Advancing Health Podcast

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Tom Haederle
The gap between supply and demand for health care continues to grow at an unprecedented rate. In this time

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Tom Haederle
of rapid change, 

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Tom Haederle
reinventing and transforming the

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Tom Haederle
nature of care

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Tom Haederle
delivery is essential for hospitals and health systems to

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Tom Haederle
achieve quality patient

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Tom Haederle
outcomes.

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Tom Haederle
Welcome to

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Tom Haederle
Advancing Health, a

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Tom Haederle
podcast brought to you by the American

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Tom Haederle
Hospital Association. I'm Tom Haederle with AHA Communications. Please join us for this discussion of how Northwestern Medicine is using digital

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Tom Haederle
technology to better

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Tom Haederle
prepare teams to work in

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Tom Haederle
the new world of health care,

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Tom Haederle
and how technology and digital mindset are vital to care transformation. Today's podcast is brought to you by Accenture.

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Michelle Hood
Hello, everyone. I am Michelle Hood. I'm the executive vice president and chief operating officer of the American Hospital Association. And I'm joined today with two guests, Daniel Derman, who is the chief innovation officer and senior vice president for Northwestern Medicine out of Chicago. And Kaveh Safavi, the senior managing director for Accenture. As we all know, the gap between supply and demand for care is growing too fast, and health systems must reinvent the nature of care delivery.

00;01;26;01 - 00;01;51;14
Michelle Hood
A combination of human plus machine can help increase efficiency for physicians, nurses and the non-clinical workforce so that they might meet the rising demand for care. We're together here at the Leadership Summit, where a number of our sessions are focused on workforce, with examples of rethinking workflows, adopting new operational models or teaming in ways we've not done before.

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Michelle Hood
I'm interested to hear how both of you are thinking about how to better prepare teams to work in this environment and how important or central is technology and a digital mindset to this discussion. So Kaveh, maybe we'll start with you.

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Kaveh Safavi
Well, if you look at all the developed countries in the world right now, they're all facing the same problem that's becoming a crisis. We saw it coming. COVID accelerated it. But the reality is that the number of people who are aging out of the workforce and need health care is growing at a tremendous rate. And the number of people who work to take care of them is actually shrinking.

00;02;25;07 - 00;02;46;05
Kaveh Safavi
So like in the U.S. specifically, between now and 2030, the number of people over who will age into the 60 and older group will grow by 48%, and they consume 3 to 5 times as much resources as people under the age of 60. The number of people working to support people over the age of 60 goes down by 17%

00;02;46;05 - 00;03;20;01
Kaveh Safavi
at the same time. So that kind of mismatch between supply and demand is leading to waiting times already in many areas, two or three months for any kind of elective procedure. And we really fear that we're going to see the same kind of waiting times that people see in Europe now, where, for example, in a country like England for an elective procedure in the NHS, you wait around 18 months. And we will never solve that problem by hiring enough people to do the work because there aren't enough people in the workforce, period, doing any kind of work.

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Kaveh Safavi
So we have to rethink the approach. And that's why we talk about moving from thinking about this as a workforce problem to a work problem. You take a job and you break it into tasks and then you ask the question, where's the best place to do this task? Some of them can be done by technology. Some of the technology exists, some is coming and some, most, will be done by people.

00;03;44;05 - 00;04;10;22
Kaveh Safavi
But in order to get the work done, you have to reorganize and reconnect the people and technology together to actually do the job. Because you're not taking a person's job whole cloth and shifting it to technology. So the orchestration or harmonization of the human and the machine together is just as critical as the technology itself. And that's where we start talking about how the nature of work and the meaning of work are changing.

00;04;10;24 - 00;04;32;21
Michelle Hood
So this is a complicated problem. There is no formula to follow. We're going to be learning as we go, but it is becoming the problem that replaces all other problems because without it, there's no access. And with no access, we have a political issue. We have an economic issue. It will be more important than the cost of care

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Kaveh Safavi
at some point.

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Michelle Hood
Yeah the declining health of the country comes along pretty quickly thereafter. Right? So, yeah, yeah.

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Kaveh Safavi
There's no such thing as a quality of care if you get no care at all.

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Michelle Hood
Yeah, exactly. So what does an innovation officer think about this?

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Daniel Derman
So let me highlight a little bit and augment what Kaveh was talking about and do it from the unique lens of health care versus just that workforce in general that goes beyond health care. And there's a unique piece, I believe, to health care that was really highlighted from the pandemic and challenges we had then. And at first everyone thought, oh, this is the pandemic once we get over it.

00;05;09;27 - 00;05;34;20
Daniel Derman
But what it really did was put a spotlight on what was a impending crisis anyways. And the thing that I'd like to add or kind of take away from what Kaveh was talking about is the joy in the nature of work and why the clinicians went into health care, and put pejoratively they didn't go into health care to spend half their shift documenting and the electronic medical record.

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Daniel Derman
Most health care staff would tell you that they went into it being somewhat mission driven and wanted that direct patient care. And there has been a number of barriers. Electronical record being one of them as an example, that took people away from that direct patient care. So I think there's an imperative here in the background which addresses some of this concept of the reduced workforce by trying to bring joy back to the patient experience and put more direct contact there and a benefit. A side benefit of the technology

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Daniel Derman
besides just getting enough bodies would be to change the nature of the work so that people have more direct care. I gave the example of the electronic medical record, but there's numerous other examples that would highlight that as well, and I think that's really the opportunity we have here, because let's face it, there's not enough health care. So I've been to places where they talk about replacing the radiologist.

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Daniel Derman
No one's going to replace anybody because there's not enough staff there. So this crisis that's upon us now, it's all about managing it and at the same time trying to bring the joy back to the practice of medicine.

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Kaveh Safavi
And that's a fantastic point because a lot of people don't fully appreciate the fact that health care is a sector that the technology will only take over part of the tasks. Best case, probably a third of the tasks. This is still predominantly a human-performed service and we need more than our fair share of people in the workforce to enter health care.

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Kaveh Safavi
And to Dan's point, the motivations are actually declining. The number of people who want to go into the profession are declining. That's a really bad place for us to be.

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Michelle Hood
Right. So if we take both of those concepts, the, you know, bringing purpose and joy back to work and redesigning the work and allowing our workforce to do what it is that they trained to do, what are each of your organizations doing to try to accelerate that? Because we don't have a lot of time.

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Kaveh Safavi
Well, we already know that people go to work for reasons that are different now than they were a decade ago. So this is not even in health care. It is across all sectors. If you actually look at why people work, we have done some research and pre-pandemic we're able to document that people go to work for more than pay and professional development.

00;07;58;16 - 00;08;30;07
Kaveh Safavi
They go to work for companies that they think resonate with them, everything from their values all the way to to worrying about their safety, their security. We call that net better off. So I work for a company that leaves me feeling net better off. And when we took those scores and we looked across the United States, across seven industries, sadly the health care sector was the worst performing of all of those industries, which tells us that we are failing even more than other options to make people feel net better off in health care.

00;08;30;07 - 00;08;53;19
Kaveh Safavi
And I think part of it goes to what Daniel describes very critically, which is they don't feel like they're actually doing health care work. They feel like they're doing documentation work. The pandemic had lots of other issues associated with it, everything from the scheduling to feeling like they were not taken care of from a safety perspective. Over time, all of these things conspired to drive people away from health care.

00;08;53;19 - 00;09;18;29
Kaveh Safavi
So what we're seeing now is organizations start to recognize, even before technology shows up, that they have to shift the way they think about this problem and expand the notion of why people come to work to be able to address this issue. One interesting phenomenon, for example, is that the pandemic made everybody in the world realize that some jobs can be done away from a physical location.

00;09;18;29 - 00;09;42;07
Kaveh Safavi
Not all, but that actually plays itself into health care, because in many cases we have individuals that are performing tasks that are both physical and documentation. The same person in a single location. But if you were to rethink the work and you separate them, you don't have to give up the documentation, but you could actually have somebody in a different place and you can start to take advantage of people's motivations for working in a different way and expand the field.

00;09;42;07 - 00;09;48;28
Kaveh Safavi
So we're starting to see people recognize you have to use everything at your disposal to address this issue.

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Daniel Derman
This is why I love doing this with Kaveh, because he sets sort of the intellectual basis and the structure for why. And then I fill it in with specific examples.

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Michelle Hood
Of practical steps.

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Daniel Derman
Exactly. Practically how we do that. So let me put some meat on those bones and give you some examples, okay? In two different arenas. So first of all, we have what we call the pebble in the shoe and it's actually a boulder in the shoe. I wish it was a pebble in the shoe, but it's a boulder in the shoe of what gets in the way with the joy of your practice everyday.

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Daniel Derman
So give you an example first from the physician side. So we're doing some early - and others are as well - some early work now with taking and using NLP to create an electronic medical record note so that the doctor can continue to have that interface with the patient and not have to do the documentation. n the other side, let's take the nursing side, for instance.

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Daniel Derman
We have a remote nursing project where the nurse can do all the work at the bedside. We have in V one, we have a nurse remotely one of her colleagues or his colleague that is now doing the documentation. So the nurse at the bedside can do that. But v 2.0 as we go up the scale is probably going to have that remote

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Daniel Derman
so that replaced with automation rather than a live nurse having to do that. Now, at the end of the day, it sounds high tech, it sounds maybe less personal, but what we've done is a nurse spends about 50% of a shift documenting electronic medical records. If all we do is reduce that by a half, forget about all of it, but we reduce it by half,

00;11;27;17 - 00;11;54;16
Daniel Derman
we probably could take care of 20% of the nursing shortage just by that alone. And the satisfaction goes way up. It's also a workforce retention issue because we see it as a recruitment tool, which makes us more attractive for the limited pool that's there by being able to offer people the possibility to have more time at the bedside rather than this work.

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Daniel Derman
Those were clinical examples. I can go on the administrative side and say the same thing. You know, it's a version of working at the top of your license on steroids, now really having the ability to do that, whether it's on the clinical side or on the admin side.

00;12;12;01 - 00;12;41;00
Michelle Hood
So jumping out from that point, let's go back to one of the pieces of the first question, and that was the mindset that needs to change in order for people to think about work tasks and series of work tasks in a different way and think about technology as a complement. So we have an existing workforce, we have leadership from the front line leadership to the boardroom that this is all new, this is all new to them in a large respect and a high percentage.

00;12;41;03 - 00;13;02;27
Michelle Hood
So how do you bring leadership in? When I talk about leadership, everything from the unit manager, the nurse manager on shift AM to the boardroom, how do you bring that mindset quickly to the recognition copy of what you said? We've got to think about it as a different problem. It's work, the redesign of work. How do we reskill these folks?

00;13;02;29 - 00;13;26;13
Kaveh Safavi
That's probably going to be a harder problem than the technology problem. People tend to think about this as predominantly a technology problem. I think especially if we look at some of the what's generative AI and large language models will do. Their ability to take these documentation tasks over is pretty profound. The problem is, if I walked in with that technology today and I put it in place, I will actually make the workforce less efficient, not more efficient.

00;13;26;16 - 00;13;49;28
Kaveh Safavi
And so we're going to have to create a whole set of skills that allow people to interact with technology to get their work done. So let's think about a couple of examples. And this has been documented in the past in terms of human machine is just getting more amplified. In health care, for example, if I give you a little bit of time back, five or 10% of your time, you have to do something intentional with that time or it's completely wasted.

00;13;49;28 - 00;14;14;15
Kaveh Safavi
Now that time may just be reclaimed by you because you're effectively already running at 110%. And that time can be spent for everything from personal regeneration of energy or more time with an individual patient or something about learning. That's what we call reclaim time. Maybe if you get more time, you actually repurpose the time and you take care of more patients.

00;14;14;17 - 00;14;31;28
Kaveh Safavi
The first units don't always get turned into productivity, but that is an intentional act. It's actually called re-humanizing time. And any time you put a human machine together and you introduce technology for productivity, the human side has to decide what it's going to do with the time back. So we don't right now have a plan for that.

00;14;31;28 - 00;14;55;28
Kaveh Safavi
We have to try to understand what that means. Another example that technology responds to humans in the way that they interact. And every time you interact with a technology, it changes. You actually have to change the way you work to get the technology to work. Dan's example of documentation is a fantastic one. So let's think about nurses. The technology that is going to exist in a short amount of time can listen to a conversation and structure

00;14;55;28 - 00;15;14;16
Kaveh Safavi
a document needs to hear a conversation. If you actually watch what a nurse does, they may or may not be working out loud. They have to be trained now to work or think out loud. Similar to what you might see today, the way a senior doctor trains a junior doctor, everyone's going to have to work that way or you can't take advantage of the technology.

00;15;14;16 - 00;15;38;17
Kaveh Safavi
So that's an example of training. That problem does not belong to the company that brings the technology in. That problem belongs to the organization that has the workforce. So one of the questions that often comes up is who in my organization is responsible for this problem? Because it doesn't actually fit naturally with the way our organization silos are built or our capabilities.

00;15;38;19 - 00;15;49;13
Kaveh Safavi
So a lot of times what you're starting to see is executives who recognize the problem and start walking it back. One of the first questions they ask is, Well, how am I going to give this problem to? Who in my organization is ready for it?

00;15;49;19 - 00;15;57;04
Michelle Hood
Yeah, because it's a combination of change management, but also a different set of skills to make it work. So dig out a little.

00;15;57;06 - 00;16;20;27
Daniel Derman
Typically, if you look at the leadership structure and you look at their age and the arc of where they're at, you end up having people that are the decision makers that invariably are not going to be there. Five...pick your year: three, five, seven years. They're not going to be there to implement it and to live with the consequences of that and to keep tinkering and modifying it as well.

00;16;20;29 - 00;16;51;21
Daniel Derman
Another analogy that I like to use is: think about it like autonomous driving and there are stages. I'll make them. There's five stages of which the first is: it's human with a little bit of augmentation. And the final stage is you're sitting in the backseat reading your paper while you're getting to work. And I would say that one of the lessons we've learned early on is to be very careful and intentional about the staging of it, both for success and for buy-in as you go along.

00;16;51;23 - 00;17;17;02
Daniel Derman
So I don't think anybody has to talk about the machine and the technology taking 80% of somebody's position. It's really just in a graduated way. And that's how we're thinking about it and how we're getting leadership buy-in is to give them a scope and a view of the whole playing field and say, okay, this is what it could look like, this is what it's at some other industries.

00;17;17;04 - 00;17;30;17
Daniel Derman
But we're going to start here and we're going to we're going to great up with it. Now, the pace of it is probably going to be faster than everybody thinks, but we're going to use examples. There'll be models out there that will end up pushing people.

00;17;30;23 - 00;17;33;22
Michelle Hood
Yeah. And defining success at every stage of the way.

00;17;33;22 - 00;18;01;24
Kaveh Safavi
So there's actually another interesting corollary to what Dan described, which I think is really critical, and this idea of having a plan and a path and an evolution not only in terms of change management, but this is actually playing itself out vis-a-vis people's trust in technology itself and the users. So we're seeing it play itself out right now with the evolution of generative A.I. and large language models, because the consumer experience for generative AI is answering questions.

00;18;01;26 - 00;18;26;20
Kaveh Safavi
People want to go, well, let's answer a medical question. Our perspective is that's the worst possible use. And in fact, I would discourage people from doing that because the language fluency in the documentation that Dan described doesn't need to have a medical answer. We're taking all the advice out of it. My fear is that people will be tinkering with this stuff and actually use it to do something like answer questions.

00;18;26;20 - 00;18;51;08
Kaveh Safavi
It will inevitably answer it incorrectly. That will result in a lack of trust and regulatory backlash and set us back. So there's a part of this that says that you need to actually know in advance what you're not going to do. And we are actually starting to see academic institutions in particular that are trying to work with generative A.I. put forth policies ahead of any actual use to prevent this from happening.

00;18;51;08 - 00;19;04;14
Michelle Hood
Yeah, and I know at the AHA we're also beginning the discussion around how do we get in front of that potential regulation, whether it be an FDA kind of approach or are some other agency who's going to want to get in to protect the consumer?

00;19;04;18 - 00;19;32;21
Daniel Derman
And it's doubtful that the agencies are going to go in a cognitive kind of straight line making good decisions. Yeah, I think either there'll be a vacuum or there'll be some knee jerk responses that are going to probably be harmful in the progress of it. So I think it is incumbent upon us, the health care system and the providers, to get out there and start to create a pathway or some guideposts, some rails or some help along the way.

00;19;32;29 - 00;19;33;27
Michelle Hood
Great.

00;19;33;29 - 00;19;47;19
Michelle Hood
How do you think people - we've touched upon this a little bit, but I'd like some amplification - about business case and use case in this. And we talked about how to convince leadership and bring skills. But talk about the business case.

00;19;47;19 - 00;20;06;10
Kaveh Safavi
Well, following in the spirit of this, let me give you the general and then Dan can give you a specific. So I think the business case for this follows a path analogous but not identical to electronic health records. If you think about the business case for electronic health records in the early days, people were trying to find a financial business case that would it pay for itself.

00;20;06;10 - 00;20;30;18
Kaveh Safavi
And the answer is it doesn't. But what we recognized pretty quickly was especially when the agenda for safety and error reduction came in, that if we didn't hardwire health care with technology, too many people would die. And we have actually delivered on that. But people stopped worrying about a short term, financially driven business case and looked at a business case that included quality of care as an example. For this kind of technology,

00;20;30;18 - 00;20;56;13
Kaveh Safavi
it's going to be waiting time and access. Now, in the short run, when you're really close in, what happens when you think about the labor problem before the technology is it feels like a cost problem. My labor costs just went up. Oh, big problem. But actually it turns out to be a revenue problem because you actually have essentially buildings with mortgages and no patients in them.

00;20;56;15 - 00;21;17;02
Kaveh Safavi
So you have a revenue shortfall and that's a tax that's put on the smaller base of services that you can give, but it flips into an access problem. And when it's an access problem, it's a political problem. I think that we are actually going to find most business cases built around access and waiting time. That will be the defining business case and everyone will be able to make the case.

00;21;17;04 - 00;21;41;00
Kaveh Safavi
It's also going to be what people are going to use when we start to get into challenges about traditional thinking about how health care should be delivered. So all human versus human machine combination and people may make the argument that the quality of care will suffer. And the answer will be, tell me how long you want to wait before the suffering for waiting is greater than whatever your theoretical suffering is for solving this problem by taking the work and changing it. Right.

00;21;41;03 - 00;21;59;18
Daniel Derman
I think Kaveh said it really well. The only thing I'd add is something that I alluded to before, and that is as a recruitment tool that I believe that those that are doing these type of activities with the job description and what people are doing will be the winners in the marketplace in terms of recruitment.

00;21;59;21 - 00;22;18;09
Michelle Hood
Fantastic. Well, thank you very much, gentlemen, for being with me today. I really enjoyed the conversation. Lots to learn, lots to live through and appreciate your input.

00;22;18;11 - 00;22;19;27
Michelle Hood

00;00;01;03 - 00;00;24;19
Tom Haederle
Despite hospitals sustained efforts to protect them, our health care workforce has faced a sharp increase in workplace violence, especially since the start of the pandemic. In fact, the U.S. Bureau of Labor Statistics has found that health care workers are five times more likely than any other type of worker to be physically attacked on the job. Can such acts of violence be predicted and deflected in advance?

00;00;24;21 - 00;01;03;11
Tom Haederle
The FBI is hard at work on that question. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Films such as Silence of the Lambs and many others paint a fascinating, if somewhat misleading - picture of behavioral profiling. In Hollywood, the good guys nail the bad guys just in time by correctly interpreting all of the signals and clues.
00;01;03;13 - 00;01;29;21

Tom Haederle
Real life is more nuanced. In this podcast hosted by John Riggi, the AHA’s National Advisor for Cybersecurity and Risk, the unit chief of one of the FBI's five behavioral analysis units discusses what behavioral threat assessment really means as it applies to the threat of violence against hospitals and health care teams. Her take: the solution lies in close partnerships between law enforcement and local communities.

00;01;29;23 - 00;02;00;12
John Riggi
Thank you, Tom, and thanks all for tuning in today on this very, very important episode concerning violence on hospital premises, violence against our workforce. Many of you may know me from the work that I and the AHA do on cybersecurity. Unfortunately, not all the threats we face in health care are virtual foreign-based attacks. They are often physical acts of violence, which occur hourly on hospital premises across the nation, often directed against staff.

00;02;00;14 - 00;02;47;21
John Riggi
Hence, the risk portion of my duties includes leveraging my background at the FBI to help hospitals mitigate the risk of these violent attacks. How bad is this problem? The CDC and other sources show that health care workers, particularly nurses, are at a far higher risk of workplace violence compared to most other professions. For example, data obtained from nurses in a major population based study showed a rate of physical assaults at 13.2 per 100 nurses per year and a rate of 38.8 per 100 nurses per year for nonphysical violent events such as threats, sexual harassment and verbal abuse.

00;02;47;24 - 00;03;20;07
John Riggi
Of course, unfortunately we have had many incidents of gun violence on hospital premises, often resulting in multiple casualties per incident. So I'm very pleased to have with me here today Dr. Karie Gibson. Dr. Karie Gibson has been a special agent with the FBI for 17 years and currently serves as the unit chief for the FBI's Behavioral Analysis Unit one, which includes the Behavioral Threat Assessment Center known as the BTAC, a National Level Multi-Agency Multi-discipline Energy Task Force.

00;03;20;10 - 00;03;50;21
John Riggi
Dr. Gibson was a supervisory special agent and profiler at BAU1 for over six years prior to being promoted to unit chief. Prior to becoming an agent with the FBI, Dr. Gibson was and continues to be a licensed clinical psychologist. So, Dr. Gibson, thank you so much for joining us here today on this very important episode. And thank you again for the partnership and working with us to help stem the violence that we see far too often in our hospitals.

00;03;50;23 - 00;04;09;20
John Riggi
So my first question is, when most people think of the work done in the FBI's behavioral analysis unit, BAU, what comes to mind is what we see on TV shows like Criminal Minds. Can you explain what the BAU and Critical Incident Response Group is and what the units do?

00;04;09;23 - 00;04;35;04
Karie Gibson
Yeah, absolutely. So the Critical Incident Response Group is our main section where the BAU lives and the Critical Incident Response Group was created so that we were operationally ready to respond to critical incidences. Part of that is the BAU. So many people think it's like TV, right, that there's only one big BAU, but in actuality, there's five separate BAU units.

00;04;35;07 - 00;04;57;14
Karie Gibson
I am part of BAU unit one, which our primary mission is to prevent acts of terrorism and targeted violence. But then there is BAU2, which is primary mission is to prevent cyber attacks and to work within the cyber arena. And there's BAU three, which is crimes against children and then BAU4 for crimes against adults and then BAU5 is our research and training arm.

00;04;57;17 - 00;05;12;12
Karie Gibson
And so we are all here to be a resource for our local, state and federal partners in dealing with behaviors of offenders. And so our units are divided up by violation to focus on those specific offenders that would fall within within our specific areas.

00;05;12;15 - 00;05;30;04
John Riggi
Thank you for that, Dr. Gibson. People might think of your unit as predicting or profiling individuals of concern. Can you explain to us what the threat assessment and threat management model is, which helps to evaluate potential threats, mitigate and prevent violence?

00;05;30;07 - 00;05;46;04
Karie Gibson
It's really not about profiling so much as it's about prevention. And so when we're in this space, our main mission is to prevent those acts of terrorism and targeted violence. And so one of the biggest tools that we have to do that is what's known as threat assessment management. And some people have heard of that and others haven't.

00;05;46;11 - 00;06;12;19
Karie Gibson
But it's more of a nontraditional tool that falls within law enforcement circles as well as other circles. It's a team approach. You have a multidisciplinary team that comes together. They look at a person of concern that's demonstrating different behaviors that they're looking at, and they're trying to figure out exactly what that means. This group comes together, they look at how that person of concern is thinking and how they're behaving, and they look at those specific behaviors and see if they're progressing

00;06;12;26 - 00;06;36;25
Karie Gibson
moving from thought to action towards committing an act of targeted violence. And so it's very important that it is a team approach. It's very important that we're looking at the totality of factors that go into that individual and the circumstances that surround them. Once we are able to sit down and look at how they're thinking and behaving and being able to see are they moving on the pathway to violence and we're able to use threat management.

00;06;36;25 - 00;06;56;27
Karie Gibson
Threat management is a very individualized approach where you are looking at all the enhancers of targeted violence and the mitigators and you're trying to increase those mitigators. And so you're trying to work towards that individual and what they need and being able to address that in a way that's functional for them. And so it's different all the time.

00;06;56;29 - 00;07;14;10
Karie Gibson
There's no cookie cutter type model that can be done. But it's very important to, again, like I said, an individualized approach for that person. And that's the threat measure piece of it. You can't have one without the other. It does no good for me to tell you you have a high concern person here who's moving on the pathway to commit X targeted violence.

00;07;14;12 - 00;07;34;03
Karie Gibson
And then I don't tell you how to fix that or how to mitigate it. Right. And so the threat management plan has to go with that threat assessment and they complement each other. And so from a law enforcement perspective, we run into a lot of different cases that people might be concerned about. And we don't have those traditional law enforcement tools present because they haven't committed a crime.

00;07;34;05 - 00;07;51;10
Karie Gibson
So therefore, threat assessment management is a tool that's available in that prevention space. And more and more law enforcement officers are using it as well as other entities like yourself, like in hospitals or in schools or private corporations or mental health practitioners all around the United States and overseas are using it.

00;07;51;12 - 00;08;17;04
John Riggi
Thank you, Dr. Gibson. And I think you brought out a point that many folks don't understand is that the FBI and all law enforcement is really limited on what they can do when there's a potential for violence, when the subject or the individual has not actually engaged in behavior that would be a crime. And there's always that Monday morning quarterbacking going on after some mass shooting and saying, why didn't law enforcement intervene?

00;08;17;06 - 00;08;34;25
John Riggi
Again, not understanding that you are limited by the laws and Constitution on how far you can go when there's just a threat or suspicion of violence. So I have a follow up here. Can you explain how or why this is relevant specifically to hospitals and health systems? I know you deal with lots of organizations and sectors.

00;08;34;28 - 00;08;56;21
Karie Gibson
It's really hard, I think, for everybody, because as we go through every day, we're seeing what's on the news. You're seeing more and more acts of targeted violence happening. You're starting to see that violence spill into different areas. It's really not a law enforcement problem. It's more of a community problem. And unfortunately, our hospitals are soft targets for violence to occur.

00;08;56;23 - 00;09;14;29
Karie Gibson
I think any place out there that has the ability to have large numbers of people there or more of a public space where people can enter at their own will, we're all vulnerable in those environments. And I think that if we go about thinking that we're immune from that violence, then we're just setting ourselves up to be even that much more vulnerable.

00;09;14;29 - 00;09;32;21
Karie Gibson
So the best option is for all of us as community members to come together and do what we can in our own spaces to protect them as well as educate individuals that are within that space and what to look for and what to do when they see something concerning and being able to work with our partners to really enhance that.

00;09;32;27 - 00;09;54;07
Karie Gibson
I think one of the biggest things that happens is we work in silos. Hospitals will have their silo, law enforcement will have their silos, schools will have their silos. And I know why we're set up that way, because we're different entities and we have different systems that we use and different rules we have to follow. At the end of the day, if we all come together and work together in more of a proactive prevention space, then everyone is going to be safe.

00;09;54;13 - 00;10;01;19
Karie Gibson
From my experience in training, hospitals are just as likely to have an act of targeted violence as anyplace else.

00;10;01;22 - 00;10;21;25
John Riggi
Totally agree with you, Dr. Gibson. You know my work in cyber, we're often faced with this issue of how much information we share with the government. How much information is the government sharing with us? How do we work together? It's clear whatever the threat issue is, we have to approach this not only as a whole of government approach or just a private sector issue.

00;10;21;25 - 00;10;41;23
John Riggi
It truly has to be a whole of nation in a community-based approach. So really love what you're doing there and in our projects going forward. Speaking of, the AHA and the FBI are working together on Threat Assessment and Threat Management Initiative, can you explain to our listeners what we are looking to do as part of that initiative in its goals?

00;10;41;26 - 00;11;03;19
Karie Gibson
Absolutely. So the FBI has been trying again in this field, in this prevention space. We're trying to be proactive and look at things in different ways. As this problem evolves, the solution needs to evolve. And so part of what the FBI is did, we built out this structure that spans the United States with the vets integrating with our FBI field offices.

00;11;03;19 - 00;11;30;04
Karie Gibson
And so there's 56 FBI field offices out there. We have partners at all of those 56 field offices. And specifically at each field office, we have what's called a threat management coordinator. And so that threat management coordinator is responsible for building assistant management capability at the local level, as well as working with local law enforcement on cases that are concerning and that need to come in to the FBI's behavioral analysis unit for mitigation.

00;11;30;06 - 00;11;53;17
Karie Gibson
And so as we are, again, looking outside of of what we can do, right, as we're being proactive in this space, traditionally we have been within the law enforcement space. Obviously with the FBI or law enforcement officers, we've been in that space. But as we've saturated that market with getting the right information to law enforcement on what to look for, how to build these threat assessment teams, how to prevent these attacks, now we want to progress out.

00;11;53;17 - 00;12;12;05
Karie Gibson
And so the hospitals is one of our stakeholders in our community, just like our schools, just like our mental health practitioners are out there and just like the private corporations. And so we are branching out into the hospital network to help build a similar structure, utilizing those threat management coordinators that are on the ground. They're the boots on the ground.

00;12;12;05 - 00;12;32;10
Karie Gibson
They already have established resources locally. And as we go forward to progress to find the best practices, we're hoping to be able to link that map of that initiative up with the hospitals and then start to build upon that. And again, hospitals have to work within their own guidelines and follow their own privacy rules.

00;12;32;13 - 00;13;13;07
John Riggi
Dr. Gibson, some might be concerned about privacy and HIPAA regulations and health care when it comes to working with the FBI. And of course, there is tremendous sensitivity around using any type of demographics when it comes to what could be called profiling. Of course, profiling has such a negative connotation to that as well. Could you explain a little bit about how what you do is very different from how the public perceives profiling and also, could you talk to us about how the hospitals and health systems are integral to the threat management teams?

00;13;13;09 - 00;13;37;24
Karie Gibson
Yeah, absolutely. So I think that there is a lot of stereotypes out there on what profiling is. And there's, like you said, a lot of negative connotations. For what we do related to profiling is much different than what the general public would think about when they're thinking about it. So from our standpoint in my unit specifically, like I said, we're focused on prevention and really profiling isn't a part of that.

00;13;37;27 - 00;14;05;18
Karie Gibson
In the behavioral analysis unit, when you hear about someone being a profiler like myself or if we are going to be doing any type of profiling, it's known as an unknown offender profile and it's a very specific technique and tool that's used. And we have an unsolved crime and we are trying to figure out what are the best options in kind of narrowing that subject pool related to what we know about the behaviors of that crime.

00;14;05;20 - 00;14;24;29
Karie Gibson
And so it's a very, very specified type of tool that we're doing when we are doing that. And it's focused on the behavior. And I will tell you, in this day and age, we don't do that very much at all as far as that traditional working with law enforcement and how to narrow a pool of subjects in that way.

00;14;25;06 - 00;14;45;13
Karie Gibson
If you think about just where we are today with technology, right, like a lot of times they already have DNA or they have different things connecting to find the individuals that have committed those crimes. And so we don't need to kind of help them understand that. In my unit, what we would focus on if we are going to do anything related to that is anonymous, threatening communications.

00;14;45;15 - 00;15;09;06
Karie Gibson
And so you get in an anonymous threatening communication and you're trying to understand, you know, what level of risk or what level of threat is associated with that anonymous threatener And what are characteristics based off of those writings that will help us identify potential leads or areas to pursue, to understand who wrote that letter? And so that's where my unit uses it the most.

00;15;09;08 - 00;15;32;15
Karie Gibson
But really in the traditional sense, what we're doing in my unit is prevention. We're focusing on the behavior of individuals. We're focusing on who poses a threat. We're always interested in if somebody makes a direct threat, obviously, but we are also interested in does this person pose a threat to the community? And that's where we are plugged in in that space.

00;15;32;18 - 00;15;58;15
Karie Gibson
As far as hospitals being attached to, you know, threat assessment management and working with law enforcement, I think that there again, is a lot of stereotypes and misconceptions about that. I think that a lot of individuals feel that they work within a hospital system and therefore that's their agency. That's where they're a part of. And it doesn't necessarily work well with law enforcement because of the privacy issues related to the care that they are giving those patients.

00;15;58;17 - 00;16;17;02
Karie Gibson
I also think that in threat assessment management, people may feel like they can't be on a system management team because of that forward leaning kind of prevention approach. And what I will tell you is that's really kind of an old way of looking at things. We have to be more forward leaning in what we're thinking and how we're working together.

00;16;17;02 - 00;16;39;15
Karie Gibson
And so what we're finding is there's a lot of ways to work together and still respect the privacy laws that we all have to adhere to. Paying attention, though, to those those concerns that we have about community safety and working together. And so somebody in the hospital setting is going to be able to see, you know. Individuals are going to be able to hear individuals talking.

00;16;39;15 - 00;17;02;23
Karie Gibson
They're going to be able to see behavior. They're going to be able to have a fact pattern that they're looking at specifically related to that person within that hospital. And it may never go anywhere outside of that. But through the process of learning more about threat assessment management, learning more about what to look for, what are the high risk factors that are out there, what are the enhancers of targeted violence?

00;17;02;25 - 00;17;22;26
Karie Gibson
They were going to be able to start to pull together rather than all these different behaviors that they don't necessarily know what that means. They'll be able to put it into an equation that helps them see somebody escalating, somebody that maybe is rising to a level that they're more concerned about than somebody else. And that's when those discussions have to be had in-house.

00;17;22;29 - 00;17;51;25
Karie Gibson
When do we meet that threshold for law enforcement involvement and how can we work together in a way that's proactive when we're in that space. And then law enforcement are working...you know, we work with them all the time on how to work better with individuals that do have privacy concerns to help them understand that they have information to share that they want them to have as part of their treatment of an individual, but recognizing that that provider may not be able to share anything back.

00;17;51;25 - 00;18;14;14
Karie Gibson
And that's okay. For us from a prevention space, it's okay for law enforcement to share information one way. That's fine, because if we're getting that key information into a provider's hands or practitioner's hands, then now they have a they can use that piece of information with law enforcement along with what they already know, and then make the best treatment options that they know based off their experience.

00;18;14;16 - 00;18;37;17
John Riggi
Thank you for that, Dr. Gibson, I think you brought out a couple of points which I'd like to emphasize. One, again, your focus is on the behavior of an individual, not their demographics, and ultimately working with the community and understanding and hospitals in particular, we are legally bound to respect the privacy of the health information of our patients.

00;18;37;20 - 00;18;58;29
John Riggi
Again, the challenge is for us is that understanding where is that point where we can certainly work with law enforcement, notify law enforcement when there is not the clear indication of violence. But there are those certain triggers, and I think that's where you and your unit have become so invaluable to us to helping identify those risks ahead of time.

00;18;58;29 - 00;19;17;10
John Riggi
Just like when I worked on counterterrorism. See something, say something, again based on actions or behavior. I know the FBI has done a lot of work in other critical infrastructure industries and with schools. How can all this great work be translated into the health care industry?

00;19;17;13 - 00;19;37;29
Karie Gibson
You know, from from my opinion, what I think is is great about the health care industry is the fact that you have this entity right, that has so many activities happening all the time. Right? So you have medical care happening, you have people coming and going, you have providers coming and going. There's a lot of hustle and bustle.

00;19;38;01 - 00;20;00;05
Karie Gibson
Some people might see all of that as the challenge as far as exposure to the threat of targeted violence. And there's so much hustle and bustle happening and everyone's so busy that they can't necessarily slow down or I see somebody who's acting differently or behavior significance is lost because of the tempo that is, that those hospitals are at that scene.

00;20;00;08 - 00;20;38;09
Karie Gibson
But I would argue that it's actually a very bystander-rich environment. And so when we are looking at all of these different concepts and how to translate them and really kind of be force multipliers for different entities out there, it's really capitalizing on the the strengths that are within those those entities. And to have all of those different individuals that make contact with people every day, the hospitals themselves turn into great bystanders of that behavior and being able to further question or see changes in that person just do their regular job, the regular course of action of what they're doing in that health care setting.

00;20;38;11 - 00;21;12;12
Karie Gibson
And so I feel like by being able, number one, to educate all of the individuals that are that are out there on those high risk factors, those pre-attack behavior indicators, those behavioral changes, being able to be forward leaning in first, letting people know what to look for, and then helping people understand how best to interact with individuals, to minimize a grievance, to minimize somebody's frustration or anger, and then having an actual system set up, referring to when we do have an issue, right, we do have a concern within our hospital.

00;21;12;15 - 00;21;30;13
Karie Gibson
What do we do with that information? Right. Having an action plan of what's going to happen in some of that action plan would include when a certain threshold is met, that law enforcement should be notified of that behavior. And the concern that we have that violence could happen by that person. And so I think that, again, it's more similar than not.

00;21;30;13 - 00;21;49;19
Karie Gibson
And it's it's really that same blueprint of having people know what they're looking for and what to do with that information. So many times in my line of work after these attacks happen, what I hear is, yeah, I had concerns, but I never told anyone or I had concerns, but it was just me. Like, who am I to say that that was a concerning behavior?

00;21;49;26 - 00;22;16;06
Karie Gibson
And the problem is, is that it's one piece, right? And unless we put all those pieces together, we don't know the significance of that behavior that we're seeing. And so we really need everybody to be looking, like I said, and be listening. And what I tell everybody is it's not just 9 to 5. I want everybody to be aware all the time, because that's how we're able to prevent is we were involved sooner versus later, no matter what our jobs are roles.

00;22;16;06 - 00;22;31;25
Karie Gibson
And so I think in that factor that's really the force multiplier. And so when we get out there, these different entities, it's the same information that we're getting out there, same kind of courses of action, but we're applying it specifically to the health care setting and being able to fold it into your guys as processes.

00;22;31;27 - 00;22;58;06
John Riggi
I appreciate the explanation, Dr. Gibson, I think they were very insightful on a couple of key points. Even though you haven't worked with hospitals and health systems, at least through this program, very much understanding that we are a 24/7 operation. We often see people like law enforcement at their worst. And we do see criminal activity, the results of criminal activity, often gun violence in the communities spills over into the hospitals.

00;22;58;06 - 00;23;21;12
John Riggi
We're treating the victims of this tremendous gun violence in our communities. And it's a delicate balance that we have to be there for the community. Community must trust us as well and not view us as an extension of the government. That will be a challenge as well for us to preserve that. Folks know that ultimately what we want to do is help people and prevent violence.

00;23;21;15 - 00;23;30;20
John Riggi
What is some of the other challenges you see developing these threat assessment and threat management strategies in hospitals and health systems?

00;23;30;23 - 00;23;58;14
Karie Gibson
From my perspective, I am a law enforcement officer and I work with many different entities all the time, but I'm also a psychologist. And so I understand the privacy laws that are out there, the confidentiality that has to be had and that need for patients to feel trust for their providers just to know that they're independent. Right. Nobody wants to feel like it if they go to the doctor, that immediately that's going to that information is shared with law enforcement.

00;23;58;14 - 00;24;18;03
Karie Gibson
Nor should it be, right? Like there's a reason why there's protections are in place. I think that from our standpoint that one of the biggest challenges that we face is because HIPAA has been such a force to be reckoned with out there. Right. Like we all know what's important. We all have to follow it the medical setting.

00;24;18;03 - 00;24;40;07
Karie Gibson
You guys have to follow it, right? And it's something we've had for a long time. I think a lot of people still, though, misunderstand that and don't understand that there are exceptions to HIPAA. There's law enforcement exceptions to HIPA. There's certain things that when that concern is present and the risk is there, right? That that that allows for conversations to be had.

00;24;40;07 - 00;24;58;26
Karie Gibson
And I don't think that people readily understand that or realize that. And they've been so used to just saying, no, we can't Talk, we can't talk, can't talk that now there's barriers. And I think that we all have to go about our jobs and do it in the appropriate way. But those barriers sometimes should be there and then sometimes they shouldn't.

00;24;58;29 - 00;25;24;21
Karie Gibson
And so what I find in challenges in working with the health care system from a law enforcement perspective is that people are misinformed about HIPAA because of the misinformation towards HIPAA. And when we can involve law enforcement, a situation escalates and law enforcement are not called until it's a really dire situation where if we would have been involved sooner versus later and some of those aspects, it wouldn't have escalated to that point.

00;25;24;23 - 00;25;52;12
Karie Gibson
And that's kind of hard, right, Because we can't undo what's already been done in certain situations. The other challenge that's there is we all want the same thing. We all want to have people be safe and prevent violence. And so we should be able to sit down and have conversations on understanding each other's processes and understand how we can work together in that space to make sure that we are saving lives versus hindering and actually enhancing the risk of targeted violence.

00;25;52;12 - 00;26;12;19
Karie Gibson
There are situation where we can make it worse, where we can actually propel someone to violence. And so talking about the active threat posed or that we face in our communities or specific individuals that are out there, we may not be able to talk about those specific individuals, but we can talk about behaviors and we can talk about what that behavior means.

00;26;12;19 - 00;26;30;23
Karie Gibson
And there's lots of us out here that are subject matter experts that can help you understand the significance of that behavior. I think that is another challenge there, is that because of those barriers, people aren't sharing those little tidbits or being able to really magnify and understand the behavior that's in front of them because they're afraid to ask the questions. 

00;26;30;23 - 00;26;55;16
John Riggi
Agreed. And I think, again, one of the points you're making is very important - among all of the points, of course, you're making - is that if an organization does not understand, if they can share a particular set of facts with the FBI or law enforcement in general without violating HIPAA, they certainly could have a discussion with you, with law enforcement in a anonymous fashion.

00;26;55;20 - 00;27;20;08
John Riggi
You have this fact pattern. Certainly they can consult with their own internal compliance and legal folks and privacy folks, and say based on this fact pattern and get a determination again without identifying the patient and see if there's a way that the information can be shared. But ultimately, we need to have the conversation before an incident, not a regretful conversation post some horrific incident.

00;27;20;11 - 00;27;34;02
John Riggi
Dr. Gibson, thanks again for being here today. Very, very insightful. What is the most important takeaway from today's discussion that you would want our leaders, our community and our listeners to know?

00;27;34;04 - 00;28;00;02
Karie Gibson
I feel really the most important thing that all of us need to focus on is we really need to collaborate. We need to come together and we need to work as a community to prevent targeted violence. As I said in the beginning, people tend to think of this as a law enforcement problem, and when something bad happens, it immediately comes to law enforcement for explanation or to look at what law enforcement did or did not do.

00;28;00;05 - 00;28;17;17
Karie Gibson
And I'm here to say law enforcement is only one piece of this, and we need our members of our community, we need all of our stakeholders to come together and we all need to work together. And that's how we take back America. That's how we get back to a safe spot. That's how we protect our softer targets that are out there in our communities.

00;28;17;17 - 00;28;38;10
Karie Gibson
And so whatever anyone's thoughts are about how we used to do things, it doesn't matter because that's not how today is anymore. We need to come together and work together. And that means law enforcement should be working with private sector. Law enforcement should be partners and have similar goals of keeping people safe with multiple industries that are out there.

00;28;38;12 - 00;29;01;05
John Riggi
Thank you, Dr. Gibson, for your expert perspective and for your partnership. And I'd like to thank all the men and women of the FBI and all our frontline heroes for everything that all of you do to protect our nation, to care for our patients and serve our communities. This has been John Riggi, your National Advisor for Cybersecurity and Risk at the American Hospital Association.

00;29;01;07 - 00;29;02;09
John Riggi
Stay safe, everyone.

00;00;00;29 - 00;00;25;04
Tom Haederle
The senseless and tragic mass shooting during the Highland Park, Illinois 4th of July parade in 2022 killed seven people, wounded another 48, and shocked and traumatized an entire community. Highland Park Hospital played a pivotal role not only in treating the victims, but in managing the aftermath of an event that left many residents in disbelief that something like this could happen in their peaceful community.

00;00;25;07 - 00;00;50;27
Tom Haederle
The steps taken and guidance provided by hospital President Gabrielle Cummings described in this podcast played a big role in keeping not only the shaken Highland Park community together, but her health care staff as well.

00;00;51;00 - 00;01;32;27
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In today's podcast, Highland Park President Gabrielle Cummings speaks with the AHA's Ben Wise about the importance of boosting morale, prioritizing staff wellbeing and cultivating resistance in the face of adversity and tragedy. This episode also highlights AHA's "Convening Leaders for Emergency and Response," or Clear Initiative, a funded partnership between the Administration for Strategic Preparedness and Response and AHA’s Health Research and Educational Trust that is committed to fostering collaboration between health care and public health to strengthen our nation's emergency management systems.

00;01;33;00 - 00;01;36;18
Tom Haederle
With that, let's join Ben and Gabrielle.

00;01;36;20 - 00;01;47;23
Ben Wise
Gabrielle Cummings, thank you so much for being here with us today. I was wondering if you can maybe provide some background on the Highland Park community as well as the events that took place at that tragic 4th of July parade.

00;01;47;26 - 00;02;11;25
Gabrielle Cummings
Hi Ben and hi to everyone listening to the podcast. So the Highland Park community is a really tight knit community that sits in the northern suburbs of the Chicago land area. We have quite a few of the communities that surround Highland Park, like Highwood, Northbrook and a variety of other communities that are closely intermingled with the Highland Park community.

00;02;11;28 - 00;02;37;28
Gabrielle Cummings
There are a lot of different activities that happen here throughout the year, whether it be in downtown Highland Park for festivals or meetings or shopping. But Highland Park really is a tight knit community. I think what shook all of us was that the shooting that took place was during an event that was meant to really celebrate time to gather independence, friends and family and, you know, the middle of summer.

00;02;37;28 - 00;02;52;24
Gabrielle Cummings
And so it was a very challenging time for all of us, given how close the community is. Not just those of us that live in the community, but also those of us that work, because quite frankly, many of the employees that work at Highland Park Hospital or at North Shore e Age also live in the communities where they work.

00;02;52;24 - 00;03;02;00
Gabrielle Cummings
And so many of our physicians, nurses, other EBS team members also live in the community, are in close proximity to the Highland Park community.

00;03;02;02 - 00;03;10;16
Ben Wise
Would you mind taking me back to that moment and where you were when you when you learned about the shooting and maybe what some of your immediate next steps and actions were?

00;03;10;18 - 00;03;32;12
Gabrielle Cummings
Sure. So I don't live in Highland Park. I live in downtown Chicago. It was a holiday. So obviously on a holiday for most administrative leaders, you have the day off. As I jokingly tell people, I was enjoying my last few hours of free time before preparing to enter into checking emails and getting back into work. I was watching a TV series.

00;03;32;12 - 00;04;00;19
Gabrielle Cummings
I was excited because the last episode of just posted and as I sat on my couch to begin hitting play, I got a series of text messages from my operations leader on the campus. The first text message said to me, There is someone who's been shot that's coming to our hospital ED. And I knew at that moment that something wasn't right, because we don't receive very many penetrating trauma or gunshot wound victims at Highland Park Hospital.

00;04;00;22 - 00;04;35;25
Gabrielle Cummings
We did several years ago, but it was a very unique event. So when I received the first text, it put me on high alert. And then when I received the second and third text about more shootings and the fact that there was a shooter in the neighborhood, obviously that put me on beyond high alert. And I began to pull my team together over the phone so we could do a quick assessment of what was happening and put a plan in action to make sure we can mobilize support for the folks that were already on the campus while we took time to get there, because all of us were geographically dispersed.

00;04;35;27 - 00;04;52;01
Gabrielle Cummings
I was in downtown Chicago. One team member was doing a bike ride with her family. Another team member was at a family event. And so we had to come together and coordinate who could get to the hospital the fastest and who was going to take on what role until we got to the hospital.

00;04;52;04 - 00;04;58;08
Ben Wise
And how long do you think it took before you realized the magnitude of the situation or what fully had happened?

00;04;58;11 - 00;05;25;05
Gabrielle Cummings
You know, being on the phone and planning with my team, because we've done exercises like this as part of our emergency preparedness activities many times before. And when you're sitting in a conference room or doing an exercise with what we call inserts with the pieces of paper that your emergency preparedness team put in front of you to say that someone has arrived, you know, my mind was a little bit on autopilot in terms of what are the infrastructure components that we need to have set up and ready to go for the day.

00;05;25;08 - 00;05;45;25
Gabrielle Cummings
And so it was a little surreal still at that point. I think when I realized that this was a major event was what I was going the speed limit for downtown Chicago to Highland Park. I won't tell you how fast I was going, but when there were police cars passing me as if I was sitting still, it made me realize that this was a serious event.

00;05;45;27 - 00;06;04;28
Gabrielle Cummings
And then when I pulled in to the Highland Park neighborhood and made my customary left turn onto the hospital street and I saw police officers with assault rifles, long barreled guns out, I knew that it was a serious situation.

00;06;05;01 - 00;06;19;00
Ben Wise
I can't imagine that that sounds so intense. And I also think about the training and background that your employees have had. What were their immediate needs when you got there? What kind of things were you seeing?

00;06;19;03 - 00;06;47;28
Gabrielle Cummings
Yeah. So I think even before I showed up to the hospital, there were a lot of immediate needs that we needed to get into play. So that the benefit of Highland Park being the part of a larger system is that I had the knowledge, the support and the wisdom of a multitude of other hospital administrators and physician leaders and clinical leaders calling me, offering assistance and support, and setting up what we would call the large incident command.

00;06;47;28 - 00;07;04;13
Gabrielle Cummings
So control command, the part of incident command structure for those of us that are all in health care, that are dealing with the kind of higher level functions of what do we need to have ready to go, what resources do we need to get mobilized, what workforce we need to get in place? What do we need to do in terms of handling media?

00;07;04;16 - 00;07;29;25
Gabrielle Cummings
I was so fortunate to have a team of colleagues who came to my assistance and a), to form another incident command structure, which is called Area Command, so that they could focus on the higher level things while I was dealing with the activities on the ground here at Highland Park Hospital. And so those phone calls and conversations began as I was going the speed limit on the highway to Highland Park from downtown Chicago.

00;07;29;27 - 00;07;52;20
Gabrielle Cummings
When I arrived on site, my my operations leader was here first. She was closest. She was actually out on a bike riding her bike to the hospital. And, you know, hearing from her, the first thing that we needed to do is make sure that the emergency department had all the equipment and supplies that they needed because there were so many gunshot wound victims in the emergency room.

00;07;52;22 - 00;08;16;05
Gabrielle Cummings
We had victims that had received injuries from ricochets from bullet fragments that occurred, from hitting the ground or hitting other parts of buildings. We had individuals that had injuries from glass flying all over the place. We quite frankly, had people who were here just terrified and mortified from being in the middle of a mass shooting. And so we needed to have a lot of X-ray equipment available.

00;08;16;05 - 00;08;36;27
Gabrielle Cummings
So we were focused on making sure that we had enough mobile x rays out and about to take care of people, making sure they had the basic medical supplies that they need to take care of the community and take care of the patients. So our number one concern was to make sure the emergency department and the clinical team in the ED had the equipment, the supplies, the support they needed to care for the patients.

00;08;37;00 - 00;08;56;05
Gabrielle Cummings
I arrived to the hospital campus about 20 minutes after my operations leader and my nursing lady was here. She actually my CNO was actually in the E.D. and went directly into nursing care. She was caring for patients and care for actually one of the most one of the most tragic patients that we had to care for that day.

00;08;56;07 - 00;09;12;29
Gabrielle Cummings
But when I got here, I then began to focus on...I had to try to fly out a little bit. So I flew out. I mean, I had to take an opportunity to fly higher and to think about, okay, my team is in the E.D., we're dealing with patient care. I need to now deal with what's happening outside of the city.

00;09;13;02 - 00;09;43;09
Gabrielle Cummings
So there were dozens of people in the parking lot of the hospital, family members asking questions about their loved ones. I'm sorry. And so I had to focus on one being strong for them and making sure that I created a sense of of safe space and peace for them while also being aware of the security risk. Because at that moment in time when I got here, the shooter was still on the loose.

00;09;43;09 - 00;09;57;11
Gabrielle Cummings
We didn't know where he or she was. We didn't know if it was a male or a female, but we didn't know where the person was. And so I had to think about I've got dozens of people in the parking lot concerned about their family members, but every one of these people is a security risk to this hospital.

00;09;57;11 - 00;10;17;24
Gabrielle Cummings
And I have to think about how do I make sure that I treat them with compassion, but also getting them screened for security threats. And so I have a wonderful public safety team. And our public safety team created a perimeter and created a screening process where we screened every person in the parking lot to get them to the hospital because it was it was July 4th.

00;10;17;24 - 00;10;40;00
Gabrielle Cummings
So it was a very warm summer day. And most clinicians and those of us on health care know that when it's a warm day and you have high stress situations, people can have a variety of different complex issues that take place. And so I needed to get people from outside of the hospital inside. So that was one of my first actions, was to take care of the individuals that were in the parking lot and get them screened and safely inside.

00;10;40;00 - 00;10;59;22
Gabrielle Cummings
And once we got them inside, we had volunteers, we had other patient advocates that were meeting with each of the individuals to let them know that we're trying to find out what's going on with their family members. And so that was that was step one for me. I then went into the mode of thinking about, okay, what other resources do we need to think about?

00;10;59;22 - 00;11;33;12
Gabrielle Cummings
So, you know, in the middle of the shooting, I still have a hospital full of patients and a hospital full of clinicians that are caring for patients that are in beds or family members that are coming here for other outpatient tests. So I had to then think about how do I what I need to do to lock down this campus? Because at this point, anyone walking in or out of this circumference of our campus could be the shooter or could be a victim of a shooting because we didn't know if he was going to come back to have round two or to do whatever it is that he wanted to do.

00;11;33;12 - 00;11;56;00
Gabrielle Cummings
And so my next line of thought was I needed to put the campus on lockdown and create an external perimeter around the campus where no one could come into the campus that wasn't clinically in need of care. So that was another key step that I took in short order after getting here. I don't know how long it took for us to figure that out, but that was something that we had to do quickly.

00;11;56;02 - 00;12;16;06
Gabrielle Cummings
Another strategy and tactics that I developed with my team was it was it was also what was a long day. So I got here about 10:30, 10:40 in the morning, and we were here until seven or 8:00 at night because a suspect was apprehended, I think until about seven or eight at night. And that's in the middle. You know, you have shift changes.

00;12;16;06 - 00;12;34;27
Gabrielle Cummings
You have family members or team members who need to go home to their families and take care of their loved ones. So I had to then decide from an HR perspective and a people's safety perspective, do I let my team members go home or do I ask them to stay and shelter in place? And obviously we followed direction from the city about sheltering in place.

00;12;34;27 - 00;12;55;09
Gabrielle Cummings
And we we did have some team members who elected to leave the campus and to go be with their families and their loved ones, which I completely understand. But there is a level of concern that you have as a leader with letting your team members leave. Right? You want them to be with you. You want them to be with their family members, but you also don't want them to get hurt because at that point we didn't know where the shooter was

00;12;55;09 - 00;13;06;07
Gabrielle Cummings
as I've said a number of other times, and I didn't want anyone else to get hurt. So that was another key component that we had to focus on and that I focused on in short order when I arrived.

00;13;06;09 - 00;13;37;04
Ben Wise
You know, it's so interesting to talk about, you know, this high functional support and setting up this incident or area command center. And it sounds like you're just you're in the moment, you're balancing these clinical needs, these security needs. And of course, as you're talking about and and showing the emotional needs of. If you could just tell us about how you and your fellow leadership staff addressed the emotional well-being of the staff, both during that long day and in the immediate aftermath that followed as well.

00;13;37;10 - 00;13;40;19
Ben Wise
How did you check in on them? How did you care for them?

00;13;40;21 - 00;14;19;08
Gabrielle Cummings
Yeah, so I think the day one, the 4th of July, you know, food always brings comfort. I think we didn't realize how much comfort food was bringing us, but there was a lot of food, right? A lot of chocolate bars, lunch snacks, water, hydration, etc.. Some people were eating, some people didn't. So I think the importance of having nutrients or nutritional food available was really important to providing people with just in time support, because at that point we were still in full fledged incident area command, but we weren't thinking about the emotional well-being of one another.

00;14;19;08 - 00;14;48;18
Gabrielle Cummings
We were thinking about the emotional well-being of the patients, of the family members, of the community, of the police officers that we all work with, and the paramedics that we all work with that were out there in the field taking care of the patients who were getting brought to our respective hospital campuses. I think just having open, honest dialog with one another and being in a room together and rounding together and respecting each other's roles and knowing that our roles changed every moment of every day.

00;14;48;20 - 00;15;06;28
Gabrielle Cummings
For those of you that are familiar with an incident command, at least in our structure, you have this whole theory that you break open your incident command box and you put on your vest that says, I'm the incident commander. And my team was following protocol and wanted to set that up. And I said, No, we don't have time to set up the box.

00;15;07;05 - 00;15;24;03
Gabrielle Cummings
And the phones and the vests. We need to focus on being out and about on the campus, making sure that the folks that are here taking care of patients, whether they be in the E.D., or on the floors, see us visible and know that they are leaders here. There are other colleagues here to support them and keep them keep them safe.

00;15;24;07 - 00;15;40;11
Gabrielle Cummings
How are you going to define safety that day? So the day of it was it was very much more just in the moment, blocking and tackling. How do we manage the media message, how do we handle what's happening with the community, how do we handle our team members to make sure that they have food if they want food?

00;15;40;12 - 00;16;04;22
Gabrielle Cummings
How do we handle that? The only members that are here on our campus and are really challenged with what's going on. We also had one patient who was severely injured and we had to to get that patient helo transported out of the campus. And so how do you handle a heliport transportation in a mass casualty incident? So that was the day of. The days after

00;16;04;25 - 00;16;27;12
Gabrielle Cummings
I think, you know, it was it was kind of surreal. It's surreal that it's already been a year. But we folks, we were laser-focused on the fifth and thereafter on making sure that the team members had plenty of support. And I can go into that now if you'd like me to, or we can save that for another segment of our conversation.

00;16;27;17 - 00;16;36;09
Ben Wise
No, no, please. I'm so interested. Both team support, team morale and how you observed that? Measured it. Fostered it? Yeah.

00;16;36;11 - 00;17;14;03
Gabrielle Cummings
Yeah. So in the days that followed, I knew when I was driving home that night that when I needed to make sure that I had support for myself as a leader because in order to support the rest of my team, I wouldn't be able to support them if I didn't have my own safety net. Right? So I, I maybe subconsciously, I immediately called people that are closest to me to get support and to have that safe place to land while I was driving home that day because I knew I had a long road, I and my colleagues in leadership had a long road ahead of us

00;17;14;04 - 00;17;43;29
Gabrielle Cummings
after we came back the days that followed. When I got my safety net and had my sister circle or my social circle there to support me and my family circle, their support me, I immediately thought about the fact that we needed to have as many emotional well-being counselors on site as possible. We needed to really create an environment where team members could get access to mental health support on site as well as virtual if they so choose chose.

00;17;43;29 - 00;18;01;26
Gabrielle Cummings
But it was important that the support was on site. So, in the days to follow for at least a solid two weeks across all shifts. Because even though there may have been people that weren't here that day, this kind of event really impacts everyone who's connected to the team members that are here and units connected to the community.

00;18;01;26 - 00;18;26;26
Gabrielle Cummings
And so I made sure that we had mental health counselors here multiple hours of multiple days, Monday through Sunday, so that they could be available on site. I also had the counselors walk with me on the floors because I realized that health care professionals are very strong people, and sometimes people see counseling as a sign of weakness when I think counseling is actually a sign of strength.

00;18;26;29 - 00;18;46;16
Gabrielle Cummings
And I realized that if I walked or if another leader walked with the counselors on the floors or in the hospital, that it created the safe space for individuals to say, okay, it's okay for me to talk to the counselor. I also was very intentional about telling my my colleagues and my team members in the hospital that I was actively going to go to counseling as well because this is going to impact me.

00;18;46;18 - 00;19;17;14
Gabrielle Cummings
And I think that that gave team members and other individuals permission to know that it's safe and it's not considered a failure or a sign of weakness to get help and support in that environment. We also launched at NorthShore before this event happened, a group called Rise, which stands for Resilience in Stressful Events. So our RISE Team members are comprised of mental health counselors, other team members that have gone through a very discrete training to help each other recover and deal with tragic and serious events.

00;19;17;14 - 00;19;41;14
Gabrielle Cummings
And so we had members of the Rise Team from all over our system come to Highland Park Hospital to be available to round in, to talk and to have decompression sessions. There were certain groups that wanted to have a decompression session with either a RISE member or a mental health counselor. Collectively, like our team, it was very important to them to have a decompression session as a collective team and to reflect and to heal together.

00;19;41;17 - 00;20;06;15
Gabrielle Cummings
There were other team members or other individual roles I can think distinctly of one of our public safety officers who wanted to have one-on-one time with a counselor by himself. And so what was important to me and to my team, to my colleagues and leadership, that we created a space where team members could access what they needed in a way that worked for them, not in a way that I thought was going to work for Gabriel or Buffy or Barb.

00;20;06;15 - 00;20;23;01
Gabrielle Cummings
That's my operations leader and Barb was my CNO and the way that's going to work for them. And so we did take feedback. We took just in time inside what we needed to do. One of the things that I learned is we needed to have a Spanish speaking mental health counselor, despite the fact that everyone on this campus can speak English.

00;20;23;07 - 00;20;53;17
Gabrielle Cummings
English is not the first language for everyone. And there were some of my team members who can converse in English, but they're most comfortable with their native tongue, which for this particular incident we needed to make sure that we had Spanish speaking mental health counselors available. We added Spanish speaking counselors to our rotation and towards us towards the latter half of our two week period after it was brought to our attention that there were some team members who felt more comfortable healing and talking and conversing in their first language.

00;20;53;19 - 00;21;15;09
Ben Wise
Really make sense that that these things would come up. And it sounds like you really were able to, to lead by example and address some of those kind of immediate concerns and and offer a lot of support and services for your staff as well as having some things in place. Fourteen months later, how would you describe kind of the long term recovery efforts and how are you all feeling today?

00;21;15;11 - 00;21;38;23
Gabrielle Cummings
Yeah, I think we were already a really close team at Highland Park Hospital and at NorthShore and now NorthShore. And so I think this event, it's just brought us closer together and just reaffirmed the importance of connection and knowing one another not just out of work level, but at somewhat of a personal level. And by personal level, I mean at least knowing people face-to-face.

00;21;38;23 - 00;22;01;05
Gabrielle Cummings
So I may not know how many children you have, but I know that you have children. And so I think as a leader, it's always been very important to me to connect with team members in a way that is deeper than just, Oh, that's an employee. Like, I want to know that's Lala EBS employee or that's Michael, our EBS employee, and know a little bit about their their personal background because a sense of connection is is important

00;22;01;05 - 00;22;20;13
Gabrielle Cummings
I think to leadership. I've learned actually quite a bit having one on one conversations with frontline team members versus hearing it secondhand to some of my leaders. And so I think, you know, we'd already, as I alluded to, created really strong connections and have really strong connections as a hospital campus. And so I think we're just closer today than we ever were.

00;22;20;15 - 00;22;41;05
Gabrielle Cummings
The other thing that was really important is we had really close connections with members of our community. And I'm not sure that things would have gone as smoothly that day if I didn't have a strong relationship with the mayor, with the fire chief, with the police chief, with other civic and community leaders who knew how to get to me and meet with them so we could deal with managing the situation just in time.

00;22;41;07 - 00;23;11;00
Gabrielle Cummings
And so the culture here is still really solid. It's really strong. I would say a year plus later, it's going to always be in our minds. It will always be with us. But it has made us stronger as a clinical team, stronger as people, and has really reinforced the importance of being here for our community in whatever way they need us to show up that day, that hour. The other thing I think that's important to share is unfortunately mass shootings are all too common in our country.

00;23;11;02 - 00;23;34;11
Gabrielle Cummings
You know, you can't watch TV without hearing about a mass shooting occurring almost every day. And there was a potential another event around the geography close to Highland Park Hospital that took place several months ago. And it generated a lot of anxiety with the team to have to get back in to kind of, you know, fight or flight mode, the fighting mode of just coming out of this maybe months ago.

00;23;34;11 - 00;23;53;02
Gabrielle Cummings
And so I think while we are strong and we are healing from it, it is always a wound that is there and that we're aware of. The one year anniversary was really important for all of us. It was very important to me and to my leadership team that we had a memorial event that was specifically focused on us as health care leaders and providers, right?

00;23;53;02 - 00;24;19;27
Gabrielle Cummings
There were a lot of different city events or external events which we attended and got involved in, but it was so critically important to have a time where we as health care leaders could get together and just emote, just allow our emotions to flow, to heal, to reflect as a care community that was here that day. And even folks that weren't here that day, but helped us do recovery and helped to manage situations over the phone if they weren't able to be here in person.

00;24;19;27 - 00;24;40;27
Gabrielle Cummings
But it was important that we got together as a collective health care community and we had a memorial ceremony for multiple shifts, like two or three shifts. I think. And we also commissioned a beautiful piece of artwork that is now installed in our healing garden outside of the campus that employees can go and reflect on and look at any time that they want.

00;24;40;29 - 00;25;03;28
Gabrielle Cummings
It's a beautiful memorial. It's a beautiful piece of artwork, but I think it created closure for us so that the team could heal and put that behind them and use that as a platform to grow and to continue to be strong. But if people want to go and reflect and remember what happened that day and what we did as a collective health care team that day, that they could go and have a safe place to reflect and remember.

00;25;04;00 - 00;25;28;15
Ben Wise
Well, I think that's fabulous. And I so appreciate you sharing all of this. I guess, you know, lastly, as a leader now who has been through this and gotten to work so closely with your community on on such a tragic event, what advice might you offer to other health care leaders in your position, both for preparing for mass casualty incidents and also supporting your workforce after this type of incident?

00;25;28;17 - 00;25;49;02
Gabrielle Cummings
Yeah, so I think a few things to share with my colleagues in the health care community. I always would laugh and joke with my emergency preparedness leaders about the, you know, the Sharknado drills. They would have us do that. We call them tabletops where we simulate an event, thought it was comical or it was kind of, Oh gosh, we got to spend 4 hours doing this.

00;25;49;04 - 00;26;13;06
Gabrielle Cummings
I would say to everyone on this podcast, please do your drills. The one thing I am certain of that made this event go so smoothly was for us the Highland Park Hospital and NorthShore is that we understood the emergency preparedness dynamic. We understood what Incident Command was. We understood what levers to push pull because of the number of drills and exercises we've done throughout our time in our years in the organization.

00;26;13;06 - 00;26;46;24
Gabrielle Cummings
So that's one key takeaway I would like to share with the groups. The second is please don't underestimate the importance of community connection, the importance of relationships with community leaders and fostering those relationships because they benefit you in more ways than you could ever imagine, in ways that you couldn't imagine at all. The other point I would love to to make for for leaders, especially for those that are in leadership positions, is that you need to take time to heal and acknowledge that you as a leader need to maintain strength in order to provide strength to others.

00;26;46;26 - 00;27;04;28
Gabrielle Cummings
Because if you don't, you could implode unintentionally. I distinctly remember my colleague Sean O'Grady saying to me about a week after kind of running 300 miles an hour was like break, you need to take some time off. And I'm like, I don't have time...I don't have time to take off work. I got to stay focused.

00;27;05;00 - 00;27;28;12
Gabrielle Cummings
But he knew that I needed some space to heal so that I didn't implode. And he was right because when I took time off, like all of the emotion started to come over me and I was reflecting and thinking about what I saw my team members faces, what I saw on the family members'faces. So as a leader, please take time to heal and acknowledge that healing and the importance of healing as a leader.

00;27;28;14 - 00;27;47;08
Gabrielle Cummings
And then the only other thing that I would would share is that unfortunately, I want folks to know that we are in a health care community that are here to serve and to take care of one another and know that you can always reach out to another hospital leader if you need help or support or insights on how you handle the situation

00;27;47;08 - 00;28;11;06
Gabrielle Cummings
during a mass shooting, I was really blessed and fortunate to be contacted by a number of health care leaders across the country who have been through similar things. They wrote me letters. They called me to offer their support and I say just thank you to all of those individuals, but also continue to be there for one another to help all of us get through these challenging these challenging times when it comes to having to recover from a mass incident or mass casualty.

00;28;11;08 - 00;28;24;10
Ben Wise
Gabrielle, thank you so much for your time today and your openness in our discussion. I know these are very difficult things to discuss and a very tough subject, and so your openness and honesty is so appreciated.

00;28;24;18 - 00;29;07;04
Tom Haederle
Presented as part of Cooperative Agreement five Hi tap 210047-02-00. Funded by the Department of Health and Human Services Administration for Strategic Preparedness and Response, ASPR. The Health Research and Educational Trust, An American Hospital Association 501c nonprofit subsidiary, is a proud partner of this cooperative agreement. The contents of this publication are solely the responsibility of the health research and educational trust and its partners, and do not necessarily represent the official policies or views of the Department of Health and Human Services or of the Administration for Strategic Preparedness and Response.

00;29;07;06 - 00;29;13;29
Tom Haederle
Further, any mention of trade names, commercial practices or organizations does not imply endorsement by the U.S. government.

00;00;00;26 - 00;00;41;08
Tom Haederle
For health care workers, the threat from the pandemic has receded, but its effect on the workforce lingers on as they continue to report high levels of stress, burnout, depression and even suicidal thoughts. September is Suicide Prevention Awareness Month. What better time to take the advice of experts and get past any shame or reluctance to talk about this? Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;41;10 - 00;01;05;08
Tom Haederle
I'm Tom Haederle, with AHA Communications. The AHA’s Suicide Prevention Learning Collaborative was created to kick start a very important dialog among health care providers about the best ways to provide the behavioral health resources and support that so many health care workers say they want and need. Operating across 24 states, Chicago based CommonSpirit Health is a participant in the collaborative.

00;01;05;11 - 00;01;27;29
Tom Haederle
In today's podcast, Paul Rains, senior vice president of Behavioral Health with CommonSpirit, joins Jordan Steiger, senior program manager of Clinical Affairs and Workforce with AHA to discuss best shared practices and the need to make sure every health care worker is supported no matter what job they hold. Says Rains, if you suspect somebody is hurting, ask, say something.

00;01;28;01 - 00;01;30;25
Tom Haederle
And with that, let's join Jordan and Paul.

00;01;30;28 - 00;01;39;27
Jordan Steiger
Paul, thank you so much for being with us today. You have such a wide experience and breadth of knowledge on this topic, and I'm excited you're able to share it with our members today.

00;01;39;29 - 00;01;41;00
Paul Rains
Thank you.

00;01;41;02 - 00;01;50;17
Jordan Steiger
So before we get started and get into the content, could you just tell us a little bit about CommonSpirit health and your role as vice president of behavioral health for your system?

00;01;50;19 - 00;02;15;20
Paul Rains
So CommonSpirit Health, as you probably know, is a very large organization in 24 states. It's a merger between Catholic Health Initiatives and Dignity Health. Was born in 2019. At the time, I was doing the behavioral health leadership role at Dignity Health, and after the merger, I have taken on a larger responsibility for that. My role as senior vice president for behavioral health certainly has evolved since that time.

00;02;15;23 - 00;02;33;29
Jordan Steiger
And I think a lot of listeners might assume when they hear senior vice president of behavioral health that you would be focused mostly on patient care and relations behavioral health. But you joined our collaborative to help your health system better learn how to support your workforce. So could you tell us a little bit about how your role has evolved in that way.

00;02;34;01 - 00;03;08;07
Paul Rains
As a clinician, my role in behavioral health has always been public facing and trying to do everything we can to improve our services for the patients that we serve. But it's always been something that as a clinician, I feel like I have a responsibility to be aware and look out for the folks that I work with. It was the COVID pandemic really that heightened that awareness to the point where we knew that this was big and this was going to require a very substantial response and developed a support system across our system, even though we know that that is important in health care.

00;03;08;09 - 00;03;22;08
Paul Rains
It became exponentially more important. So I just kind of forced my way through the door of the conversation and took a seat at the table and started working with a great group of folks within CommonSpirit that were already working on a well-being initiative.

00;03;22;10 - 00;03;35;06
Jordan Steiger
That's great, and I think a lot of listeners will probably resonate with having to make that pivot after COVID and really making sure their workforce was taken care of. But why do you think this should be a priority for all hospitals and health systems?

00;03;35;08 - 00;04;02;20
Paul Rains
You know, one suicide in any context, in any population, for me is one too many. Certainly in our workforce where we expect health care clinicians and workers to be resilient. It's obvious that resilience is not something that is a, I guess, a common characteristic. And we're human, right? So we can only take so much. It's so important for us to be addressing this.

00;04;02;22 - 00;04;33;15
Paul Rains
I think that AHA's being a facilitator of this project, suicide prevention in the workplace, really makes our voice much larger, much bigger, and addresses something I don't think that we've really addressed is: what is best practice? What is evidence-based practice in this area? When we first started doing this work, we were reviewing research, looking at all the literature on trauma in populations and things, and certainly after natural disasters, things like that, that there were certain characteristics could be identified for things like post-traumatic stress disorder.

00;04;33;17 - 00;04;52;22
Paul Rains
But this was different. This was like going to war. I mean, like being drafted to go to war in a situation where folks that had no expectation of ever being put into the situation facing death day in and day out. Nope, that happens in health care. We faced that. But this was different. It was traumatic and it was hard to watch.

00;04;52;22 - 00;05;03;20
Paul Rains
It was hard to not be a frontline nurse on the firing line where this was happening every day. But knowing that my colleagues and peers were having to deal with this and just it was something I could not stop thinking about.

00;05;03;27 - 00;05;24;05
Jordan Steiger
I'm sure, especially as a nurse, it was hard for you to watch. And I think this is a great way that you've been able to contribute still, without being on the frontline. So you've mentioned the Suicide Prevention Learning Collaborative that we've been working on together. Could you just tell our listeners a little bit more about the collaborative and the work you've done at CommonSpirit through this participation?

00;05;24;12 - 00;05;48;16
Paul Rains
Well, initially what I wanted to be able to offer our system was bringing in the concept of peer support. In my work, I've done a lot of work around peer support, especially in recovery, like recovery from substance abuse disorders. But knowing the value of what it is for someone that has been through it, to be able to have that ability to share and listen to someone else.

00;05;48;18 - 00;06;06;08
Paul Rains
There's a healing aspect of that. It's hard to measure that, and I don't know that there's a lot of research out there on that, but participating in this, I wanted to bring that component to the wellbeing initiative, and we first looked at models like the Mental Health First Aid Model, thought that was a really great model and kind of patterned what we did create

00;06;06;08 - 00;06;34;26
Paul Rains
after that. We really want to be able to have a level of saturation in our system so that no matter what shift someone was working in, no matter what environment they're in, whether they're in the OR up on a medical floor, working in our registration reception areas and or in emergency departments, that no matter where someone is, no matter who they are, no matter what role they play in our system, that there's going to be somebody they're around, that they can identify as someone that they can go talk to.

00;06;35;03 - 00;06;57;01
Paul Rains
And often times these are people that they know anyway. Right? And likely and hopefully trust to be able to say, hey, I'm not doing so well, you know. Then conversely, these folks can also kind of spot their coworkers and say, hey, are you okay? You know, asking the question. Taking the time to care. We get these catch phrases, you know, like see something, say something.

00;06;57;03 - 00;07;03;04
Paul Rains
This is another one of those times when it's like if you suspect that somebody is hurting, ask, say something.

00;07;03;06 - 00;07;23;17
Jordan Steiger
Absolutely. And I think oftentimes people are very scared to do that. So I think having a more formal process and approach throughout your system is very, very powerful for your workforce. I know people are often afraid to ask about somebody's mental health, about suicidal ideation, because they're afraid they're going to make it worse. We know that's not the case.

00;07;23;17 - 00;07;45;07
Jordan Steiger
But I think just empowering people to know that it's okay to ask those questions is such a great thing that your system is doing. I want to ask, though, you exist in a huge health system across 24 states, lots and lots of employees. I know you just mentioned that you want this to touch every single person within the organization.

00;07;45;09 - 00;07;47;27
Jordan Steiger
How are you doing that in such a big organization?

00;07;48;04 - 00;08;10;27
Paul Rains
That's a great question. I was just talking to one of your colleagues earlier about how communication, much like your organization, communication across many different departments, can be challenging. And so, you know, how do we make this work in a system that's in 24 states, 145 hospitals and 2200 other care sites? It is challenging, but we have a great group of people that have come together.

00;08;10;29 - 00;08;37;13
Paul Rains
You know, initially what we were faced with was different initiatives that were going on in different markets across our system. And we actively reached out to those markets to ask them, what are you doing and how is it working? Largely around the ERP process, things like that. And then as the word got out that we were doing this work, we had others contact us and say, Hey, I'm doing the stress first aid in our Midwest division or I'm doing the We Care program, or we have a program for physicians.

00;08;37;15 - 00;08;56;26
Paul Rains
And our response was, That's great. Let's put it all together. Let's create an eclectic program that honors what you're doing and the evidence that you've gathered. And let's bring it all under one umbrella and let's create it for the entire system, and then let's communicate it effectively through a mechanism so that we're not asking people to look in ten different places.

00;08;56;29 - 00;09;17;20
Paul Rains
We're giving them one place to go to be able to access - here's what you do for your wellness and then here's the connection. So having these what we call peer ambassadors out there, those are the folks are going to be educated not only in how to know how to ask those questions and approach folks, but also knowing about our program and being able to educate their peers and coworkers on this.

00;09;17;23 - 00;09;32;09
Jordan Steiger
Sounds like you're really breaking down some of those barriers to access, and I love that you're honoring all of the different approaches from your different hospitals across the system and bringing that together. I think getting that buy-in from the workforce is so important. And this work.

00;09;32;11 - 00;09;52;03
Paul Rains
This initiative that AHA is sponsoring, it has allowed us to share best practice across organizations because there are some topics that it's just it's not proprietary that, you know, it's not something that we need to keep to ourselves. Hey, we're doing it the best. This is an issue that affects us all and affects our communities. These are our brothers and our sisters, aunts and uncles.

00;09;52;03 - 00;10;17;13
Paul Rains
These are our family members. The health care world is a very large, very large world population of folks. But what AHA has done is brought us together so that we can compare. And I really appreciate the ability to validate what we have put together when we see other folks that have come to pretty much some of the same conclusions and said, Yeah, we've come to learn that this we feel like this is evidence-based and best practice and that's what we have arrived at as well.

00;10;17;15 - 00;10;20;01
Paul Rains
That's validation of what we're doing. We're on the right track.

00;10;20;02 - 00;10;40;08
Jordan Steiger
Absolutely. It makes you feel good about the support that you are giving to the people within CommonSpirit. I think that's great. So as we close here, we all know, I think that September is Suicide Prevention Month, as many of our listeners will observe this month at their own organizations. What do you think they really need to remember about this discussion?

00;10;40;11 - 00;10;59;25
Paul Rains
You know, mental health, the topic, the stigma. I mean, at some point we've got to get over ourselves. We're ashamed to talk about it, too. We're afraid of what's going to happen if somebody knows. We need leaders to step up and speak up. I mean, we need leaders to be able to say, yeah, I had those thoughts of I don't know whether it's worth going on or how much more I can take.

00;11;00;03 - 00;11;19;26
Paul Rains
Right. I think all of us have had thoughts of despair. At some point when those thoughts become, well, I don't see very many other options to stop this feeling that we just need to talk about it more. We need to be willing to come out and say, yeah, I've been there. I've been to that place where I wondered whether or not I should go on. I've personally been there more than once.

00;11;20;03 - 00;11;29;09
Paul Rains
Right? So there's something we need to remember. And for me, you know, September may be Suicide Prevention Month. For me, every day is suicide prevention. That's right.

00;11;29;10 - 00;11;54;09
Jordan Steiger
So I think that's a great takeaway and really getting that leadership buy in and that leadership support and speaking out I think is so powerful. And I appreciate you sharing that today. I think that maybe will encourage other leaders to do the same within their own systems. So, Paul, thank you so much for joining us today. If anybody is looking for additional resources about health care worker suicide prevention, please visit AHA.org/suicide prevention/health care workforce. Thank you.

00;11;59;00 - 00;12;00;15
Paul Rains
Jordan, Thank you for having me.

00;12;00;17 - 00;12;01;02
Jordan Steiger
Thank you.

00;00;01;05 - 00;00;41;26
Tom Haederle
The U.S. health care system has plenty of critics. But to one European-trained physical therapist, wastefulness and inefficiency were much worse where she came from. Welcome to Community Cornerstones: Conversations with Rural Hospitals in America, a new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this episode, physical therapist Clare Fox with North Country Healthcare in New Hampshire, shares with the AHA’s Elisa Arespacochaga why she left her native England to pursue her health career dreams in the U.S., and how adapting LEAN training has made all the difference.

00;00;41;28 - 00;00;49;07
Tom Haederle
This series was recorded at the AHA's 2023 Rural Conference in San Antonio.

00;00;49;09 - 00;01;00;13
Elisa Arespacochaga
Good morning. This is a Elisa Arespacochaga at the American Hospital Association, and I'm here this morning with Claire Fox, director of performance improvement at North Country Health Care. Clare, welcome.

00;01;00;20 - 00;01;02;23
Clare Fox
Thank you very much. It's very nice to be here.

00;01;02;25 - 00;01;07;18
Elisa Arespacochaga
Well, that sounds like a little bit of an English accent, I hear. Clare, how did you get into health care?

00;01;07;21 - 00;01;27;15
Clare Fox
I think I was always destined to go into health care. At three years old, my mom was quite sick with Crohn's disease, so I decided I wanted to become a nurse. At six years old, I was a tomboy, so I decided I wanted to become a doctor because there weren't many females in medicine at that time. And 11 years old, I was a runner and I sprained my ankle and I got introduced to PT

00;01;27;15 - 00;01;50;19
Clare Fox
and from then on goal-oriented, I'd found my profession. So I was lucky enough to go to physical therapy school in England. And when I graduated in the early 1990s, I was honestly devastated with what health care was really like. I think I'd had health care on a pedestal for all these years, and when you get into it and you find out what the reality is, it was awful.

00;01;50;22 - 00;02;07;09
Clare Fox
I think I would honestly say that I was burnt out in my early twenties of of health care. And so at the time, 50% of jobs were vacant in this country. And so recruiters used to come over to Europe and said, hey, we'll double your wage...pay for you to get there, pay for three months rent. You just have to sign on the dotted line for a year.

00;02;07;11 - 00;02;11;00
Clare Fox
So that's how I ended up in Berlin, New Hampshire is where I landed.

00;02;11;05 - 00;02;29;21
Elisa Arespacochaga
That's awesome. And it's an awesome story. So as you came here, you're already thinking, I don't know if I can keep doing this. I've just come into a situation where so many jobs are vacant. How did you think about how to do the work? And you mentioned to me earlier that you were introduced to LEAN as part of this this journey across the ocean

00;02;29;22 - 00;02;33;26
Elisa Arespacochaga
among other things. How did that help you think about your own work?

00;02;33;29 - 00;02;53;02
Clare Fox
So I think I mean, I came from socialized medicine. And so at that time in the early nineties, there were a lot of waiting lists. I mean, if you had an acute injury, you'd wait two weeks to get into PT. If it was chronic, we'd see you in 3 to 6 months. If you needed a total knee joint, you'd get put on the waiting list and you'd be there for two or three years.

00;02;53;02 - 00;03;11;14
Clare Fox
People would literally die on the waiting lists. And so I knew that when I came over to the States, I'd be introduced to a completely different health care system. And whilst I don't really believe you should profit from health care, hence I worked at a non-for-profit.  I knew I had to experience something different. And so I was introduced to Lean.

00;03;11;14 - 00;03;45;19
Clare Fox
In about 2017 I met a gentleman called Dan Fleming from GBMP, and after he introduced me to...after I left that course that day, I was like, this is it! I really felt as though that this was my destiny. You know, they talk about the eight wastes in health care and I'll just mention briefly, and we do these very well in health care but inventory: too much of it. Motion: I can't find. Movements of information and materials. Overproduction. Over processing errors.

00;03;45;19 - 00;04;04;13
Clare Fox
We make errors in health care. Waiting - we have real estate dedicated to that. And under-utilization of people. And I think that's one of my biggest concerns is, is that so many people today that they they start their day and they're literally like, okay, where's the fire today? We've got one smoldering over there. We've got smoke over there.

00;04;04;19 - 00;04;25;06
Clare Fox
Fire. Oh, inferno. I'm going over to their first. And they're doing so many wasteful things. Unfortunately, they just can't really sort out the value from the non value added. And so I think that's why for me I'm like I think this is the only way we can save ourselves and our patients is to really help make health care a lot more efficient.

00;04;25;12 - 00;04;50;13
Elisa Arespacochaga
I love that you've tied this to your work around wellness in burnout, not just improving the performance of the organization and the efficiency, but the benefit it brings to your team in terms of their own wellness. So tell me a little bit about how you've been thinking about that linkage between performance improvement, wellbeing of your team and then that piece of that ties it together of the efficiency of practice. 

00;04;50;15 - 00;05;09;05
Clare Fox
Right. Like I said, a lot of people are stressed in health care and we do a lot of things that aren't very efficient. But I think one of the most one of the most important things is that people who do the work know the work best. And so I don't feel as though sometimes that their opinions are always respected or heard.

00;05;09;07 - 00;05;43;07
Clare Fox
And I think when they are not, that that leads to a lot of demoralization and hence burnout. And so I think that that's what LEAN for me offers, it offers us to be able to go to the place where the work is done and say, "Hey, guys, you're the experts." You know, let's use data and measure things and then looks really, truly understand the problem, figure out how we can how we can fix it, and then look at the comparative data before and afterwards and help to take out the variation and then get less errors, but also help to save ourselves.

00;05;43;10 - 00;06;07;24
Elisa Arespacochaga
Absolutely. So you mentioned a little bit about really going to the place where the work is being done, and that really feeds into the culture of the organization. Right. That front line bringing elevating that work at the front line to the entire team and understanding how it is that the culture of the organization impacts both the performance and the well-being of the team.

00;06;07;24 - 00;06;13;01
Elisa Arespacochaga
Can you tell us a little bit about how you're engaging with the culture? Because that's everybody in the organization.

00;06;13;01 - 00;06;35;02
Clare Fox
Sure. We had a new president in the mid 20 teams called Mike Petersen, and one of the first things he did at NCH was he spent a long time building culture and so he had teams and and they were build they were writing booklets and throwing out, you know, words of sense of ownership, collaboration, quality, integrity, flexibility, communication, service and accountability.

00;06;35;08 - 00;07;00;08
Clare Fox
And I'll be honest with you, I didn't really get it. I was like, oh, my goodness, let's just, you know, work on improving things, shall we? And then I stay. As I did more work on LEAN, I realized so much of it is built on the foundation of culture. Are we a facility who punishes when there's an error or are we a facility who says maybe it's not the people who will come to work to deliberately make a mistake?

00;07;00;14 - 00;07;16;09
Clare Fox
Maybe it's the processes. And so if you don't have that baseline culture, you can't improve things. I swear I could improve any anything in any industry. But if you don't have the culture to support it, it's only going to be like a flash in the pan.

00;07;16;11 - 00;07;21;25
Elisa Arespacochaga
Absolutely. So tell me a little bit about what you have done at NCH thus far.

00;07;21;27 - 00;07;45;07
Clare Fox
Sure. So we've built our wellbeing program under under three pillars work, general wellbeing, culture and also efficiency. And some of the things that we've done within NCH: we initially focused a lot on the providers, but now we're we're trying to grow it to everybody and I mean everybody, not just clinical staff. So we have a professional wellbeing team.

00;07;45;09 - 00;08;09;00
Clare Fox
We wrote a peer to peer support for providers. We've done one on one shadowing to try and see how we can make their work a little bit more efficient. Our AD director Dr. Moore got her certification in chief wellness officer and due to the way that behaviors of our patients have changed over the years and not always for the better, we've had to put posters around our facilities.

00;08;09;00 - 00;08;27;29
Clare Fox
We do not tolerate or, you know, please respect, which is kind of sad. But the other thing that we've done is, is we've committed committed to LEAN Six Sigma. And so by September of this year, 50% of our employees will have taken the class and 100% by September of next year. People can do a project if they choose to.

00;08;28;05 - 00;08;52;24
Clare Fox
But now we're all have it all speaking the same language. And we have change agents everywhere among our everywhere in our organization. We're going to have a thousand people who potentially are empowered to be able to make basic changes of their work area. You can't beat that. No. I mean, we have onsite clinical psychologist, we have music therapy, and this isn't across all sites.

00;08;52;24 - 00;09;04;20
Clare Fox
It's just some of the things that we've done. But it's certainly a long journey for us. And we know I think it feels like we're in mile one of a marathon and it's definitely very complicated, but we're certainly excited.

00;09;04;22 - 00;09;38;15
Elisa Arespacochaga
Yeah, and I know we talked earlier a little bit as we were getting ready for this, that health care is in a place where we're going to have to work smarter because we will not have more likely not have more people coming into health care to fill all of the positions that were there. So as a health care leader and someone who's focused on performance improvement and quality, what kind of advice do you have for those who want to really marry both the efficiency and the improvement, along with maintaining that well-being of your team?

00;09;38;15 - 00;09;42;29
Elisa Arespacochaga
Because you obviously need all three pieces to to work better and smarter.

00;09;43;02 - 00;10;07;21
Clare Fox
I love to use the old adage, just do it. But I'd say lead with humility. Respect your workers. Let's try and get out of our silos that we are so well at working in in health care. Collect the data before and afterwards. Make sure you truly understand the problem, Make the journey your own. And it's a long journey.

00;10;07;27 - 00;10;14;11
Clare Fox
But I think we owe this to ourselves and our patients to do it because we have to save ourselves here.

00;10;14;14 - 00;10;23;22
Elisa Arespacochaga
Absolutely. Claire, thank you so much for sharing your thoughts, your advice. And I'm looking forward to continuing to watch what you do at North Country Healthcare.

00;10;23;24 - 00;10;24;20
Clare Fox
Thank you very much.