Internal Medicine Faculty Meeting
December 17, 2019December 6th, 2019
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Transcript
- 00:00So Good afternoon, then welcome to faculty meeting.
- 00:07Around here.
- 00:09So today, we have a very.
- 00:15Important faculty meeting and in our guest speakers are rigged Aquilla Tom buses. I can pull Tahiri, who are going to discuss Neil driven hospital health system in India medicine strategy for 2020, so before letting them come to the podium just a few announcements.
- 00:38Uh this weeks going around it will be Daniel Philip K body lectureship and images. Sis was a professor in general medicine in the speaker? What can aging with HIV teach us about aging itself.
- 00:52The week after next would be al sure from the section of infectious disease, protecting although adults against influenza Infinity Game Infinity War end game.
- 01:05On December 26th when well will be cancelled because of the Holidays.
- 01:12And then Biomedical Research seminar, which is on December 16, which is next week will be a joint effort by Fred goal again myself and we will be talking about the biology of survival factor, which is winner list, which I discovered my laboratory.
- 01:28Uh some Kudos Server Chaudhry from general medicine, Erika Herzog or the new Associate Deans for the office of student research and they were placing.
- 01:41John and I don't think the audience. That's a really important position and please. When you see them. Please congratulate them, but we're looking forward to working with them.
- 01:54We highlight the result is the president elect of the American Committee of molecular cellular in middle class classic ality his associate professor of Medicine in the infectious disease section.
- 02:08So now I'll just list the grants and contracts. We've gotten this past month.
- 02:13And the first is 1 by sip some low from the right and it's a 6.5 million dollar grant.
- 02:222nd is ascended Springer from the infectious disease section is a 5 million dollar grant.
- 02:31From the NIH.
- 02:38Gentlemen.
- 02:40From General Madison.
- 02:45Will Becker, who works primarily at the VA?
- 02:49But that's in a square.
- 02:55You being you being young from Cardiology.
- 03:02Lynn filing from general medicines.
- 03:07The wind from the impact endocrinology.
- 03:15Heidi Zapata from ID.
- 03:21Seattle mayor societies the inaugural director of the Global Health Institute. He said his pediatrician is works in vaccine development and is easy within the infectious disease section.
- 03:40Because Villanueva from the ID section.
- 03:46Greg roulette from geriatrics.
- 03:51Kimberly I can't pronounce your last name.
- 03:56Yet.
- 04:00You're so cool, he will carry.
- 04:05So infideles
- 04:06From The Prodigy.
- 04:10Alexandra lenski from Cardiology.
- 04:17Federal law from geriatrics.
- 04:23Sukanya from infectious disease.
- 04:27Owen from digestive disease?
- 04:32Doctor Rio from home and ery.
- 04:37And I have a hand Gary from pulmonary.
- 04:42And those are great this past month, so any questions or comments or did I forget anything.
- 04:51OK, if not, I'd like to call with equal to the podium to begin with discussion Rick.
- 04:58As you know, Rick is the president of the living hell system. Thanks Good afternoon. Everybody we typically do hospital. Updated health system update and I know Yo Medison does as well, what we thought we would do differently. This year is combined. The discussions also with doctor ballsacks presentation. It really prevent present kind of a unified overview.
- 05:23Of how the Medical Center is positions in aggregate for 2020. We're going to try and keep it to 25 minutes and keep a good half hour for questions and Fortunately we have relatively few slides for that.
- 05:43I really good when I tested this earlier.
- 05:49Left hand.
- 05:53All right now, we're good so I want to just kind of really want to start with kind of how we did in 2019, was yet again. Another growth year for Yale, New Haven Hospital. There are a number of several numbers on this page. I'm going to call out a few.
- 06:18Uh the far and away the most important number is the Top left, which is 23 serious safety events over a period. An you know that really is. The combined work of several years of focusing on high reliability, engaging our employees and physicians and everybody focusing on zero events of harm and that's still 23, too many events apartment that number is down dramatically when we started the journey nearly 6 years ago.
- 06:52And it's on what is now an enormously busy Medical Center with all their over 2 million patient touches in aggregate so again we don't rest until that number hits, 0 that will be a never focus of our work and effort, but if all the numbers on this page. It's the number that were most pleased and proud to present.
- 07:20Not so happy about patient experience. We continue to struggle with patient experience scores that are not where we want our Medical Center to be a lot of this is some of this can be the physical conditions. The crowding the boarding. But some of it is the basics of connecting with patients communicating as a team quiet at night. Other things that patients are really are very particular about in their hospital experience and all of those.
- 07:51Can be exacerbated by some of our physical facilities?
- 07:56You know that our patient population is sicker and sicker. This is our highest case mix index ever. It's a reflection of our growth in Y axis transfers and just in general. The work to build complexity in destination services and how that has affected our case Mix Index and we'll talk about some of those factors in a minute and then Lastly we achieved again in a very difficult financial environment and operating margin.
- 08:28Of that, so that beat our budget.
- 08:32It allows us to make the kind of investments in 2020 that you know that allow us to move forward with a growth and Programmatic Enhancement Agenda. My only other slide is this and I wanted to kind of just in one overview.
- 08:50Provide a focus on what we are at Yale, New Haven Hospital working on in in 2020 and beyond.
- 08:59Are the fundamentals really the very much the continuous basics of patient experience high reliability focusing on engagement for employees and physicians alot of work around Lenfestey Management. We are as you know incredibly crowded and bed relief is still several years off. We're dealing with a number of interim moves to create additional vet capacity, but let this day is an area of constant focus.
- 09:32And you'll hear later about our work with yellow Medison to be much more thoughtful about patient access and help patients. Find us and navigate through the complexity of our health care systems.
- 09:47We're still in an environment where growth is important, and there are a number of unique growth and enhancement plans for 2020. One of them is I hope everyone is heard by now about our investments in the same rayfield campus. The additional beds and focus on neuroscience is that will take place on that campus and that's when it is completed, it will give us the opportunity to start to work through the ultimate decant of the East Pavilion in the renovation at the South Pavilion needs to have.
- 10:22Take place so that is right now still working its way through the approval process in New Haven. It's on schedule, which means we're still targeting the end of 2023 for those beds to come on line and you know, we're not seeing neighborhood opposition to that project, which is which is really important. The primary care consortium is also received as necessary approvals and it started its construction process.
- 10:52Uh in that work will build a much more definitive investment in primary care in our community, partnering with our community health centers lot of work around the ambulatory growth and development in greater New Haven and beyond.
- 11:07Uh we can talk to some of the specific centella health or the kinds of investments that we're making there as well as our relationships with Trinity Health with the language. Trinity continues to be a major partner for Yale, New Haven Hospital Anele Medison in areas like cancer neurosciences and cardiac care last thing I want to focus on is just so far work around integration across our health system. We are really focusing on.
- 11:38Efforts to build a care signature Tom Doctor Ball sack will talk more about that. We have finished the acquisition of Milford hospital are in are in the process of building that out. Is it geriatric center of excellence. I mentioned ambulatory care. There are number of ambulatory sites that are either being optimized fully built out like North Haven or looking at expansion opportunities for moving more and more services out into the community. There's a strategy built.
- 12:09Being built around population health and clinical integration and Iraq is our acronym. It is a regional Center for distribution technology. An support space is being built in West Haven and it's an example of where a number of hospitals can share infrastructure and do it in a way that's more cost effective.
- 12:35So that's a That's a year that we just finished and this is the year that we are facing in 2020. I'm going to turn it over to my colleague Doctor Tahiry to do the same for Yale Medison.
- 12:50Thanks Rick so I'll just following the same format. I thought I'd share with you a couple of data points that are relevant from the ym perspective and then the next slide is really about some of the key priorities in issues. We're dealing with so briefly just so we get a sense of where we are. We're doing about our growth. Historically has been around Seven 8%. Sometimes, 9 were right on target with that.
- 13:20We're at 7 four point 4% last year word about 8% in this current year. You never know how the year is going to end but that's about where we are now I think one of the key things that we're doing in that we're starting to see his incremental growth outside of New Haven, which is a deliberate strategy. Organizationally, which is we're trying to grow in Fairfield and new one. Blendon specifically that is happening. We are targeting about have about 20% of our revenue.
- 13:53On the YM side in those regions over the next couple of years were at about 13% right now and that's growing more rapidly than New Haven County itself is growing at about 6 1/2%. So teryx point. There's still growth here. But we are growing faster on the outside. Of course, that's on a lower base, but that's part of our strategy. If you will one of the important numbers that I like to talk about for a minute is Arnett collection rate so.
- 14:23Many many of you periodically look and see the ratio of sort of charges to collections. But the real number that I would tell you is more important than anything else is that? What do we? What are we getting about we're supposed to be getting not based on? What we're charging payers and so right now, we get about 93% of what we should get from the payers. There's a whole host of reasons why we don't get 100% but we're supposed to get but we're about 93% just so you know that puts us in.
- 14:53Certainly the time 25th percentile or 75th percentile. If you will performance against our peers. This is the academic peer group, so our friends and colleagues at Hopkins Pan etc. So the collection rate is actually good always going to be better room. We're working to do that. But just sort of a knows that number is pretty good. We're seeing about million two patients a year that number continues to climb as you would expect.
- 15:23And we are out doing over 6 million RV use as a practice itself briefly. There's two other issues that I want to talk about one is access in one is a government payor mix. So let me just talk about government payor mix for one moment in general or government payer mix goes up about 1% a year and the commercial payer mix goes down about a percent a year So what we're seeing is increasing government. They're less commercial payers. Some of that the aging of our state.
- 15:56Uh and so that you know that's not a lot. We can do about that. But that's part of the reason why we have expansion into other areas because the some of the other areas are actually growing Fairfield County slow growth, but still growing were sort of a neutral here and just kind of aging so we want to go a little bit to the West, where there's some stone modest growth, but a better pairing so that's the rationale behind that because if we become 100% federal or state payor mix. We're going to have some economic issues so we really need to?
- 16:31Make sure we try and balance are pair mixes to stay solvent basically an another minute on the access center that I wanted to talk about just sort of understands we've completed the phase one of the access center that some of you are participating in already Phase 2 is docked for launch in January and the just to give you some brief numbers. Today, just with a quarter of the practice about 400 providers.
- 17:01We have about 4000 calls that come in there, a day in that setting so far. We've been working with the docs about modifying certain templates, which they have allowed to occur and it's really standardizing return visits and things of that nature, but that's already occured when we have over 1000 templates. Now that are sort of much more uniform than they were in the past, so a lot of work is going on there. Still, this is a big initiative for the Medical Group and the health system writ large, which is why we wanted to.
- 17:33To talk about this, but I think it's important to be in a sense that this is a very big undertaking and this is only 1/3 of the practice so you can do the math. It will get much larger as we so couple of priorities for next year. They're kind of listed here and I think a couple things are important so as we work to be more aligned with the health system. One of the things we know we need to do is actually redesign some of our sort of committee structures and how we just generally operate ourselves.
- 18:07So for example, we now have a joint meeting at 7:30 in the morning.
- 18:12With Rick and myself and in many other chairs, about 7 of the chairs and all the senior vice presidents. Gary is certainly there. We really talk about institutional strategy and directions and resource allocation. Those kinds of things that happened there. But this is while it's not necessarily exactly new to this cohort. It's really starting to take hold and become very important body organizationally. It is really sort of getting to the point of decision making an sort of executing and moving forward with our strategic initiatives some of which.
- 18:45Rick is highlighted so I think we understand that we have to change how we do sort of organize ourselves and now we don't have to change employment. All that, but we do have to think differently about an enterprise whether you can call or Medical Center health system. An enterprise wherever you want to phrase it as but to work much more collaboratively and much, much more organized fashion. So then we have really in the past, so this is an evolution, but it's actually happening.
- 19:15Uh you can see little bits of it with the project management office. We've merged. The reason that project management office has been merged. His really begin to allow that group. There now jointly look at many common services that each party has and should we bring them together for example, how we credential are physicians. As many of you know that'd be painful, it seems like you're doing everything 2 or 3 times for those of you who are new you probably can remember those fiddly, but so.
- 19:46Unifying some of these things so the providers aren't sort of dog with all these would seem to be nonsensical ways of doing business so that's part of what the project management office is going to do to look across the enterprise at things that we have multiple duplication sometimes triplicate between northeast Medical Group between ym between the hospitals the delivery networks we could have 6 different processes all trying to do the same thing we want to get rid of that duplication.
- 20:16Rick already mentioned a little bit about the Trinity. But we are looking to expand along the Trinity Lines, an Tom is going to talk about the since why won't talk about that. Let me briefly talk about quality. So we have Steven Joy, who many of you may know or may have met is our chief quality officer. He's actually a joint higher between ym and health system. But the Steve is actually going to work with a lot of vice chairs and develop a process. So where we are very much focused on some of the busier.
- 20:50Reporting and we are actually ticking and tying various quality issues. We have in the practice because when we compare ourselves to some of our peers. We have areas where we need to make significant improvement in our quality reporting. We have lots of people have looked at this and some of its documentation. Some of it's our infrastructure costs. 'cause those unpacked some of these reports, but nonetheless. We simply have to score better on these and I will tell you that.
- 21:21Steve is has presented she toys presented to the why I'm bored and he's sort of been tasked with creating a process and a plan to sort of begin and execution phase to enhance our scoring on the busy and score card, so that will be happening over the next several months. I talked a little bit about access and let me just talk about clinical optimization, a little bit about telemedicine. I'll turn it over to Tom.
- 21:48So many of you know about bobber khokhars work and in clinical optimization going to clinics and identifying issues that both impacted the patient and the providers and trying to streamline the Workflow and enhance epic as we go through. We recognize that work is highly valuable and valued by many people. But we actually need to make more investment. In doing these things to really make the clinical environment, much more palatable an inhabitable.
- 22:19By our provider so there is work underway right now to develop a process to sort of level set an optimized what should be in our clinics in terms of staffing in terms of epic support in terms of space, which I know is a big issue and that actually that analysis is being done with Baba ran the project management office right now, so we're working on that and hopefully can come out in the next. I would say next few months, but a plan about how to really optimize our clinics yet to another another level.
- 22:52Uh and I do want to mention telemedicine 'cause. This is an initiative that has many shapes and flavors. We've had some early successes. With this, particularly with the econsult with the primary care folks and many of our specialists. So this actually started with the FQH. CS Yale Health and Cardiology. It is now we are ticking and tying about one specialty or subspecialty every month. We're adding to this 'cause there's a lot of.
- 23:23Appeal on both sides and I think the reality of this is. It also helps us decant the clinic space from visits that really is a highly specialized group. We would find to be not necessarily need to come in and see some of our providers. So this is all being done by Britta Roy with bobbers were oversight as well. And we were just doing it as folks want to come on, but we have a laundry list of folks and services that are queued.
- 23:55Oh man over the next several months, so this will probably coming to your service, but rest assured, everything is done with your approval. We don't just show up and say we're going to do it. You've got less when you want to do it and then we make it work, so let me. Let me just give him the time. Let me stop there and turn it over to Tom and then we're going to do some after that night.
- 24:21So thank you. Paul and Good afternoon. Everyone I'm going to try to go really quickly through some pretty dense stuff. So I will have time at the end to talk about questions and dig deeper, and whatever part of this, you'd like to get more into what I'd like to do is talk a little bit about what are combined strategy is looking like in in that session that Rick and Paul described in the morning where we really sit down on every other week basis and talk about where we need to go as a combined entity.
- 24:51As a health system and as a faculty and as a group of physicians. How are we looking at the future and what is key to our continued success and growth and development in pursuit of our missions of care for our community and education. Research and clinical care and how do we remain continue to be successful and relevant in today's Today's date. So you probably heard one or more discussions about our pursuit of value in this concept that we need to provide high quality care that is.
- 25:23Safe and provides an experience for our patients at a lower price than we currently do and we've been successful over the last 3 years of actually delivering lower cost higher quality care on a per patient basis across our health system. The challenge for us in the state of Connecticut is we haven't been able to pass that lower price on to our patients because of the Medicaid problem that we faced in the state of Connecticut, so as we've been able to provide lower priced care for all of our patients.
- 25:53The tax that's on hospitals in the state of Connecticut's basically absorbed all that savings and we haven't been able to pass that price along to our patients that something. Hopefully, that will change in the coming year with the settlement that you've heard about coming out of the governor's office. But now we also want to not just provide higher quality safer care with a consistent experience at lower price, but we need to make sure that we do so consistently across all of the locations that we are jointly operating together. This concept of care signature.
- 26:24It's not enough to deliver high quality care, but there has to be a feeling in a look and feel and a set of experiences that are the same, so we need the same clinical protocols and some of you are on either clinical redesign projects or are integrated care model projects where we're driving similar processes across all of our sites are environments need to look and feel the same and we need to spend a lot of time working on? What Rick mentioned which is the experiences of patients in navigating our care. Where do we do that? Well.
- 26:55I think we do it pretty well right now with our smilow network. I've had experiences personally with my family. I think many of you have a tell you a very quick patient story. We like to use stories. 'cause I think they put some real. I think human feeling behind some of our data. But up here in the upper North western part of the state. My sister lives just outside of Torrington and her step daughter came home from college and was diagnosed with lymphoma.
- 27:25And my sister called me in a panic and said the pediatrician who is a local person in Torrington wants to send her to the smile care center in Torrington, but my sister, said. Can I go to the real smile? Oh, the concept that this is the Mecca in anything outside of this is not the real smile. Oh, but I think where we are with smile. Oh, now as you know that all those cases that are treated at any of our care centers are all reviewed centrally and that there is no difference in the care in any of our care centers.
- 27:56That our processes are saying the protocol is the same. The faculty are all integrated and so that is what we need to strive for which is no matter where you go that you will get the same level of care the same quality of care and have it be integrated so that if she does have a recurrence and she needs a transplant. She'll come here. But other than that, she should get all of a routine follow up care in her local site close close to home. Rick mentioned are high, reliability work and I can't resist the urge to put up the.
- 28:29Why can Sutcliffe construct around? What underpins our high reliability work because I think it applies to all the work that we are trying to do whether it be care signature or high reliability. But I think the principles that they point to our principles that can help us get success, which is we need to be preoccupied with failure, which is kind of an odd one right. We spend our entire careers focusing in imagining what success should look like so why would we focus on preoccupation with failure.
- 29:00Well, if we don't figure out what we could stumble on or what holes we could fall in we might not avoid those holes and I don't know high reliability work. It's all about failure mode effects analysis. What is it that could go wrong and how do we prevent that from happening so I think there's an important message there is reluctance to simplify the environment that we live in. We've all had dinner time table conversations that if they only did this, then that wouldn't have happened and we know that the world is much more complex than that, so we need to be reluctant to simplify what is really pretty?
- 29:30Is fast evolving in complicated world we need to be sensitive to operations. The folks that are at the front lines in this incredibly complex organization actually know best? What is going on in how to operate and that also speaks to the difference to expertise and finally we need to be resilient in our work. It's a difficult environment? What we do is very difficult working in. I think we need to make sure that as we struggle. We need to be resilient about about being.
- 30:00Successful Speaking of resilience Rick mentioned are 23 serious safety events in the past 12 months. I hope you've seen this graph. If you haven't you're not reading my medical staff bulletin. It's in your email box every month. And it outlines exactly what our numbers are around healthcare associated infections. That's the middle number. HAIPSC's or precursor safety events. Those are events that some people called near misses. That means they they vent of harm reached the patient but didn't actually cause harm.
- 30:32And these are the numbers of quarterly across the bottom serious safety events. You can see that we made remarkable progress. In 5 years and challenge for us now is we've stalled so how do we go from 23 events of harm to 0. That's our question right now and there's a lot of work that needs to be done on this, if you want to read more about this. I'm happy to tie you into some of the work that's being done in our organization that's in my medical staff bulletin and on a monthly basis. We do the serious safety event disclosures in park history.
- 31:03Meaning that we go up over the serious safety, then in detail the root cause analysis and what steps we put in place to prevent that from happening vis-a-vis the healthcare associated infections again. We made a lot of progress, but to that that we struggle with our central line associated bloodstream infections. We've seen an uptick in that we have seen a lot of progress in our centralina. Susan Foley catheter related urinary infections in C difficile big, big, big improvements over the last year.
- 31:35I'm moving to this concept of care signature one of the things that's most important in trying to get to care signatures reduction in clinical variation. I hope that you know what the clinical redesign work has been accomplishing over these past couple years. These integrated care models are going to be hearing more about these are what would be considered pathways in the old lingo. We've got a lot of work across the health system bomb policy spent standardization. Paul mentioned credentialing for example, so there's about 15% of our medical staff.
- 32:07At this institution that have joint appointments at other medical Staffs within the health system so we're trying to standardize all of our policies and practices to try to make sure that it's easier to practice from one institution to another and then many of you were involved in the nurse position dyads. We have a diet breakfast. Once a quarter and we have ongoing meetings where we are actually trying to embed these standardizations of protocols and so forth within our practice groups so together taken together, these operational standards and clinical standards really should.
- 32:38Lead us to getting a more consistent experience for our patients across our health system for wherever they touch our patients. Just spending a brief moment on something that is really important to me is this improvement in how our lives in practice? Are we've all experienced. The challenges of electronic medical record to pick on something that we all like to pick on and we've shown over the last 2 years that were able to reduce a lot of what people call pajama time, which is the time spent documenting.
- 33:09After hours, we still have a lot more to go here, but there is a lot of work than that. You should be seeing in terms of trying to make standardizes in how our order sets are done and also in terms of how we can try to make it easier for us to interface with the electronic medical record a lot more to do here. Finally, I'm going to spend a moment on the clinically integrated network fall introduced this rip touched on it? What is the clinically integrated network?
- 33:39Well, I think as physicians and as patients. We don't recognize that there are community. Doctors University physicians in northeast Medical Group physicians. We just recognize that there are physicians that care for us, our families and our loved ones and that we, as I think as a Medical Center. We touch all of these positions independent of where they work. But there are real barriers that we run into because they're different employment models. There different incentive models. There's different contracts were working against different sets of goals.
- 34:11And our goal in this clinically integrated network is to essentially create a single physician group irrespective of what your employer is but really, really wrapped around this idea of signature of care meaning that we should be able to at some future state and we are close to being able to put together a set of agreements on paper, contractually obligate all of our physicians right. Paul that we're going to be able to do this as a virtual group where we're going to be able to sing.
- 34:43Have a singular set of goals singular set of contracts in a singular set of methods of caring for patients that will completely. I think really revolutionized the way we work with one another. This will be a virtual network. It won't be a change of anyone's employment, but it will obligate us in a different way and will be. I think behaving on a structural level much more that in line with how we behaved.
- 35:14On an individual clinical level with patients.
- 35:17So finally within the last minute. Let me turn it over to Rick and Paul to talk about patient experience and then we'll take questions.
- 35:24This is this is the last slide and it is really a reminder of what we're trying to accomplish when you step back and look at it patients look at all of us, Yeah Haven Health. Yale Medison Northeast Medical Group, an they struggle to differentiate who is who is a separate Corporation who's a separate organization. They get bills that are confusing to them and they get multiple bills even in physical places.
- 35:55They could end up registering in multiple places in the same building an you know what we're trying to do what Paul and I are working on and we have a large steering committee working with us on.
- 36:06Is where can we simplify that process where we can we be more thoughtful about how patients call us? Find us navigate through our systems. Can we integrate billing can, we make it easier for the patient and that is the work that is really preoccupying us. These days were determined to make it better and do it through the lens of patients who else us as GAIL GAIL patients and it's it's an important experience to get right and.
- 36:38We're determined to do that, so with that. I'm going to stop. I want to open it up for questions. I want to ask Paul and Tom to come on up here and take all the tough questions.
- 36:53What can we tell you more about?
- 36:56Yes, you gave 4.5% as the margin how much money does that translate in do.
- 37:07That's about 170 million dollar operating margin and that gets invested every year back. I mean, just by comparison, our capital budget. The technology the investments in it. The investments in bedside technology or about 220 million dollars a year last year, we put in capital alone, that back into our organization.
- 37:33That 4% covers additional staff and finances. The growth and staffing because of patient acuity. It gives employees raises and it is about 4% is traditionally the minimum to stay healthy year over year that an organization is not for profit has to achieve.
- 37:54I guess my question is based on this conception of physicians, moral distress that appears to be almost unknown present in all of our institutions how it is that we are addressing that problem. That seems to have its origins in physicians, finding themselves in the vice.
- 38:19I'm too little time to fulfill their Noble aspiration is preparing of patience and so how it is that the rescue them. By providing them an environment in which they have time to actually interact with your patience.
- 38:40You know, I think a couple of responses to that 'cause it reacted buys us. It's an important issue and Tom gave examples of epic and there are other examples of virtual scribes and things we are doing to make FaceTime more on the present and make it easier where we can, but you know that vice is for the entire institution.
- 39:04You know yell New Haven Hospital and Yale, New Haven Health and Yale Medison.
- 39:09Are a safety net organization, we turn nobody away. None of us? Do regardless of ability to pay we take transfers from all over the country, 700, a month. Now, nobody gets turned away at clinics. Nobody gets turned away in the emergency Department.
- 39:25The state of Connecticut and the federal government under pay us for Medicare and Medicaid. Yet this Medical Group in this hospital and where the biggest tax payer in the state of Connecticut.
- 39:37Uh and so we're on a treadmill and that treadmill isn't just affecting our physicians. It's affecting our employees who are burning out and getting the very real sense that they're just not getting ahead. 'cause the patients are sicker than ever.
- 39:53Uh and the environment is more compressed so you know it's it's it's everywhere in the organization level and we will I think the?
- 40:06Couple of issues, one is we know the ambulatory space as follows. The impatient franchise is over crowded in many.
- 40:15Weather is not enough rooms could be patients. None of Staff. None of Doc Time. Whatever that's what one of the areas. We know we need to focus on and we are so let me be specific so in some settings. We know there's a mismatch.
- 40:31We don't have enough staff, we were committed.
- 40:34We have metrics we know what we know how many people should be really at the park test and we have spaces where there's a line every day.
- 40:41Yeah.
- 40:44Do we know areas where there's not enough space in their model?
- 40:49That is not an easy problem to solve but we are having that discussion that I think we should work permit recognized that discussion. We're having at the YM Board, which is which area chairs as I think you recognized and that is about actually should we change the way in the timing of how we deliver some of our care greatly, saying maybe we should have $9 that would relieve people potentially from the day hours. So we're not changing anybody's clinical FTP. We don't do that.
- 41:22All done it is apartment level, but we also recognize that we're doing this in a disorganized way today, so right now neurology sees patients and why PBS Saturdays. They've chosen child study sections. These patients Monday through Thursday in the evenings again. That's all been by their structure and their desire to do that some of that one kids.
- 41:46And orthopedics for example, is taking there any new hire and saying it is our expectation orthopedics that you will work.
- 41:571 evening, we can one weekend a month. We decant weekday or what you know, so maybe work Thursday nights, but you don't want Tuesday mornings whatever that's all Lokoli decided but we do have economic constraints in the organization and I will go as we extend in the evening and weekends. This is all going to be with the approval up at the apartment. Nobody's mandating anything but we need to build the infrastructure behind it, so somebody's here Tuesday night, the whole organization.
- 42:27Not just a doc running around in the clinic by themselves it's not going to be the case but we have to do this obviously properly and in a way that ensures the right consistency of care that could be given whether it's 2 in the afternoon or 7 PM at night anyway we're not planning on having 2 AM hours or anything like that but this again I want to emphasize this is being discussed at the YMA word and so this would be a sensually a physician decision.
- 42:59Organizationally, it will be broken down by those I would say the sectional level Department, but I think these are the kinds of things we just have to begin to explore in earnest as an organization are not going to mandate.
- 43:14But we do think we need to take a serious look at how we're delivering those because we had. We know that the certain aspects of our enterprise or just just two congested and it does it's not conducive to the right title here so we have to fix?
- 43:32Well, I I was the desktop, but expand on the work that you do information will be within the health system. You you're the expert on that, but I think as you know, we have a program with Indian school. To actually look at being Edward submitted earlier, but in parallel is that there is there is a lot more work done with this account system and younger than hospital. Toms office is eating that I think converges in some way we will rebuild so one of the things that we do have.
- 44:06People trying to make life official better and many of the things that we've had come in for a mission had been have been suggested so I'm looking forward to that work in that and I'm waiting for my Kylie actually this absolute discussed this, but I'm very concerned about vision and I think that's the system is Indian. So so I can I can assure you that we're going to pay attention to this?
- 44:35John.
- 44:38You know a large graduate all of these guys that I've had family members.
- 44:48In the hospital lately versus 20 years.
- 44:53But you know the growth of the clinical practice, I think sometimes seems like it's has runs arrested overwhelming academically in the research practice, especially in Times Square, the federal government scandal. Stager says so as it grows more insulated better integrate. The research mission. With growth in the code conditions there a way that I mean, I know it's not cost effective.
- 45:26Space in new clinics for controlling patients in studies sample collections, etc. Etc have that feel plan extension of how to integrate the research mission information a little better 'cause otherwise.
- 45:44We see that we have this huge clinical operations or is it not really an academic practice anymore. What defines an academic practice as compared to just a big health system right so as a great question is something we are actually addressing so we, we want to see really an academic health system. Not just mall located in New Haven, but spread across the enterprise and so there's actually work groups right now looking at the key but concretely I'll take Greenwich for example, where?
- 46:17We've recently had norm. Robbins video over and come to the board and talk about some of his vision of how he wants to extend the Academic Medical Center to rent a lot includes things like which we agree with by the way what shoes are things like clinical trials office being physically. Now, they're having a site specific that will service that greater area around the furniture had to it would be expanding some of our educational programs and seizure.
- 46:48He participated in one or 2 options already about creating resident opportunities out there, so surgery. For example, is probably going to offer collective next year as I believe is urology. It's an elective we are, we now have 128 positions that runs our Prudential to work at Greenwich. So we have a base of Physicians that would that our residency program directors think could provide teaching substrate.
- 47:21Teaching environment for those particular brothers team Richard delivers has been in the discussions as well from a perspective of being able to bring students down to the branch area. So you're exactly right. We are, we are consciously trying to avoid becoming just a giant clinical enterprise. It doesn't recognize who we are, which is your vision driven organization and we have 3 measures so that is exactly what we're trying to prevent.
- 47:53You know a great deal of chronic disease burden is attributable to aspects of the patients lived environment and and their behavioral factors whether it be lifestyle. Whether it be medication. Adherence things of that kind. There are models where it's certainly in the primary care setting. There is there's a delivery of integrated care where behavioral health providers are working side by side.
- 48:24With physicians and physician extenders citations pharmacist and the like. And certainly we have that example it across the street. So to speak at the VA. I'm wondering if there's any exploration of implementing those types of programs within our health care system here.
- 48:43So, in terms of here we've done this in even worse mad. There's math. Sorry recently over the past year or so we've added behavioral health report? How's it going? So great, you made. A big difference to have that integrated care inside so that was just so you know that came about through really discussion at the group level at the board level.
- 49:07Amen so that was actually funded if we will buy the broader Medical Group because these 2 things are important to do. That's been our autopilot cited well but it's it's I think benefited locations and.
- 49:23That's that's great that's a great model is it scalable.
- 49:28How do we scale it I think that we've had experience with our own employees that helium health system get 35,000 covered lives. We we own first dollar cost of our employees and their dependents. And so we have models in that for that kind of service for our employees. It's really important for us to be able to do those kinds of experiments because now this clinically integrated network, we're going to go directly to the disparities in the state of Connecticut in large employers and say, these wrap around services or kinds of things that we can provide.
- 50:01Because over the long haul, you get greater benefit for your patience your employees and so forth so it's it's nice to be able to do these we are. We are also scaling it a little bit and you cannot use Medical Group and it's slow to be able to do that. But it's really. I think for us. The idea of one of the ideas of disclosure gated network is to be able to do those kinds of things at scale. So it's not just leave off for Northeast Medical Conference. All the primary care physicians that are in arms network services.
- 50:31The 3rd mission, beyond research and clinical is education and what we're noticing at the medical school for preclinical education. That doesn't generate RV use is increasing challenging getting positions to be willing to give up an afternoon to do electrical run a small group and miss out on the RV use becomes really quite intense in the last 2 or 3 years. Such that we are unable to have the size of the group that we want for our students for their education.
- 51:06You think about the research mission of this organization, we need to think about the educational mission, and it wasn't that long ago in positions were willing or able to cancel the clinic or reschedule something so that they could teach and now it's almost impossible to find people to do it and it's distressing to the students.
- 51:25Yeah, I I recognized it, I'm not sure we have the best answer yet.
- 51:32I know this is something I'm sort of on the docket as my friend.
- 51:38Brahms, coming.
- 51:39But I think there's something we know about yeah, I don't care.
- 51:44So we have to find a way of funding.
- 51:53I want to ask you questions so you mentioned the.
- 51:57This is what that means here and so the the over the overarching plan for Saint Rayfield's are 2 dead. Towers in an ambulatory facility that will largely consolidate and move all of the neuroscience clinical activity to that campus that will companion with musculoskeletal in the emergency Department and we will focus on that campus for one example and stroke here.
- 52:28By using the emergency Department there's a practical a very real practical application for this campus.
- 52:35Uh it will add 205 brand new vets and that will allow us to start to thin out the East Pavilion and ultimately take it out of service as an inpatient facility.
- 52:47Uh and it also gives us the ability to renovate with neurosurgical activity moving to the other campus fully renovate the South Pavilion.
- 52:58Our goal is to bring unlike the East Pavilion. The Southfield Pavilion can be brought back as a brand new hospital with proper renovation. An we want to kind of bring it back as a Heart Hospital of cardiac facility and by having campuses that are focusing on cancer and heart disease and neuroscience is we have that opportunity. So very real practical sense beds and an expanded emergency Department a defined focus on Neural Sciences.
- 53:29And ultimately renovate the South Pavilion for a cardiac facility.
- 53:34Thank you for this presentation of the question I have for anyone of the three of you a physician burnout.
- 53:47Is a real problem and increasing problem?
- 53:52And my question is what has the hospital done specifically to address the problem of physician burnout.
- 54:02Facility in a practice that we all want.
- 54:10So I can pick up I'll pick up where Gary left out so you probably know that means 3 committees on client and one was around engaged in one was around Wellness. In one was around leadership. So we at the health system. We've organized across the CMO's of the different delivery networks. A similar structure and whereas he referenced in the midst of now, merging those 2 but for concrete steps what we decided in it really mirrors the report that Gary is talking about that it was delivered to the Deans Office.
- 54:44It really kind of two or 3 general themes that emerge around burnout. Both here, but also mirrored across the United States. One is around? How do you relieve the burden of day today? But not probably kaminski if he was here would say the stone in your shoe? What are the things that are bothering you on a day-to-day basis that get in the way of being able to rapidly and efficiently. Do your job things like epic things like trying to schedule things like the barriers that we all face and trying to get through pre certification and all those different challenges that we have.
- 55:15Trying to eliminate those to the greatest extent possible and everyone lands on efficacy electronic medical record is the thing that causes the biggest trouble. So we've really tried to focus on what Alan Shaowei. Stuff aren't really supported team that runs our infrastructure, IT infrastructure can do so. That's where the investments and things like virtual scribes and the tap and go and all the different little tiny things that can add up to real minutes saved during the day and if you look at our overall data.
- 55:46Over the last 3 years, the amount of time per patient and the time after patient visits has actually gone down. You may not feel that in your own Department division or clinic. But as a global enterprise. We've seen less position time in the medical records. That's one small thing by no means is it done. It's only beginning so I guess the puzzles in hassles is Christine Olson calls them that stone in your shoe. That's one two is around? How do we meaningfully engage with our medical staff to communicate and as we get larger now operate thousand medical staff in our health system.
- 56:18It was harder to engage you discuss and have that socialization and so we've tried to do things like for example, last week. We had a new position party for all new positions that were invited and all the leaders in the organization at the Peabody and try to create some opportunities for socialization and Connectedness. Some stuff that we've I think Los amongst away and the 3rd is is you know how is it that we give people meaningful things as part of their job something that we all went into healthcare not because it was a job because it was.
- 56:49Something that was bigger than a job it was something that we went and felt that he should be doing this for reasons bigger than ourselves and somewhere we lose that too. And that gets lost in a busy clinics and how busy we are from the day-to-day basis. But how do we give back people time if they are interested in doing position communication or data was here. We need to go there. She is and how we give people support. People in sort of getting into pursuing their interests outside of direct patient care, but also give people sort of meaningful things.
- 57:21Not perhaps just an IT job supporting so they can pursue things that they like but give something more globally overarching and try to create those opportunities or creating at least an environment where they can be they can be pursued now. Maybe I'm Pollyanna, but I think we're making a little progress in those but there's only you know, there's a lot more to be done and it's against that I think are very difficult environment. But we're not the only ones that are struggling. But I don't have the right to dad. I want to address the last question, I would add that.
- 57:51One of the themes that kept him out of the order service. We did was this issue of what color is control that is lost control of our lives that we don't do it so I think it's important for us as we are changing the environment in in implementing changes that we get there put engage interchange, so that they feel part of the change. Otherwise, you, you feel like you've lost even more. So when we when we look at the care center, Florence and how we implemented so very, very proactive way out.
- 58:21Everybody who is being affected by the changes to get there by 2 very slow processes live with us if we think.
- 58:31That's just a small example, many of my patients primary care and even the inventory setting enjoy my chart because lots of messages and I think it enhances their care, they appreciated it takes Time Is there any?
- 58:47Movement towards either capitated or some kind of set of fee for service, you got it come in. We can take care of it through my chart that really appreciate it? Where is that headed?
- 58:58Messaging electronically provide patient education about the lab test. X-rays questions that emerged and consumes a big fraction of the day I enjoy it. We don't get paid for that.
- 59:10Yeah, so I'm not sure I have the best answer yet, but I I do understand the issue the circumstance. I think well. You should like that, but we are.
- 59:20We first of all we want to get as many faces just sort of. You know like everybody on my chart that we can right now our numbers are still in the low 30s to maybe 40% of our patients around my chart. The reason for that is. I think is rescheduling a lot, that can be done through my chart. They give you a comparison NYU is about 80% of their page.
- 59:40So we got along.
- 59:43Do we do as you enter into the care center process and will see that there are some.
- 59:50Redistribution of public work the ideas did not vote as much.
- 59:55Oh certainly in basket, you figure it out.
- 59:59Uh so hopefully part of this is to garys point. This is really customized to a certain level by the Cold War and so it won't be just you but it will be your coworker match the cohort that's going to decide what messages don't wear so you'll have some opportunity to actually correct those things, assuming just replacement code words you get paid for that project.
- 01:00:24OK great thank you very much.