Advancing Health Podcast

00:00:00:08 - 00:00:31:11
Tom Haederle
Hospital and health system care teams provide amazing care to countless patients every minute of every day. But they are human and mistakes do happen. No one pretends otherwise. If an error is discovered, it's important that anyone feel comfortable reporting it and sharing that information with a patient as well. Sometimes saying sorry the right way makes all the difference.

00:00:31:14 - 00:01:17:26
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. CommonSpirit Health, a vast network of more than 2600 care sites spread across 22 states, has worked to adopt an organizational culture of transparency and compassionate communication. In fact, it created a toolkit around that effort that anyone can adopt. As we hear in this final episode of AHA's Safety Speak series, hosted by Joy Lewis, senior vice president of health equity strategies and executive director of AHA's Institute for Diversity and Health Equity, a feeling of psychological safety not only benefits patients, but impacts equity internally within the organization by allowing anyone to freely speak up, regardless of role or department.

00:01:17:29 - 00:01:28:21
Tom Haederle
Her two guests from CommonSpirit are Beth Miller, system director for patient safety performance improvement, and Austin Peterson, system director, patient harm prevention.

00:01:28:24 - 00:02:00:10
Joy Lewis
CommonSpirit Team, Beth and Austin, thank you so much for being here with me today and welcome to Safety Speaks. I really am looking forward to exploring this topic of CANDOR and how accessible it is as we think about advancing equitable care, and I think we should start really just with setting the stage. I think CANDOR is familiar to those folks who work in the quality improvement and patient safety space.

00:02:00:10 - 00:02:19:14
Joy Lewis
It's familiar language to them. But others of our listeners may be wondering what exactly is CANDOR, which stands for Communication and Optimal Resolution Approach. So can you just elaborate on what exactly CANDOR is. Let's pitch that to you, Austin.

00:02:19:16 - 00:02:28:09
Austin Peterson
Sure. I'd be more than happy to. So there's a couple of different ways to pronounce CANDOR. Some people might call it a SCRP or communication resolution program.

00:02:28:09 - 00:02:57:17
Austin Peterson
We just adopted the agency for Health Care, Research and Quality and Language of CANDOR, as you alluded, is a communication and optimal resolution program. And really, it's a patient safety program to help health care organizations respond transparently and effectively to adverse events when they reach our patients. The key components of it is really emphasizing early communication, providing a thorough event review, utilizing RCA squared, and providing resolution.

00:02:57:19 - 00:03:17:05
Austin Peterson
And this whole program is about fostering trust, not just with our patients and families, but also with our staff members if they make a mistake that leads to a potential CANDOR event. And the ultimate goal is to try to make what's right that we can with our patients and families but also improve our health care system so it doesn't happen to anyone else.

00:03:17:07 - 00:03:52:16
Austin Peterson
And I'd just like to take a moment and start by saying I'd be remiss by not acknowledging some key individuals in our industry who has developed this transparency movement of communicating events to our patients and families. And the list I'm going to say is not exhaustive, and I apologize in advance for missing anyone critical. But our work at CommonSpirit Health has been built on many others, such as Dr. Lucian Lee. Dr. Tim McDonald and Rick Boothman with their Seven Pillars, and Dr. Tom Gallagher and his studies advocating that patients and families value compassionate communication and an honest apology post error.

00:03:52:18 - 00:04:33:24
Austin Peterson
And also our patient advocates who keep us honest in the health care industry. But I want to shift again to discuss the agency for Health Care, Research and Quality, who developed CANDOR with some key individuals within our organization, Linda Ubaldi and Dr. Morelli at Dignity Health and also Barbara Pelletreau, who ensured CANDOR was successfully adopted across all Dignity Health and now CommonSpirit Health before her retirement. As a health care organization that collaborated with AHRQ, and they have contributed to the creation and the refinement of the CANDOR toolkit that is open access and free for everyone to adopt. The collaboration of all, providing insights and feedback based on our experiences with our patient safety leaders and

00:04:33:24 - 00:04:41:11
Austin Peterson
communication practices. And it really helped shape the toolkit's content and implementation strategies that exist today.

00:04:41:13 - 00:05:10:27
Joy Lewis
Well, thank you so much for that context. And I would imagine CANDOR is something we can all get behind, because what you just outlined for listeners is really a level of humility that the health care system brings to the patient care experience and really focusing on being transparent and learning and improving, and to all of that and really creating an environment of trust.

00:05:10:29 - 00:05:23:13
Joy Lewis
So can you go a little bit further and talk a little bit more about how you implemented the CANDOR approach inside and across such a large system?

00:05:23:15 - 00:05:35:03
Austin Peterson
You know, with any large projects such as this, it really needs to be led by our executive leaders who say that this is the right thing to do and get behind it, to push all of us in that direction.

00:05:35:03 - 00:05:59:27
Austin Peterson
Again, that was led by Barbara Pelletreau and Dr. Robert Weaver. Initially because we were smaller at Dignity Health, we had the opportunity of providing these two-day workshops where key leaders of the hospital would be our chief nurse, chief medical officer, quality directors, patient safety leaders. Our claim leads who get together and they learn about the principles and foundations of CANDOR while also practicing that empathetic communication.

00:06:00:00 - 00:06:24:13
Austin Peterson
Now, with the merger of us becoming CommonSpirit Health spread across 22 states, 150 facilities and 2600 care sites, it is impossible to do that two-day workshop. And Covid really forced us in a new direction due to constraints on providing education in a new way, and we did this via electronically using Zoom, having four-hour sessions of going through the whole training and people practicing.

00:06:24:13 - 00:06:45:02
Austin Peterson
But it's really hard pulling our leaders away for that long of a time when they need to be with our frontline staff and our patients and our families. So we've revolutionized what we do, and now we provide this in a learning management system and four self-paced modules that all of our leaders go through. And we say all of the leaders, if you're in the leadership capacity, we recommend that you go through CANDOR.

00:06:45:04 - 00:07:08:02
Austin Peterson
That is completed by having a live practicum where Beth and I reinforce the training with experiential learning. And we've also rolled out an advanced CANDOR series where we include many unique scenarios that our leaders come across. And as you alluded to, we've trained a lot of people. To date, our organization - we've trained over 1,300 leaders, including our physicians. And we're continuing to push to ensure that everyone receives this training.

00:07:08:04 - 00:07:08:27
Joy Lewis
That's massive.

00:07:08:27 - 00:07:11:04
Joy Lewis
You're really doing this work at scale.

00:07:11:06 - 00:07:34:09
Joy Lewis
And it's really interesting how you've evolved your approach pre-Covid and post-Covid. But at the end of the day, it sounds like transformational leadership is what's really needed to move the needle here. So talk about that transformation. How has the CANDOR training program transformed your organization's approach to patient safety and equity? Beth, can you elaborate on that?

00:07:34:12 - 00:08:01:02
Beth Miller
I love that question, Joy, and I think it's an important one. But I think to try to sum it up is that CANDOR's success really ultimately relies upon robust event reporting. You know, people have to feel free and comfortable to report safety events, you know, quickly and often in order for those things to get escalated. And then for the CANDOR program to effectively be implemented and launched, and for all of those pieces to start to come together.

00:08:01:05 - 00:08:35:25
Beth Miller
So really, our organizational culture plays a big part in the ability to achieve any of this. You know, we have to know about events in order to then act. And, CommonSpirit has invested heavily in establishing psychological safety in order to make it easier and then safer for teams to speak up and report. And I feel like this is where CANDOR really impacts equity internally within our organization, is that psychological safety really seeks to ensure that everyone feels safe and comfortable speaking up, regardless of their role, regardless of their department and where they sit and within the organization.

00:08:35:28 - 00:08:47:07
Beth Miller
And so we feel like it's been an important aspect of equity internally as we work with our teams to try to help improve internal communication. But then obviously it also does affect our patients as well.

00:08:47:10 - 00:09:13:06
Joy Lewis
Right. But you've done a really good job it sounds like of having your workforce, each member of your workforce, regardless of where they sit inside the organization, to see themselves as a health equity influencer, if you will. We always talk about how culture eats strategy all day, right? All the time. So you've also invested in creating that culture of safety where people feel comfortable speaking up.

00:09:13:08 - 00:09:30:03
Joy Lewis
I imagine you're tracking and leveraging data and analytics to really inform and drive your actions in this space. What tools -dashboards, scorecards? What are your mechanisms for tracking progress and outcomes?

00:09:30:06 - 00:09:58:25
Beth Miller
Great question. And again I would say we're using all of those things. We're using various reports, dashboards, we've customized and again invested heavily in all of our different analytic tools to make sure that we're using what we have available to us. But then layering on that CANDOR lens to see how the things that we're currently measuring, we can then also include specific elements of CANDOR in those measurement principles.

00:09:58:27 - 00:10:20:03
Beth Miller
And so we do - we use a ton of various scorecards, dashboards that we develop internally in connection with our event reporting system, so that that way we can make sure that data is shared appropriately with various stakeholders at different levels in the organization. You know, with an organization as large as ours, data sharing amongst the different layers, you know, can be quite a challenge.

00:10:20:09 - 00:10:41:13
Beth Miller
But we've spent a lot of time with our teams developing those specific things so that it can be shared effectively, but also in a more simple fashion, so it's a little easier to understand. Data is a powerful tool, but it's only as effective as someone can understand it. And so we spent a lot of time making sure that it's displayed and presented in a way that's easy to digest.

00:10:41:19 - 00:10:43:23
Beth Miller
So then people know how to act upon it.

00:10:43:25 - 00:10:59:02
Joy Lewis
Can you share a little bit more about the different audiences that you're reporting out to it? Does it go all the way up to the board? Are you sharing this information with community leaders, community stakeholders, internally, who are your target audience?

00:10:59:04 - 00:11:25:10
Beth Miller
Honestly, it's a bit difficult to answer because we try to customize various reports and information based on that particular audience. So the information, you know, shared with a patient safety quality leader is really going to focus on how they impact the work, versus information shared with, you know, an executive leader is then going to focus, maybe in a slightly different area with relation to how they impact the work.

00:11:25:10 - 00:11:38:24
Beth Miller
So the data does, you know, look a little different depending upon what your role is in the organization. But it all comes from the same place. So it's the same information just presented in a slightly different way depending upon the role.

00:11:38:26 - 00:12:06:18

Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo the AHA’s chief physician executive and a champion of AHA Patient Safety Initiative. AHA’s Patient Safety Initiative is a collaborative data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

00:12:06:20 - 00:12:38:19
Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1,500 other hospitals already involved, visit aha.org/patient safety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the HHS Patient Safety Initiative.

00:12:38:21 - 00:12:45:28
Chris DeRienzo, M.D.
Remember, together we can make health care safer for everyone.

00:12:46:00 - 00:13:07:05
Joy Lewis
Once you have those data, the goal of course, is to make the data actionable, right? So can you talk a little bit more about how implementing this CANDOR training program has actually yielded a positive outcome on your patient safety incidences. How are the trend lines shaping up for you? Austin, what do you think about that?

00:13:07:07 - 00:13:11:15
Austin Peterson
So I will say that safety is a moving target.

00:13:11:17 - 00:13:29:21
Austin Peterson
You know, initially we started with the IOM and the 44,098 deaths per year. And then we get better ways of looking at what is a safety event is and we see that the numbers jumped up to 220 to 440,000, which is the third leading cause of death in the United States. You know, so we put in checklists, we put in standardization.

00:13:29:21 - 00:13:42:13
Austin Peterson
We're able to reduce CAUTI, CLABSI, BTEs. That's great but that's only one part of patient care. What else is out there that we can continue to move? So I'm going to say that is a constant moving target as we learn more as we go there.

00:13:42:16 - 00:13:50:03
Austin Peterson
That's a really good point. We never say, you've achieved health equity because there is no endpoint, right?

00:13:50:10 - 00:14:19:19
Joy Lewis
There's this constant journey that you're on, to refine, to iterate, to do better. And so I would imagine when we look at the triad of quality patient safety and health equity, it's kind of that same mantra. You're always working at it. You're always looking to improve and do better. Now that you've really, you know, gotten folks on board, how do you plan to sustain your current efforts and maybe even build on those efforts?

00:14:19:19 - 00:14:25:02
Joy Lewis
So you've got some wins. How are you going to sustain those wins and bring others along?

00:14:25:05 - 00:14:49:29
Beth Miller
I love that question. I think sustainability really of any program is always, always a challenge. Lots of competing priorities. You know, it's obviously a heavy lift to get things going, but it's almost even more difficult to keep it going. But I think that there's some really exciting developments in the health care landscape, you know, especially recently in the last year that will help CANDOR to sustain and then even maybe even be more in the focus in the future.

00:14:50:00 - 00:15:13:27
Beth Miller
You know, one of the things that is top of mind is the patient safety structural measures recently passed by CMS. It directly addresses CANDOR, specifically in domain number four. And so we're excited about that. You know, focus that's being put into play. Because I think it's going to help allow our sites who have had that long standing history of CANDOR to be recognized in a different way for their efforts.

00:15:13:29 - 00:15:40:13
Beth Miller
But it also helps as an organization to help really look at those additional feedback loops that maybe we need to strengthen, which then will help with sustainability. And I also wanted to mention, you know, the AHA's focus on health equity, I also think is a great contributor to helping with sustainability of the program, because the AHA is demonstrating, you know, that this focus and our work and our mission as an organization is relevant, and there's still a lot of work needed in the industry.

00:15:40:13 - 00:15:43:28
Beth Miller
So I think both of those things will really help with sustainability.

00:15:44:01 - 00:16:10:11
Joy Lewis
Yeah, I think you're spot on. They complement each other well. And I do want to recognize CommonSpirit Health for the great deal of work that you've engaged with us around our health equity roadmap, and congratulate you for having all 142 of your eligible hospitals participate with our HETA, or Health Equity Transformation Assessment and continuing to do the great work of doing equity, as I like to say.

00:16:10:14 - 00:16:29:15
Joy Lewis
So I thank you both for joining us today and for sharing your expertise and your on the ground experience in implementing a CANDOR strategy to address patient safety outcomes. Keep up the good work. Thank you for being so dedicated and innovative in your approaches.

00:16:29:18 - 00:16:38:00
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:00:11 - 00:00:22:04
Tom Haederle
Hospitals and health systems are continually advancing innovation and using technology to transform patient care and improve health outcomes. Examples include better methods of collecting and organizing mountains of data, as well as partnering with universities to advance research. Artificial intelligence plays an ever-growing role as well, a trend that many leaders in the field consider the only way forward

00:00:22:05 - 00:00:44:07
Tom Haederle
in a time of diminishing resources. Will the wider use of innovative tech make care more impersonal and put a damper on the human connection between patients and their doctors? Experts say no. In fact, just the opposite.

00:00:44:10 - 00:01:07:12
Tom Haederle
Welcome to Advancing Health, the podcast of the American Hospital Association. I'm Tom Haederle with AHA communications. In this month's Leadership Dialogue series podcast hosted by Dr. Joanne Conroy, CEO and President of Dartmouth Health and the 2024 board chair of the American Hospital Association, we learn how Banner Health has gone all in with its commitment to embracing technological innovation.

00:01:07:15 - 00:01:20:05
Tom Haederle
Artificial intelligence and other technologies can relieve caregivers of many of the tedious aspects of their jobs, freeing up precious time to spend building relationships with their patients and greatly increasing patient satisfaction.

00:01:20:07 - 00:01:46:15
Joanne Conroy, M.D.
Thank you for joining us today for another AHA Leadership Dialogue discussion. It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and the current chair of the American Hospital Association Board of Trustees. I'm looking forward to our conversation today with my colleague Amy Perry, president and CEO of Banner Health. That's headquartered in Phoenix, Arizona.

00:01:46:17 - 00:02:19:03
Joanne Conroy, M.D.
Amy has a passion for innovation and research and has embraced Banner's mission of making health care easier so life can be better. Her career has been spent championing a people-first approach to health care. And as you'll hear, that approach extends to innovation and research that will make care better. Banner is a not for profit health system with 33 hospitals, including academic medical centers that provide access and health care services to over six states.

00:02:19:06 - 00:02:42:21
Joanne Conroy, M.D.
And it is so well-suited to advancing innovation and research that improves the lives of patients, families and the communities that it serves. What is the role do you think that technology plays? Because I know Banner is investing big in technology to kind of help us move from aspiring to deliver greater value to actually doing it.

00:02:42:23 - 00:03:11:21
Amy Perry
Yeah, I think it's the only way forward for us because we need to do things dramatically different. We don't see the reimbursement moving at the rate that it costs us to deliver the care that we need to. And at Banner, and I'm sure similar to other nonprofits, we deliver $760 million in free care and uncompensated services a year so, three quarters of $1 billion dollars,

00:03:11:23 - 00:03:38:17
Amy Perry
how do you make up that kind of difference? And we're going to try to do it through technological innovation. So our board has agreed to put aside $1 billion dollars, that's a really big amount of money that we're planning to invest in technology. We're nine months into our strategy. And number one is,  and it's no big surprise, it's really organizing our data.

00:03:38:20 - 00:04:05:01
Amy Perry
And when you have a big health system like Banner that has really grown over the years, you find that there's a lot of data platforms that have been plugged in throughout the years. And so we need to create one data platform, and that's what we're working on right now. We are, you know, unifying our data fields pulling all of our -I mean, massive amounts of data.

00:04:05:03 - 00:04:36:16
Amy Perry
We see 3.6 million unique lives every year. So you can imagine the data - that's more than 10 million encounters on an annual basis. So the amount of data that we need to manage is just extreme. So we need to do that. We need to have proper indexing. And with that platform, with that foundation, we believe we're going to be able to do all of the wonderful things that we hope we're going to be able to do with AI:

00:04:36:16 - 00:05:01:05
Amy Perry
ambient listening, making it easier for our caregivers, letting our caregivers really work at the top of their license. So our technology plan is not only exciting. I think it's mandatory for our future sustainability, not just at Banner, but everywhere, because we're going to need to learn to work with less.

00:05:01:07 - 00:05:31:21
Joanne Conroy, M.D.
When you think about data and using data to make the right clinical decisions, and then all the AI, generative AI, ambient listening, all the chat bots, things that you almost say replace vacancies with technology, how do you marry the two, and how would you describe that patient experience once you get that marriage of the data as well as the sexy generative AI?

00:05:31:24 - 00:05:37:26
Joanne Conroy, M.D.
You know, having Hal in the room with you to guide you to care for your patients.

00:05:37:28 - 00:06:05:13
Amy Perry
Yeah, it's a great, great point. First of all, I don't think we're really going to be replacing humans with technology any time soon. I think what we want to do is enhance the lives of the people that are providing the care, and allow them to work more efficiently so we can increase our access. You know, in Arizona, which is our largest market, it's one of the fastest growing cities in the US.

00:06:05:13 - 00:06:47:03
Amy Perry
So just keeping up with the growth, what I'm hoping is that we can do more with the same number of people because we will, and not completely, but with less of a 1 to 1 addition, because we will be adding technology to make people's jobs more efficient. You know, I love ambient listening and having a one on one, eyeball to eyeball conversation that gets, you know, automatically absorbed into the chart, helps build and document and do all the tedious work that keeps our caregivers from being able to have that pure relationship with their patient,

00:06:47:05 - 00:07:21:22
Amy Perry
that really gives them the joy that they came into medicine to have. And so I'm hoping that technology actually brings humans and our human interaction closer together, because it's doing the tedious work so our people can build the relationships that they care about. So, I just feel like all of this, including device integration, all of the fundamental things that we need to do to be able to improve eye contact, be able to improve the human experience.

00:07:21:22 - 00:07:26:09
Amy Perry
And I think it's going to have a dramatic impact on patient satisfaction.

00:07:26:12 - 00:07:53:23
Joanne Conroy, M.D.
Yeah. When we talk to our providers that are using the ambient technology, it is they're never going back, right? It's interesting. They initially say they it's a little bit more difficult because they're used to like filling out a framework. And now they're just having a conversation. So they have to kind of adjust their perspective a little bit. But they love it because it does

00:07:53:23 - 00:08:30:12
Joanne Conroy, M.D.
just as you have said. It removes a lot of the tedious work. But there is tedious work that I think we're hoping that AI will do for us, you know, outside of the patient visit. And that is not only a back office billing where we've actually had AI in revenue cycle for years, but probably in writing code so all of our platforms will talk to each other, as well as actually getting patients to the right place, minimizing the number of calls that they have to make or people they have to talk to.

00:08:30:14 - 00:08:40:01
Joanne Conroy, M.D.
Is there a downside to all the technology, though? Is there something that we should be concerned about and/or is Banner concerned about?

00:08:40:04 - 00:09:04:23
Amy Perry
Absolutely. I think that the number one concern that we have is quality assurance. And so pretty much all of the AI that we've implemented, in fact, all of it has what we call humans in the loop. So we don't have any autonomous AI because we just are not confident with the data sources to make sure data in, data out.

00:09:04:25 - 00:09:33:20
Amy Perry
So everything we do now does have, a quality assurance review, a human review, a make sure that we don't get too confident at this stage in the development that the technology is going to be right 100% at the time. So what we're really hoping is that it just elevates each of our abilities, whether it's in a business function or in a clinical function, but doesn't completely replace it.

00:09:33:22 - 00:10:11:06
Joanne Conroy, M.D.
Talk a little bit about research. When I think about AI in research, I'm thinking it almost helps the patient kind of become a better patient, become more educated about the conditions they have, maybe access clinical trials if they're candidates for them and/or almost make every single interaction be kind of part of medical knowledge. But that's probably maybe overly simplistic as you look at really data and AI in research at Banner, what are your hopes for what that can do for you?

00:10:11:09 - 00:10:37:20
Amy Perry
I think it'll have an incredible impact in a very good way. And you know, we have a very large relationship with the University of Arizona, three medical campuses and a lot of incredible researchers who need quality data to work through their ideas and to follow through in determining the potential for clinical trial candidates, things like that.

00:10:37:20 - 00:11:06:07
Amy Perry
So our ability in the future, to be able to identify people who could benefit from a emerging technology and emerging drug and emerging treatment. I mean, I think we're going to be able to be so much more proactive because of the ability to have a computer scan all the data, find people that would be candidates for solutions that may not have existed when they were first diagnosed.

00:11:06:07 - 00:11:30:28
Amy Perry
So I think that data, again, it all goes back to data, which is why that's the core of our technology plan and making sure that we're creating availability and access. Again, so much of this is access - to the trials that we currently have open, which is, you know, hundreds of trials through our relationships and through our amazing, principal investigators here.

00:11:30:28 - 00:11:54:09
Amy Perry
And I'm sure you see the same thing, you know, working in an academic health system like you do. You know, just being able to match patients that could benefit from these emerging technologies. And that's just in and of itself, impossible without these kinds of data intervention bots, the kinds of things that are going to help us streamline that.

00:11:54:11 - 00:12:12:03
Amy Perry
And then, of course, you know, the vaccine development, the kinds of things that were never even contemplated years ago are now facilitated with, you know, large processing, the ability to process just huge, large data models. So I could not be more excited.

00:12:12:05 - 00:12:37:11
Joanne Conroy, M.D.
Yeah. You know, there are certain areas that just are hotbeds. I think our radiology, you know, they've been using AI for a long time. Maybe people are not aware of it, but almost a second set of eyes, on you know, every single image. And our pathologists, are you know, doing amazing things. And as our organization says, oh, we have to get our arms around artificial intelligence.

00:12:37:11 - 00:12:58:10
Joanne Conroy, M.D.
And I feel like saying, hmm, it's out of the gate and halfway around the track already. And how do you actually support our researchers who are doing things  at both of our institutions are amazing. I think the world that's facing us is going to be filled with technology and innovation, and we all just have to be a little bit nimble and open to change.

00:12:58:13 - 00:13:20:01
Joanne Conroy, M.D.
But you are so well positioned to do that. So we want to thank you for sharing your valuable expertise and insights. You've had a remarkable career and have served in just an incredible array of payment systems that you're perfectly positioned to make a real impact at Banner in the six states that you serve.

00:13:20:05 - 00:13:22:25
Amy Perry
I feel fortunate. So thank you.

00:13:22:29 - 00:13:36:14
Joanne Conroy, M.D.
Well, thank you for doing everything you do, Amy. And until next time, thank everybody for tuning in. And I look forward to seeing you at next month's leadership dialogue. Have a great day.

00:13:36:17 - 00:13:43:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you

00:13:43:26 - 00:13:44:27
Tom Haederle
get your podcasts.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

00:17:34:28 - 00:17:43:10
Tom Haederle
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