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This is Laura Dirda with the Becker's Healthcare
podcast. I'm thrilled today to be joined by
doctor Marley, chief medical officer at Geisinger Clinic.
Doctor Marley, it's a pleasure to have you
on the podcast today.
Such a pleasure to be here, Laura. Absolutely.
Now I'm excited for our conversation because I
know Geisinger is such a innovative organization and
and truly,
an area where in health care, you know,
there's so many opportunities to do things differently
and use technology as well as transformational efforts.
And so I'm excited to learn more about
what you're doing at Geisinger. But before we
do, can you introduce yourself and just tell
us a little bit about the health system?
Sure.
So I am a nephrologist
by trade and serve as the chief medical
officer at Geisinger Clinic.
And Geisinger as an organization is an integrated
health system that has a very broad footprint
across Pennsylvania.
We serve some urban areas, but largely rural
communities
across
Central,
Pennsylvania.
Today, we care for approximately
1,200,000
unique lives,
across the clinical enterprise. And this would be
the hospitals. It would be the ambulatory care,
the post secured care, the home based services
that we provide including our health plan.
While that skill gives us opportunity
and a responsibility,
it
lays out the need for us to design
care models,
that are clinically excellent,
but also deeply patient centered
with a great focus on zero harm and
high reliability
where safety is our core value.
I hope that that provides you some sense
of who we are as an organization.
Oh, absolutely. And I I think, you know,
having that ability to design those care models,
think about clinical excellence, and then really define
it as zero harm and high reliability,
you know, is truly a huge goal and
a huge undertaking. And so to see how
successful
that you've been at Geisinger, in achieving those
things is is, really inspiring.
Now I was wondering wondering if we could
zero in on the last year or so.
Could you tell us about the most important
initiative that you led? What did you do,
and what were the results?
Yeah. So my my role is actually
bringing physicians,
clinicians,
nursing, as well as operational teams altogether and
greasing the skits. Right?
There are several projects that we've been involved
in, whether it is related to access,
new patient access, whether it's care redesign,
whether it's innovative care models,
so on and so forth.
But I think the most meaningful initiative for
me this past year has been a system
wide redesign
of our approach to serious and advancing illness.
The work is sorted
on a very simple but uncomfortable truth.
While everyone agrees that advanced care plan conversations
are important,
they often happen late,
are inconsistent,
or do not happen at all.
Most people want to die at home surrounded
by the comfort of their
family as well as the familiarity of the
home, and yet
only a very small fraction of people actually
do.
This means more to me because I lost
my mother this past year and my mother-in-law
the year before, both of whom who died
at home.
For our seniors, that cost
of that disconnect
between their desires
to what really happens
is
enormous.
Too often,
we as clinicians
fail to involve patients and families early in
a shared decision making,
and these conversations are hard. They're not easy.
They compete with many other clinical priorities in
practice.
And when they happen too late,
patients are deprived of a chance to develop
prognostic awareness
to reflect on what truly matters to them
and shape the care of
the process
as well as the support to preserve quality
of life.
So but when it's done well and when
it is done early,
those conversations change everything.
They improve outcomes,
related to disability, related to pain,
treatment invasiveness. They address mood and psychological distress.
And they also actually help families to see
death as a non traumatic event,
not as a failure and as a natural
outcome of serious illness.
And so importantly, it reduces
unwanted in hospital deaths and very late referrals
to hospice where patients can find comfort and
improve quality of life.
Yet there is a paradox. In our entire
country, this paradox exists.
Everyone knows that these conversations are important.
And when everyone knows these conversations are important
and it becomes everyone's job to address it,
it becomes no one's job to do it.
They go far beyond delivering bad news. Right?
They translate directly into medical decisions. They require
coordination across settings.
And in the absence of clear medical guidelines,
clinicians are left to balance between patient autonomy
and non maleficience,
something we do imperfectly and for that matter
the whole country does imperfectly.
So we started to establish a very clear
baseline
and I think it was important for us
to know how effective we were,
in terms of our advanced care planning
with our senior bundles.
And what our dashboard showed is that we
haven't budged our numbers
beyond five percent until a year ago.
Those numbers made that very, very real.
And so what we did is we looked
at it clinically and operationally.
We focused on care fragmentation.
We focused on patient experience. We focused on
end of life outcomes, and we completely redesigned
the model end to end.
At the core of this model,
we have a very high touch,
tightly integrated clinical model
designed specifically to care for the sickest of
our sick.
We embedded a very focused team with very
deep palliative expertise
and clear clinical oversight to partner with patients
who have a predicted life expectancy
of twelve months or less
using a validated predictive tool.
The team works alongside with the patient
and basically goes throughout the entire last mile
of their journey.
The role is not scripted at all. It
is a series of conversations that happen longitudinally
and help patients
cope with their serious illness and the enormity
of their illness through a continuum of conversations.
These conversations are delivered reliably and consistently.
And whether the patient's at home or in
a post acute setting, it does not matter.
This team actually focuses on that.
And the intent is very simple. Right? Give
patients and families time.
Time to cognitively and emotionally
understand and process the prognostic information.
Time to oscillate
naturally
between
hope and realism and type to adapt.
So the work did not happen just like
that. It took a village.
In fact, it required our ethics teams to
come together
to review our tools,
the College of Health Sciences from the standpoint
of cascading education,
multidisciplinary
clinical teams, specialists in palliative care, the hospital
partners, the nurses,
and the nursing leaders all stacked hands
recognizing both the urgency as well as the
complexity of the work.
Along the way,
we confronted real challenges.
Okay. It was difficult to actually cascade that
education
on dying with dignity
because we had imperfect triggers.
And the care was very, very fragmented between
the inpatient, the outpatient, the post acute, as
well as the home settings.
So we also had to acknowledge that
there was a hard truth.
The truth was that we commonly used a
surprise question, and the surprise question was asking
our physicians and clinicians
whether they would be surprised if this patient
died in one year. And realized that that
was a very imperfect signal when patients and
family needed
deeper support.
So what we did is we pulled in
our my care choices team.
We helped explore
the elements that really matter.
We went through that process intentionally
and then wanted to get to real change.
This far, we've enrolled about 1,800 patients or
so of the highest risk sickest of the
six seniors.
The book focused on exploring their hopes, their
worries, their grievances,
their clarity on priorities, as well as building
coping skills to live with the serious illness
at home. And as I said, this is
not a single conversation. This is a very
iterative process that unfolded over months.
And as patients integrated that information,
they understood the trajectory of their illness
and started to focus on what matters most
to them.
Those things translated to clear goals and values
of shared decision making for them as well
as our teams. This was a huge cultural
chip. So we started with about a five
percent bundle rate,
and now we are holding at about forty
five to 50% of our identified patients completely
engaged in the process.
And
in the recent snapshot
of the thousand or so patients who had
been completely engaged,
we recognized that close to about a third
of them had celestial ascent.
And of the third, 50% of them spend
their time in hospice with an average hospice
time of approximately thirty days. So a significant
shift from where we were. And this to
me was the most meaningful initiative
that we've had from my perspective.
I I know this was a very long
response, Laura, but I thought it's important to
lay out the the elements.
Yeah. Absolutely. No. That was fantastic. And I
really appreciate you going into detail about how
you put this together and and why it
was so important and critical,
because I think it's something that, you know,
many,
hospitals and systems overlook or or just continue
to handle this patient population in the way
they always did, which is high cost and
not exactly, as you mentioned, you know, what
the patients or families want,
in the experience for the the end of
their life. And so I know it's so
critical having these conversations and putting these systems
together. And, you know, I I appreciate you
also mentioning all the the number of folks
that are involved in, putting this together, whether
it's the clinical
leaders as well as the ethics teams and
and everybody else just to make sure it's
done in the right way, in a meaningful
and a compassionate way too,
because it's
a a a very challenging time. I know
in the patients and live lives of their
family members too. And so,
it makes a big difference. Now when you
think about the future, where do you see
the, system heading? What are some of the
big priorities and headwinds that you have your
eye on for 2026?
Oh, there are several. But but I think
I think when I think about it,
perhaps the most important piece
for us to scale
what we need to do as an organization
is the physician APP alignment.
Right?
I think the care team realignment
and having the teams practice at the top
of our license is a refrain that we've
heard for a long time. But in reality,
that alignment and engagement is probably one of
our biggest opportunities.
The other pieces that come along with that
is workforce sustainability.
Trying to use data or, you know, what
is right now the buzzword AI,
in terms of services.
Access redesign,
which is again
a bread and butter element, but looking to
figure out how we can actually improve access
for our new patients and more importantly,
continuity of care that is not episodic or
fractured
is is another element.
We have other areas that we are working
on as big ticket,
issues
related to clinical pathways,
having a pharmacy led management,
and then focusing on patient experience,
particularly as it relates to their likelihood to
recommend as the primary signal
that we follow from the standpoint of care.
Now none of these topics that I'm sharing
with you are new topics. These are topics
that have
been things that we are working, but we
are reengineering these all and again to address
what needs to be done.
Now in terms of your question related to
headwinds,
I think the
biggest headwinds
are workforce constraints. Right? The changing mix in
terms of physicians versus,
APPs or clinicians,
and then clinician fatigue. Because now you have
sicker, older patients in the hospital setting,
particularly in a rural environment where there are
also financial challenges and challenges of social determinants
of health,
that is substantial.
That
is in
further it is kind of tied in with
the financial pressures of the decisions that are
coming down the federal as well as the
state,
related regulations
and support from the standpoint of health care.
And then aligning
what is required
from the standpoint of clinical care with the
patient,
and what the patients actually want.
So so those, I think, are the big
headwinds that one needs to think through,
from the health care landscape.
I love that. I think all those things
you mentioned are are so critical, and especially
the workforce piece. That's something I hear time
and time again from leaders across the board
who are trying to
design a system of more collaboration, more alignment,
more, connecting points between physicians,
APPs, and and clinicians across the board and,
you know, their nonclinical counterparts as well to
make this whole system work.
I'm curious. What do you think the hardest
thing you'll have to do in the coming
year will be?
That's a tough question because there are so
many things that are coming down the pipe.
But I think the most important,
thing will be driving behavior change at scale.
At the heart of our mission,
we have an unwavering commitment to bring high
reliability,
which really means we are pursuing
zero harm and embedding safety in every aspect
of our care because we believe that that
is the driver of trust.
Achieving excellence without exception
every time is not just an aspiration,
but it is a core expectation
of our leadership.
Our CEO has set the stage in terms
of what is important,
and the entire executive leadership team is working
on excellence without exception.
And when I mention zero harm, I'm not
talking about
zero events,
but really talking about
zero errors
from the standpoint of zero harm. And we
wish to ensure that every patient, every family,
every team member can trust
that their well-being is our highest priority
And that our systems, our process, and the
culture are aligned to support
safe,
reliable, and exceptional care at every encounter. So
that probably
is the biggest piece. All of those are
behavioral
change elements
because it needs
both our clinicians,
our nursing teams, as well as our entire
staff
to rethink
long standing habits.
When do we intervene?
How do we talk about prognosis?
How do we define success?
What really matters?
How do you understand this from an empathetic
angle?
And then stop being heroic or reactive, but
really focusing on being intentional,
and anticipating
care and providing that care
with hope and compassion.
So that's really the fundamental change. So changing
culture is probably the most important thing in
my mind.
I love that. And I know much easier
said than done. And when you look at
that culture change needing to make the shift
and wanting to zero in on that high
reliability,
zero harm, culture and mission,
how do you do that,
in, you know, have that mission out in
front of folks,
communicate that, and then really hold that bar
high, as you're going through these changes in
in in different
team members might be in in different places
in terms of how easily and and quickly
they can adapt and others who maybe are
holding on to the way they always had
done things, differently. So, I'm curious. How do
you manage all of that, especially in an
environment as we talked about that, you know,
finances are tight, a lot of changes in
all the other dynamics that are happening in
the health care space today?
Yeah. As I shared before, our CEO as
well as the executive leadership team has made
complete commitment to that. So, basically, we are
bringing all our leaders for training on HRO
and zero harm.
Every staff member with about 1,100
sessions
are going to go through this program
on the education
as well as understanding
what this really means and what should be
the change in the strategic mindset to deliver
on that.
But
rooted in all this is the process of
just culture and all the safe tenets of
what a high reliability organization is.
And so,
that's really how we're going about the process.
It's going to be a journey. It's gonna
be a journey of this next year, but
that's really the biggest
area of focus for us as an organization
for this year towards the end of this
year.
Absolutely.
Makes a ton of sense. Thank you for,
sharing with us. Now before we wrap up,
I have one more question. Where do you
see some of the best opportunities for growth
in the coming year or two?
I think I can give a standard
response of saying that, well, growth can be
on clinical excellence, it can be on patient
experience, it can be on value based care.
But I I really think it is at
the intersection
of all these three elements.
Specifically when I think about it, I think
that,
much of the growth has to be in
home based care models where we can deliver
better care and better outcomes
and also on the patient preferences.
We think that there's opportunity for integration across
the continuum. I shared with you how fractured
health care is across the country.
There is opportunity in terms of partnerships, both
external and internal.
We don't need to build every wheel.
We can buy the wheel off the shelf
and actually move things faster.
And then more importantly, developing our leaders as
well as our teams so that they are
comfortable
operating in a space of ambiguity and complexity,
and also recognize our unwavering commitment to
high reliability organization
with safety as its core value.
Ultimately, the growth for us isn't about size.
Right? It's really about impact. And if we
can consistently deliver that care to our patients,
that we would choose for ourselves and our
families
and deliver that excellence without exception,
we will have succeeded.
I love that. Thank you so much, doctor
Murali, for joining us on the podcast today.
This has been such a fascinating discussion.
I I really learned a lot, and I
can tell you're so passionate about what you
do. So, thank you for the time, and
I look forward to seeing you as well
in April. I know you'll be speaking on
one of our panels at the annual meeting,
and so it'll be great to catch up
and dig a little bit deeper into all
of the things we talked about today.
Thank you, Laura. You've been exceptional and kind,
and thanks a million.