- This is the Becker's Healthcare Podcast, created
by the team of Becker's Healthcare,
a multimedia company devoted to the people
who power us healthcare.
Four new 15 minute episodes are released daily containing
industry news analysis and thought leadership from powerful
healthcare decision makers Support our show
by leaving it a five star rating and review on Apple Podcast
or other platforms you use.
It's a chance to tell us what you like about the show
and act on your feedback.
Thanks for listening. Now here's the episode.
- This is Laura Dedo with the Becker's Healthcare Podcast.
I'm thrilled today to be joined by Dr.
Heidi Wald, chief Quality
and Safety Officer at Intermountain Health.
Dr. Wal, it's a pleasure to have you on the podcast today.
- Great. Good morning. Nice to be here.
- Now I'm really looking forward to our discussion.
We'll be talking a lot about quality improvement,
especially thinking about the OR and ICU.
But before we dive into that discussion,
can you tell us a little bit more
about yourself and your background?
- Sure. I am an internal medicine doc.
Um, I am, uh, I have a subspecialty in geriatric medicine
and a background in health services research
and also health policy.
I, uh, spent much of my career in academics until about, uh,
five and a half years ago.
Um, and that academic career was always actually focused on
quality and safety as my area of interest.
Uh, I helped run, uh, co-lead for my clinical work, um,
and acute care for the elderly inpatient service,
where a lot of what we did was focus on
mitigating the risks associated with hospitalization
and illness in the frail elderly.
And that just was a, obviously a natural,
my clinical work was a natural connection to patient safety
and quality, um,
and started to really move, um, through, uh,
pilot projects into implementation, science types
of research, and then ultimately also into leadership roles
in the Department of Medicine where I was at, um, university
of Colorado about five years ago, uh,
five or five, six years ago.
I left there
and, uh, took a role,
which ultimately ended up being a chief quality
and safety officer role at SEL Health.
About a year and a half ago, SEL Health merged
with Intermountain,
and I was honored to take on the lead role, uh, same title,
uh, with the much larger organization.
- That's amazing to hear.
And what a great career journey I could imagine, you know,
especially going from, as you were talking about, um,
just really some of the projects
and initiatives you were doing with the,
the elderly population
and then into, you know, working
with SDL Health and now Intermountain.
How has that transition been since merging in
with Intermountain and really, um,
now having accountabilities over a, a very broad,
uh, health system?
- Yeah, well, it, it certainly has been a journey.
First was the journey from academics, um, into, you know,
more operations, um,
and then the journey from a, you know,
smaller health system, um, to a much larger organization.
Uh, so the, you know, what was interesting about
the kind of alignment with SEL Health
as it integrated inter into Intermountain is in
the quality space.
We had been on, uh, similar journeys over the past five
or six years, I would say.
We were taking different approaches, uh, to those journeys.
And so a lot of the work of integration
has been figuring out how to merge the
way we approach things.
And that's, you know, that's not easy work,
and we feel that, you know, we need
to have a one Intermountain approach.
It, it's more efficient, more effective, more able
to move the needle quickly,
and when we need to adjust to improve quality, uh,
and, um, improve safety for our patients.
- Well, that's great to hear. And can you tell us a little
bit about your quality improvement programs?
How are you optimizing patient care?
- Right, so that is a short question,
and there's really not a short answer to it, .
So I'd say, you know, we're, it's a pleasure
to be in an organization that so
prioritizes quality, safety, actually safety, uh,
if we think about our fundamentals of care
that we focus on at Intermountain, safety, quality,
patient experience and equity, and from, you know, uh,
and then there are four additional ones,
but the ones in the space
that I focus on are the first four.
Um, and so it's such a, you know, a pleasure, um, to know
that our leadership
and our, all of our caregivers really prioritize safety
and quality and patient experience above all else.
Um, uh, not that there aren't other important priorities,
and I'll, I'll, I'll loop in their caregiver experience
as well, caregiver and a physician and APP experience.
But the, um, I, as I was thinking about how to answer
that question, I think there are maybe three, um,
major points that I wanna make.
One is, how do we make big changes
and alignment as to, to make sure we're aligned
with evidence-based practice, especially
as evidence-based practice evolves over time.
Um, so that's kind of a macro view.
How do you make sure that, you know, you are
executing on the best evidence, um, in a way
that's consistent across the whole organization.
And that's really what Intermountain is known for.
That's what, um, Brent James kind of put us on the map for,
um, in terms of, you know, establishing
clinical leadership that identifies best practice,
identifying how to measure that, right?
And then looking to make sure that we are doing
what we say we're gonna do in terms
of meeting those process measures and outcomes
and making sure that we're structured,
uh, to do that the right way.
So that's the, the macro. Um, and we still do that.
The way we do that has evolved over time.
Um, but the, and I could take, you know, an hour
and describe work of many colleagues.
Um, uh, but I'll, I'll stop there,
but kind of macro, how do we, um, stay aligned
as a big organization and move, uh, the needle?
The other is, I would say micro Intermountain also is known
for being really a strong operating model
and baked into the Intermountain operating model is,
are the concepts of high reliability, right?
How is it that we get the goals of what we're trying
to do all the way down to the frontline?
Um, how do we have situ situational awareness across the
organization on a day-to-day basis?
And then how do we improve, right?
How do we, if,
if the people at the frontline know the goals,
they also have to know how those goals relate to them
and know, you know, how we're trying
to move the needle in their particular area of practice.
So, um, and that's the micro, right?
There's day-to-day improvement work that just has to happen,
um, that, um, comes up in daily work.
And then finally, so a macro approach, a micro approach,
and then I would say a, um, a commitment to build capacity
so that, um, wherever you are in the organization,
you have some skills, uh, to identify, you know,
when there's an opportunity
and how, what is the best way to approach it.
And either, you know, doing a small project in the space
where you work or kicking it up to, you know, uh, you know,
a system level where we need to make a systematic change.
So I guess I'd say three main strategies.
Um, and there are,
and I would be remiss if I didn't add in, um,
learning from all of our data.
We're just so awash in data
and we don't always use it to our best,
um, to the best effect.
And so we get data from, uh, event reporting, right?
We get data from complaints
and grievances, patient feedback, um,
and figuring out ways to use all of the rich data
that we have to, um,
gain insights and act on them.
- That's amazing to hear. And certainly, you know,
it's been impressive to see how the data
and technology can really weave into the clinical care.
And as you mentioned, um, having a strong culture
and approach to doing that, um,
certainly makes a difference.
I'm wondering from your perspective, what are the strategies
that have been most successful in particular
with improving patient care in the OR and ICU?
- Yeah, so I would say, um, the, uh,
ICU, uh,
and we've, we've seen some really impressive work out of our
critical care units.
The one is,
the ICU work is incredibly multidisciplinary , right?
It's, um, about a team coming together, right?
So, um, two, it's about bundles
of evidence-based practices, right?
What, what do we need to be doing reliably for each patient?
And the third thing I, as I was thinking about this,
is really how do we use data in our workflow?
So a really strong example has been, um, the spread of the
practice of low tidal volume ventilation
in our intubated patients.
And we've, um, with some, um, great clinical leadership
have really, you know,
provided data in the workflow of the team members, right?
And, and that involves respiratory, involves nursing
and involves the critical care doc, um, et cetera.
You know, how do we use that data, bring it to the bedside
so that they, um, can execute on a protocol.
Um, another example we're, um, we're having, you know,
some great successes, the awake and walking ICU concepts.
Um, one of our hospitals, uh, LDS hospital really, um,
was a pioneer in this space
that is incredibly complex, right?
The, you need physical therapy, you need nursing,
you need respiratory therapy, um, to, uh, get up, you know,
get a patient out of bed, um, uh, lift, lift their sedation,
get them out of bed, um, and allow them to be upright, um,
and, um, sometimes even take a shower, right?
. So, but to do that, right, again,
multidisciplinary, um, really
what are the evidence-based practices we need
to bring to bear?
And then how do we support that with the right data, um,
to, to help with improvement.
And I'd say final area is really making sure
that we're leveraging, um, end of life care, um,
appropriately in, in patients who are dying, um,
and that we are, um, valuing, you know, providing them
with, you know, the most effective medical care while
they're dying, and that may involve palliative care
and may involve referral to hospice.
So another space in which we are spending a lot
of time thinking about how to improve those connections.
Um, in the, or I would say it's really about,
um, culture there.
A lot of our work in ORs is about culture of safety, right?
How do we make sure that the timeout is effective,
the briefs and debriefs that, um,
the protocols are, are followed.
And if, if they are not followed, then anybody in the
or, um, is able to stop the line, right?
Um, and speak up. And that is hard work, right?
You have to talk about safety,
safety culture every si single day, day in
and day out, um, to really, uh, make sure that
that is, that, that folks have that mindfulness that,
you know, emerges out of a high reliability organization.
- I love that. And I think, as you mentioned, it seems
so critical to be able to have, um, that culture in place
and, you know, making that change or,
or really getting into a space where, um, you know,
that all the, um, providers
and everybody that you're working with really
has, um, that in mind.
I can imagine, as you said, it's,
it's easier said than done.
Um, when you look at having that culture,
you've talked a couple of different times about having
that information, um, flow down into the front lines and,
and really, um, having trust that things are, are, um,
the way they're supposed to be.
How do you really build that?
Um, especially after bringing together two organizations,
and for some, you know,
there's gonna be some significant changes.
Um, what does that look like when you're just starting off
and then, um, as you mentioned, a continuous reminders
or continuously, um, making sure
that that culture is in place?
- Well, we're right in the middle of it right now, ,
so it's a timely question, right?
The, the, when you think about a merger,
and I don't know if, uh, your listeners, you know, have,
if they're in healthcare, there's chances are they,
you know, they might have been involved in a merger,
but, you know, there's the, uh, the official, you know, kind
of merger period is a, a lot about the back.
Well, I, I don't say this in a judgy way, ,
but the back office functions, right?
Getting HR aligned, getting finance aligned, um, getting,
you know, those, um,
getting legal aligned and compliance, right?
The, um, actual, it takes a while for
that alignment to come to the clinical space,
and you have to be really committed to it
because it is hard.
Um, so we are in the middle right now of
aligning our safety culture programs, right?
We are in the middle right now of aligning our surgical kind
of periop services leadership.
And so I would say even 18 months in,
we're not finished yet, right?
And so we're, um, working on that diligently right now.
And I think the, the, the reason that we're not done yet is
because we're really committed to doing it, right?
I think there's a lot of mergers where, um,
there's maybe not a commitment to really pushing, um,
that alignment to the same degree,
but we really are committed to one Intermountain.
Um, and so I guess we are for the most part, um,
at the frontline clinical, we're still not operating
entirely the same, but that is our goal, um, going forward.
So anyway, I don't know if that answered your question,
Laura , um, but I hope that's helpful.
- Yeah, absolutely. Extremely helpful.
Um, and definitely great insights to have.
Before we wrap up here, I'm wondering,
what is your experience implementing enhanced surgical
recovery programs and what are the
- Results?
Yes. So the experience I'm gonna tell you about is the
experience, um, from our peaks region, which is Colorado
and, uh, eight hospitals in Colorado
and Montana, um, from the legacy SEL Health organization.
Um, and we really, um, started a, um, diving
into the enhanced surgical recovery programs,
and we refer to it as, um, E-E-R-A-S in our organization,
um, enhanced, uh, enhanced recovery
after surgery, um, for, um,
because our anesthesia providers were asking for it.
Um, and so we have been in this work, um, for,
uh, multiple years now.
Um, we have, um, uh,
so we had great physician champions, um, to lead out,
and we, um, we looked at all the protocols,
and I think we might have done something a little bit unique
in that, um, we did start with one
or two types of surgeries.
So let's say we started with colorectal,
but what we started to do is really think
what are the key principles that apply across surgeries?
Um, and I would say things like early mobility, um, uh,
the approach to pain control, right?
Minimizing narcotics when possible,
the using the alternatives to opiates, um, the
nutritional approaches, right?
Um, minimizing the amount of, uh, NPO, um, the, the,
um, approach to carbohydrates, et cetera, pre
and post the surgery, right?
So we found those principles
and we decided that was our evidence-based bundle,
and how could we apply them across
as many surgeries as possible.
And so, over several phases of the work at each of our,
at all of our hospitals, um, we
identified, um, how we could apply those principles, um,
more globally, not just, um,
procedure by procedure.
And my understanding is that
that's maybe a little different than
how some places are doing it.
So at this point, we have 90% of our surgeries,
um, in the region are essentially using,
uh, eras protocols.
The 10% that aren't, are usually urgent or emergent
and are not appropriate, um, for, you know, uh,
some of that management.
Um, in phase one where we were doing just a subset
of surgeries, um, we, um,
noted an 18% shorter risk adjusted length of stay if, um,
the procedure had met the process pass rate, all, all,
you know, kind of five, uh, elements of the bundle were met
in phase two.
Um, another, um, kind of outcome that we had was a, a 16%,
um, morphine equivalent unit reduction.
And so redu reduction in use of morphine or, or,
or morphine equivalents,
and that is length of stay adjusted,
and that's across all surgeries.
Um, and so, you know, we are, and, and,
and again, a kind of a similar length of stay reduction
as our first phase implementation.
So, you know, we, you know, feel
that we had great outcomes related to that.
It's really just kind of baked in.
It's our standard of care now, um, for, um, certainly
for all, um, elective surgeries where it's appropriate
to apply those principles.
And so the, the, the philosophy that we took was really, um,
that's, uh, eres is our approach to surgery.
We are now working and to the point we,
we made earlier about integration, we're now examining if
that approach would be best spread across the rest
of the organization
and comparing, you know, lining up what work has been done,
um, in, um, the legacy Intermountain organization.
So, so hope that's helpful.
- Yeah, that's so interesting to hear.
And definitely, um, great to know that, you know,
the process is obviously, um, takes a while,
but certainly to get everyone on the same page,
it seems like it makes a big difference.
- Yep, absolutely.
Um, and so, and, and you don't wanna change,
you don't wanna break processes that are in place, um,
you know, just for alignment
and yet, you know, at some point, um, it, it,
it is, I think something you have
to look at if you really wanna operate in the same way,
- Way.
That makes sense. Dr. Wald, thank you so much
for joining us on the podcast today.
This has been such a fun and interesting discussion,
and I look forward to connecting with you again soon.
- Wonderful. So nice to chat with you.
- It's so important for leaders at the top of organizations
to keep learning, stay sharp, grow their networks,
help our audience better do this in a more simplified,
personalized, and meaningful way.
Becker's Healthcare has launched my BHC,
it's your trusted Becker's healthcare experience
and more with content, connections, events,
and learning opportunities, join the community free
of charge@www.my dot becker's hospital review.com
and we'll see you there.