purpose and mission statement together Lauren illustrated how Ingenovis Health linked their purpose and mission statement in a post-Covid context. ‘’The mission statement for Ingenovis Health is that we create ecosystems where healthcare talent can grow, thrive, and deliver the best patient care. And so as I was mentioning before, another thing that was coming out of COVID was you'd find a nurse or a doctor who had just done 18 months of COVID assignments back-to-back and really needed a break. And so through the merger of our seven different companies, we provide those opportunities that they can choose based on where they are in their careers, their lives, or their psyche. So for example, someone who's really burned out on bedside can come to our company healthcare support and get a mental rest. Maybe take a one year or two year assignment as a case manager, someone who's working remotely, just not bedside, but still apply their clinical talents. On the flip side, you might have a nurse who's trying to quickly grow their experience and accelerate their earning potential, and they can take a one week strike assignment with U.S. Nursing, working a 60 hour week in a high stress situation where there's really very little orientation and training, and that grows their value and their experience. And we offer the same thing for doctors. Doctors within our locum tenens company, VISTA can take short or longer term assignments around the country and through our brand CardioSolution that places cardiac specialists in underserved communities, rural communities nationwide for one to three year assignments. So there's a lot of variety there. And depending on where you are in your career, we feel you've got the home, you can stay in this ecosystem and still have a lot of different experiences.’’ 19:40 The common challenges of achieving buy-in Lauren said the key to delivering purpose is the support of the C-Suite. ‘’What I've seen is that you do need the support of the CEO or your executive leadership or your managing director, whoever it is, or people don't take it seriously. And not everybody is always going to be the optimistic, hopeful champion of your purpose that you are envisioning. But those folks can get on board if they see it in the leadership above them, and they can at least believe, well, this is where he thinks we should be going, where she thinks we should be going. So again, that top-down leadership is vitally important, and then you have to be serious about it. It has to remain a focus in your strategy as well as operations. So did you hire the proper people? Are they properly skilled? Did you devote resources? Did you give it attention? Are you talking about it? Because if you're not authentic in your commitment to the purpose, it becomes pretty clear, especially during tough times when you have to make difficult decisions about where to invest time and money.’’ 22:08 How to bring purpose to life Lauren said Ingenovis try to understand the voice of the clinician and recognize their teams to bring their purpose to life. ‘’Some of the things we do, in addition to trying to understand the voice of the clinician, we also make sure that we take time to recognize the opportunities to reward them, recognize them, like Nurses Week, Doctor's Day, Mental Wellness Week, these are the things that we try not to miss, and we try to say, you're thinking about it, we're thinking about it. Let's make a big splash with the resources we have. We've also had a very successful PR campaign over the last few years where we've been able to secure placements for our nurses and our doctors on really large media outlets, including the Today Show multiple times. Good Morning America, CNBC, Fox News, really, really big news outlets who are giving our nurses and doctors a voice and a chance to be heard. And that's an authentic way for us to bring the purpose to life because going back to that research we did before developing the ACT program, how can you develop a program if you don't know what people are seeking, what they're dying for? One of the things we heard is that the nurses felt like they weren't listened to and they didn't feel like they were part of the conversation, and they got a lot of hero accolades in the beginning of COVID, and then it really died down and got quiet. But it's not because they stopped doing exactly the same thing. It's just our attention moved on to other things.’’ 24:56 Leading by example and leaning into purpose Lauren said the customer must be the focus in all areas of leadership. ‘’…. like anything in marketing, just be thinking about your customer. And for me, again, I made such a big shift. I was working in sports for a long time. I made this shift into healthcare, and I've just learned so much and grown to respect and value the contributions of everyone in this industry. It's complicated and it's often challenging. There's many opinions about who's the villain and there isn't one. It's just a really complex market with financial pressures and these shortages that are happening. So just always be thinking about your customer. The other thing I would say is lead by example, because it's just amazing how much other people will mirror your attitude and your actions, and you want to be a force for good in your organization. That I think the last thing I'll say just based on our topic today is lean into purpose as part of driving clarity and focus for your teams. So you're not only creating alignment, but you're also inspiring passion for what you do and why you're doing it, and giving them a sense of pride in the mission. So that consistency in action and messaging is really important.’’ Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Lauren Pasquale Bartlett on LinkedIn Check out VIE Healthcare and SpendMend You’ll also hear: Linking purpose and passion: ‘’I think different companies do it in different ways. For us, we look at the purpose as the North Star, the guiding light, your vision for what the company stands for today and in the future. And the mission statement for us is how you achieve that grand vision. So in other words, the mission statement is what you're creating along the way to fulfill on your purpose.’’ Creating a clinician focused clinician first purpose; the rationale behind ‘’A home for healthcare talent.’’ How purpose creates passion, and the study that found nearly three quarters of respondents believe purpose should ‘’have more weight than profits’’. Creating the ACT program (Advocacy, Careers, Tools). How Ingenov
Why Nurses Need Mentorship with Jenny Finnell | E. 69
Growing numbers of nurses are struggling with the demands of their profession. Jenny Finnell explains the benefits of mentorship and the expanding mission of Nurses Teach Nurses to Jim Cagliostro. Episode Introduction Jenny shares her foundational belief in ‘’paying it forward’’, how everyone has a role to play in mentorship, why nurses need a safe zone, and the impact of the pandemic on burnout. She also highlights the financial benefits for hospitals supporting mentorship, her global vision for Nurses Teach Nurses, and why a 45% rise in demand for advanced practice nurses reinforces the urgent need for support. Show Topics Journey to CEO and Founder of Nurses Teach Nurses The reality of a career in nursing Providing a safe zone for struggling nurses Learning to cope with suffering and death How the pandemic contributed to burnout Encouraging nurses into mentorship The benefits of mentorship for hospitals 02:35 Journey to CEO and founder of CRNA School Prep Academy and Nurses Teach Nurses, Jenny explained how Nurses Teach Nurses grew out of community. ‘’I've been an anesthesia provider now for nine years. Prior to that, I was a medical ICU nurse for three years. I've been in the realm of nursing for 14 years in total. Back in 2018, I actually got on social media for the first time since prior to grad school and I called myself Jenny CRNA, and I started getting direct messages on, "Hey, I've been facing a lot of setbacks and failures. Can you help coach me on how to get into CNA school?" I started doing that and I handed out my cell phone was chit chatting with people, probably about 10 or 15 people when I actually decided, "Wow, this is getting to be a lot. Let's make a Facebook group so I can talk to everyone at once. I'm kind of a broken record sometimes, so that way I can say one thing and have everyone hear it." I had a network, I had a community. I knew program faculty, I knew a lot of CRNAs, a lot of CNA leaders. I really pooled on my community to really help these nurses. They were finding a lot of success and just overjoyed with the help they were receiving. Before I know it, that group grew to 6,000 people. I was finding myself spending a lot of time mentoring and coaching, and that's when I started CRNA School Prep Academy because I was kind of burning myself out, if I'm being honest. I was working 40 hours a week, had two little kids and spending 20 hours teaching for free. I'm like, "Wow, I really want to do this, but how can I monetize my time?" CRNA School Prep Academy was born and where Nurses Teach Nurses comes into play is I've been doing CRNA School Prep Academy and mentoring for three years now and we've mentored over 5,000 ICU nurses and went through the pandemic during all that time.’’ 08:13 The reality of a career in nursing Jenny said nurses are the only people who relate to the needs of other nurses. ‘’…I think what's hard is the reason why I like the concept of Nurses Teach Nurses is no one can really truly understand the footsteps of a nurse unless you have been there. It's like being at war and being in the trenches with someone else. You understand what it's like, and that's what nurses need. They need that relatability piece. They need their peers to fall back on for that support. I knew now was the time, because I don't want to see this happen to our profession. I want to see a big change happen in a big way. Sometimes I think I'm crazy for dreaming up all the things that I hope to accomplish. I think a lot of people are stepping up to the plate, but we have to try to tackle this big problem in our country. We're all going to be in big trouble. We rely on nurses for healthcare, and we need to help them flourish in this profession, not deter them and help them leave, which is all we've been doing. While this is not one thing fixes all, I do think providing support and mentorship and career opportunities, career advancement opportunities, connection with community, that's a huge part of it. We've never had a platform to really stick together and do this. I hope to create this big platform to bring nurses more career opportunities and satisfaction.’’ 12:42 Providing a safe zone for struggling nurses Jenny explained why the absence of the right support is having a significant impact on nurses. ‘’So I think a lot of nurses struggle with guilt and wanting to leave the profession that they thought they were so passionate about and loved. I know a lot of ICU nurses feel that way. I didn't cut it, I didn't cut it. I thought I was capable and I clearly wasn't. It's not their fault. They just didn't have the right support system. I think that's part of the reason why we're seeing these nurses in the first few years burn out because they were struggling and they feel alone and they're scared, they're fearful. All this media that has been pushed in the media, they're afraid to go to jail. They're afraid to be put in prison. They're afraid to make a mistake. They're afraid my coworkers are going to think I'm stupid. I'm not capable. They don't tell a soul. They don't think they can even talk to their coworkers or they're afraid they're going to be a black sheep now in their unit. What I think about Nurse Teach Nurses is, we can provide that safe zone of, I don't know who you are, I don't even know where you work. Let's talk. I know you're a nurse in the ICU, in the medical I C U. I need support. I feel like I can't get it on my unit because maybe it's a toxic unit and I wish that wasn't the case, but it's true. I think all nurses need access to a safe place to ask questions.’’ 16:23 Learning to cope with suffering and death Jenny said young nurses in particular need support in dealing with the trauma of their job. ‘’…. if you think about where you are when you graduate nursing school at 21, 22 years old, you really are, I feel like I'm aging myself, but you are a very young adult, if not a very large child. That's for my own self. Right? I know for me, speaking back when I first started in the medical ICU, I saw death all the time. I didn't live through a pandemic. H1N1 was the scariest thing I saw. I saw girls my age dying, having babies in the ICU on ECMO and Prisma and things like that. It was terrifying to go into a room with someone on my birthday and take care of them on their deathbed. That being said, it was so hard for me to cope. That was the only time in my life I could probably say I was clinically depressed. It's because I was faced with the fact that I was taking care of death and suffering all the time, and it really broke my soul. I think as a young adult, if you don't have a good idea of what death is to you and what it means for afterlife and all of the things that you have to really think about as you get older and you typically do when you have more death around you, it's abrasive. It's like a gut punch in the stomach. It's a hard face of, this is a really cruel, harsh world we live in. As a young adult, it's hard to cope with that. You feel like maybe you're not strong enough and you kind of take this badge of honor. I should be tough and I don't want to cry. I cried one time so much in the ICU that I actually got a tear duct clog the next time.’’ 21:10 How the pandemic contributed to burnout Jenny said a focus on mental health and support through mentoring can help nurses to cope with managing complex emotions. ‘’… I do think the pandemic poured gasoline on a fire essentially where it was already burning and now we're burning more. We're seeing a more noticeable statistical exit. I also think that the stress the pandemic has put people in a mental state of not having the energy to talk about it and to deal with it. I experienced this particular experience when I was in grad school where just the idea of coming home from a stressful day and trying to talk about it, I was like, I can't. I'm empty. I can't. The whole idea of talking about it rehashes those emotions and feelings and stress to where that in itself seems like a huge chore. I think that's where nurses are at right now. They don't even want to try to deal with it because that in itself would be the breaking straw that could kill them. Mentally and physically, burnout and doesn't just affect your mental status, it affects you physically. The stress hormone, cortisol does wreak havoc on your body, panic attacks, high blood pressure. There are a lot of things, no sleep, insomnia. There are a lot of physical problems that develop from emotional stress that's not handled. I think we've let it go so far that we just, I don't think there's a way to turn a hundred percent back, but what I do think is going forward, we have to focus on mental health and support and guidance and the outlet for these nurses to share what their emotions with someone who gets it, someone who's lived through it with them, who can give them that sounding board of you're not abnormal. It's okay to feel these frustrations, anger, grief.’’ 28:31 Encouraging nurses into mentorship Jenny said mentoring offered a huge opportunity for professional growth and fulfillment in the nursing profession. ‘’…how can we get someone's interest in doing this? That's why, again, they monetize their time. Do you go out and garden for an hour, or do you spend an hour on a call with a nurse? Both are really rewarding, but I think it's just getting someone in that habit of, okay, I'm being rewarded for my time and I'm getting people kind of used to that. This is a normal relationship to have between nurses. Yeah, what my fear is, if we don't make a big change to allow nurses to connect with other fellow nurses and bring in all of the expertise and like you said, the retirement nurses brains or experienced brains to share with our next generation, we are missing a huge opportunity for growth both professionally and innovativeness for the community, but just fulfillment wise for the actual nurses who are currently doing t
Exposing Healthcare Fraud with Jonathan Tycko | E. 68
High levels of government funding means that the value of healthcare fraud runs into billions of dollars annually. Attorney Jonathan Tycko discusses his role in representing whistleblowers, with Jim Cagliostro. Episode Introduction Jonathan explains why the value of healthcare related cases under the False Claims Act ($1.8 billion recovered in 2022) represents only a fraction of the real total, why most people are reluctant to become whistleblowers, and shares the universal mistake all health systems make. He also urges hospitals to focus on mission over money and explains why compliance isn’t the enemy of healthcare. Show Topics Representing whistleblowers in qui tam lawsuits Understanding healthcare fraud Analyzing statistics in healthcare fraud Whistleblowers share key characteristics The risks of becoming a whistleblower Compliance should not be seen as a problem Hospitals must focus on mission, not money 02:46 Representing whistleblowers in qui tam lawsuits Jonathan explained his move into the healthcare niche, and the meaning of ‘’qui tam.’’ ‘’This particular practice that I'm in now where I represent whistleblowers for reasons we can get into as we go along here, tends to be very focused in the healthcare sector….about 15 years ago, I got a call from a person who was involved in one of these cases and he says, "I'm a relator in a qui tam lawsuit and I'm looking for a new lawyer to help me with an appeal." And I said, "I don't even know what those words mean." Even though I had been practicing law for about 15 years at that point I had never heard of these kinds of cases before. It is really a very niche practice, there are very few of them. But I took his case and through that really learned a little bit about the False Claims Act, which is the statute we operate under mostly. And just got really interested in it from that one case. And then slowly over time started to look for other opportunities to represent clients in that area. Did a little marketing and so forth and over time built up the practice. And now this is almost exclusively what I do as a lawyer, which is representing whistleblowers in what are called qui tam lawsuits, which is where a whistleblower is bringing a claim for some type of fraud, where the fraud is really committed on somebody else, usually the government or government programs. But it is brought by a private whistleblower that is specifically authorized by certain laws.’’ 06:03 Understanding healthcare fraud Jonathan said any type of fraud in healthcare is likely to fall within the False Claims Act due to the extent of government funding. ‘’Well, at a very high level of generality, it's just what it says. It's any type of fraud scheme that is impacting the healthcare system. What we're focused on a little bit more specifically is, like I said, there's this statute called the False Claims Act, which makes it illegal to basically commit fraud on the government or on programs that are funded with government dollars. And as you know, obviously a huge percentage of healthcare spending is funded through Medicare, Medicaid, Tricare, the VA system, and these are all programs that are covered by the False Claims Act. So any type of fraudulent conduct or unlawful conduct that is widespread and that impacts the healthcare industry is likely to cross paths with the False Claims Act because of all those government dollars that are used to fund our healthcare system. And so any sort of fraud... And I can run through a whole bunch of different categories and give you some sense of what the types of cases are, but pretty much any type of fraud that is ongoing in the healthcare industry is likely to also violate the False Claims Act. And so a whistleblower, somebody who has non-public information about that fraud, is a potential whistleblower under that statute.’’ 07:45 Analyzing statistics in healthcare fraud Jonathan said that the high levels of healthcare spend makes it difficult to provide accurate figures on fraud. ‘’It's really hard. It's an interesting question. It's really hard to talk about fraud in a statistical sense because you only know about what gets reported. And so you never really know how much fraud is occurring that you don't know about. So what I can give you some sense of is what is reported by various government agencies that have access to some statistics. So what we know is that pretty much every study that's done of any government program where they're looking at what are the rates of what folks in the government call fraud, waste, and abuse. So it's not all just intentional fraud, but it's also just wasted money. They're looking at, "If we spend a billion dollars, how much of that is going to actually go to the program and how much of it is going to just get siphoned off through fraud, waste, and abuse? And they pretty much always conclude that it's about 10%, which is a shockingly high number, but that's usually what they conclude. And so what I can tell you is I can give you some more very, very specific statistics. So if we look at just this past year, 2022. The government reports statistics under the False Claims Act every year. So in 2022, the government recovered about 1.8 billion in healthcare related False Claims Act cases. And that's somewhere around 2 billion a year. Again, that's what they recover. So the actual amount of fraud is probably some multiple of that. And that's just the federal government, right? The state governments recover more on top of that if there are Medicaid dollars, because Medicaid is jointly funded by the federal government and by state governments. So that's even a little bit of an underestimate. My sense is probably the real number is about 5 billion a year in recoveries and maybe five X or 10 X more of that that isn't recovered. So it's a lot. And it's a lot because healthcare spending is so huge.’’ 12:44 Whistleblowers share key characteristics Jonathan said most people are reluctant to take action when it comes to whistleblowing. ‘’….everybody, when you ask them in the abstract, "Well, if you saw your employer doing something illegal, would you turn them in?" I think most people would say, "Oh, yeah. Yeah. Of course I would." But then in practice, most people actually don't because we have these very, very strong instincts to want to get along with the people we know and work with. It turns out that most people, even most good people who would never themselves do something dishonest, won't blow the whistle when they see it happening in an employment setting. And what I've noticed is that the people who do, the people are willing to blow the whistle, tend to have some fairly unique personality types. They're people with a strong sense of self-identity. They're not necessarily people who are just going to go along to get along. They have a strong sense of right or wrong. Often they have a strong sense of patriotism because a lot of these cases have to do with injuries being done to the government and to taxpayer dollars. And so they have this sense of wanting to stick up for the country or for the community. And so they're often are motivated by some strong personality trait, and they tend to be very strong-willed people.’’ 13:36 The risks of becoming a whistleblower Jonathan said whistleblowers risk dismissal from their jobs for raising concerns with employers and play a key role in providing information. ‘’And this goes to the question of what is the role of whistleblowers within organizations? Often by the time somebody has called me, they've already tried to solve the problem internally at the company or in the office or with their employer. And what they've run into is being told to keep their mouth shut, being dismissed, being told they're crazy, maybe being fired because the company doesn't want to deal with it. And so they've tried to fix the problem and they had been met with this stonewalling or evidence that the company isn't going to deal with it. And that's usually what's happened before they call me. Then the next question is, "Well, what role does the whistleblower actually play in one of these cases?" And what are called again, qui tam cases. These are cases brought under the False Claims Act by the whistleblower. The main role in that case is for the whistleblower to actually provide the information to the government.’’ 19:35 Compliance should not be seen as a problem Jonathan said that healthcare’s focus on the bottom line is an obstacle to compliance. ‘’If they're in a rush to ramp up the company and they're trying to turn the company profitable and go public or sell it, trying to get to the next round of VC money or whatever it is, there's a strong pressure to focus very much on the bottom line. And sometimes compliance issues can at least not stop that, but can slow it down a little bit. And so often when the whistleblower raises his or her hand and says, "Well, wait a second. Isn't the way we're marketing this drug or isn't the way that we're billing for this procedure, whatever the issue is, isn't that maybe wrong?" There's often, in companies like that, a tendency to instinctively say, "We don't really want to hear about that." No. No. Because God forbid the answer be, "Yeah. It's wrong." Then we might have to change how we do things and we don't want to change how we do things. So there's that instinctual resistance to it. So again, that's a corporate culture thing. So what I would say is you can't, and particularly in healthcare where it's such a heavily regulated business, you can't just view compliance as a problem. You have to view it as just part of the business, right? That you have to deal with compliance. You can't have this negative view that compliance is just something to be minimized and dealt with. And so if a whistleblower within the company... They're not really a whistleblower at that point, they're just an employee who is raising an issue that
US healthcare costs are the highest in the world, yet health outcomes lag behind other countries. Preston Alexander shares his mission to prioritize patient care and clinicians over profit with Jim Cagliostro. Episode Introduction Preston explains that the principal issue with US healthcare is its profit-driven approach, why healthcare must be a forward-thinking Netflix, rather than an obsolete Blockbuster, and why the nursing shortage is the result of a broken system. He also emphasizes how understanding the line item hospital costs can significantly benefit clinicians, and the importance of an empathetic mindset. Show Topics The current path of healthcare is unsustainable Turn the ship around or build a new one? Clinicians need to understand the business of healthcare The ability to analyze financial statements is an invaluable skill Hospitals benefit from having clinicians in leadership roles Preparing clinicians for leadership 06:08 The current path of healthcare is unsustainable Preston said the profit driven nature of healthcare is leading to higher costs and poorer outcomes. ‘’. .. I think the primary issue that I see is that, and you talk about systems level problems, is our healthcare system operates within a much broader context. The context being a system of capitalism. And it was created in a way, in more modern times, I suppose, if you want to look at it that way, to maximize profits. And all the systems we've designed have created a little bit of a bifurcated system whereby you have wealthy individuals who are covered by insurance and can afford all the out-of-pocket fees and charges they have to pay if they need healthcare. And then the rest of the population who's functionally uninsured or underinsured or doesn't have insurance at all, and then what they can access. So, if you wanted to just really take one big giant swath, like what's the problem in healthcare, is that it's fundamentally profit driven first, and healthcare fundamentally is a function that can't be delivered appropriately to everyone with profit being its primary driver and outcome. We see examples of it all over the place. You have insurers who are supposed to help you avoid catastrophic costs related to healthcare, who make... United Health Group, I think in 2022 profited $20 billion or something like that. So you're just talking about outrageous numbers. It made, I was just looking at their financials this morning actually, $340 billion in revenue. And it's like, what are we getting for it? More expensive treatments, more cost, worse outcomes, lower life expectancy, less access, more people left behind by financial design.’’ 09:51 Turn the ship around, or build a new one? Preston said the broken healthcare system is the cause of the nursing shortage, but change is possible. ‘’… I am still going to believe, and I'm probably wrong, but that we can turn the ship because systems are what drives everything.... It's what we see with all the nursing shortages right now. We don't really have a shortage of talent, but we have a brokenness of systems. Today, we're 300,000 nurses short. If I gave you 300,000 nurses tomorrow, we'd be short again within a year or two because the systems are broken. You can't just throw good people into a broken system. But people design systems, people can change systems. So with that sort of premise foundation, the ship could be turned. We could turn the Titanic, but it's going to take leadership, it's going to take people at the top, it's going to take bottoms-up approach. It's going to take a lot. It's not an easy thing to do, neither is building a new one. But that's the alternative. We can try our hardest and get our CEOs on board or the people in charge or mutiny so they have to listen to us or whatever the things are. Or you can say, we're going to just do something different, not to minimize it in any way, but we're going to make Blockbuster obsolete. We're going to be Netflix. We're going to create something totally different and not even disrupt the system because it's so useless to us. So we're just going to go over here and do something else…..So it's, what can you do to build something outside of that traditional healthcare system? And I think both ways can work. I honestly think building a new ship is probably the best solution at this point, although I don't totally want to believe it because there's a lot of meaningful infrastructure. But also once you build a new ship, everybody aboard the old one's going to want to come over there and you can really access a lot of that existing infrastructure in positive ways.‘’ 14:18 Clinicians need to understand the business of healthcare Preston emphasized the need to prioritize patient care and clinicians above profit. ‘’We have this big underserved population. And this hospital was dragging down the bottom line of a big not-for-profit health system that makes plenty of profit, believe you me. And so they closed the hospital. And that hospital had a lot of problems. It was under-invested in for a long time. It has a troubling financial population, but they approached it the wrong way. It was finance only, right? Like, "Let's just bottom line, little investment, and then let's get out of this and not take the black eye." But you can do the right things, but also understand the economic realities, like how do you invest in a new parking deck? Which they needed, because they had a condemned parking deck. You know what I mean? So bridging that gap, I think really helps everybody. So in the first way, it's just to get on the same page. We need to do the right things for patients. We need to do the right things for clinicians, deliver the best care, highest quality, all that stuff, first and foremost, absolutely. But then how are we going to cover it and pay for it and actually deliver it and pay people well and pay people fairly? Those are just the economic realities of the broader systems that we live and operate in. And so people always talk in a way that's like, it's either or. And I think it can be both. And I also firmly believe that if you do the former, which is start with patient care in mind, quality, safety, take care of your clinicians, the profit and the money takes care of itself on the backside. And I mean, we've seen examples of this before.’’ 19:55 The ability to analyze financial statements is an invaluable skill Preston said understanding financials gives clinicians insight into what’s really happening versus ‘’red herrings.’’ ‘’But then more applicable to our conversation, I just think it's really beneficial, again, to my previous point, of knowing what goes into and what's required to operate a large organization. When we look at hospital financials, you see line items, and I think staffing costs are the biggest line item of any hospital. And you see that it's, I don't know, $13 billion. You're like, "Oh, whoa, wait a sec, I didn't realize that. What goes into all that?" Or you see supply costs $20 billion, and you're like, "Man." But in the same breath, you see revenue, $150 billion. Not for a hospital, it wouldn't be that much, but whatever it is. $14 billion or something. It starts to shift your perspective a little bit and you start to see, wow, these are really big, a lot of moving parts and pieces. Here's what goes into it. It's also a way to see the red herring where it exists, because in healthcare we have a lot of issues and then everyone's going to spin it in their own particular way.’’ 24:53 Hospitals benefit from having clinicians in leadership roles Preston said clinicians can help hospitals to make better decisions on costs. ‘’Some really great, awesome tech wizard, hoodie-wearing guru comes in and sells this awesome vision and then the C-suite says like, " We're going to make this extra money. We're going to reduce costs here," And then you go to implement this $5 billion whatever thing you just signed up for. And then all of your clinicians are prepared to mutiny because you just jacked their workflows in an incredible way. And they're just like, "How much more work do you expect me to do to realize this sort of pipe dream that somebody sold you? And had you just had the previous chair of surgery now working in a nonclinical leadership role, who could have been in on those conversations?" Not to say that every hospital leaves clinicians out of the discussion, but I mean, they're a minor part. But when you can be at the table and say, "This is a terrible idea. Do you know what this is going to do to our workflows? This is not a good investment." So it can help really dictate not only don't cut this cost or don't cut this cost, it can really propel the financial health of an organization forward in meaningful ways too, to say, "We have these resources. This is where they'd probably be best allocated for patient care, for patient experience." And it's like, "And here are the returns that you can get from that improvement in patient care and experience." Because I think that's just such a big piece that's missing is the short-sighted financial management to lower expenses and maximized revenue.’’ 27:19 Preparing clinicians for leadership Preston said building relationships with people in nonclinical positions can empower clinicians for leadership roles. ‘’.. I think the one thing that is super powerful and helpful is just to make friends with people who are in nonclinical positions. So I talk to people sometimes who wanted to make that jump in administration or something, and I say, "Well, go spend time in the purchasing department with supply chain, go set up internal meetings." I used to do this all the time in my previous companies. And I mean, listen, I get it. Everyone's super busy. And when you're on shift, bless you if you can find a bathroom break time. It's hard. You know what I mean? I totally understand that. But it can be very, very meaningful and help
Giving nurses a voice in healthcare is the mission of Rebecca Love, Chief Clinical Officer at IntelyCare & President of SONSIEL. Here she explains why to Jim Cagliostro, and how a hackathon changed her life. Episode Introduction In a powerful conversation, Rebecca discusses the impact of the Woodhull study, plummeting post-Covid retention rates in nursing, and how the perception of nursing as ‘’cost’’ is damaging to healthcare. She also reveals the imminent launch of the Commission for Reimbursement, why every hospital should run a hackathon, and how encouraging others raises the voices of the entire nursing profession. Show Topics How a hackathon changed Rebecca’s life Nurses as innovators: changing the perception The findings of the Woodhull study The real reason nurse retention levels are falling Gaining a voice during the pandemic Advice for the C-Suite: Run a hackathon Encouraging nurses into leadership 04:25 How a hackathon changed Rebecca’s life Rebecca described her experience of being a nurse in a room full of decision makers. ‘’… It was at a hospital in Boston. I'll never forget crossing into it being the nurse, not knowing anybody there. And everybody in Boston was there. All of the major tech startup CEOs, the CEO of the hospital, all the doctors, engineers, scientists, everybody was in this room, hundreds of people. And that's when I walked around and I realized there were no other nurses in that room, James. I was like, "Oh my God, I'm not supposed to be here as a nurse, this is where the decision-makers are." We feel this way constantly as nurses, we know everybody that makes all the decisions are in rooms that we're not in. But nobody asked me to leave that weekend, James, and I ended up joining a team, and that's when my whole life changed because we were sitting in these rooms where we were hashing out. I had a doctor and my team, I had an engineer and an occupational therapist. I had a scientist, were all in there. And in walked the CEO of the hospital and he literally sat down next to me and he said, "So, tell us what is your problem and what's your solution that you're fixing?" And this gentleman, our physician starts talking like, "Well, here's the problem and here's how we're going to solve it on the floor." And I'm squirming, right. Because I'm hearing this doctor explain a solution that's not going to work. So, I finally speak up and I say, "That's not how it's done on the hospital floor. If we do it that way, it's just going to create more work for the nurses." And they looked at each other and the CEO looks at me and goes, "Well, how did I not know that's not how it worked on the floor of the hospital?" And I said, "Well, did you ever ask a nurse?" And they started laughing. So then, I started laughing because I didn't really know what was funny. And then, I realized they thought it was funny to have ever thought about asking a nurse how they should solve these problems.’’ 07:22 Nurses as innovators: changing the perception Rebecca explained how SONSIEL (Society of Nurse Scientists, Innovators, Entrepreneurs and Leaders) evolved out of her first nurse hackathon. ‘’And that's when I hypothesized, oh my God, if we had nurse hackathons, we could change the future of healthcare because nurses have the practical knowledge and experience that they are closest to the problem. That if they were given the opportunity a team to be heard and seen and built towards the solution, we could solve all of the insanity that we live every day as nurses that we could fix healthcare. So, I went on, and that was the story. We finally, after 200 phone calls connected with the dean at Northeastern, Nancy Hanrahan didn't hang up the phone on me and she said, "Next summer, Rebecca, I'm running a conference on innovation entrepreneurship. Why don't you run a hackathon?" …. And I said, "Sure, I've been through a hackathon. I'll run one for you." And just jumped in. And that event, that nurse hackathon at Northeastern that we built to which nobody talked about innovation or entrepreneurship as nurses back, if you look in 2015, there was like a handful of articles that mentored those words, but none of them in the same sentence. Like nobody believed nurses could be innovators. And we built to that event in 2016 that ended up changing my life and ended up changing the idea that nurses could be innovators and entrepreneurs because we built the first nurse innovation and entrepreneurship program out of Northeastern for two years and then spun that out into SONSIEL. So, James, that was a very long story about one of the things that we didn't talk about, but change the credit, and I'd say this to nurses all the time, A hackathon is going to change your life because it empowers you to take ownerships of the problems you want to solve.’’ 10:35 The findings of the Woodhull study Rebecca said the study revealed how the views of nurses were overlooked during important discussions around healthcare. ‘’... It was founded by Nancy Woodhull, who was the editor of USA Today, who in 1998 wanted to understand why nurses were missing from so many media stories in the mainstream media when they represented at the time 3.5 million in the entire country, the largest healthcare workforce like it is today. But they were absent from many of the conversations that they would've been centered to germane to the story as she said. So, they found in 1998 that 4% of all media stories were nurses would've been relevant. That is all they were quoted of the 100% of our only 4% of news stories mentioned or quoted nurses at that time. So, they reran the study in 2018, co-sponsored by woman under the name of Barbara Glickstein. Now in 2018, did we expect that number would've gone up or down?You would hope up, except the study showed not only had it not gone up, it had gone down by half. Nurses in 2018, were now sourced, incited less than 2% in all major media stories and absolutely devastating one. So, nurses have abdicated their voice to everybody else except ourselves to speak on our behalf. ‘’ 16:37 The real reason nurse retention levels are falling Rebecca said the view of nurses as a ‘’cost’’ is causing nurses to leave the healthcare sector. ‘’There is a shortage of nurses willing to work in the healthcare environments again, that they are today. And the numbers showed out even before COVID, 57% of new grads left the bedside within two years of practice. Nobody wanted to address that, right? They're like, "We're just going to produce more nurses." And a lot of the conversations I'm hearing at the federal level are saying, "We're just going to produce more nurses." We produce plenty of nurses. What we don't do is we don't retain them. Do you know that since COVID, before COVID, the average length of an experience on a 12-hour shift was six years of experience. Today, it's 2.7 years of experience of a nurse. That is your average nurse length of experience. That's still a novice nurse, but it dropped almost three years from length of experience on being on 12-hours shift. So, here's the reality. Why is this existing? The reason exists today is because nurses are cost to healthcare system, James, and because they are cost, we deinvest in that there is always an argument to say, "We need more nurses," and hospital systems will say, "Well, we can't afford more nurses now," but they always can afford more physical therapists or occupational therapists or doctors, right? They're not a cost to healthcare systems. They have a reimbursable service that pays for them. But as nurses, we only are cost. ‘’ 26:43 Gaining a voice during the pandemic Rebecca gave examples of how nurses are gradually becoming more involved in the decision-making process. ‘’… I still think that there's barriers, but I think even in COVID, we saw that nurses really were able to take charge of a lot of their systems and supply chains failed, GPOs, group purchasing organizations and vendor management platforms. They all failed in the name of code and allow nurses to get really savvy about getting what they needed into hospital systems. Now, you have people like Hiyam Nadel, the first director of Innovations at Massachusetts General Hospital nurse appointed over to really recognizing, "Hey, what products would help us work better for our nursing workforce?" We saw a rollback of the role of the chief nursing informatics officers after EHR's rolled back, but now we're seeing a resurgence of those chief nurse informatics officers who are being employed by hospital and healthcare systems to basically validate the technology from the nursing perspective. So, this has been a really exciting thing. So, you just saw Becky Fox just be chain, the chief clinical informatics officer for all of Intermountain, for example, you have Brian Weirich, he's the chief nurse information executive for all of Banner Healthcare. These are newer roles that are helping hospitals shape, you know what? Okay, we're going to roll out this product. We better have our nurse informaticist officer check to make sure that it's going to work out. That is super exciting, and I think the best hospitals are starting to see that this is going to happen. And so, there is the American Nurse Association of Informatics, really cool group of rockstar nurses who are pioneering this space and demanding that their voices are heard.’’ 36:10 Advice for the C-Suite: Run a hackathon Rebecca said a hackathon can offer health systems the opportunity to value nurses and deliver vital solutions. ‘’... I feel the stress that our leadership is under in these executive positions because they're caught in some really difficult positions. That being said, we know that healthcare does not function without nurses. And for a very long time, we have not given nurses a seat at the table to drive the changes they have. So here's my advice, instead of spending the millions of dollars that you are
Every year, nearly 800,000 people in the United States have a stroke. Listen in to a Stroke Coordinator on how his role helps to save lives, transform patient care, and reduce costs. Episode Introduction Monte explains why data abstraction is the biggest part of a stroke coordinator’s role, the importance of maintaining patient focus and why ‘’responsibility without authority’’ means teamwork and communication are vital. He also highlights his unique position in understanding the time sensitive nature of treating stroke patients, and how patient arrival time dropped by 100 minutes following a community awareness campaign. Show Topics Data abstraction is the biggest factor for a stroke coordinator Ensuring patient follow-up for better patient care Making a difference as a stroke coordinator The ads that transformed patient education Why teamwork and communication is a must The cost savings benefits of hiring a stroke coordinator Leadership is about helping others to succeed 07:47 Data abstraction is the biggest factor for a stroke coordinator Monte explained the ‘’life-changing’’ impact of data abstraction on his role and ability to improve patient care. ‘’The largest part of being a stroke coordinator is data abstraction. There is tons of data abstraction. It's incredibly time-consuming. There's information that I have to gather on every single patient that arrives with stroke-like symptoms. That is probably two to three times the amount of patients that actually become stroke patients. So it's a huge number of patients. So every code stroke in the hospital, which sometimes there's two, three, four a day, those are patients that I have to do data abstraction on. Then I also have to understand how the data determines opportunities for improvement, and that was something I was so completely unaware of as a regular nurse. I was just working in the hospital. Data seemed, it used to make me angry when someone would come at me with data because I'm like, "I don't care about your data. All I care about is the patient. So then I learned that data actually drives this change, and so I learned how data drives the change, and it's been really, really fascinating and very life-changing for me and being able to look at things and say, "Oh, here's where we can make improvements for these patients." 11:15 Ensuring patient follow-up for better patient care Monte said that arranging neurology appointments for all stroke and TIA patients was another key element of the stroke coordinator’s role. ‘’Right now we're providing neurology appointments for all of our stroke and TIA patients. So I spend a lot of time going back and forth with their office to create those appointments and tracking those. There's just tons of tracking of everything. …..that's something …. that we just started doing this last year. We just started doing the TIA patients first, and then we added all the stroke patients in. So that way they have follow up outside of the hospital once they go home. Because a lot of people went home and they didn't follow up with someone and we found that if we create their appointment for them before they leave or even shortly after they leave, then they're more likely to go to the appointment.’’ 12:44 Making a difference as a stroke coordinator Monte said the stroke coordinator is vital for stroke centers to receive certification and in ensuring rapid treatment of patients. ‘’Well, number one, the easiest one to tell you is to be a designated stroke receiving center by the county. We have to be a stroke certified hospital, so we can't lose that certification. So in other words, in order to be that receiving center, what a designated receiving center is? Well, when someone picks up the phone and calls 911 and the patient has stroke-like symptoms, they immediately go to our hospital if it's the closest hospital to them because we are the stroke center. Now in Monterey, two of them, and one is on the west side of the county, one's on the east side, we're on the east side, and we don't fight over patients. There's no argument or anything. It's just split right down the middle. And so if they're on the east side, they come to us. If they're on the west side, they go to them. But that is one of the biggest things, is if we didn't have that designation, we would lose a lot of patients to another stroke center. And the other thing is for cardiac, we always heard time is muscle, the second is true for stroke, time is brain. And people don't realize that approximately 1.9 million neurons die every minute during a large vessel occlusion. So we are racing, when they first come in, we are racing to give them treatment to dissolve that clot or whatever else so that we can restore that blood flow back to that area of the brain, because the longer they go without that blood flow, the more brain damage they're going to have. So that is what the whole thing is when they first come in.’’ 14:10 The ads that transformed patient education Monte said the average time for patients arriving at hospital after a stroke dropped by 100 minutes through raising awareness. ‘’And the other thing where we make a huge difference in the community is because stroke is very time sensitive as far as treatment is concerned, you communicate and teach the community about stroke, stroke symptoms and recognizing those and getting into the hospital as quickly as possible. My partner, who is the cardiovascular coordinator, he and I have gone back and forth. We've gone to so many community events and everything trying to make a difference, and nothing has really made a difference. All of a sudden one day he said to me, "Why don't we advertise on the side of buses and advertise in the theater?" …… So this is where data comes in handy. If it makes a difference, we're looking at the time someone recognizes their symptom to the time they arrive at the hospital. If it makes a difference, it should be shorter. We did that and it was fascinating. We only ran the ads for three months and we could see that time. The average time dropped almost 100 minutes over those three months, and then after the ads stopped, they slowly started coming back up again. So the next year we thought, okay, this is maybe a fluke. Let's do it at a different time of year, whatever. This time we both did the ads because the bus ads did nothing. We ran both of our ads in the theater, same thing happened within a short time. Those times dropped down over 100 minutes this time. So now we advertise in the theater year round. And we started that and then all of a sudden COVID hit, which was funny, and all the theaters closed. So we had to wait until they opened up again to redo that. But it makes a huge difference to our patient population.’’ 17:52 Why teamwork and communication is essential Monte said stroke coordinators have a lot of responsibility but no authority, making communication and teamwork essential. ‘’So for instance, I want to make a change or something. Any change that I make, it will require someone else or some other department in order to make that change. So if I make a change in the code stroke process, for instance, it's going to affect the ER physicians, the ER nurses, the lab techs, CT techs and EMS. All of those people and all of them have to be involved in that change. So you really create buy-in and get people to understand why we're making this change and why it's so important. So for instance, we brought the MEND exam, which is a stroke neurological exam. You to go back, be educated in Miami and have four other people be educated as well, and then bring the class to our hospital and start teaching that class in the hospital. But in order to get our nurses to actually learn the MEND exam, we had to release a health stream for everyone to do it because we couldn't require that advanced stroke life support be taught to them, which teaches the MEND exam, because the union. So if we want to make it mandatory for say, the stroke unit or ER or ICU, we have to go to the union and have that negotiated into the contract for those things. So these are the things that requires a lot of time communication and working with every single person involved. Right now we're bringing in new drugs. We're bringing in ANDEXXA, which is a reversal agent for apixaban and Rivaroxaban. That included our physicians, our nurses, our clinical informatics to write the order sets. And coming up, we're going to be bringing connect to place in. So we're going to have to go through the same thing again. So each one of those things requires communication, buy-in from all these departments and everybody being on board. And if I don't have that, it's not going to happen.’’ 21:04 The cost savings benefits of hiring a stroke coordinator Monte highlighted the best practices of stroke coordinators that enhance patient care, while saving money. ‘’Well, first of all, being a stroke designated center by the county brings those patients there. So that immediately brings patients that we wouldn't normally receive. But how we help our patients is, for instance, we know that and studies have shown that for every 15 minutes we can shave off of the time that symptoms have started to the time they get treatment, the patient is that much more likely to walk out of the hospital as opposed to going to a skilled nursing facility or rehab event. That is why we put this money into our theaters to bring patients in sooner, because the sooner they get there, the more like they're going to be walk out instead of go to one of these places. That also decreases their length of stay, which it lowers their cost as well as our cost. So each one of these things that we do, we bring best practice to the hospital for stroke, which actually improves our performance. It improves best patient practice and best patient experience.’’ 27:34 Leadership is about helping others to succeed Monte said that tra
Viz.ai is a tech company on a mission to fundamentally improve how healthcare is delivered through AI. Senior Director of Global Clinical Affairs, Moleen Madziva shares strategy and insights with Jim Cagliostro. Episode Introduction As AI continues to reshape healthcare, Moleen explains how Viz’s cloud based system drives efficiencies in patient care, and reveals the unique mobile app with a critical impact on surgeon decision making. She also explains why hospitals must allow the data to lead, how Viz.ai systems work in parallel with clinical workflow and why ‘’kindness wins’ permeates the company’s approach to building relationships. Show Topics How our lived experiences shape healthcare leadership Detecting disease on a medical image with AI Enhancing patient care with a mobile app Allowing the data to lead The importance of human connection Inspiring change with personal integrity Getting everyone on the same page 05:04 How our lived experiences shape healthcare leadership Moleen recalled how her community upbringing taught her the real meaning of wealth and empowered her for her role at Viz.ai. ‘’I was born and raised in Zimbabwe in Southern Africa, so shout out to all my fellow Zimbabweans out there. We are really flying the Zimbabwe flag high. I'm based out here in the US and currently living in Southern California. I was raised in a small village called Macheke and I really lived under communitarian community that really honored what it meant to have each other's back. It wasn't until much later as I was growing up that I realized how wealthy and how rich I was because my upbringing was really filled with so much love and care and really nourishing me with culture that has really been shaping generations for so many centuries, but in such a way that even now as someone in technology and clinical research, I realize that all of those lessons have really empowered me for the type of leader that I am, but also for how I visualize doing ethical clinical science.’’ 07:56 Detecting disease on a medical image with AI Moleen explained how Viz.ai’s cloud based system drives care efficiencies. ‘’So our mission at Viz is to bring lifesaving treatments to patients. …So think of it this way, when a patient comes into the ER for example, they get a medical image like a CT scan. That image actually is shipped to the Viz system that sits in the cloud, and from there it is processed and almost pretty much in real time the care coordination team, the physicians and everyone else in that system is able to get the notification for them to be able to start deciding what to do for the patient. One of the things that we're talking about when we say we drive efficiency in care is that we are bringing all the key stakeholders for that care coordination in one place, in a HIPAA-compliant platform where everyone can communicate and be able to really drive efficiency in how patients are cared for. So that's one piece.’’ 10:18 Enhancing patient care with a mobile app Moleen explained how the Viz app enables surgeons to make critical decisions from anywhere in the world. ‘’So we have a mobile app also it's available through the web where the rest of the team that's actually put onto to the Viz system are able to see within their clinical hospital system what they need to be doing for the patients that they get the notifications for. So in many ways it's really more about bringing key stakeholders into one place so that they can actually be able to efficiently make decisions. Think of it this way, let's just say that a very key surgeon is not on campus at the time and they're away somewhere, but a critical case that is come through. Instead of waiting for the surgeon to drive all the way back to the hospital and make some decisions, after looking at a case on a computer on campus, they can actually make that decision from wherever they are in the world, 24/7 by actually being able to access the Viz app on their mobile application.’’ 12:59 Allowing the data to lead Moleen said that allowing the data to lead can help to overcome hesitancy around AI in healthcare. ‘’When we think about hesitancy, a lot of times it's really more about not having really led more from understanding how do you validate it? How do they see the economic impact? How are they actually able to make decisions really from allowing the data to lead. This is where I really come in in my role recognizing that yes, we have an amazing marketing team, we have a great engineering team and AI team, but research is really integral to what we do because then we're able to really validate for real world evidence that can support a lot of the decision makers who may have had questions. So any of the research questions that we ask really should be really lending more to where is the gap within the clinical discourse? Where is some of the hesitancy? How can we actually start making some of those decisions a little bit easier for those that are tied to making these very important decisions for any of their healthcare systems across the country?’’ 14:45 The importance of human connection Moleen explained that Viz.ai systems work in parallel with clinical workflow. ‘’So as I pre-empted earlier in my introduction of myself really having been born and raised in a communitarian spirit and recognizing that human touch is really the integral part of who we are as a human experience, but what I can say is at Viz.ai, we really developed our AI systems that work in parallel with the clinical workflow. So we're not replacing radiologists or any other of the specialists. What we're actually doing is just providing a tool that can actually make their work more efficient. So there are several different areas that we work with experts within the field to really be able to drive that point that we are not here to as a replacement, we actually honor the fact that there is a human touch.’’ 17:49 Inspiring change with personal integrity Moleen emphasized the need for starting with the ‘’why’’ to get buy-in on strategy and change. ‘’… for me it always starts with my own personal values that then overlay onto my professional brand in the work that I'm actually set to do at Viz. From a personal perspective it is really more about integrity. In who I am I am actually able to define what sort of work I want to do in the world and how I do that work. But most importantly why. So we always want to start with the why because as we're inspired, others then really begin to buy into the story because they're recognizing this is actually legacy work. It is beyond what we are doing in our time. What I really wish to see is 50 years from now, a hundred years from now, well past our time, others will remember and look back and say, we're so grateful that there was this generation that came in and did such quality work with such kindness, with such quality in such a way that they really opened up the door for what AI can do, what clinical trials and clinical research can actually do in terms of shaping the direction in which healthcare is going.’’ 20:30 Getting everyone on the same page Moleen said looking for things people have in common helps to overcome differences. ‘’So as part of my self development, my professional development, I recently took a course out of University of Pennsylvania through the MBA program that's called Executive Presence and Influence. One of the things we're talking about in that class is really recognizing that influence is a lot more about narrative. So really beginning more with my story so that we can actually find ways in which we have a lot more in common than we have in differences, but also really being able to have this specific communication that recognizes that you may not be seeing things from my vantage point because you are not there yet. So I tend to be very patient. When I'm building relationships with our clinical partners I recognize that it is really more about waiting until the time is right for us to move a certain project in a different direction. In the meantime we continue to build the relationship through other things where they're kind of ready to actually be able to talk about.’’ Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Moleen Madziva on LinkedIn Check out VIE Healthcare and SpendMend You’ll also hear: Moleen’s career history, from engineering graduate at Drexel University, to Viz.ai, via telecommunications and clinical trials. ‘’When I joined about two years ago we didn't have a structured clinical program, so it has really been my task every single day to ensure that we can bring forward a clinical science program, clinical operations program, and expand it.’’ The growing impact of Viz.ai in global healthcare. ‘’We are live in about 1400 hospitals across the US and also live now in the number of hospitals within the European region. So just to be able to say that, yes, there are many hospitals that are recognizing the impact of AI and really leaning into embracing what it can actually do within their systems.’’ ‘’Kindness wins’’: How Viz.ai’s core value permeates their approach to customers, physician partners and clinical partners. Putting patients first: inspiring change based on the premise that ‘’no patient should get left behind.’’ Bringing lifesaving treatment more efficiently to patients. Why Viz.ai’s mission is a legacy work. ‘’We’re not doing it just for one company or one patient. We’re really doing that as a global phenomenon.’’ What To Do Next: Subscribe to The Economics of Healthcare and receive a special report on 15 Effective Cost Savings Strategies. There are three ways to work with VIE Healthcare: Benchmark a vendor contract – either an existing contract or a new agreement. We can support your team with their cost savings initiatives to add resources and expertise. We set a bold cost savings goal and wor
Changing Your Healthcare Mindset with Rhone D’Errico | E. 63
Changing times require a change in mindset. Episode Introduction The pandemic forced health systems to explore new ways of delivering care and education. Rhone shares the benefits of LinkedIn as a mindset platform, the skills unique to Nursing Practitioners and how students in search of preceptorships can benefit by taking the ‘’cookie basket to the clinic’’. He also explains why telepsychiatry provides patients a safe space and extols the power of servant leadership. Show Topics Changing your mindset: LinkedIn as a daily platform Overcoming the stigma of online learning for Nurse Practitioners Responding to the preceptorships crisis The benefits of hiring Nurse Practitioners Telehealth is a mindset shift Leadership lessons – getting in front of the problem 12:31 Changing your mindset: LinkedIn as a daily platform Rhone described how LinkedIn provides a platform to highlight the benefits of changing your mindset. ‘’….. it kind of reflects probably what my true passion really is and it's teaching, it's coaching, it's advising, it's helping others, all high performing professionals, but especially nurses, nurse practitioners, to really find their true profession and their true passion and where they want to go in their profession. So basically in LinkedIn, I just started writing, it's my daily writing platform, and I got to the point where I just want to write about what I'm just obsessed about, and I'm obsessed about nurses leveraging our skills and ability and our knowledge to become creators in this digital era because we have this whole new world to us and there's so much burnout and stress and pain among healthcare professionals. And I'm not trying to pull anybody away from the bedside, I honor the bedside, it's a necessary position. I honor those that are doing it, but I just want to make sure that I am illustrating to my audience options. And, the main start is you have to change your mindset, that's where it all begins. All the technology, all the toys, all the tricks are not going to do you a bit of good until you really change that mindset and say, "Hey, not only can I do this, but I have so many resources as a nurse or any healthcare professional, that there's a whole world out there that would love to take advantage of that knowledge, and I have this tunnel vision that all I can do is bedside, administration, education." So, that's really all about. So I post on LinkedIn, I post pretty much every day. I invite anybody that wants to follow along, please do. I talk about mindset. I talk about very tactical tricks and tips on how to promote yourself online, how to find your niche, how to build an online business, those sorts of subjects.’’ 15:55 Overcoming the stigma of online learning for Nursing Practitioners Rhone said that the pandemic ‘’normalized’’ online learning and the didactic portion is delivered online. ‘’But in terms of delivering our didactics online, communicating online, using Zoom, using online learning management systems, we were ready to go at the graduate nursing program and we were ready to really bring that skillset, and we were kind of the bullied kid in the corner that got to say, "Hey, now you need us. Now you need online education." And so what I would say mainly, especially to employers, to hospital systems, there's always been sort of a stigma about online. And, we've had to defend that and a little bit less now because of COVID, honestly, because so many people did it and it got normalized, but I will say don't necessarily be frightened off by that online if you see that related to a graduate school. Like all education programs, there can be some variance in quality. We have accreditation programs that really work to make sure that that variance in quality is very narrow. We always work to have high quality graduates. And then within all the schools I've ever worked, there is strong quality improvement mindsets involved there. So, your one big trend though is that nurse practitioner education, to the large extent, not 100%, but to a large extent, the didactic portion is delivered online. And, what that's led to also is an explosion of nurse practitioner programs because you don't have quite the same capital investment cost to build a new building when you can deliver so much of your didactic education online. Now, that's of course, this is market forces we know on the business side. So, now we have a pretty large pool of nurse practitioners, primarily family nurse practitioners, that's why a lot of them went to the psych NP route as a post-master's, but now we're seeing that with psych too.’’ 20:19 Responding to the preceptorship crisis Rhone offered advice for clinics inundated by calls from NP students for preceptorships. ‘’That's the bottom line. Nurses, nurse practitioners, physician associates, physicians, we all need to learn by actual patient interactions. Some of these clinics are getting hundreds of calls a day from nurse practitioner students from around the country because a student may be in that area, but they're actually attending a program where the didactics are offered online, so the headquarters of the program could be in another state. So, these clinics are being inundated with student requests for preceptorships, and it really is a crisis because it's such a struggle. I don't know that there's not enough placements for everybody. I tend to think it's a systems issue, and that's where I think the solution's going to come, where if you're not properly distributing your asks, that's where trouble comes up. Now, the university I work with right now does an excellent job of that, previous university did as well, of having a really active placement coordinator that is being very mindful. Okay, I've already asked this site. They said no way, so I'm not going to bother. I asked, this site's taking three students, I'm not going to keep asking them because I've kind of filled them up. Here's a new one, maybe I'll reach out to them. And, what I tried to do in my roles is really teach some of that biz dev, teach them business development to the universities and that mindset of like, "Don't just call with an ask. Take that cookie basket to the clinic and not just the cookie basket, sell them on it." Our students are very qualified, they're very well supervised by their faculty. This could be an opportunity for you to grow your own staffing, et cetera. You have to have some sales and some strategy to get that, but the bottom line is we have a lot of students, and we don't necessarily have enough clinical placements, at least in a way that's efficient, and it's just becoming more and more of an issue, and it will continue as more and more students enter these programs.’’ 23:34 The benefits of hiring Nurse Practitioners Rhone said that NPs offer both clinical and interpersonal skills for hospitals. ‘’Absolutely, and I think that's a great question and I think as nurse practitioners, we have to lead with our value. You always lead with the value you bring. So, nurse practitioners have been providing safe and reliable and evidence-based excellent patient care for well over 40 years now. I think we're going on 50 years since the foundation of our profession. So when you hire a nurse practitioner, you're hiring someone that has some registered nurse experience to some degree. It can be a relatively small amount, it can be many, many years, but you have somebody that is comfortable with that fundamental patient interaction. I think that's really the advantage you're getting as an employer. You're getting a clinical expert, someone who is trained to perform clinically in whatever specialty they're being hired into, but they also have that human connection that's offered by a nurse, the ability to make that interpersonal connection with your patients. That's the mindset we come to it as nurses. So, I don't bring in a bunch of comparisons to other professions. I honor all healthcare professions and the roles we play, but I do know that nurse practitioners bring very real value in terms of quality focus on patient care, efficiency, and really making that human connection to ensure that our patients are healing and able to live their best possible life.’’ 26:53 Telehealth is a mindset shift Rhone said that telehealth is integral to healthcare and help with maintaining appropriate boundaries. ‘’ I tell my students as they come through that and as they're graduating, and this kind of comes back to my coaching, advising mindset, I say, "Listen, A, don't try to hide that you did some of your clinical work via telehealth and don't be ashamed of it. You need to put that front and center and say, 'In my nurse practitioner program, I specifically learned the best practices of telehealth and I actually practiced in that modality for a portion of my clinical experience.'" So, again, it's mindset shift. That's something to brag about because I was assigning assignments about, tell me the best way to deliver a neurological exam via telehealth. You only have telehealth available, you need to perform a neurological exam, what are you going to do? And they would do research, go into the literature, and come back. So, we learned about that telehealth and there's lots of literature out there showing what incredible patient outcomes we've had. I have a great rapport with my patients via telepsychiatry. In telepsychiatry specifically, I think there's a benefit to it because a lot of what we deal in psychiatry, especially with our most vulnerable populations, which is what I deal with, there's a lot of boundary issues. And being physically in front of a healthcare provider can be very, very intimidating or triggering or anxiety-inducing in some psychiatric clients. And so this telehealth, they really open up to me because they're safe, and I meet the requirements of that eye-to-eye, face-to-face contact initially, but I always tell them, listen, once
Learn about HeartFlow, the technology revolutionizing precision heart care. Episode Introduction Heart disease is the leading cause of death in the US. HeartFlow’s non-invasive, cutting edge technology aims to improve the patient experience and make cardiovascular care easier for physicians. Topics include, the barriers to obtaining an accurate diagnosis of coronary artery disease (CAD), condensing the patient experience into a single CAT scan, the data supporting the new technology, and why 80% of the top 50 heart hospitals in the US use HeartFlow. Show Topics The challenge of diagnosing CAD Invasive treatments impact the patient experience Condensing the patient journey into one CAT scan The importance of data in making treatment decisions HeartFlow is revolutionizing precision healthcare Embracing new technologies 12:00 The challenge of diagnosing CAD Lauren highlighted the difficulty in getting an accurate diagnosis for the causes of chest pain with existing processes. ‘’….heart disease is the number one killer of all Americans. One in every four deaths is going to be related to heart disease. And when someone has stable chest pain, so I'm not talking about MI, the big MIs, those are going to go right to the cath lab or surgery, but when someone has stable chest pain, historically this would trigger a clinician to order a stress test, whether that be exercise, an echo, there's different nuclear scans, all of which have their right place within the medical field and can be very useful. However, specifically for coronary artery disease, these tests show areas of decreased blood flow in a particular area of the heart, or raw motion abnormalities. But it's not clearly answering the question at hand, which is, "Do I have coronary artery disease that is causing my chest pain? Where? Which artery? Is it several? Is it just one? At what spot?" When you want to ask these specific questions, those tests really don't answer those questions. And in fact, 20 to 30% of the time when you go for these tests, they are inconclusive or can give a false reading. So that's pretty concerning. That was surprising to me, personally.’’ 13:30 Invasive treatments impact the patient experience Lauren said that over half of patients undergo diagnostic cardiac catheterization unnecessarily. ‘’Imagine you have this chest pain and they say, "Oh, we don't know what it is," or, "Looks great." Then something bad happens or looks bad and you end up with further testing that ends up being nothing. So usually it starts with some type of non-invasive test. If the chest pain continues, then the patient would typically be sent for an invasive cardiac catheterization. We're using needles catheters, it's usually in the groin or the arm, dye and radiation are administered. You shoot that dye and you can visualize the coronary arteries on a 2D image that looks like an x-ray in the cath lab. And that's often the gold standard of historically ruling out, that true coronary artery disease, yes or no. Another surprising thing I found when I came to HeartFlow, 60% of the time when patients go for this invasive test, the coronaries are found to not be obstructed. More than half. More than half of the people going to get a diagnostic cardiac catheterization, either they find nothing or they find something that can't be intervened. So you have a ton of patients in a healthcare system getting tests that may not be helpful in their diagnosis for creating a treatment plan. And this causes a real strain on the patient experience, so they're getting bopped around from test to test, not quite getting their answers yet. Staffing, huge issue right now. Costs to the healthcare system, accuracy of the diagnosis, like you mentioned with your family member, and ultimately the outcomes. There is a problem that we are definitely trying to solve here.’’ 16:30 Condensing the patient journey into one CAT scan Lauren explained the proposed new testing pathway with HeartFlow and the benefits to the patient experience. ‘’HeartFlow, it takes the coronary CT angiogram, so a CAT scan of coronary arteries, which is then analyzed by our proprietary software to provide non-invasive CT derived FFR. So we refer to this as FFR CT and we can help physicians understand the physiology and clinical significance of a disease in the coronary artery now in a non-invasive way. So everything that we just talked about, that historical patient journey, can be condensed into one CAT scan, and we can get you so much information in one short visit. So the proposed new testing pathway, which has been... It's in the guidelines as well, the patient undergoes a typical coronary CT angiogram. This is fairly quick, it's not invasive, your coronary CT is extremely accurate in providing the anatomy. So this has been proven. Your CT can show narrowing versus not narrowed arteries. Physician sits down, they're reviewing the images, and they notice a narrowing of 40 to 90%. At that point, he or she can request a HeartFlow analysis. So the raw scan images are sent to our artificial intelligence-based technology that creates a 3D model of the patient's arteries. So it's a combination of both artificial intelligence, deep learning, and people, because the next step is that trained analysts, human beings, review the model for accuracy. So at least two people, sometimes up to five, depending on how complex it is, will actually sit down, look at every lumen, look at every tracing that the computer has derived to say, "Is this accurate?" And then the model uses some pretty high brow mathematics and computational fluid dynamics to quantify the blood flow in those modeled arteries. The completed analysis is then returned back to the hospital via the PAX imaging system and/or the EMR, the electronic medical record, within about four hours. And we even have the abilities... It's very cloud-based as well, so that you can also access it on a phone, an iPad, or any PC using our HeartFlow user interface, which is certainly securely stored. And then after that initial CT scan, there's no additional testing to get the HeartFlow analysis. That's really important. The patient doesn't have to come back in. We can just apply the technology to those who need it. And in about 30 to 40% of coronary CTs this will be applicable.’’ 20:30 The importance of data in making treatment decisions Lauren said the data supporting HeartFlow helps to ensure doctors don’t put stents into people who don’t need them. ‘’A clinician now has information on both anatomy and physiology regarding patient specific coronary arteries. And it's amazing how those two do not always match…..And even with very visually narrowed arteries, like 70 to 90%, there's still a one in four chance that it's not physiologically significant. So the fact that those two things don't always match or they're discordant means that we really need information on both. And there is a risk, there really is a risk of doctors putting stents in people who don't need them. It's Not a benign procedure, and ultimately what we are providing is the data for physicians to make the right decisions for the right treatments at the right time…. And it's also backed by long-term studies with data out to five years. We have evidence from over 500 peer reviewed publications. It's recognized in the professional guidelines. Just last year in 2021, the chest pain guidelines were revised, I think for the first time in 10 years by the ACCAHA organizations. So now FFRCT, which is only offered by HeartFlow, is in those guidelines, and you may even hear the term CT first as a hot buzzword out there, and that's a result of the guidelines that getting that coronary CT scan is a level 1A recommendation for stable chest pain… 23:30 HeartFlow is revolutionizing precision heartcare Lauren explained how HeartFlow empowers the patient with a comprehensive and rapid analysis. ‘’… we're patient centric because we offer the first and only test in the market that helps physicians give the patient answers about their heart disease in a non-invasive way. I imagine if you or I had chest pain, I kind of want to know the answers pretty quickly to what's going on with that, knowing what we know. And my favorite part of the job, as you mentioned, is when a patient sees that model of their 3D analysis, seeing that visual…..So medication and health compliance, discussing care plans, and certainly even follow up to the primary care provider or that referring physician is impactful. These physicians are sending the patient for a test and it's wonderful to empower them to understand what's going on in those arteries and then be able to pass that along to the patient family. And we even take it a step further. We have a recent FDA clearance of two additional offerings, so we're not stopping at just FFRCT. We are going a step further. We have the roadmap analysis, so that provides support for a quick analysis of potential stenosis areas in an anatomical model. And then plaque analysis helps physicians to identify and quantify plaque in the coronary arteries. This is phenomenal. I think it's going to be a game changer. So we're the first and only company to offer a full analysis on your anatomy, physiology, as well as plaque, putting all those pieces together. So that's how we're moving the needle forward.’’ 32:30 Embracing new technologies Laurie said that ultimately, the adoption of new technologies is often based on the patient experience. ‘’I think for clinicians the science has to be solid, number one. The workflow must be easy. I mean, clinicians have so much on their plate nowadays in such limited time that it has to be efficient. And ultimately, adoption, in my opinion, seems to be based on the patient experience. The first time a clinician gets information on that suspicious lesion that's further validated by HeartFlow, FFRCT, they can feel confident in makin
Healthcare Cost Management Best Practices | E. 61
Discover six ‘’better than best’’ practices in cost savings for hospitals. Episode Introduction Adopting new habits can reap significant cost savings rewards. Lisa introduces six proven best practices including, creating an Accelerating Cost Savings team, why hospitals should follow the cost savings ‘’yellow brick road’’, and why frontline employees are your best source of innovation. Lisa also cites Tom Cruise as an illustration of how hospitals can benefit from cost reduction experts and reveals why reducing waste and understanding variation is the new area to uncover cost savings. Show Topics Creating an Accelerating Cost Savings team The vital role of a cost savings roadmap Following the example of Tom Cruise The cost savings benefits of negotiation skills training Vendors and employees: the price of relationships Ask for new ideas from your frontline employees Implement a cost savings discipline Reducing waste and understanding variation 01:54 Creating an Accelerating Cost Savings team Lisa said the creation of a leadership team for cost savings must include key department leaders, not just the CFO and their team. ‘’One of the best practices from the field that I have been involved with over the number of years, but particularly in the last two years that's been particularly successful during this challenging time, is creating a leadership approach to cost savings….. I've taken some wording from different hospitals that have used a version of this. We kind of created our own now, but it's called Accelerating Cost Savings team. So having an accelerating cost savings team and this team just can't be the CFO. The CFO does absolutely need to be involved but this needs to be a leadership team that consists of a CNO, the CFO, the Chief Medical Officer, VP of Supply Chain, VP of Performance Improvement, and key department leaders that come in and out of the group as needed. And this doesn't have to be an overbearing, "Oh, it's another meeting." This is a weekly meeting. It's usually kind of in conjunction with an outside partner. We've done this work and it's been really effective and I think from the feedback we get from hospitals and why these teams have been so successful in pulling together these cost savings initiatives and achieving tremendous outcomes is having a trusted partner as part of the team. And I'm soon going to be finishing up on lessons learned from one of these teams and we've had the opportunity to interview everybody on the team and get their feedback. We asked them 10 questions and we've pulled it all together and it's going to be really interesting research, but I do feel like having this team, even if they can meet, be a conference call, even if it's 45 minutes a week, I will tell you that it's transformative.’’ 07:49 The vital role of a cost savings roadmap Lisa cited Keith Cunningham’s philosophy of following the ‘’yellow brick road’’ to cost savings to achieve your goal. ‘’Number two is to have a detailed cost saving strategy, a roadmap. We work on these cost saving strategies and roadmaps for our clients and they take a totally different approach or a totally different and totally different outcome versus those hospitals that just say, "Okay, our strategy for this year is we need to take out $40 million and that's our goal and we're going to take out $40 million. Go do it. Go find it." And it's departments it's kind of divvied up. And that's a really hard way, I think to go about it. These goals are just getting bigger and bigger. So better than best practices. Have a strategy, sit down, spend the two or three days, bring somebody in that can lead the initiative and kind of pull it all together.Have a roadmap, this playbook that now you know, what's going to happen in January? What's going to happen in February? Where are we going to look for savings and which departments? It's not a broad takeout 5%. These are the areas we're really going to focus on and this is how we're going to do it. And this is...really going to focus on. And this is how we're going to do it and this is who's going to do it. I'm going to cite Keith Cunningham again. I just recently went to one of his training programs, it's called Plan or Get Slaughtered. It's amazing. I highly recommend that to those listening. But he talks about create the yellow brick road, like you want to get to 40 million in savings, what's the yellow brick road? He often talks about, what's the Google Map? If you want to go somewhere, you need a Google Map to get there. And sometimes we don't create the map, we don't create the steps, the roadmap.’’ 11:46 Following the example of Tom Cruise Lisa shared her reflection of why hospitals can benefit from experts when it comes to cost savings (inspired by Mission Impossible). ‘’ I think it was on LinkedIn or somewhere, but it was Tom Cruise. They were showing him in his new movie. It's the new Mission Impossible movie…..And they were just talking about all the experts he brought in. And I think that's what caught my attention because we, I think, downplay or we don't invest or we don't see value because we just think it's the money. Everyone is, "Oh, it's too expensive." Well, it's probably too expensive not to do that. So it caught my attention. So I just watched it, which it's kind of funny. And I probably should just put on my LinkedIn too, because it's so interesting. So what happens is in this Mission Impossible movie, from the seven minutes I watch, he basically has a motorcycle and he motorcycles off his ramp. I think they're in the Netherlands, into a canyon. And he's got a parachute, so the motorcycle's got to go drop. And then he got a parachute to the small space in the canyon and he does the stunt. You have to watch, it's remarkable. So they show him, during this seven minutes, that he basically practices motorcrossing on this ramp. Something like 1700 times, he's practiced this jumps. The small first jump is like 10,000, sorry, 10 feet, 20 feet until he can jump 70 feet or whatever it is. And he becomes this expert at jumping in a motocross jumping. And then he ends up, so parachuting out of a plane, he ends up doing it like 10, 15 times a day. A day. And he's doing all these things, so he could be so competent. He has all these experts. … We all think it's for the elite athlete, business elite, but it's possible for us to do the same thing. It's not meant just for the elite. Why aren't we any different? We're not different. 17:47 The cost savings benefits of negotiation skills training Lisa emphasized the difficult and psychology-driven nature of negotiation with vendors. ‘’It's really hard. This isn't just getting into an office and dunking it out with somebody on pricing. Negotiation, is a lot of influence driven, it's a lot of psychology, it's a lot of alignment. And most people-don't like it. Most people are not good at it. And either you need to have skills training, like you talked about, you have to practice. Having a coach is really important because you need to be able to bounce off ideas or here's my experience in this situation, you want to try this? Negotiations can move the financial needle big time. I'm talking, I have seen, again, situations where we've had the absolute best analytics, strategy, alignment and we may not have been in that negotiation for whatever reason and I just see it, the returns diminish. Versus, a well executed negotiation strategy just has, just compounding dividends.’’ 18:59 Vendors and employees: the price of relationships Lisa Larter highlighted the impact of relationships on discussions around money. ‘’ I think one of the things that people forget is that employees who work in hospitals develop relationships with vendors. And when you have to try to negotiate something with someone you have a relationship with it's hard. There's all kinds of emotional stuff that gets in the way because you're trying to protect the relationship. And so when you have that outside person that helps you formulate the strategy so that you can negotiate from a place of, I guess, authenticity and integrity it's just so valuable. Most people are uncomfortable talking about money period. And so when you are putting somebody into a situation where they have to negotiate something that isn't really their money, let's be honest it's not their money, it's the hospital's money, there's all this garbage that shows up in terms of your mindset and belief on what is possible. So I think I really like that one, having somebody to help you because it's a really difficult skill to do by yourself.’’ 22:48 Ask for new ideas from your frontline employees Lisa said the most innovative, entrepreneurial insights don’t necessarily come from leadership or the lab. ‘’Number four, and I feel like this used to be done a lot more and this isn't an idea box but it's a lot of different ways to do this, but it's asked for ideas on the front lines. It's an interesting study that shows that about over 62% of new innovations and ideas and entrepreneurial insights come from employees and not from leadership or the lab, it comes from them. And I know that hospitals have these kind of virtual ways that people can put their ideas in. I feel like there really needs to be a more engaged, substantive process and maybe a kickstart to it all. We used to do very frequently, don't do them as much now and I think hopefully we will now somewhat post-COVID, but we call them Excite Programs. So we'd come in and we'd lead these Excite Programs, it's about two and a half hours and we would really have a lot of fun and have some ideas and some teamwork environment and track those all the way through. But I think it has to start with some kind of formal engagement, some kind of formal way to bring people together versus an idea box. Certainly that's probably a podcast for another day. But how you get those ideas is important too. Somet
Innovative Cost Savings Ideas For Hospitals In 2023 | E. 60
The top healthcare cost savings strategies for 2023. Episode Introduction As hospitals struggle with spiraling costs, Lisa Miller reveals seven key ways to save money in the next 12 months. Topics Include how ‘’flickering’’ helps to reflect on cost initiatives, the need for a Chief Expense Officer, the midterm contract reviews that helped to save one hospital over $19 million, and how data creates a 14% cost shift when presented to physicians. Show Topics Adopt a comprehensive approach to cost savings Hospitals need a Vice-President of Costs (or equivalent) Successful contract management requires a mid-term review strategy The benefits of zero based budgeting Insource versus outsourcing Raising physician cost awareness Creating a cost-conscious culture in hospitals O1:30 Adopt a comprehensive approach to cost savings Lisa challenged hospitals on how much insight they have into their cost savings projects. ‘’So what I mean by this is today, if you're a C-suite leader or you're a supply chain leader, if you wanted to know every single cost savings project that's going on in your organization, could you open up an Excel, some kind of dashboard, platform or something, and have line of sight into every single one? And my experience has said, when I've asked that question, that 100% have said, "No. We do not house every single initiative that's going on in the organization." And I think that bringing these initiatives all together so you get a complete picture with complete visibility, cohesiveness, understanding what's going on, and of course that terrible A-word which is accountability, bringing it all together, we'll have just another level of savings because you just have a complete view. And so I challenge anyone that's listening to the podcast today… I'm going to tell you that the effort to just house everything together is literally ... game changing for a lot of reasons. And I'll talk about those for a moment. But I want to give you one more nuanced thought…..Could you go back 12 months or go back in the last six months and say, "Okay, what are all the initiatives we worked on and what will be completed?.....my number one advice is to pull those projects together…. get a complete picture, invest in that time.’’ #2 Hospitals need a Vice President of Costs (or equivalent) 09:00 Lisa explained why every health system would benefit from a position that focuses on costs ‘’This vice president of costs or this person who just focuses on costs where they can have line of sight to everybody and they work with everybody. …. last month, just by accident, I came across somebody, and I'm hoping that I get that person on this podcast soon…they do have a title and I've researched it since then. And there's a few of these titles out there. The title is Chief Expense Officer. I've taken an excerpt from their LinkedIn page and it says, "Senior leader collaborating with the health systems' clinical and administrative leadership to identify opportunities to create value." There's also this really great line, and I think I'm going to say this super slow. I might repeat it. It says, "Leveraging experience in expense management and analytics to reduce waste and unwarranted variation and eliminate excess cost. Leveraging experience in expense management and analytics to reduce waste and unwarranted variation and eliminate excess cost." .. their job is a Chief Expense Officer. So I feel like that's an innovation for hospitals. Again, an innovation is a process. It's a way to think about their business, a new position, right? Innovative positions. And I think that Chief Expense Officer is an innovative position. And I had in years past said there really needs to be this Vice President of Cost or of Costing or Cost Structure. But you can have a VP of Expense, but this, another CEO, Chief Expense Officer, I think makes a whole lot of sense.’’ 12:00 Successful contract management requires a midterm review strategy Lisa shared how her team identified over $19 million of cost savings carrying out midterm contract reviews for one hospital. ‘’Everybody has a strategy for contract renewals. So when renewals come up there's a strategy, an RFP strategy or a renegotiation strategy. There's a strategy for net new, going out to the market. And again, it could be RFP or it could be a rigorous internal process. But I does feel like there's really, again, an innovative process to look at your contracts, and that's having a midterm strategy. And so having a midterm agreement strategy means that you've got probably a large amount of your agreements now, maybe 50 to 60% of them that aren't coming due in the next year, 18 months. They're in that three to five year, three to seven-year cycle. And so that usually gets tucked away and like, "Oh, we're going to do that in the next two or three years." But I think every hospital at some point or other, you can't do this all the time, but at some point they put a stake in the ground and say, "We're going to look at all of our agreements that are in midterm and we're going to benchmark them. We're going to analyze them." And we had done that for a lot of our hospitals. We actually did this for one health system just for their IT. They were a large IDN, several hospitals. The CIO wanted to look at all their agreements. In particular, wanted a company that had expertise looking at contracts midterm and could renegotiate them... we looked back after about two and a half years and saved them over 19 million dollars.. some of the greatest savings came from the midterm agreement renegotiations. Now if you think about it, these are agreements that wouldn't have been looked at for years.’’ 19:00 The benefits of zero based budgeting Lisa outlined the financial benefits for hospitals adopting zero based budgeting. ‘’..Zero based budgeting essentially is assuming, given your budget is zero, and now you've got to explain everything you want to put into your budget versus having a budget and saying, "I'm going to keep that same budget for 2023 or 2024 and I'm going to plus or minus five or 10%," or there's some kind of way you look at it. You can look at it rolling 12 months, rolling three months, versus saying, "I've got to explain everything I'm going to put in." And that is just a really high performing way to look at your budget. And we've done that with hospitals, taken away the heavy lift part of it because it is a bit of a heavy lift and really it's just been remarkable how much we take out by taking that approach.’’ 20:00 Insourcing versus outsourcing Lisa said hospitals that outsource should make 2023 the year to carry out an in-depth analysis to ensure it is still cost effective. ‘’You could, right now, insource your dietary and you may in the past have taken analysis to look at, well, what it would save us or what would be the benefits of outsourcing? I think this year we've got to look at that again. And so much has changed. It may be very beneficial to outsource dietary or, for your hospital, it may be really beneficial to insource. Lisa, you and I talked on the past episode about food costs and maybe it would make sense to bring in dietary and use local providers for dietary that could bring down costs. Years ago, I remember having school lunches and I've had community members or family members who actually did the cooking for the school. This is way back because I'm aging myself a little bit, where you would have people cooking in the back and you'd have really well prepared lunches for schools versus some of the things that may happen now versus home lunch. So what innovative ways could a hospital say, listen, maybe we want to insource it and maybe we want to use the local community. Maybe that's the way you don't want to outsource anymore because the outsourcing costs too much. But I think the whole idea around this is that whatever you're looking at internally that you've insourced, that's not a core business, consider the analysis to outsource.’’ 24:30 Raising physician cost awareness Lisa explained why consistency in providing cost data to physicians can result in significant cost savings. ‘’Physicians, their decisions drive about 70% of costs in organization. And so I feel like we don't do a good enough job at showing physicians their cost. It's not telling them how to do business. We, of course, sometimes have to get them aligned when there's a cost savings initiative. But sometimes it's simple as just telling them, showing them where their costs are and showing them the numbers. And I feel like ... I often say they're scientists. If you give them the data and the information and given some comparisons in a very smart analytical way, they're going to make some really great decisions. We just don't do it, give it to them in a way that's meaningful and then we don't do it consistently, if we do it at all. And they were frustrated that when we come to them for a cost savings initiative, maybe there's a little bit of conflict because that's the only time we come to them. So I think this physician cost awareness, in a really collaborative way, getting a champion and putting that together, again, it requires some planning and maybe some outside resources to help you with that, but it's really important. There's a study that shows that they had two groups of physicians in a surgical line in the OR, and just by showing this one group of physicians their cost ... they just showed it to them, they didn't tell them they wanted anything. They reduced their costs by 7.2%, just showing them the data. The control group, which didn't get the pricing data, the cost, they had an increase in that same time period of like 6.7%. So if you can imagine, there's this shift of 14%, right, by just showing physicians the cost information. And the ones who didn't see it, they just had a natural increase in their cost. So why aren't we just using this very innovative, sim
2022 Healthcare Cost Savings Year In Review | E. 59
Lisa Miller shares her experience of successful hospital cost savings projects from the past 12 months and looks ahead to 2023. Episode Introduction Lisa Miller shares her experience of successful hospital cost savings projects from the past 12 months and looks ahead to 2023. Topics Include. the need to set big stretch goals, how dysfunctional teams affect change management projects, the in-depth cost analysis that saved jobs at one hospital, when people would ‘’rather be rich than right’’, and why the ‘’tsunami’’ of inflation is still healthcare’s #1 priority in cost management. Show Topics Healthcare’s approach to marketing needs to change Huge cost savings are still available for hospitals Incentivizing right behaviors to achieve big wins The 5 dysfunctions of every team Big health systems have big spend challenges Purchased services spend is a cost savings opportunity The ‘’tsunami’’ impact of inflation on hospitals 01:33 Healthcare’s approach to marketing needs to change Lisa Larter said businesses and hospitals must focus on the things they can control, rather than media negativity. ‘’…one of my insights is the marketing landscape has changed significantly in 2022, and things that once worked no longer work. And so whether you're a hospital who has a marketing team or you're an entrepreneur or a small business owner, the way that you approach marketing needs to really change. You can't do what you used to do to get the results that you want, because what used to work isn't working. And there's an expression out there that if you just try harder at something that doesn't work, it doesn't make it work. So it's really a time for innovative thinking when it comes to marketing. The second thing that I would say that I've noticed in 2022 is too many people are listening to the media, and they're buying into doom and gloom instead of taking charge of what possibilities are out there. I think that people forget the media gets paid for clicks, and they get paid for impressions and eyeballs and all of that stuff. And so when people read headlines in the media about the recession and they start to panic and worry about things, instead of getting into a place of "How can I make changes? How can I improve my business, how can I improve my profitability? What is within my control?" I feel that they're missing opportunities. So I see a lot of people that are almost immobilized by what they see in the media, instead of taking control of the so many things that they still have control of. So those would be the two things that I've really noticed this year.’’ 08:33 Huge cost savings are still available for hospitals Lisa Miller shared a ‘’wow experience’ of how digging deep into cost saving prevented job losses at one hospital. ‘’I absolutely, unequivocally know there's opportunity in costs. And our clients are achieving unprecedented cost savings in almost every single area. And what I think is very interesting is we're finding big savings. And it's not because these initiatives weren't done prior or people aren't good at what they do, I just feel like we're going deeper. We're taking more time. There's a lot of AI and technology, and we have technology too, but nothing replaces human thinking, a human review, expertise. And we're finding just enormous amount to take out in cost. So I feel like that's an opportunity. It shouldn't be perceived as a downer. Like, "Oh, we've got to have a cost review." And I think really we need to flip the script on it. And I think there's opportunities to connect growth, connect employees and morale and have a culture around that. One of the things that happened last year, I had a number of these situations happen, but we had one, it was really unique. We had uncovered a couple of line items that happened to just fall off contract. We were just, and this is a very advanced health system, very smart people, and it was just this odd connection issue. And it just turned out to have a several hundred thousand dollars savings. And when we achieved it, we brought it to the department leader. The leader was about to have to lay off three people in their department. And these were just, I think it was an environmental service department. And because of that savings, he did not have to lay off anybody. …. it's a wow experience for me.’’ 16:20 Incentivizing right behaviors to achieve big wins Lisa commented that hospitals need to set one or two big stretch goals to achieve significant cost savings. ‘’And so many of our hospitals bonuses, part of the bonuses put in place are hitting certain milestones. And cost savings is one. And I think that's fantastic. I think the nuance about that is what I've noticed is sometimes people get one cost savings goal. Let's say they have to achieve, I don't know, a million dollars in cost savings for the year. And sometimes they may achieve that in the first quarter. Like me, Lisa Miller, my goal is achieve $1 million for general hospital, and I could hit that in month three. Now I have other responsibilities, of course. It's not my own responsibility. I have to, I'm strategic sourcing, I'm doing all these other things, but what happens for those other nine months? And so my experience is very well-intentioned. Good people have checked the box, have said, "I've got that one covered. Now I can focus on my other day-to-days." And I work and I may get thrown something else. So I check that box and I think, "Oh my goodness, you got nine more months. Come on, let's save more money." And they got a lot going on, and they've clicked that box. So I think there's an opportunity to really evaluate these cost savings goals and make a stretch goal. So you have a million, but maybe there's two stretch goals. And I think there's a missed opportunity there.’’ 21:41 The 5 dysfunctions of every team Lisa said there is a change management aspect to achieving cost savings. but team dysfunction can be a barrier to success. ‘’So okay, this is where I might get a little controversial. So with cost savings and contracts benchmarking, pricing, analytics, looking at negotiations, this is whole part of the aspect of achieving savings. There's a methodology, and there's a way to do it, and there's a lot of work that gets done on that side. And what I've seen over the years and what's really jumped out at me this past year…, is that there's a change management aspect to achieving performance improvements, like an organizational-wide cost savings initiative. That's a change management project. So I'm going to probably do a longer podcast about this, but something happened a few months ago, and it made me realize that unfortunately, there's dysfunctions. And we all have dysfunctional families, dysfunctional business relations. I mean, just people. So there's going to be dysfunctions. And change management's really about how do we identify, assess, and pull it together and recognize that we might have to change some of our behaviors in order to have the best outcome for the organization? So it led me to reread a book called The Five Dysfunctions of a Team. And the reason why that happened is because over the years, I have noticed that we could pull together the most brilliant strategy, have the right analytics, the right benchmarking, the identification, pull everything together, and we have this tremendous cost savings number. It's all teed up. There's no reason in the world why it can't be implemented. 30:36 Big health systems have big spend challenges Lisa commented that just one category of spend could equate up to $40 million in hospital costs across multiple vendors. ‘’So number six, and this relates to, I would say about 50% of the hospitals and health systems, but it's important because I saw this a lot in 2022. That big health systems have big spend challenges. These are health systems that have multiple hospitals across multiple states, many vendors for the same category, and they need to see their spend in many ways to make important operational decisions. And those operational decisions for those big health systems, those mega-systems, may actually impact cost savings more than pricing only. So these are the systems that may have 15, 20, 30, 40 hospitals. And now they've got to say, "Okay, we have a," let's say a linen contract. Or "We have linen services." Or "We have dietary services." They have need to have multiple vendors. Typically one vendor can't serve all the system, and it's may not even be a good idea to do that, but they have multiple vendors serving their whole system, their corporate system. And how do they take that volume of data? It's just massive. One category, let's say dietary or linen or regulated medical waste. One category could be 20, 30, 40 million across 10, 15 vendors. And so big systems have big spend challenges. And so we saw in 2022, and we were really supporting that is, taking all that data and looking at it as a collective spend. And being able to slice and dice it, helping hospitals say, "Wait a minute, General Hospital is doing something different than Fairview Hospital. And what are they doing differently and what's the variation?" But that's really very advanced analytics, but that's what the big systems need.’’ 35:49 Purchased services spend is a cost savings opportunity Lisa said that purchased services spend needs to be included within the supply chain for more effective cost management. ‘’So my number seven, which we'll wrap up this podcast with, and one of my favorite topics, of course, is purchase services remains a challenge and an opportunity. It's funny you said that, because our biggest challenges do become our greatest opportunities. So this space still is 50% of non-labor costs, and there's a lot of activity around it and focused on putting some of these services on a GPO contract. Whether or not that remains to be the best place or position for a hospital to do that, I'm of the ins
Why Communication Matters with Brian Morgan | E. 58
Explore the impact of the written word and what it means for healthcare. Episode Introduction In this episode, Lisa Miller, Managing Director at SpendMend, interviewed Brian Morgan to learn more about the principles and mission of Think Deeply, Write Clearly. Topics include the impact of language and communication on business credibility, why comprehension of the written word belongs only to the reader, how better communication could improve healthcare, and why innovation isn’t always exclusively about technology. Show Topics Why we’re good at writing, but terrible at thinking for writing Solving the challenges in the drafting stage Comprehension belongs to the reader alone Communication at discharge is a big challenge for hospitals Treating patients as more than a transaction Our default position is to protect ourselves The impact of hospital bills 06:24 Why we’re good at writing, but terrible at thinking for writing. Brian explained how the language and communication we use can create a business credibility or cultural problem. ‘'…..we can run through life where we have provable statements that are not useful statements. And we aren't very good at saying, "Well, wait. What is this problem in its entirety? What are all of the factors that go into that problem? What are all the factors that go into that decision? And then, how do we curate all of that information down to show not what we believe, but why we believe that to be true and a trustworthy decision for you?" And that would be the same in real estate as it would be in a hospital as it is for somebody working on their marketing or anything else. How do we create trustworthy conclusions, where people see the transparent assessment as opposed to hide the transparent assessment because there's a certain amount of data that is not realistically supporting facts….there are cultural ramifications for this. And so I would say as a rule, we have not treated language and writing and communication with nearly the business credibility problem that it creates or the economic problem that it creates, and certainly, the cultural problem that it creates…We're very good at writing, but we're terrible at thinking for writing. So I decided to take that on.’’ 09:30 Solving the challenges in the drafting stage Brian noted that templates must help people think well, rather than short-cut the critical thinking process. ‘’…there are a ton of factors that go into that drafting stage that we hardly ever talk about, and many of them are just business process communication things. For instance, what would normally happen is somebody says, "Well, we have a template for that." And so we say, "Well, okay. That's fine. Let's grab the template." And the template is going to say something like "insert site description here." Well, there's a lot of ways you can write a site description. And the client wants it a certain way, and somebody who's been in the business for six months who's drafting this document because they're inexpensive and we think that that's the way to use money and usability well, is to have that person draft the document. And that person drafts it the way they want it. And now the manager and the editor are going to spend a ton of expensive time fixing that and reframing that site description. And so, all of a sudden we're at, "Well, now we have to talk about factors and we have to talk about checking in and we have to talk about are these templates actually helping people think critically about the problem, or are these templates just rote things that we say, 'Well, if you follow this, everything's going to be fine.'" And if you asked any company across this country, they would all say, "Our templates are not helping people think well. We're trying to shortcut critical thinking with our templates and it shows up in the end product, that we have a short-cutted critical thinking process here." 14:11 Comprehension belongs to the reader alone Brian explained why it is only the reader’s comprehension that matters. ‘’We are writing as if we have to provide the decision-making information. And that is true, except we're missing one big part of it, which I'm now going to mention. The writer never, ever, ever gets to comprehend for the reader. Comprehension is completely the reader's. So we can do this with your podcast guest right now, right? So if I say, "Lisa, picture a coffee cup." You and I are probably going to end up with a very similar image, but I'm not holding a coffee cup and you're not holding a coffee cup. So what I'm doing is triggering an image that we happen to agree upon for you, but your comprehension is yours. I didn't tell you what it looked like. I didn't tell you what it was made of or if it had a handle or didn't. Your comprehension is completely yours. And so when it's a coffee cup, it doesn't matter. Nobody cares. But now, I'm going to say, "Lisa, the most important thing for this particular hospital is that they spend $3.5 million on this initiative." And now somebody says, "Hey, wait a minute. What's that coffee cup made of?" Right? And comprehension is theirs, it's not mine. Now I have an obligation to say not, "This is the right thing for you to do," ….But I can say, "Let me describe for you how I see the coffee cup. Let me describe for you of what I looked at, all the factors that I looked at, and let me transparently assess all of those factors….We have to understand that they own their own comprehension and we have to respect that. And then, we have to say, "I've thought about this problem enough. I'd like to share my thinking on you and this is why I'm suggesting this conclusion." And they say, "Yes, I think that's a coffee cup, too." (22:01): Communication at discharge is the most challenging aspect for a hospital Lisa commented that the point of discharge in hospitals has the potential to be transformational with better communication. ‘’I think you would just do an amazing job if someone said, "Okay, Brian. Here are our communication points to our patients. We want you to review them." Often when I have been in the hospital or a family member has been in, sometimes I read things and I'm like, "Oh. This could be just stated better, kinder, or with more detail," right? Because there's room for confusion. There's an interesting aspect to a hospital, where a point of discharge is really the most challenging part. And how they communicate at the point of discharge, even that of itself could be just transformational because that's where people get confused. They're not hearing things. But it's a printout, it's … a template…. So there are all these areas to how we communicate with patients and there are areas of how we communicate with physicians. We wonder why we can't get alignment, administrators with physicians, because we're not communicating well. Sometimes we'll work with physicians or hospitals to communicate, and we don't have those same problems because we are thinking deeply... I'm always thinking about putting myself in their position or just providing information in a way to help them make their own decision, not trying to manipulate it.’’ 25:50 Treating patients as more than a transaction Brian shared an experience of ineffective communication in healthcare. ‘’….I'll give you a quick sort of related story for a second. I had an ophthalmology appointment last week, and it was very clear to me that these people who've been my ophthalmologists for a decade had no... If they wanted me to quit being a client, it was very clear from their communication that they would not mind me quitting being a client. But that was very clear. And it was just the way the forms were written. You've got to fill out this form for Covid. You've got to fill out, then if you don't do this, you're going to owe us a hundred dollars and we're going to transfer your... We're going to... All of this stuff. And I've been a client there forever. And of course, inside the doctor's office everything was fine. There's no problem. But man, were those forms really difficult to read…did I feel like, "Man, I don't even know if I want to do business with you guys. I don't feel like a respected client. I feel like a transaction that you're trying to cover all your bases." And she's a great doctor, but….was that a terrible feeling. And so, my sense is that that's probably happening all throughout the hospital. And so, well, why is that happening? Well, it's very difficult for us to understand our own subconscious responses to things and to get a hold on them. And so, let's take my ophthalmology appointment. They were really concerned during Covid that people would cancel and they would be out money and time, and they've got to pay their staff. And I understand that and I don't even mind giving them a credit card. I mind how it was phrased…..But how do I frame this around somebody else's comprehension so that they understand exactly where I'm coming from and why?’’ 29:52 The default position is protecting ourselves Brian said our first instinct is always self-protection, which gets in the way of successful communication. ‘’We are right to protect ourselves. There's no person on earth who should be running through the planet saying, "You can have my life. I don't have any value here. And so, just take advantage of me." … The problem is, without the ability to protect ourselves with nuance and with nuanced understanding and with a well-observed, then it's going to come out fast. And Danny Kahneman's terrific book, Thinking Fast and Slow, is about this. We work a lot with lawyers, right? Because lawyers end up writing contracts (that) deal with these issues. And so, in essence, what we end up saying is, "I'm going to write this as a document that protects myself. And because I need that so much, I don't even care how you read it." And so, I just made you a transaction. I don't want to make you a transacti
The role of a nurse coach and her impact on the nursing community. Episode Introduction In this episode, Jim Cagliostro, VIE Healthcare’s Clinical Operations Performance Improvement Expert, interviewed Alexcie Sanchez to learn more about nurse coaches. Topics include, taking a more holistic approach to health and wellbeing, the growing need for nurse coaches, the positive impact of nurse coaching on burnout, and why nurse coaches are a ‘’shining light’’ in healthcare. Show Topics What is a nurse coach? Exploring available options for nurse coaches Partnering with a nurse coach is a powerful experience Covid-19 – a tipping point in self-care Coping with burnout during a crisis Utilizing nurse coaches in a hospital benefits everyone 02:14 What is a nurse coach? Alexcie explained that a nurse coach works with any individual who wants to improve their health and wellbeing. ‘’….simply put, a nurse coach is a registered nurse who has specialized training in the art of coaching. We're trained to use a holistic approach, so I love to use the phrase a whole person approach. We really look at the individual's life when it comes to caring for an individual. So their lifestyle, their daily activities, their food intake, sleep habits, everything when it comes to caring for an individual, and I always want to make it clear right off the bat too, because we're called nurse coaches, we don't actually just work with nurses. It just means that we're nurses that are specialized in coaching. So nurse coaches work with anybody and everybody that has any desire to make a change.’’ 03:28 Exploring available options for nurse coaches Alexcie shared the options open to nurse coaches, from hospitals to private companies, emphasizing that working with a nurse coach not a one-time encounter. ‘’I have my own private practices as a nurse coach. So I work virtually with individuals. If they're local, I'll work with them. If they want to meet in person, I can do that. But basically, nurse coaches can have their own private practice. They're hired by insurance companies to help patients manage chronic or new acute illnesses, especially if it's like a terminal illness. They can provide that emotional support to them and their families. Nurse coaches can be hired by organizations and companies to promote just overall health and wellbeing, which helps not just the employees but the organization in general. And then nurse coaches can also work for hospitals where they not only help the patients while using that holistic approach, but also helping the staff and the employees of the hospital as well. So nurse coaches can really work in any sort of environment. They can work at clinics in doctor's offices, they can work for themselves. It's just really a matter of who they desire to work with and what sort of environment they'd like to work in…..It normally wouldn't be a one time encounter, it will be an encounter that lasts over weeks to months depending on the person's desires.’’ 12:15 Partnering with a nurse coach is a powerful experience Alexcie said our minds can dictate our behavior. Nurse coaches encourage accountability and offer reassurance. ‘’…anyone that is desiring to make any change in their life can reach out to a nurse coach. Whether it is health or disease related or not. We're really also trained in that mindset modification. Our minds, our thoughts really dictate a lot of our behaviors. So I know we often feel like we can do things on our own, but with a partner, whether it's for accountability reasons, reassurance advice, sharing your journey with a nurse coach can be a really powerful experience. And many nurse coaches specialize in certain niches. So for example, maybe you're a med-surge nurse or a PCU nurse and you're really well versed in type 2 diabetes and you love that education. There's nurse coaches out there that specialize in just working with individuals with type 2 diabetes to help them manage or reverse their disease. There's nurse coaches out there that have OB and maternity experience, so they just work with pregnant women or postpartum nurse coaching. So there's literally so many different niches within the nurse coach community that you can seek a nurse coach that is specializing in whatever you're looking for.’’ 15:31 Covid-19 – a tipping point in self-care Alexcie commented that Covid raised awareness of the importance of taking care of ourselves. ‘’I think it's really about health awareness at this point, not just the nurse world. And I'll start with this example. So Covid comes in and I think a lot of people, or at least I especially witnessed that our pre-existing conditions, our comorbidities are playing a substantial role in how covid is managed, treated and recovered from. So my hope is that we can continue to become more aware of how we take care of ourselves and how every aspect of our life plays a factor. What we eat, how we sleep, how we move, how we think, how stress plays a role in our overall wellbeing. So all of these things are exactly what a nurse coach can help with. So I'm hoping that as health awareness increases the ability, the desire for someone to want to make change in asking for help, and that's where a nurse coach can really come into play.’’ 17:15 Coping with burnout during a crisis Alexcie said that she worked with her own nurse coach to help her work through fatigue and burnout. ‘’…I came to realize that these things were not going to happen overnight. Our system is potentially broken, but nothing's going to change tomorrow. So that's when I started really looking within myself and figuring out, "Okay, how can I cope with this today? Because I don't want to leave the emergency department." I loved where I was, I wasn't ready to leave. So how do I manage it better? How do I deal with the fact that I can't change what's going on around me, but I can change how I deal with it? And that's when I really started looking within and seeked my own coach that I've worked with in the past to really work with me in those moments to figure out, okay, how do I get through this frustration, this fatigue? And it really came down to just self-care in those moments. How do I take care of myself? How do I take care of me right now while this stress and overworking and fear of the unknown is going on?’’ 20:03 Utilizing nurse coaches in a hospital benefits everyone Alexcie said leadership, nurses and patients all thrive when hospitals use nurse coaches. ‘’So utilizing nurse coaches in a hospital setting literally is a win for everybody, right? When preceptors and management are trained in holistic nurse coaching, they'll first learn how to develop a truer sense of themselves. Because if they go through this training, it's really about finding within their strengths and how they can capitalize on becoming better mentors and leaders, which is a win for the nurses and the overall staff when we have management that is taking care of themselves holistically. When the staff has strong understanding, compassionate leadership, they will ultimately thrive. And when the nurses thrive, the patients will thrive, retention will improve, nurse shortages will diminish and appropriate nurse to patient ratios will follow. It's literally a win for every single person in the hospital.’’ Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Alexcie Sanchez on LinkedIn Check out VIE Healthcare and SpendMend You’ll Also Hear: A journey to nurse coaching working in ER during the pandemic: how Alexcie’s nursing career evolved into a more holistic approach to care. ‘’My mom really raised my brother and I in a more Eastern philosophy manner. So I've always taken that approach when it came to healing and then being an ER nurse, it's two different worlds in a sense.’’ The importance of the mind-body connection and how to become a nurse coach. ‘’You must be a registered nurse with at least two years of working experience and you have to complete at least 60 continuing nursing education hours in holistic nursing. And then you also need 60 mentored or supervised coaching hours. I personally used what's called the Nurse Coach Collective’’. Raising the profile: why education and raising awareness of nurse coaching is vital to the healthcare sector and patient care. How Alexcie helps nurses rediscover their power and true potential. ‘’Right now, my mission is really to help nurses…..I love to go really deep with these individuals to figure out how to create happiness.’’ Shining a light on a broken system: How the pandemic highlighted the flaws in the healthcare system. ‘’… unfortunately along with the patients, the nurses were at the center of it all. We were in the middle of chaos in a sense. Unknown fear, I think a lot of fear also comes to play. I can share personally, it was scary.’’ Why nurse coaches are a ‘’shining light’’ in the lives of individuals. What To Do Next: Subscribe to The Cost Advantage for Healthcare Leaders and receive a special report on 15 Effective Cost Savings Strategies. Learn more about the simple 3 step process to work with us. If you are interested in learning more, the quickest way to get your questions answered is to speak with one of our margin improvement experts. Schedule a call with our team here.
Health equity and caring for people with intellectual disabilities. Episode Introduction In this episode, Jim Cagliostro, VIE Healthcare’s Clinical Operations Performance Improvement Expert, interviewed Nate Myers to discuss his experience serving adults with autism. Topics include the motivation behind Nate’s move to Keystone, the goal to provide health equity for people with autism, the growing demand for medical experts and advocates in the field, and the ‘’Platinum Rule’’ of Keystone Human Services. Show Topics Working towards healing and wellness by focusing on strengths ‘’We grow the most when we’re stretched’’ Providing community support to adults living with autism Leadership begins with having a passion for your work Achieving a certification in developmental disabilities nursing Striving for health equity for people with autism or disabilities The need for more experts and advocates in the medical field The ‘’Platinum Rule’’ of Keystone Human Services 03:08 Working towards healing and wellness by focusing on strengths Nate said his decision to become a nurse was influenced by understanding that everyone deserves positive relationships and experiences. ‘’I'm pretty patient, I'm good at keeping a positive regard and encouraging others, so it just seemed to work. And I quickly developed an understanding and appreciation that every person desires and deserves everything good in life, to be understood, to be appreciated, to be independent as possible, do things that they enjoy, have positive relationships and be healthy. So that's the same for people with intellectual disabilities or autism. Of course, they want those things just like everyone else does. And so I learned a lot about what it means to be a human, and deciding to become a nurse was kind of just an extension of what it means to care for someone who's in a vulnerable position for sure but also working towards healing and wellness and focusing on strengths and not weaknesses. So all that kind of came together in my decision to be a nurse. And actually, when I told my wife, "I think I want to go to nursing school," she was like, "Yes, that's perfect. Go for it." So she was always an encourager for me and rooted me through a lot of the difficult aspects of becoming a nurse.’’ 07:49 ‘’We grow the most when we’re stretched’’ Nate said that asking lots of questions helped him to develop a keen understanding of the nursing basics. ‘’I think that's really important when you're in nursing is to challenge yourself. And I remember, going back to that encouragement from my wife, I remember when I started in the ICU, I felt so new and like I was in over my head. And my wife reminded me, we often grow the most when we're stretched, when we feel stretched. And so I've remembered that. I've taught that to other people. And I just remember every time I face a challenge that I'm stretching and I'm growing at the same time. So I think that's important to remember on anyone's journey. But in all those settings, I developed kind of a keen understanding of all the basics of nursing: physical assessment, clinical skills, differential diagnoses, how to do patient education, just working with people. And I always ask questions of all the physicians. Probably people got tired of me asking tons of questions.’’ 09:36: Providing community support to adults living with autism Nate explained how his nursing background helps to provide medical care in the community for individuals with more complex needs. ‘’The majority of our participants actually live in home and community setting, meaning they're living independently or with a roommate or with family, with their parents. We do also have some care dependent individuals. They receive 24/7 support just based on their support needs. And I was kind of pulled in, I think, primarily because some of those medically complex folks, they just needed a nurse to join the multidisciplinary team to assist all the staff and the leadership in what to do with those individuals. So yeah, so that's a little about my experience. And I really feel like the role that I'm in now really blends some of those skills with just my personality and all my interests in a unique way. And I think at the very heart of nursing as a profession is a desire to optimize health and wellness for each patient. So I feel lucky because I get that opportunity to work as part of this multidisciplinary team, all these different disciplines. And in the community setting, I get to join the rest of the team to work on these person-centered strategies to overcome barriers and improve health and wellness. And it's exciting because everyone's different.’’ 14:11 Leadership begins with having a passion for your work Nate said leaders must create culture and inspire excellence in everything they do. ‘’I think leadership has to start with having a passion for the work that you're doing. It's so important to have a sense of purpose or mission so that that is your compass. I feel like if you don't have a compass to guide and direct your responses and your actions, it's really difficult to educate, support and lead others if you don't have that compass driving you. So leaders create culture, and I think it's important to inspire excellence in everything that we do. I think leaders should be prepared as much as possible, pay close attention to the details while also remembering that bigger picture.’’ 16:51 Gaining a certification in developmental disabilities nursing Nate explained that gaining certification came out of a desire to support the team at Keystone Autism Services. ‘’Right. And the experience definitely weaves itself into leadership. You can lead others without a lot of experience for sure, but after being a nurse for over 10 years, you want to pass on what you've learned to others. And so getting that certification in developmental disabilities nursing really came out of a desire to be a leader in the field, but also to help really support the team at KAS as best as I can. So yeah, experience definitely, like I said, weaves itself into leadership kind of naturally….Because again, I had this kind of underlying passion for this population. So I've always kind of been interested in it, but again, you have to really be in a specific role serving the population for a certain amount of hours to achieve it. So it was kind of always unattainable before. Definitely not mandated, but if you're interested in pursuing a specific population or a specific set of skills, I think if you're driven and you have that level of interest and you want that experience, getting that certification is just kind of a solidification of that mindset, I think.’’ 19:43 Striving for health equity for people with autism or disabilities Nate outlined the services KAS offers to the local community. ‘’And so for KAS, services are catered to each individual so it's very person-centered. It includes coordinating care for healthcare and therapy, various behavioral supports, family supports. We have a lot of emphasis on vocational and educational support for each individual and just enhancing wellness in general. And so the way I fit into that from a health perspective, we're always striving for health equity in the population we support. So for the most part, all the recommended health related screenings for the general population based on age are going to be the exact same for individuals with autism or disabilities. So get all that as a baseline. So make sure that they're getting those routine screenings: annual physical, dental exam, reviewing their medication appropriately. And then beyond that, when you talk about health equity, it's identifying barriers that exist for individuals with disabilities and then enhancing supports to overcome those barriers. So we help identify specialists that address unique needs.’’ 21:22 The need for more experts and advocates in the medical field Nate observed that the prevalence of autism has increased, but individuals are not always getting the routine, preventative care they need. ‘’And so my goal when I'm teaching is to create a context in which we can meet the patient where they're at and modify care appropriately to create positive outcomes. I mean, I feel like it's really important for anyone that works in healthcare to know about. The prevalence of autism has only gone up in the last 20 years. We've seen it. CDC has a autism and developmental disabilities monitoring network, and in 2000 it was one in 150 8-year old children had an ASD diagnosis. Now the most recent is one in 44. So those kids are going to age out of the school system where there's a lot more coordinated and kind of concrete support into adulthood where there's a big gap and a big need for support. So that's the population that we support, both vocationally and from a health and just life span perspective. So we need more experts and advocates in the medical field who have a deeper understanding for ASD, autism, and in general, intellectual and developmental disabilities. People are living longer lives and they often miss out on routine preventative care. Other issues like challenging behaviors can be treated with psychotropic medication or the accumulation of more meds than they need, but it could be just underlying illnesses that are missed, like GERD or gut sensitivities, things like that. And even in COVID, if your listeners are interested in learning more, the National Council on Disability put out a detailed report called The Impact of COVID-19 on the People with Disabilities.‘’ 26:08 The Platinum Rule at Keystone Human Services Nate said Keystone advocate for the Platinum Rule in the way they treat people. ‘’And then I'll finish up by saying something that impacted me during my new employee orientation here at Keystone Human Services. I'm sure you've heard of the Golden Rule, treat others the way you want to be
Medical Device Warranty Credits With Al Brander| E. 55
How SpendMend's Explanted Medical Device Warranty Credit Tracking solution helps hospitals to avoid costly fees and penalties. Episode Introduction In this episode, Lisa Miller, founder of VIE Healthcare and CEO of Spendmend ,and Jim Cagliostro, VIE’s Clinical Operations Performance Improvement Expert, interviewed Al Brander to explore in detail the challenges and financial risks of managing medical device warranties. Topics include the risk of ‘’Medicare fraud’’, how hospitals are throwing away cash, why financial and legal responsibility lies with the explanting hospital, and a detailed presentation on the compliance and revenue benefits of SpendMend’s innovative software solution. Show Topics Background to the Explanted Medical Device Warranty Credit Tracking solution The risk-reward element that helps hospitals to avoid penalties and add revenue The high risk of financial penalties for failure to comply Mock audits are invaluable for hospitals in this low frequency/high risk areas The simple shipping label that keeps vendors accountable How SpendMend’s software provides audit defense Understanding revenue benefits at a glance Main Topics 04:43 Background to the Explanted Medical Device Warranty Credit Tracking solution Al explained that when a device fails, hospitals have a responsibility to return it to the manufacturer to obtain warranty credits. ‘’…there are all kinds of great implants that we put into people to make their lives better, the most common of which is a pacemaker, but there's all kinds of neural stimulators, total joints, all of these items. And so interestingly, all of them come with kind of a warranty. They're expected to last for a certain amount of time, but all of us have cell phones, so we understand that batteries and motherboards don't always last as long as they're supposed to. And so for years, CMS, the Center for Medicare and Medicaid Services, is the primary buyer of these things because most of them go into our elderly patients. And so CMS realized that "hey, we pay for the first device to get put in and then if it does fail, we pay for the second device to get put in and the hospitals are supposed to be sending back these devices, back to the manufacturer to see if there's a warranty." When the hospital gets that money, well really it's not their money, it's CMS’s money. And so the new standards came out in the late 2000's, actually. And what the expectation was is, when there's a device that fails, for whatever reason there's a malfunction or patient morbidity that happens because of that device, when it gets switched out, hospitals are expected to send it back to the manufacturer and pursue those warranty credits.’’ 06:05 The risk-reward aspect that helps hospitals to avoid penalties and add revenue Al said that hospitals could be literally throwing away cash by failing to return medical devices under warranty. ‘’In order to incentivize hospitals to do this every time, they've said, "Hey look, if that warranty credit is 50% or more of the replacement cost of that device, then send it back to us. But anything that's 49% or below you guys get to keep. We know we've paid for the full cost of the device, but that additional 49% is yours because you've gone through the effort to return it….the first part to remember about these is that probably 90% of the warranties are going to be below those 50% threshold. So this is just money that the hospital gets to keep. And I can tell you as a bedside nurse, there was a huge reliance on the vendor rep and just asking them, "Hey, do we need to send this back for warranty?", "Is this under recall?" Because in the heat of the moment, in that case I would have no idea. And so if the rep said no, I would throw that device into the biohazard bag, literally throwing cash in the trash can. Because these devices could have anything from a $3000 to a $15,000 warranty credit on them.’’ 07:53 The high risk of financial penalties for failure to comply Al said that fines have increased significantly in the past few years. ‘’So the first is under the prudent buyer standard. Before it was, "if you got the credit, repay the credit" and now they've said, "Hey, regardless of whether you get the credit or pursue the credit, if there was a warranty, you owe it to us." So that's where it's a double whammy for the hospital. If they don't return that device but there was a credit, they lose out on that money and they have to pay CMS. The fines have greatly changed. It used to be a $5,000 flat fee and they would have you return the monies that you had and maybe charge a slight interest payment if you've had it for a number of years. Now they've gone to a per-instance fine. So the bottom of that fine is about a little over $11,000. The high end of that fine is 22.9, so almost $23,000. So if you take a $20,000 credit that you don't get, now you need to pay that fine. And what CMS has said is that, "hey, if you don't do this correctly, you don't just owe us that credit, you owe us three times that credit. So that $20,000 you just lost out on now turns to $60,000 and if we apply the high end of the fine, you're now at $80,000." So it adds up very fast…..’’ 17:52 Mock audits are invaluable for hospitals in this low frequency/high risk area Al gave an example of one high performing hospital at risk of a $1.5million to $2 million fine. ‘’We go in, we get information from the hospital on what they've purchased, what devices they've had. So they're paid history from the big fours, we call them, the big four cardiac manufacturers. Then we get all of the credits that they've issued to the hospital, all of the devices they've sent for the hospital to have warranty. And then we plug it into our database that has all of these warranties to figure out which ones qualified, which ones do they need to report back. Then we take a deep dive into the UB-04s of all of those patients, to make sure it was credited properly and the right condition and value code was there. So those are invaluable to the hospital. One of the things this is really falls into that low frequency high risk area. So we recently just did an audit for a 250 bed community hospital. Standard average American hospital across the country. There's more of those than just about any other size hospital. And they did 2200 implants/explants a year. So over the six years, you guys can do the math, they only had 28 mistakes. So if you're a nice statistics geek, that's way inside of the standard bell curve. But when we extrapolated out that money, those 28 mistakes were just over $300,000. And if OIG had found that $300,000, they would've had to pay back $900,000, because it's the three times rule. And if they applied the low and high jeopardy, you were between a $1.5 and $2 million finding. And so by us going in there and doing this mock audit, we were able to find where the holes were in their process, have them report it without having any fines. One of the things that has been very cool is we help hospitals self-report this. We've never had a hospital fined in hundreds that we've done across the country, large and small health systems.’’ 27:04 The simple shipping label that keeps vendors accountable Al presented the Explanted Medical Device Warranty Credit Tracking solution, and highlighted the need to monitor the role of the vendor. ‘’So the key to this is that on the clinical side, all I need to do or worry about as a clinician is the front end of this. And if I do my part right, and SpendMend's going to make sure that I do, we're going to be okay. Then when it's time to send it back, we're working with supply chain, "Hey, you need to send this back. Here's the label." You can get boxes still from the manufacturers. In fact, we have a link in our help section where you can just go on and order those boxes from each manufacturer. Then when it goes to the vendor, we're communicating with them. It's amazing how often we hold the vendors accountable. They'll say, "Well, we didn't get that device didn't ever show up." We can prove from the shipping label, "Yes it did.’’ “Well it came after 30 days.’’ “No it didn't. This is Joe who signed for it on the loading dock and you did get it." We also hold them accountable to their warranty rules. What is very interesting about this, CMS does not dictate what a warranty is. CMS does not dictate what qualifies. CMS doesn't even have a list, which would be incredibly helpful, of all the devices that have warranties. It is 100% up to the manufacturer to create those rules and conditions for returning that warranty. However, once that warranty is returned or once there is a warranty on that device, now CMS is involved, making sure that you return those.’’ 31:31 How SpendMend’s software helps hospitals provides audit defense Al highlighted the benefits of SpendMend’s software for hospitals, including visibility, insight, standardization and audit defense. ‘’What we learned early on, the first software that I worked on the tissue side, that was one where we could sell a software to a hospital and they could run it. They could manage the program. With this, because it's five to six departments over across a six-month timeline, we learned very early on that the service was the critical component to this. And that service, looking back at what you've done previously to make sure you have no risk. And then day to day. We don't just sell a software and walk away, we sell you a process, we sell you the software to make you standardize. My mantra, when I was running the OR, was "consistency in procedure is going to lead to predictability of results." There is no process flow out there that needs more consistency and procedure. Imagine a health system with 14 hospitals and each cath lab and each OR all have to do this. And each supply chain, and each of those hospitals have to track this. …., this gives visibility and ins
The World of Travel Nursing With Rex Hartman| E. 54
The reality of life as a Travel Nurse and the impact of the nursing shortage. Episode Introduction The shortage of nurses in healthcare was exacerbated by Covid. In this episode, Jim Cagliostro, VIE’s Clinical Operations Performance Improvement Expert, interviewed Rex Hartman, to explore the factors that fueled his decisions to become a Travel Nurse. The conversation was wide and varied, covering topics including the impact of an aging nursing population on healthcare, why nursing is no longer a priority for young people, and the benefits and risks to hospitals of hiring traveling staff. Show Topics Working in ICU through Covid-19 The decision to become a Travel Nurse The retiring Baby Boomer generation affects the nursing shortage Why young people are turning away from nursing as a career option How hospitals benefit from Travel Nurses The health systems providing their own in-house travel staff Potential risks of hiring traveling nurses Main Topics 06:24 Working in ICU through COVID-19 Rex shared the reality of working in ICU during a pandemic. ‘’When COVID-19 hit, about a month in in South Florida, when we started seeing cases, out of nowhere, my hospital administration came to me and said, "Oh, by the way, starting tomorrow, you're going back full-time to the ICU to take full assignments." That was just a little bit of a shock. It would be as if anyone working in a clinical area all of a sudden said, "You're going back to another clinical area without any forewarning or discussion." ……For about a month and a half, ICU was full. Everyone was freaking out a little bit. If we can all remember back those two years ago, the PPE shortage and all the other types of mask shortages where we started re-wearing PPE and everything like that, we clinically started to do things that we knew were no-nos and boo-boos, but a lot of things happened across the nation where infectious disease protocols that had been set up and established for over that decade that I've been in healthcare, well, now we're re-wearing and sanitizing our PPE because there's a shortage, and I can't help but wonder how much of that created other issues for our population.’’ 07:45 The decision to become a Travel Nurse Rex said that variety and compensation were two key factors in his decision to become a Travel Nurse. ‘’And from that period of time, if you're working in full-time ICU or somewhere in the hospital, even if you're in ancillary services, you're in surgical services, departments are getting shut down. Workflow is being stopped. And then you hear the travelers coming in by the droves. You see them, and they're like, "Hey, where are you from?" Maybe you've never met... I had never really met or worked with travel nurses until they came to the ICU. And they started to tell me, "This is what I do. This is how I work. This is how I structure my entire life." And man, if that didn't sound, first of all, a whole lot more interesting, as far as the variety of labor you can get into, the different clinical areas you can travel to and different hospitals, different regions if you're into that, but also we can't underscore enough: there was crazy amounts of money being thrown around for travel nurses in 2020. And I'm not saying that I'm not a loyal person to my community, but if you want to pay me to do the same job about four or five times more, I'm hard-pressed to say no, especially if I know I'm not breaking any laws to get it.’’ 11:39 The retiring Baby Boomer generation affects the nursing shortage Rex commented that the large numbers of nurses retiring will hit the healthcare sector hard in two ways. ‘’A couple of additional factors that you didn't mention is that we have an aged nurse population, and this isn't just in nursing. This actually spans, I think, almost every major industry in the nation right now. As the Baby Boomer generation retires, multiple people have not only noted, but shown, that the birth rate in most industrialized countries are declining. So there's an immediate discrepancy between the consumers of healthcare and the providers of healthcare, and that's going to be fully realized when most of the Baby Boomers reach that 75-85 age window. And a lot of them are still working right now, but they're in their last few years, and many of them preemptively retired due to COVID. So we had a huge retirement and we have a coming retirement of all of these Baby Boomer aged nurses who were the primary teachers of people like myself, experienced seasoned nurses. They were a career nurse. They were there 30 years, or plus, even, some might say. And that can't be overstated, that when you have such a high proportion of your employees in that age category, ready to move on, it's going to hit really hard. And not only that; they're immediately turning the coin and they're going to be consumer of healthcare. So they're retiring and immediately, within the next five, ten years, they're going to be needing some type of nursing or healthcare situation.’’ 13:07 Why young people are turning away from nursing as a career option Rex said social media and other industries mean that talented people can make money easily without considering nursing. ‘’Beyond that, and this is just going back to 2016: when I entered nursing, the state of social media and opportunities for income, or let's say not even social media, but opportunities for, let's say, influencer-category income were little to none. That has actually changed. If you're a young person coming out of high school, looking at college or tech school or whatever across the panel, you actually stand a pretty good chance to find a way to earn money without going to nursing school or going to get any type of college degree, if you wanted to directly go into business. Or if you wanted to try to support yourself on YouTube by customizing trucks, to give an example, there's such a higher level of stratification in the last six to eight years of how people can earn money, and the problem is... I'll use it for an example. If I had the opportunity to work for Walmart now, what the hospital was paying for a PCA, I would have worked at Walmart, but the hospital was paying more. And I think this is one of the factors that comes into the shortage. The shortage that's coming up is because there are other industries that young people can get into that can outpace both growth and income than nursing income. It's good in a way, because you have a portion of people who won't chase the money, but then it's bad in a way, because it's hard to get new talent: people who might be really good nurses, but now they're somewhere else.’’ 16:39 How hospitals benefit from Travel Nurses Rex commented that Travel Nurses bring significant experience to a position, but prices are beginning to fall. ‘’ Where the traveler comes in, they've been there, they've done that, hopefully, and they will just pop right into the situation as an experienced person, and with very little updating, be able to function, maybe while you bring someone else, a new hire, up to speed for three months. A typical traveler contract is 13 weeks, which is three months in change. That's the ideal situation in which a hospital system uses a traveler. Where we're at now, people have left the industry, they're retiring, and healthcare needs are in general growing. So where we're at now, we have this limbo where there's thousands.... I think every major agency advertises that there's 18,000 to 21,000 open spots in the country. And while that doesn't sound like that many as far as a profession, remember there are very few people who are willing to travel as a nurse. We're grounded. We have families. Not everyone's willing like I am to pick up the family and hop over the country for three months. So because of that, you run into a price war. And with COVID, when there was federal money pouring in to assist with COVID emergency stuff, it wasn't that big of a deal for hospitals. But now that that's gone, the hospitals are eating the bill. So prices are coming down, which they have to, but now we're working into, how do I meet my continual short-staffing need with experienced people?’’ 18:20 The health systems providing their own in-house travel staff Rex highlighted the healthcare organizations investing in their own agencies to provide traveling staff. ‘’There's HCA, which is also known as HealthTrust, and I know of a couple other examples, which I can't necessarily completely demonstrate this, but many people are buying agencies. By people, I mean hospital systems are buying agencies to staff themselves, and they are paying the people who are agency workers a higher wage, like a traveler would make. And they will even sometimes contract them at a higher rate than their normal staff, but not such a high rate as maybe an outside traveler would make. And they will use these staffing agencies to shore up their semi-long-term needs, if I can make that a term. So it's a tactic that people are employing, and there are many people who are travelers like myself, that hospitals, they no longer really heavily enforce that radius rule. If you're not familiar with that, it's rules that facilities set that you can't travel within a certain distance, but what they will say... They need the staff members, right? They will say, "Well, we'll give a local person a slightly lower rate than we would give an away person." So I don't know if that's discouraging enough to get people to come back to work full-time, but those are a couple tactics that hospitals are using to try to shore up their semi-long-term needs for experienced staffing.’’ 25:28 Potential risks of hiring traveling nurses Rex highlighted potential risks hospitals face when working with Travel Nurses ‘’You asked me, have I
The challenges of hiring healthcare workers in the wake of ‘’The Great Resignation.’’ Episode Introduction Demand for urgent care has intensified since 2020. In this episode, Jim Cagliostro, VIE’s Clinical Operations Performance Improvement Expert, interviewed Creston Tate to explore the impact of the pandemic, the growing demand for urgent care facilities, the reasons behind the ‘’Great Resignation’’, and the need to adapt to a shrinking talent pool. Show Topics The growing demand for urgent care. How the ‘’Great Resignation’’ affects patients. Reimbursement and the Walmart/Amazon challenge. Flexible schedules are essential to attract the right people. The shrinking candidate pool. Ensuring safety means urgent care sites may close temporarily. 02:13 The growing demand for urgent care. Creston highlighted the exponential growth in demand for urgent care in the past 6 years. ‘’My experience grew, my appreciation for medicine grew, my appreciation for the urgent care world, I call it the episodic world of medicine really grew too. There's clearly a huge gap in care for this particular type of patient that isn't being provided in the outpatient world. I did that for 17 years and just about six years ago, I transitioned into more of an outpatient urgent care directorship through my current healthcare system and have really enjoyed the growth that we have had, which is probably somewhere around the 12 to 13% growth rate per year in urgent care. As we started with five and now we're opening up our 15th urgent care this year with record volumes. I've seen it in the inpatient world, in the emergency room, and now I'm seeing it in the outpatient world and I'm bringing it all together and it's been fun to see that happen…..With the influx of patients to emergency departments and the overcrowding of EDs and wait times, perhaps some of your listeners have actually unfortunately experienced a 10 or 12-hour wait in emergency departments, it's just not fun. It's been estimated that even up to 50 to 60% of ED visits could have been handled outside of the emergency department, if the resources were there. I think that's where urgent cares and primary care providers can step in, if there's enough providers and enough access available for that. I've seen a huge switch. I know that for us, we open 12 hours a day. I think if we opened 18, we would have just as big a volume as we do now, if not larger.’’ 06:08 How the ‘’Great Resignation’’ affects patients. Creston explained the difference between unfilled jobs in the healthcare sector versus vacancies in retail. ‘’Whether you go to a restaurant or you go to a convenience store, it seems like there's a paucity of workers. Despite the published low unemployment rate, it does seem like there's a lot of jobs that just aren't being filled. You take that for what it's worth, but clearly healthcare, maybe isn't affected more as far as numbers, but what I will say, Jim, is that healthcare is affected more impactfully because it is an essential piece of our fabric. If we don't have the right number of healthcare workers, people's health suffers. If we don't have enough people working at a Walmart, well, you might just have to search around for something a little longer yourself or wait in line a little bit longer, or maybe the shelves aren't stocked as readily as you would like them to be. The impact there is certainly felt more if somebody can't get their diabetic medication or their follow-up or their blood work or that CAT scan that they've been looking for to follow that tumor, than if somebody is simply shopping for material goods. I do agree with you, the resignation as it's been called, we've seen it. We certainly in our healthcare system have seen it tremendously. What I will say is that we haven't seen a tremendous loss of... And again, I'll speak from my own personal experience. In the urgent cares that I work in I don't think we've had a huge number of people leave healthcare. We have had a number of them switch out of urgent care, which has been inundated with complex patients, probably more complex than we should see, and also sicker patients. Going through the pandemic and gowning up with gloves and masks and goggles and all this paraphernalia to try to protect our healthcare workers, it has been quite a ride for our providers and our staff. Quite frankly, I think the burnout rate is really more just fatigue. They're just tired of this continual ask to see patients who are sicker and sicker and they don't feel as though perhaps they're getting reimbursed for the higher level of risk that they're taking compared to rest of society.’’ 10:16 Reimbursement and the Walmart/Amazon challenge. Creston said the higher salaries offered by Walmart and Amazon make it difficult for healthcare organizations to compete in attracting talent. ‘’One of the greatest challenges in healthcare is going to be the big box store. Whether you look at the Walmarts or you look at the Amazons out there that just bought up one medical and 125 stores, which were like healthcare facilities that they bought up. Now there's going to be a challenge of trying to retain our own employees when maybe someone like Amazon could offer them more dollars per hour. You thin out the potential pool of good healthcare workers, even greater when that kind of thing occurs. Again, that's big business. I understand that. Their goal is to try to provide better healthcare to more people in a more efficient and cost-effective way. Whether or not they succeed in that, I don't know, but you have that. Then you also have the challenge of other very wealthy companies who are offering $17 or $18 or $19 an hour as a startup when we're looking for medical assistants that typically are $17/16.50 an hour. They may not go into medical assistant work. Instead, they're going to take another job because it pays $3 to $4 an hour because inflation is causing them to make those decisions for their family so that they can feed their family. We're seeing perhaps the same number of workers who are being thinned out and perhaps pulled away from healthcare that once maybe in the past would have considered healthcare to go into as a stable job.’’ 12:40 Flexible schedules are essential to attract the right people. Creston commented that healthcare must adapt to candidate needs to fill the gaps in the workforce. ‘’When I went into medicine, when I got hired by that first company to work family medicine, I worked hard and I came in on Saturdays and I took call. I didn't complain. I double and triple booked. It was all that sort of thing, because it was kind of expected perhaps at that time. When we interview candidates now for positions, I had to put that own bias aside and I had to say, "If I see a candidate who is really a strong candidate for us, that I want to get on our team, I may have to think a little bit outside the box and say, 'Okay, I have a 25 or a 28-year-old mother who's perhaps an RN who we want to hire because she is just fantastic. Her skill set is great. Her fit and personality is perfect for our team. I have to figure out a way that I'm going to have her on our team.'" It may be that I have to work my schedule a little bit differently because of her because she has a family and she has other things that are balancing her life a little differently than perhaps I would have back in those days. I would have to also think about healthcare. How can we give her the hours that she needs so that she can help us and also provide the healthcare for her family that she needs? I think there's a lot of ways in which I think we, as leaders of these larger companies have to start thinking ways of adapting to the needs of our workers today. If I were to simply say, "Well, that's just not the way we've done things." I probably wouldn't find anybody to work for me because we have to work around people's schedules today.’’ 17:44 The shrinking candidate pool. Creston stated that numbers of available candidates have fallen significantly since Covid. ‘’Prior to 2020, for any given opportunity to work as a provider or staff member for us, we would have five to seven candidates. Now we have about three. Our qualifications perhaps haven't changed too much, but we've had to sometimes look a little bit deeper, maybe ask a little bit different type of question to the three candidates that we may only get and say, "Okay. Well, we're only going to get three for this position because we need to get somebody relatively soon, who is the best one out of these three?" I think that's been a little bit more difficult for us. I guess, we don't have... Obviously the larger the pool, the better you can say, "Okay. This is the perfect person." When your pool is narrowed, you sometimes have to take chances and sometimes our chances are right on and we thought, "Boy, I thought you were going to be a question mark, but you have turned out to be an amazing provider." We've had to do that. Our number of candidates typically is much smaller now to find the best fit. One thing that we've also changed and really try to do more of is we try to involve our providers a little bit more in that interview process, meaning that the leaders will do the initial interview and then we bring that candidate back and we have them spend six or eight hours in our site. It's volunteer hours, but we tell them, "Listen, it may be worth it for you to make sure that you are working in the right place for you. We like you, but we want to make sure that you like the site, that you like the people that you're working with. Because if you sense there's going to be tension here, we would rather you know that at the very beginning of your employment, and we can address those issues if that's going to be the case." 23:12 Ensuring safety means