Advancing Health Podcast

00:00:01:02 - 00:00:27:03
Tom Haederle
Welcome to Advancing Health. Experts say mental health issues and substance use disorders in people over age 65 is underreported, under-diagnosed and deserves much more attention than it gets. In today's podcast, we learn more about how the brand new Henry Ford Behavioral Health Hospital created a designated unit dedicated to older adults to help focus on their behavioral health needs.

00:00:27:05 - 00:00:55:24
Rebecca Chickey
Hello, my name is Rebecca Chickey and I am the senior director of behavioral health for the American Hospital Association. And it's my honor to be joined today by Dr. Zaira Khalid, who is the senior staff geriatric psychiatrist at Henry Ford Behavioral Health Hospital, which is located in West Bloomfield, Michigan. Today, our discussion is entitled Improving Behavioral Health for Older Adults: Lessons from Henry Ford Health.

00:00:55:26 - 00:01:25:08
Rebecca Chickey
Thank you so much for being here with us today. What I'd like the listeners to learn and hear first from you is what is the situation? What's the prevalence of psychiatric, or substance use disorders in individuals who are 65 and older? And what are the perhaps unique circumstances that older adults may experience that may drive conditions such as depression or anxiety?

00:01:25:10 - 00:01:50:15
Zaira Khalid, MD
Rebecca, thank you for having me. Thank you for shedding light on this very, very important topic that I think doesn't get enough attention and should be getting much much more attention just because of the need that there is. So in terms of mental health and substance use disorder treatment, it is definitely underreported and underdiagnosed in our elderly patients.

00:01:50:17 - 00:02:25:15
Zaira Khalid, MD
Having said that, the numbers are still very high. So, patients who we look at that may be, let's say admitted to the hospital with medical concerns and have medical comorbidities. Their prevalence of having psychiatric disorders is going to be anywhere between 40 to 50%. That's very, very high. Substance use disorders in the elderly...I believe the last time I saw a good study was in 2022. Eleven in 60 adults, older adults, had a substance use problem.

00:02:25:17 - 00:02:55:00
Zaira Khalid, MD
And that's only those that are being diagnosed. You know, I can tell you from personal experience, it's a lot higher than that. We just don't recognize it. So a lot of our elderly are struggling, not getting the help they need, not seeking the help they need due to various factors. But what leads them to where they are with their mental health and where they are with their psychiatric health are that they're a unique population, they go through stressors that the majority of the other population doesn't.

00:02:55:02 - 00:03:20:23
Zaira Khalid, MD
They're at a stage in life where they are losing their loved ones around them. They're losing their friends that they've had their entire life. They are retiring from their jobs, which is what gave them meaning in their life. Their kids are moved out of the home, busy with their lives. That was a huge part of their life that gave them meaning - parenting, raising their kids.

00:03:20:25 - 00:03:54:29
Zaira Khalid, MD
They're now sometimes, most of the time, having to give up their homes, and they're moving into assisted living or nursing homes. And it's a completely different environment, completely different level of independence. They're not driving anymore. So all of those things put together, I think, would be stressful for any one of us. And once you add on medical problems like not being able to walk as well, having diabetes, possibly a stroke, it just leads to sort of a concoction of items that's going to lead to poor outcomes

00:03:54:29 - 00:03:56:18
Zaira Khalid, MD
if not intervened.

00:03:56:21 - 00:04:23:18
Rebecca Chickey
Absolutely. I saw my own mother go through this, and now my husband's parents have done exactly what you've described. They've moved into an assisted living facility. My father in law is now 94 and wheelchair bound. And my mother in law is younger and still active. And so there's also that sort of strain. Luckily, they do still have friends that are their age that are in that same living facility

00:04:23:19 - 00:04:31:00
Rebecca Chickey
so that's helping offset. But, but it doesn't eliminate all the other challenges that you described.

00:04:31:02 - 00:04:34:27
Zaira Khalid, MD
Yeah. Social isolation is very real and very dangerous.

00:04:34:29 - 00:04:54:22
Rebecca Chickey
Absolutely. So tell me, in the design and the development of the new Henry Ford Behavioral Health Hospital, what did you do to better meet and accommodate the needs of the older adult population? Both perhaps from a physical design, but, additionally, from a treatment design. What's your approach?

00:04:54:25 - 00:05:20:29
Zaira Khalid, MD
Well, we wanted to make sure we had a designated spot and a separate unit, a physically separate unit that was dedicated to older adults so we could focus on the design being different and accommodate all their needs. Simple things like having handrails on the walls in the hallways so that they were able to hold them and walk, which, you know, is not something that you commonly see in an inpatient psychiatric hospital.

00:05:21:01 - 00:05:48:14
Zaira Khalid, MD
Having a courtyard outside that allows for more relaxation. It's surrounded by trees. There's benches, sunlight. Which is very different than some of the other courtyards we may have for a younger population where they we want them to be a little bit more active. So they've got basketball hoops and such. Things like having call lights. So, a psychiatric hospital, generally we don't have call lights because it can be a safety measure.

00:05:48:17 - 00:06:06:25
Zaira Khalid, MD
We don't want to have a lot of cords and strings. But for our geriatric unit, we wanted to make sure we have those in case there's a fall while they're using the restroom. We have more bathrooms on this unit that are ADA accessible and have shower chairs so they're able to sit and take a shower with handheld showers so they don't have to stand for too long.

00:06:07:02 - 00:06:29:17
Zaira Khalid, MD
Those would be kind of some of the design, major design elements that we've tapped into account. And the other was really having staff that has been trained and experienced in dealing with this population and knows what to look for. And it's not just about the treatment they get here, but also what we set them up with once they leave here and staff that has the knowledge of that.

00:06:29:17 - 00:06:51:19
Zaira Khalid, MD
So how do we set them up with resources that is going to keep them involved in the community, keep them active? And how do we give them tools that they can learn here and continue to utilize outside of here? So that's a social worker that is well versed in some of the resources we have here. The PACE program, which is designed for the elderly, day programs for the elderly.

00:06:51:21 - 00:07:18:22
Zaira Khalid, MD
We've got activity therapy that is used to doing activities that, you know, may be designed for those with less cognitive reserve, and sometimes it may just be as simple as musical instruments because that's the cognitive capacity we have. We had exercise equipment that some of the activity therapists can bring on to the unit and teach them how to do exercises, just, you know, sitting in the dayroom.

00:07:18:25 - 00:07:36:13
Zaira Khalid, MD
It's something that they can translate into their own living rooms when they get discharged. So we really wanted to make sure that the staff is able to identify those needs in these patients and help them teach some of the skills that they can also translate outside of here, because this is just a week of their life or two weeks of their life.

00:07:36:16 - 00:08:07:02
Rebecca Chickey
I had a thought while you were describing all the talents of the staff that you've recruited and wondering - I'm kind of leading the jury here. Also, staff who care and who look forward to working with individuals who are in perhaps their last decades of life. And it's been my experience working in health care for over 30 years now, that there's often less of a shortage for people to work in the labor and delivery unit.

00:08:07:09 - 00:08:20:28
Rebecca Chickey
They want to see the new life come forward. They want to work with the babies and the new moms. But geriatric care has had its own challenges. So has that been something too, that you've focused in on to find those people with that passion?

00:08:21:00 - 00:08:41:03
Zaira Khalid, MD
100%. So everyone that works on the geriatric unit, the staff that has always voiced that they want to work on the geriatric unit and always has in the past. So our social worker has been in geriatrics for a long time. Our activity therapist has been in geriatrics for a long time. So I mean, I love working with the older adults, it's all I do.

00:08:41:05 - 00:09:00:12
Zaira Khalid, MD
So all of us share that passion and I think that's why we work so well as a team. I think that's why our patients can see that when they're here and getting the care that they want. So for sure, I think passion has a lot to with it. It's not a population that most people choose to work with or want to work with. Something

00:09:00:12 - 00:09:11:17
Zaira Khalid, MD
I've never understood why - I think it's the absolute best population, the sweetest population, and the most rewarding population you could work with. But the passion of the team is definitely there.

00:09:11:20 - 00:09:34:20
Rebecca Chickey
Wonderful. I think another, not to say that that what I'm about to say doesn't exist in individuals who are under the age of 65, but often individuals who are 65 or older may have physical illnesses as well. Their diabetes may have gotten to a certain stage or their congestive heart failure. So how do you integrate physical and behavioral health?

00:09:34:22 - 00:09:59:07
Zaira Khalid, MD
It's a wonderful question. So one of the things that I'm very passionate about is cut down their meds. A huge problem we have in our geriatric population is poly-pharmacy, meaning they see multiple doctors because they need to. And there's a lot of multiple medications being put in. And sometimes they interact. They cause side effects. Then medications are prescribed to counter those side effects.

00:09:59:07 - 00:10:25:25
Zaira Khalid, MD
And this is a population very sensitive to that. So we have a fantastic family medicine team that we work with very closely. They're in-house seven days a week. A wonderful pharmacist who helps us. And we really try to treat the patient as a whole. So for example, let's say someone gets admitted for uncontrolled anxiety and they've also got diabetes.

00:10:25:27 - 00:10:51:27
Zaira Khalid, MD
My first approach is not to go ahead and prescribe them something for anxiety. It's to look at their blood sugars, because we know fluctuations in blood sugars caused anxiety, geriatric or not. It's just it's much more prevalent in geriatrics because they're more sensitive to blood sugar fluctuations. So my first thing is let me work with my family medicine counterpart and let's get these blood sugars under control.

00:10:51:29 - 00:11:13:17
Zaira Khalid, MD
And if we're still seeing the anxiety, then yes, we will intervene with something that is safe, doesn't interfere with their diabetes medicines, their heart medicines, and try to treat those. Working with nutrition, who's here and making sure that these patients have the adequate diet, have the adequate protein levels in order to gain some strength back that they might have lost.

00:11:13:19 - 00:11:21:24
Zaira Khalid, MD
So putting all those teams together and really having that multidisciplinary approach to patient care, I think is what works really well.

00:11:21:27 - 00:11:33:22
Rebecca Chickey
Yeah. Whole person care. Who knew? The brain is connected to the rest of the body. Do you have a story you'd like to share for the listeners? A success story when you've seen this approach be used?

00:11:33:25 - 00:11:55:06
Zaira Khalid, MD
Yes. Actually, the diabetes medication, a story I just example I shared with you was a real life patient. So, I mean, these are all sort of lessons learned, and educating families on how important, you know, managing their blood sugars are. We see this day and night. Another very common thing that I see a lot of times is the sleep.

00:11:55:08 - 00:12:15:20
Zaira Khalid, MD
You know, a lot of our elderly have trouble sleeping. That leads to irritability the next day. That may lead to behaviors like agitation in a nursing home, or they're coming in because they might have hurt someone in a nursing home. And when we really kind of think back and look back into it, one of the biggest things is sleep.

00:12:15:20 - 00:12:36:19
Zaira Khalid, MD
It's not that they are agitated because they have bipolar disorder or they have something else going on. It's sleep and having to target that. And once they've gotten a good night's rest for a few nights, they're a completely different person. And I think we can all relate to that. I mean that nobody does well without sleep, but these patients and their brains are much more sensitive to that.

00:12:36:21 - 00:13:10:18
Rebecca Chickey
Absolutely. So I have a couple more questions before we wrap up. The first is if one of the listeners is thinking about creating such a program as yours in their own organization, whether it's in a freestanding psychiatric hospital like yours, or they're going to try to adapt it inside a general acute care hospital, do you have maybe 2 or 3 things that you think you did as you were planning for this that really provided the successful foundation that you're operating from now?

00:13:10:21 - 00:13:37:06
Zaira Khalid, MD
So I think number one is what you touched on earlier, having staff that is passionate about this population. It is not an easy population. There's a lot of medications, there's a lot of social factors that are involved. I think one of the other key elements is collaborating with your community resources. We can only do so much. They are going back into the community, and they're going to need those resources.

00:13:37:13 - 00:14:06:25
Zaira Khalid, MD
So knowing what those resources are, knowing how to refer patients to those resources is going to be extremely, extremely important. Those are two of the biggest things I think that leads to success when treating geriatric patients. And then having a collaborating counterpart that is going to be medicine, because these patients have significant comorbidities that you're going to need the help of your family medicine colleagues, or your internal medicine colleagues.

00:14:06:27 - 00:14:13:07
Zaira Khalid, MD
I think if you can work together as a team with them, you can really, really help these patients significantly.

00:14:13:09 - 00:14:33:27
Rebecca Chickey
Well, I'm so inspired. If I had the capability to go start one of these programs, I think I would do it right now. But, I don't. Thankfully, we have professionals like you and the wonderful team at Henry Ford Health. My last question to you is, do you have words of inspiration or a call to action that you'd like to share with the listeners of this podcast?

00:14:33:29 - 00:14:56:16
Zaira Khalid, MD
Sure. I think Call to Action, for me, the biggest thing would be check in on your older loved ones, please. I think a lot of them are part of a generation that doesn't talk about mental health. They're from a generation that did not necessarily believe in mental health. And, had the mindset of just keep pushing and it'll get better.

00:14:56:16 - 00:15:22:08
Zaira Khalid, MD
Just keep going and you'll get better. And sometimes it doesn't. Check in on them. Also, please keep a close eye on them for any substance use. We continue to see a rise in substance use in our elderly. It's really leading to a lot of other complications as well. So, you know, I'll give you an example. For example, if a grandmother falls down the stairs, our first instinct is she's old, she tripped and she fell.

00:15:22:10 - 00:15:46:18
Zaira Khalid, MD
We don't ever test her, or very rarely do we test her for alcohol. Was she intoxicated? Is that why she fell? It's not our first thought. So please look at those things. Look at their safety in their home. See if they're involved in the community or if they're spending all their weeks in their apartment. Get them involved volunteering at the library, community center.

00:15:46:25 - 00:15:55:23
Zaira Khalid, MD
Day programs, whatever it may be. Giving them a purpose, giving them a routine can be so, so beneficial for them.

00:15:55:25 - 00:16:06:13
Rebecca Chickey
That's wonderful and exceptional. And thank you so much for your willingness to share your passion, your time, your expertise and to inspire others on this really important journey.

00:16:06:16 - 00:16:14:27
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:29 - 00:00:23:14
Tom Haederle
Welcome to Advancing Health. The perinatal period is a delicate time for a new mom's mental health. In fact, 1 in 4 moms experiences perinatal depression and anxiety. Coming up, a look into how a leading specialty hospital for women and newborns developed a program that helps prevent perinatal depression.

00:00:23:16 - 00:00:44:29
Julia Resnick
Hi everyone. I'm Julia Resnick, director of strategic initiatives at the American Hospital Association. I am so pleased to be here today to talk with all of you about perinatal depression. I'm joined by two experts from Women & Infants Hospital of Rhode Island. We have Shannon Sullivan, who is the president and chief operating officer, joined by Dr. Caron Zlotnick, who's the director of behavioral medicine research.

00:00:45:01 - 00:00:49:04
Julia Resnick
Shannon, Dr. Zlotnick, so happy to be here with you all today.

00:00:49:06 - 00:00:50:04
Shannon Sullivan
Thank you. Julia.

00:00:50:05 - 00:00:51:12
Caron Zlotnick, Ph.D.
Thank you for having us.

00:00:51:16 - 00:01:02:02
Julia Resnick
So let's dive right in. Shannon, I want to start with you. Can you start with some background on your hospital and your community?

00:01:02:04 - 00:01:37:21
Shannon Sullivan
Sure. Absolutely. So Women & Infants is one of the largest freestanding women's health hospitals in the country, exclusively dedicated to serving women and their families. We do about 8,700 deliveries annually. We have an 82 single bed level, 3 to 4 NICU with about 1,100 discharges annually. We have a comprehend of women's medicine program that includes an inpatient unit, GI, OB medicine, endocrinology, basically anything that cares for women during the course of their lifetime.

00:01:37:24 - 00:01:58:23
Shannon Sullivan
We are also the only OB hospital in the region that is an obstetrical tertiary care hospital. Plus, we have one of the largest NICUs in New England and actually on the East coast. So we care only for women here, only for women and their infants. And we feel really strongly about their care being really high quality.

00:01:58:25 - 00:02:16:09
Julia Resnick
That's amazing. And I love that whole life cycle from when they're young until when they're much older. And for this podcast, we're really focusing on your hospital's pregnancy and postpartum care. So how are you thinking about that whole continuum and making sure that that care extends to women after they give birth?

00:02:16:11 - 00:02:40:10
Shannon Sullivan
You know, I think it's important to note that even though I'm the president and chief operating officer now, my background is I'm a perinatal social worker. I've a master's in social work and I practiced in this setting for about ten years before I got into leadership. And so I can tell you, we're particularly dedicated to the pregnant and postpartum care, especially the mental health needs of women across the state.

00:02:40:13 - 00:03:12:03
Shannon Sullivan
And so, you know, currently, when you look at morbidity and mortality across the United States in the pregnancy and postpartum period, suicide and overdose are climbing higher in that list, and mark two of the top ten reasons that women get sick and die during their pregnancy or one year postpartum. It's a particularly delicate time for women and their families, and that's underscored not just by the data and the research but a lot of the anecdotal stories that you'll hear, you know, across news outlets.

00:03:12:03 - 00:03:38:12
Shannon Sullivan
And so it's incredibly important for us, being that we are a women's hospital, being the types of patients that we care for, that like I said, come from a wide variety of backgrounds. And given what we know about women in their pregnancy and postpartum period and what's happening nationally. And so there are not ever enough resources to care for women during this particularly delicate time during their life.

00:03:38:14 - 00:03:47:26
Shannon Sullivan
And so we've really spent a lot of time in the last 25 years investing both in the research and in the care of women.

00:03:47:28 - 00:04:04:27
Julia Resnick
I think what your hospital is doing is so important because it connects the research in this space with the care. So, Dr. Slotnick, you're an expert in this space. What were you seeing that helped, you know, it was so important for your hospital to do more around postpartum depression care?

00:04:04:29 - 00:04:34:22
Caron Zlotnick, Ph.D.
Well, my expertise and focus is preventing postpartum depression. When I first started at Women & Infants Hospital, which was, many, many moons ago, you know, Women & Infants has a large ObGyn clinic. The majority of their perinatal patients are on Medicaid. And this is a very high risk group of women who are at risk for postpartum depression.

00:04:34:24 - 00:05:01:08
Caron Zlotnick, Ph.D.
When I started at Women & Infants Hospital as a clinical psychologist, I treated many of these perinatal patients with mental health issues. So I heard firsthand the struggles of these patients with mental health issues. You know, we know society  - you could even look on Facebook - tells us that having a baby is the happiest time of your life.

00:05:01:10 - 00:05:20:00
Caron Zlotnick, Ph.D.
And, these patients really experienced a lot of stigma and shame around their mental health issues. You know, that got me thinking that, you know, screening and treatment is very important but prevention is better and more cost effective.

00:05:20:06 - 00:05:23:11
Julia Resnick
So talk to me more about that. What does prevention look like?

00:05:23:13 - 00:05:52:27
Caron Zlotnick, Ph.D.
Well, there's no proven or consistent way to predict who might be at risk for postpartum depression. You know, it's probably more cost effective to offer a prevention intervention like program to prevent postpartum depression to every pregnant woman rather than guess who may benefit from the program. So, the Rose program: Reach out, stay strong,

00:05:52:29 - 00:06:21:29
Caron Zlotnick, Ph.D.
essential for mothers with infants. So the overall aim of ROSE is to reduce suffering and increase joy for as many new mothers with an infant as possible during a time when which can be very stressful and lonely. The Rose program is administered during pregnancy, usually in small groups consisting of four sessions during pregnancy and a postpartum check-in post delivery.

00:06:22:01 - 00:06:54:22
Caron Zlotnick, Ph.D.
The ROSE program tries to focus on those risk factors that fall postpartum depression that are amenable to change. So the session topics focus on improving relationships and support system, effective strategies to communicate, like how to say no, how to ask for help. Very important in the postpartum period. Self-care strategies, ensuring that new moms have me time, that they don't get depleted. And goal setting.

00:06:54:25 - 00:07:27:17
Caron Zlotnick, Ph.D.
We also provide information on different types of stresses that can occur in the postpartum periods, you know, such as baby blues and what is involved with postpartum depression and how to identify it, we try to destigmatize it. It is a common struggle for many postpartum women. You know, 1 in 7 experience full-blown postpartum depression. We tell them how and where to reach out for help.

00:07:27:19 - 00:07:53:28
Caron Zlotnick, Ph.D.
To accompany our sessions, we have a patient workbook, which is available in English and Spanish. We did a very large implementation study in which we had 98 sites across the country, delivering Rose. So some sites delivered Rose virtually, others in person. Now, what is important with delivering Rose is that you don't need mental health expertise.

00:07:54:00 - 00:08:27:17
Caron Zlotnick, Ph.D.
So we had the full spectrum of people delivering Rose: clinic nurses, doulas, medical assistance navigators, community health workers, and actually mental health providers. And the training for those who want to deliver Rose is relatively an easy process. The ROSE website, which is hosted by Women & Infants, has all the training intervention materials. The training videos, as I mentioned before, the patient workbook.

00:08:27:19 - 00:08:38:08
Caron Zlotnick, Ph.D.
And Rose itself is highly scripted. So there's a scripted manual there. We have slides for virtual delivery and all free of cost.

00:08:38:11 - 00:09:01:27
Julia Resnick
That's amazing. And I think just having this publicly available is so hugely important. And also there are so many communities that don't have enough mental health providers that it's really powerful that you can be a lay provider or just a medical provider. I want to pivot slightly. I know that your hospital is doing work in perinatal depression and supporting postpartum women in their families beyond the Rose program.

00:09:01:29 - 00:09:05:20
Julia Resnick
Shannon, can you talk a little bit about what else is going on?

00:09:05:22 - 00:09:44:01
Shannon Sullivan
One of our more proud moments is how dedicated this organization has been to the totality of care of women. Not just their medical care, their psychological care, their socioeconomic care, their social determinants care. And really making sure that they support the whole woman in their family, for many decades now. And that is mostly our premier program, the one that, you know, Dr. Zlotnickwas just talking about, that she had started in is our day hospital program and our partial hospitalization program, which opened 25 years ago.

00:09:44:02 - 00:10:14:09
Shannon Sullivan
It was revolutionary at the time. I would argue it's still revolutionary today. It was a program for assessment and then care of pregnant and postpartum women with perinatal and postpartum depression. And what was so revolutionary about it is it was a program that allowed women to get that intensive outpatient care. So coming every day, but with their baby. Oftentimes you would find women were separated during treatment from their children.

00:10:14:09 - 00:10:42:01
Shannon Sullivan
And then, you know, psychiatrists, psychologists, social workers couldn't really assess bonding. They couldn't really assess how women were doing and caring for their infants as well, as it didn't allow women more time to be able to bond under the professional treatment that they received. So that was opened late 90s, early 2000s and still remains actually one of the only in the country and cares for a wide variety of women, really across the region.

00:10:42:03 - 00:11:04:09
Shannon Sullivan
And since that time, more recently, we've increased the amount of women and the types of care that we're providing. So it's no longer, you know, postpartum and perinatal anxiety and depression. We also have an OCD track. We found there's a higher prevalence, especially for women who've previously experienced obsessive compulsive disorder in the postpartum period. That can be a really difficult time.

00:11:04:11 - 00:11:28:13
Shannon Sullivan
So we've opened an OCD track to the partial hospitalization program, and most recently, within the last six months, we've reopened a substance use track so that we can, you know, try to work together. We work together with a Suboxone program. We have family medicine who's been coming in and helping us to care for not only the patients, but also the babies that are in that program with their mothers.

00:11:28:13 - 00:11:47:18
Shannon Sullivan
And so we're really trying to diversify the types of patients that we're caring for in that program, all along the lines of treating mothers while keeping them together with their children. It's really been well received within the community. We can't keep up with the volume as you can imagine, and so we're continuing to find ways to grow it over time.

00:11:47:21 - 00:12:14:09
Shannon Sullivan
Two other ways that we're really looking is Dr. Emily Miller, who's the division director of maternal fetal medicine here, has an RO1 grant for the Compass Plus program, which embeds social workers and case managers within obstetrical practices for that assessment, grief intervention and then referral. And then our newest program that we're most proud of that hasn't started yet is our mobile van program.

00:12:14:10 - 00:12:40:16
Shannon Sullivan
CVS Health recently gave us a grant to purchase a mobile van, and in that mobile van, we'll have a nurse practitioner and community health workers. What we know about our particular community is especially the patients that Dr. Zlotnick was talking about, our high Medicaid clinic onsite. It's hard for patients to get back. You know, you're asking them to deliver a baby and then they might not have reliable transportation, they might not have reliable child care.

00:12:40:22 - 00:13:12:18
Shannon Sullivan
And, you know, I will tell you, as the mother of three who had reliable transportation, who had reliable child care, getting out of the house with my children during that postpartum period was really challenging, especially to take care of myself. And so the postpartum van is going to be able to go out and really provide that care in communities to patients in their home and in the van, and be able to identify and then refer either to Rose or to Compass Plus or to the day hospital program when they're meeting with patients in their own community and really seeing what's happening in their home.

00:13:12:20 - 00:13:30:18
Julia Resnick
That's really amazing and impressive work. And please keep us posted on all of these new programs. It sounds like they'll be incredibly impactful. To wrap things up, I just want to pick your brains about what you've learned while implementing these programs, because I'm sure we have people listening who are thinking, how do I do this in my community and in my setting?

00:13:30:25 - 00:13:38:11
Julia Resnick
So what do you think those key takeaways are - that others could learn from your experiences to set up their own programs?

00:13:38:13 - 00:14:02:24
Shannon Sullivan
I think execution is always a problem and a lot of that has to do with, you know, these are complex clinics, these are complex patients. And everything, of course, requires resources. And all of those things make it more complicated. I would say that one size does not fit all for everyone. We've seen many people fail trying to implement a postpartum day hospital program.

00:14:02:24 - 00:14:30:19
Shannon Sullivan
We've seen many people with the best intentions. And so you have to partner with a wide, wide variety of people to get any of these programs off the ground. Your payer contracting teams, your operational needs, your clinical needs, your patient liaisons, your community health workers. And so it really does require a multidisciplinary approach to execution and probably much longer than any of us ever

00:14:30:19 - 00:14:42:21
Shannon Sullivan
like when it comes down to that. But I would say if you get the right multi-disciplinary team, embedded in doing your work, you can do it, but you certainly can't do it alone.

00:14:42:24 - 00:14:44:15
Julia Resnick
Anything to add, Caron?

00:14:44:17 - 00:15:16:00
Caron Zlotnick, Ph.D.
I can say the organization has to have the capacity to implement a program like Rose. What I would also like to say is that in recruiting potential sites, it was very heartwarming to hear from administrators, directors of programs really expressing a deep passion about improving maternal mental health. You know, in our study we realized that it makes a difference if you have a cheerleader.

00:15:16:02 - 00:15:48:24
Caron Zlotnick, Ph.D.
Best if leadership is the cheerleader but even those who are delivering Rose. And I just want to mention that on our website at Women & Infants Hospital, we actually have an implementation plan for agencies and hospitals that are thinking about implementing the Rose program. That really helps these sites to think through what it is that they need to do to successfully implement Rose or actually any program similar to Rose.

00:15:48:27 - 00:16:15:03
Julia Resnick
Fantastic. So I think three key themes that I heard was that you need passion, you need partnerships and you need patients. Shannon, Dr. Zlotnick, thank you so much for sharing this fantastic work that you're doing. To our listeners, you should check out the Rose program website on the Women Infants Hospital website. Thank you all for listening. And thank you again to Shannon and Dr. Zlotnick for your passion for this issue and for sharing your expertise with our listeners.

00:16:15:05 - 00:16:15:18
Shannon Sullivan
Thanks so much.

00:16:16:09 - 00:16:19:07
Caron Zlotnick, Ph.D.
Thank you for giving us this opportunity.

00:16:19:09 - 00:16:27:20
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:27 - 00:00:24:15
Tom Haederle
Welcome to Advancing Health. For stroke victims, speed and survival are closely linked. Quicker diagnosis and treatment can make a huge difference. Coming up in today's podcast, a look at how those two letters we hear more and more about in today's health care - A and I - artificial intelligence, are being applied to protocols for stroke treatment.

00:00:24:18 - 00:00:43:24
Tom Haederle
Hi everyone. I'm Tom Haederle, senior communication specialist with the American Hospital Association and pleased today to get to do one of my favorite parts of this job. And that's highlighting the amazing work that goes on every day among our member hospitals and health systems. And here's a great example: the integration of artificial intelligence into treatment protocols for stroke victims

00:00:43:24 - 00:01:08:11
Tom Haederle
at Detroit-based Henry Ford Health. Joining me from Henry Ford to talk about this are Dr. Aaron Lewandowski, an emergency medicine doctor and the emergency medicine stroke representative at Henry Ford West Bloomfield Hospital, and Doctor Alex Chebl, a vascular and interventional neurologist and director of the Henry Ford Stroke Center and the Division of Vascular Neurology. Doctors, thank you both for joining us on this Advancing Health podcast today.

00:01:08:11 - 00:01:09:08
Tom Haederle
Appreciate you being here.

00:01:09:09 - 00:01:10:07
Aaron Lewandowski, M.D.
Thanks for having us.

00:01:10:09 - 00:01:11:10
Alex Chebl, M.D.
Thank you for having me.

00:01:11:12 - 00:01:20:03
Tom Haederle
Dr. Lewandowski, let's start with you and a basic question: why is speed of diagnosis and treatment so critical when treating victims of a stroke?

00:01:20:05 - 00:01:40:23
Aaron Lewandowski, M.D.
There's a common saying in neurology and stroke care that time is brain. It is estimated that millions of neurons are irreplaceably lost each minute during an ischemic stroke. So the sooner that we are able to diagnose and treat a stroke, the more brain we're able to save and the patients are able to have a easier outcome and a better recovery.

00:01:40:25 - 00:01:45:28
Tom Haederle
And what exactly does AI lend to the process? How has it improved how we're doing this now?

00:01:46:00 - 00:02:12:10
Aaron Lewandowski, M.D.
AI has been used in multiple ways across medicine. In stroke care particularly, we're able to use it in helping with diagnosis of stroke in a timely manner. Our program specifically is called Rapid AI. It is a software program that allows for quicker diagnosis of strokes and also facilitates communication between physicians. Dr. Chebl was actually the physician that brought the idea to our stroke committee, and we've been using it for approximately two years.

00:02:12:12 - 00:02:23:19
Tom Haederle
Does it actually paint - and this is a question for both of you - does it paint a picture of what's going on inside the stroke victim inside the brain actually allow you to see something you couldn't see before. Dr. Chebl?

00:02:23:21 - 00:02:44:01
Alex Chebl, M.D.
It's not so much as paints a picture as gives you an exact picture of what's going on. So the challenge we have in stroke neurology, unlike, say, when a patient comes in with a heart attack, you know, a patient grabs a chest, they're having chest pain. You can do an EKG and a cardiologist emergency physician can know immediately where the problem is.

00:02:44:03 - 00:03:08:12
Alex Chebl, M.D.
The trouble in neurology, is that there are many different types of stroke. Some types of stroke are caused by bleeding into the brain. But the more common type of stroke and why we use AI most commonly is called a ischemic stroke where there's a blockage, and the treatment for those two types of stroke are exactly opposite. One causes the other, and so you have to know what type of stroke you're dealing with.

00:03:08:18 - 00:03:17:15
Alex Chebl, M.D.
And this is why it's more complicated. And knowing what's going on inside the brain with the arteries is critical. And this is where the AI helps us.

00:03:17:17 - 00:03:52:12
Aaron Lewandowski, M.D.
Particularly with ischemic strokes, the issue is trying to figure out what part of the brain has been affected by the stroke and also where the blood clot is. And, is it amenable to intervention? There's medicines such as TMK which we're able to use to try and break down the clot during an ischemic stroke. But particularly where I used it for our purposes is in the use of the thrombectomy procedure, which is where you're able to intervascularly go up into the brain and actually remove the clot that's causing the stroke if it's located in an appropriate and amenable position.

00:03:52:15 - 00:04:15:02
Aaron Lewandowski, M.D.
So the program serves multiple purposes. The AI portion of the program evaluates the CT angiogram and the CT perfusion studies of the patient looking for any asymmetry in blood vessel distribution or perfusion. This is able to allow us to quickly evaluate for signs of what we call a large vessel occlusion. Those are the types of strokes that are most amenable to the thrombectomy procedure.

00:04:15:04 - 00:04:24:03
Tom Haederle
How much time has the use of Rapid AI shaved off of the diagnosis and allowed you to figure out accurately what's happening?

00:04:24:06 - 00:04:51:18
Alex Chebl, M.D.
Approximately 30 minutes. When we look at patients who are candidates for mechanical thrombectomy, that's the procedure where we pull the clots from the brain. We've reduced our door-to-puncture time. That is, from the minute the patient arrives in the emergency department until we actually puncture the artery to get to the brain, we've been able to save about 30 minutes, bringing us down to within the 90 minute ideal window for that treatment.

00:04:51:25 - 00:05:13:01
Alex Chebl, M.D.
But, just as importantly, it's also helped us with our door-to-needle time. So that balloon scan mentioned that you can also give the clot busting medication. That has to be given within 4.5 hours. And so we've now are consistently able to treat patients instead of roughly within an hour presentation. We're now being able to treat almost all patients with 45 minutes.

00:05:13:01 - 00:05:19:16
Alex Chebl, M.D.
And we're approaching 30 minutes from door-to-needle. And every minute is essential in that effort.

00:05:19:18 - 00:05:22:27
Tom Haederle
That's really impressive. What's been the impact on patient outcomes?

00:05:23:04 - 00:05:44:13
Alex Chebl, M.D.
Tremendous patient outcomes. If you look nationally, but also at our sites, you look at the number of patients, proportion of patients who recover to normal or nearly normal has increased. If you look at the number of patients who are discharged to home rather than to rehab, a good measure of whether patients have disability, that has also increased.

00:05:44:15 - 00:05:58:13
Alex Chebl, M.D.
And nationally, the data clearly support, this overwhelmingly so, so that the American Heart Association, for example, keeps shortening the time metric, because the sooner we do it, we're getting better outcomes.

00:05:58:15 - 00:06:17:21
Tom Haederle
Really good news for patients. I'm wondering, given the size of Henry Ford, a big, big system you have. And I imagine that rolling out any new technology or software or changing how things are done, particularly across a scale like that, has got its challenges. Did you run into any kind of bureaucratic obstacles or resistance? We don't know what this thing is . . .

00:06:17:21 - 00:06:21:23
Tom Haederle
Prove it to us. Was it hard to sell, or not really?

00:06:21:26 - 00:06:45:08
Aaron Lewandowski, M.D.
What? Dr. Chebl first brought the idea to us at the West Bloomfield emergency Department, it was certainly interest in, you know, ways that we can improve our stroke care. I would say overall, we didn't really experience any significant barriers to implementing Rapid AI here at Henry Ford. I would say the hurdles that we faced were the standard hurdles you faced with integrating any new piece of software or technology into your preexisting hospital system.

00:06:45:10 - 00:07:23:24
Alex Chebl, M.D.
Yeah, I would second that. You know, there was some trepidation amongst some team members. You know, our implementation of Rapid AI, there's many different ways that you could implement such a program. One could be it just notifies the radiologist, "hey, there's a potential stroke. Take a look." We have gone to the exact or most extreme or the deepest implementation, meaning all members of the team are notified when we have a stroke, and this has minimized the number of phone calls we have to make to get the patient ready, to get the OR team ready, etc. and when you have that many people learning something new there can be some trepidation.

00:07:23:24 - 00:07:44:12
Alex Chebl, M.D.
And the biggest fear really was, why do I have to have another app? And this is just going to increase my workload, right? I'm going to be bothered all the time with these unnecessary things. And in fact, it's the exact opposite. Most people got used to it. They could not believe that they were living without it. It's made their lives better.

00:07:44:12 - 00:07:49:11
Alex Chebl, M.D.
Not just the patients lives better. It made all of our lives better because it's simplified the communication.

00:07:49:14 - 00:08:21:26
Aaron Lewandowski, M.D.
And I would certainly second that. From an emergency medicine perspective, a lot of our job on a day to day basis is discussing phone calls with consultants and trying to communicate with other team members. So being able to have that initial phone call with the stroke neurologist to discuss the initial plan of care, but then everything else being in the, HIPAA secure chat with rapid AI has certainly allowed for our communication to be much more effective and much more quicker so that everyone can see in real time what's going on, what's the plan?

00:08:21:26 - 00:08:23:14
Aaron Lewandowski, M.D.
What are we doing for the patient?

00:08:23:16 - 00:08:44:22
Tom Haederle
Yeah. You hear that so often about applications of AI and in almost any capacity, ambient listening or anything else. People are delighted. It's a time saver and a work saver. And you've seen that with the with the implementation of, Rapid AI at Henry Ford. Any thoughts you would share about another system or hospital that is considering going around and maybe integrating it for the first time?

00:08:44:25 - 00:08:50:24
Tom Haederle
What would you say in terms of it's utility, in terms of its ease of use, that kind of thing?

00:08:50:26 - 00:09:17:29
Alex Chebl, M.D.
Well, I mean, I think there's two aspects. One is you've got to lay the groundwork for this. You need a stroke champion, champions. Certainly someone from emergency department is critical. You need someone on the neurology side. And they need to then sell this to everyone. Once you've laid the groundwork and you've got buy-in from everyone

00:09:18:01 - 00:09:41:20
Alex Chebl, M.D.
the actual implementation isn't that difficult. Securing IT, and the firewalls, etc.. The company helped set up. They also have individuals who can come and help train users. How to use it, how to adjust the settings, etc.. So we found that it was pretty straightforward to initiate the Rapid AI in our system.

00:09:41:26 - 00:10:00:29
Alex Chebl, M.D.
And one way to do it, I guess, would be my suggestion would be don't start too big. You know, maybe start if you have a large system like we have, you know, start locally, 1 or 2 smaller hospitals. Don't include every single team member. Get the bugs worked out of the system and then expand.

00:10:01:01 - 00:10:21:13
Aaron Lewandowski, M.D.
And definitely when you're trying to, you know, sell the idea to administration or other departments, certainly focusing on the benefits to patient care, like quicker diagnosis and also the benefits to the team members, such as more effective communication. I think is a really good way to show the positive benefits that can come from this.

00:10:21:16 - 00:10:47:18
Alex Chebl, M.D.
You know, obviously we do everything focused on the patient. We want the best patient outcomes, but we can't deliver good health care without paying for everything that's required to do so. So the money does play a role. And I think this is where it's important for an administrator to understand is that the better the patient does, the shorter length of stay, the less money is spent on that patient.

00:10:47:22 - 00:11:02:22
Alex Chebl, M.D.
And therefore a health system can keep more of that money for the other services that they need. And I think that's very important. I mean, after all, this is why we were able to convince CMS to pay for these very complex treatments is because overall it ends up saving money.

00:11:02:24 - 00:11:09:23
Tom Haederle
It's a great point, thank you. As we wrap up, any final thoughts? Anything we haven't talked about that you'd like to say about Rapid AI?

00:11:09:26 - 00:11:35:20
Alex Chebl, M.D.
You know, these systems now? Although they're mostly started in stroke, there are many competitors, Rapid AI as well, but they have other modules. And so these systems can be used for other disease states, pulmonary embolism, the identification of intracranial hemorrhage, cerebral aneurysms. And so there are many opportunities for multiple different departments to collaborate. And that can also help with the financial aspects of this.

00:11:35:21 - 00:11:46:14
Alex Chebl, M.D.
You know, the more users you have on board, it tends to be, you know, cheaper than just having each individual division having their own systems working independently.

00:11:46:16 - 00:11:51:12
Tom Haederle
That's a great point, thank you. Thank you for bringing that up. Dr, Lewandowski, any final thoughts?

00:11:51:15 - 00:12:09:23
Aaron Lewandowski, M.D.
I've certainly enjoyed the implementation of Rapid AI. It makes my job simpler. It provides better patient care. You know, I don't think that AI will ever replace physician assessment and judgment, but it's very impressive what a powerful tool it can be when used appropriately, to improve the care that we provide to our patients.

:12:09:26 - 00:12:21:22
Tom Haederle
Absolutely. Thank you both so much for your time today and this great discussion. And I hope it reaches a lot of ears and get some people thinking about just how powerful this tool is. So again, appreciate your time. Thank you for being on Advancing Health.

00:12:21:25 - 00:12:22:15
Aaron Lewandowski, M.D.
Thank you very much.

00:12:22:20 - 00:12:25:05
Alex Chebl, M.D.
Thank you. Have a wonderful day.

00:12:25:07 - 00:12:33:18
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:01 - 00:00:26:02
Tom Haederle
Welcome to Advancing Health. Cybersecurity is a risk. And because of that, a priority for all hospitals and health systems. In this Leadership Dialogue, Tina Freese Decker, chair of the American Hospital Association, and John Riggi, AHA’s national advisor for Cybersecurity and Risk, discuss planning for cyber attacks, putting protections in place, navigating cyber threats, and rebuilding trust and confidence in the system

00:00:26:04 - 00:00:31:01
Tom Haederle
when cyber attacks do occur.

00:00:31:04 - 00:01:00:23
Tina Freese Decker
Hello, and thank you so much for joining us today. I'm Tina Freese Decker, president CEO of Corewell Health and the board chair for the American Hospital Association. From data breaches to ransomware attacks to outages, cybersecurity affects patient safety and enterprise risk and is increasingly a strategic priority for hospitals and health systems. Planning for cyber attacks and putting the proper protections in place is key to ensuring sustainability, patient privacy and clinical outcomes.

00:01:00:26 - 00:01:34:22
Tina Freese Decker
So I am so pleased to have the American Hospital Association's John Riggi joining me for today's conversation. John is an expert in this field, and he serves as the AHA's first national advisor for cybersecurity and risk. He joined AHA in 2018 after a long, distinguished 30-year career with the FBI. He brings with him tremendous experience in the investigation and disruption of cyber threats, as well as the unique ability to provide informed risk advisory services to hospitals and health systems.

00:01:34:24 - 00:01:41:26
Tina Freese Decker
So before we jump into the conversation, John, can you just tell me a bit about yourself so that our audience can get to know you a little bit better?

00:01:41:29 - 00:02:08:13
John Riggi
Thank you, Tina, so much for inviting me here today to discuss these topics, which unfortunately, as you said, top of mind for everyone. So when I ended my 30-year career at the FBI, I still wanted to be in a position to serve. I spent a lifetime doing that, and in my last role at the FBI, my job was to establish mission critical relationships with private sector, with critical infrastructure in the health care sector in particular.

00:02:08:15 - 00:02:29:22
John Riggi
That's when I had the privilege and honor to be introduced to AHA and Rick Pollack in talking about cyber threats. And that's when I really learned how critical a role that the American Hospital Association served for the entire health care sector. I could send over, you know, an immediate urgent alert to the and with a single press of a button

00:02:29:29 - 00:02:56:16
John Riggi
5000 plus hospitals received that alert. 50,000 executives received it. So I understood at that point we needed to engage in that continuing relationship. And when I retired, fortunately for me, Rick Pollack in the team said, John, you know, we've been listening to you and we think cyber will be an emerging threat, going forward. Unfortunately, none of us realized how significant a threat it would be.

00:02:56:19 - 00:03:00:12
John Riggi
And so, again, my privilege and honor to be here with you today.

00:03:00:14 - 00:03:22:21
Tina Freese Decker
Well, we are privileged and blessed that you are part of the American Hospital Association team, and you're helping us navigate so many of these issues that come forward. Let's start with kind of one of the underlying questions that I have. We've seen all these cyber and physical threats that have targeted hospitals and health systems. How have they evolved over the last, let's say, 7 to 8 years?

00:03:22:24 - 00:03:58:21
John Riggi
Yeah, unfortunately they've increased pretty dramatically. So not only are they increased in frequency, but also in complexity and severity of impact. So on the cyber front, we have seen a, for instance, in hacking of patient health information. In 2020, it was about 450 hacks impacting 27 million individuals, not inconsequential. Last year, last year with the Change Healthcare attack, we had 259 million Americans had their health care records stolen or compromised by foreign bad guys, by foreign bad guys.

00:03:58:27 - 00:04:24:17
John Riggi
If we add up the numbers, just since 2020, over 500 million Americans have had their health care records compromised or stolen. So, John, wait a minute. There's only 330 million Americans. That's the population. Meaning that every American in this country has had their health care records compromised more than once. But what really concerns us are the dramatic increase in ransomware attacks, which are often accompanied by data theft attacks.

00:04:24:19 - 00:04:51:12
John Riggi
So these bad guys, primarily Russian speaking, believed to be provided safe harbor by the Russian government primarily but not exclusively Russian, have increased these attacks so that the impact really is not only disablement of technology, internal networks get shut down, data gets encrypted, organizations are forced to disconnect from the internet has a very, very dramatic impact on care delivery.

00:04:51:15 - 00:05:18:21
John Riggi
So this resulting disruption, delay to care delivery and ultimately posing a serious risk to patient care and safety, not only for the patients in the hospital, but for the entire communities that depend on the availability of their nearest emergency department for life saving care, radiation oncology, so forth. So we've seen that evolve again very significantly, and one of the reasons I think it's evolved so dramatically.

00:05:18:23 - 00:05:30:21
John Riggi
Geopolitics is part of that. But I think on a very base level, we as a sector depend more and more on network and internet connected technology and data.

00:05:30:24 - 00:05:56:13
Tina Freese Decker
Very true. You know, I did a podcast earlier this year about trust and rebuilding confidence and trust and having that public trust in health care systems and hospitals. And when you have a cyber attack or an act of violence that targets hospitals, health systems, it impacts patients, like you said, it impacts staff and our communities. How can we go about building that trust and regaining that confidence when we have these instances occur?

00:05:56:15 - 00:06:06:23
Tina Freese Decker
And do you have some examples of stories or insights organizations have used that have helped them navigate those cyber threats and build that public trust?

00:06:06:26 - 00:06:32:07
John Riggi
Great question, Tina. And also on the on the violence side, unfortunately, as I wanted to mention as well, that's increased pretty dramatically to set the stage there. I was shocked, as a former law enforcement officer, to find out nurses are the second most assaulted profession outside of law enforcement. And, you know, we expect it as law enforcement officers to be engaged, confrontational engagements.

00:06:32:07 - 00:06:37:09
John Riggi
You're making arrests, but nurses who just want to deliver care to help people? Shocking.

00:06:37:09 - 00:06:38:19
Tina Freese Decker
It's sad and unacceptable.

00:06:38:23 - 00:06:58:27
John Riggi
Agree, totally. So I think how do we how do we get that trust in the community? I think one - and I think we've done a fantastic job with your leadership and the AHA - acknowledge the risk, acknowledge the threat. Let's not hide it. Let's not pretend it's not there. But then to take real steps to prepare and help mitigate the impact of these threats.

00:06:59:00 - 00:07:25:01
John Riggi
So now we see, on the cyber side, hospitals are actively working to develop better downtime procedures, better backup systems to help shorten the length of the impact and help recover more quickly. And work with the federal government. Exchange threat information across the sector with our partners in other sectors. And really understand if we're attacked, this isn't a stigma.

00:07:25:02 - 00:07:51:18
John Riggi
This isn't something that an organization failed to do. We're all in this together. And on the physical side, we're working very closely with the FBI to help develop resources to help identify and mitigate targeted acts of violence directed toward health care organizations. But most importantly, our frontline health care heroes, our frontline health care workers. And again, working with the community, this is all partnership with the community as well.

00:07:51:20 - 00:08:08:05
Tina Freese Decker
So I'm sure you have a top ten list of things that we could do to prevent these attacks. But if you could share the top three things that we should do to prevent these attacks and how we can be resilient. And when I say attacks, I'm talking cyber and physical. We have limited time, we have limited resources.

00:08:08:05 - 00:08:10:19
Tina Freese Decker
But what is the most important things that we should be doing?

00:08:10:22 - 00:08:36:21
John Riggi
I think the overarching umbrella that all the others follow under is leadership. And really looking at these risks, acknowledging them and ensuring that both cyber and physical risks are treated as an enterprise risk issue. And then within that, on the cyber side, making sure on the defensive side that you're following well known, well-established, recognized cyber frameworks, making sure you start there.

00:08:36:24 - 00:09:03:08
John Riggi
Second, really thinking about third party risk. What we have seen is that a majority, the vast majority of cyber risk, cyber attacks we face come to us through insecure third party service providers. Insecure third party technology and insecure supply chain. Doesn't negate us from our responsibility to do what we can, but we have to understand that. And then the third thing is ultimately prepare.

00:09:03:10 - 00:09:24:08
John Riggi
We must prepare for the attack. There's an often, I would say, overused expression in the cyber security world. It's not a matter of if, but when. It's true. But I would also change that a little bit about it's not a matter of if you will be attacked. The question is are you prepared? So focusing on resiliency and so forth.

00:09:24:10 - 00:09:55:13
John Riggi
And then with on the physical side, education of staff, leadership priority, and working with the FBI and local law enforcement to potentially identify ahead of an incident acts of targeted violence directed towards the hospital. And then working together as a community help mitigate and prevent that act. The police always want to respond, can respond after the FBI. But I can tell you from personal experience, we'd rather prevent a crime, prevent an act of violence than respond after the fact.

00:09:55:15 - 00:10:19:15
Tina Freese Decker
Agree. And I think that developing those relationships with local FBI, with local law enforcement is critical because you to your point, it's not if, but when. But we'd like to be able to prevent all of it. Having those relationships is key. So I know that the AHA has been working very closely with the FBI and some health care systems to exchange that threat intelligence and enhance collaboration across our sector

00:10:19:15 - 00:10:28:21
Tina Freese Decker
and with federal agencies. Can you share more about that partnership and how it has helped us in identifying and mitigating both physical and cyber threats?

00:10:28:24 - 00:10:51:26
John Riggi
Great question again, Tina, and thank you for highlighting what we're doing with the FBI. So on the cyber front, we've been actively engaged in cyber threat, information threat intelligence exchange. Both on a very technical level, exchanging what - without getting too technical - threat indicators, malware signatures and so forth, but also identifying big strategic threats that we may face as a sector.

00:10:51:28 - 00:11:19:23
John Riggi
So, for instance, working with the FBI, we helped identify last year a threat to the blood supply before it was on the government's radar. We helped the government understand that cyber attacks on hospitals are not just data theft crimes. These are truly threat to life crimes. So the federal government actually previously raised the investigative priority level of ransomware attacks on hospitals to equal that of a terrorist attack once they understood what the impact was.

00:11:19:24 - 00:12:00:17
John Riggi
We are working very closely with the famed Behavioral Analysis Unit of the FBI, the profilers that many books and TV shows and movies have been written about to develop resources to help hospitals identify targeted acts of violence, threats that are pending against hospitals, and again, help intercede, intervene and help prevent those attacks. We have a whole series of resources available on the first ever joint FBI and Joint Health Care Sector webpage. We're about to issue a manual coming out here within the next month or so, based upon, joint work with the FBI in the field on best practices and lessons learned to prevent these acts of violence.

00:12:00:17 - 00:12:06:08
John Riggi
So we have a robust, almost daily interaction with the FBI and other federal agencies.

00:12:06:10 - 00:12:25:15
Tina Freese Decker
It's so helpful to know that we have those robust partnerships at the national level, and then we can create it at the local level, and to make sure that we're all in this together to, help protect our patients and the people that we care for in our community. So that's wonderful. My last question for you is just one about how we look forward.

00:12:25:17 - 00:12:38:26
Tina Freese Decker
Can you tell us what you think about is going to happen in the threat environment for 2025 and maybe into 2026? What are those things we should be watching, looking out for? And is there anything positive that you can see?

00:12:38:29 - 00:13:11:18
John Riggi
I will let you know there is some hope. Talk about the realistic environment. Then we'll talk about where I see the hope. So first of all, I do believe that the frequency of the attacks may decrease, but I think the bad guys are looking to make a greater impact. We have seen them go after systemically important organizations that serves health care. Change Healthcare, for example. Last year, attacks against the blood supply. The year before they attacked - found vulnerabilities in a commonly used technology and software known as Move It.

00:13:11:21 - 00:13:41:03
John Riggi
By attacking that software, it gave the bad guys, a Russian ransomware group, were able to gain access to millions and millions of patient records. I do believe geopolitics will have a very significant influence, for better or worse, on the level of cyber threat we face. Depending on how we deal in the outcomes of our negotiations, of our diplomatic efforts with Russia, China, North Korea and Iran has the potential to mitigate or increase the cyber threats that we face.

00:13:41:05 - 00:14:08:19
John Riggi
And ultimately, again, third party risk, major, major issue. Where do I see the signs of hope? And there are signs of hope, folks. Honestly, I have never seen the sector come together to share threat information to prepare for attacks, best practices, lessons learned not only amongst the sector. We see channels of threat information sharing and best practice across with other critical and sectors, with the federal government.

00:14:08:21 - 00:14:45:26
John Riggi
We've had victim organizations, CEOs come out publicly. Dr. Leffler from University of Vermont, Chris Van Gorder from Scripps. We've had Eduardo Conrado from the recent attack against Ascension not only come out publicly, but testify before the UN Security Council last November about the impact of this Russian ransomware attack against Ascension. So what I see is hope. The fact we are banding together and with the government and I hope, as we did in the great fight against terror, international terrorism, we will come together in a whole of nation approach to help mitigate that risk.

00:14:46:01 - 00:15:09:17
John Riggi
Now, Tina, I know I've done a lot of speaking here, and if I may, and with all due respect, I'd like to ask you a question if I could. Tina, in your role, you have very unique dual role. You're CEO of a large health system, and you're also the chair of the American Hospital Association board. So how do you think about cyber and physical threats for your own organization

00:15:09:19 - 00:15:11:20
John Riggi
but on a national level?

00:15:11:22 - 00:15:33:26
Tina Freese Decker
Well, I believe that cyber and physical threats must be prioritized. It's a strategic risk. We have to understand how we focus on it, and we have to significantly prioritize it and emphasize what we're doing there. Previously, maybe 5 or 10 years ago, it was just thought of as a technical issue. It's not that. It's how we operate. Because like you said, we're so connected,

00:15:33:26 - 00:16:01:07
Tina Freese Decker
it's critical infrastructure and we must make sure that we are coming together. So for us as an organization, we prioritize our efforts, our investments, our work on it, but also prioritize business assurance. So how do we operate and make sure that everyone understands all the key components and the lessons that you shared on this discussion today, but also when we've had conversations before, how are we making sure that we know those and our teams know those?

00:16:01:09 - 00:16:25:19
Tina Freese Decker
I think the importance of safeguarding sensitive patient data and ensuring the integrity of our systems cannot be overstated. And that applies for my organization, and that applies for all of our members throughout the American Hospital Association. And so I think those are some critical points. As we think about this it is making sure that we are safeguarding sensitive patient data and ensuring the integrity of our systems, as we go forward.

00:16:25:19 - 00:16:59:14
Tina Freese Decker
That cannot be overstated. And as we do that, I think we all uphold that level of commitment to excellence that our patients and the people in our community want. So, John, thank you so much for your time today, for sharing your expertise. While we may not be able to prevent or mitigate everything, you have given us such great advice and we should make sure we take that down, but also listen to many of your podcasts that you put out or the Action Alerts that you sent through because they are helpful and direct and provide that great advice to move forward.

00:16:59:16 - 00:17:17:11
Tina Freese Decker
And I know that you are available to connect with all of our members if there is a specific situation, or they just want to learn more to make sure that we're better. So thank you, John, for being here. And thank you to all of those that have tuned in to this conversation. We will be back next month for another Leadership Dialogue.

00:17:17:13 - 00:17:25:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:01 - 00:00:30:06
Tom Haederle
Welcome to Advancing Health. Quality and patient safety are the twin engines driving the mission of every hospital and health system, and both clinicians and board members have an important role to play in achieving these goals. Coming up in today's podcast, we hear from two experts from University of Utah Health about some of the best ways to help board members understand the critical role they play in making sure that quality and safety are always foremost in the patient experience.

00:00:30:09 - 00:00:53:15
Nikhil Baviskar
Hi, I'm Nikhil Baviskar program manager, trustee services here at the American Hospital Association. Today I'll be discussing the critical role the board plays in quality and safety. With me are Dr. Kencee Graves, who is the interim chief medical quality officer at University of Utah Health and is an associate professor of internal medicine, where she practices as a hospitalist and palliative medicine physician.

00:00:53:18 - 00:01:16:24
Nikhil Baviskar
Also with us today is David Calling, who has served on the University of Utah Hospitals and Clinics Board since 2016 and is currently vice chair and co-chair of the board Quality and Safety Committee. Dr. Graves, I'd like to start with you. You recently presented to the board at University of Utah Health on quality and patient safety, an extremely important topic now and always for board members.

00:01:16:29 - 00:01:19:18
Nikhil Baviskar
Can you give us an outline of that presentation?

00:01:19:20 - 00:01:51:22
Kencee K. Graves, M.D.
Thanks for having us. And I think this is a really important topic. So when I gave this presentation to our board, I was new in this role. And what I learned was people around me, our board, our staff, people did not really understand the nuts and bolts of quality and the details. And so one of the things I offered to do was a quality 101 session. And my intent in doing that was to make sure that the group I would be working with and I were starting on the same page, so we both knew kind of what was going on in the landscape of quality.

00:01:51:25 - 00:02:10:18
Kencee K. Graves, M.D.
So the content of my presentation really came from the questions I was being asked in my first few months in this role. And that is, what is quality? What is safety? How they are different. So what sets those apart? What are these ranking systems all about? Why do we do that? What are accreditation bodies, why do we do that?

00:02:10:20 - 00:02:22:05
Kencee K. Graves, M.D.
And then, what is a quality structure? So what are you responsible [for]? Who works for you, that kind of stuff. And so really that's what my outline was, was just the basics, what I consider the basics in quality.

00:02:22:07 - 00:02:38:29
Nikhil Baviskar
I think it's great that you, you did something where everyone starts at a level playing field. That sounds like a really wonderful way. I know that not everyone has the opportunity to do so, but definitely a good way to get everyone on the same page. Can you give us the response that you received from the board members to that presentation?

00:02:39:01 - 00:02:57:20
Kencee K. Graves, M.D.
Yeah, I do want to call out - when I started, I actually had really good support from our board members. And they told me that this is something that they wanted. And so I felt like I had an open invitation because Dave and our CEO said, hey, we really think people could use something like this. Would you be open for it?

00:02:57:20 - 00:03:15:20
Kencee K. Graves, M.D.
So they gave me the time. Many of them had been to the AHA and we used an AHA podcast by Jamie Orlikoff to kind of set the tone for that session. And so people went in with a really curious mindset. I actually did a Google survey after I gave the talk to make sure people learned and felt like it was valuable.

00:03:15:22 - 00:03:35:21
Kencee K. Graves, M.D.
The feedback I got were that people felt like they knew more about quality after this session than they did before. They loved hearing about what we did at the U. They really felt strongly about supporting quality and supporting our leadership and driving toward high quality care, and they wanted to know how they could be more involved.

00:03:35:23 - 00:03:44:27
Nikhil Baviskar
So, David, question for you as one of the University of Utah Health board members, what was your reaction to this presentation?

00:03:45:00 - 00:04:03:12
David Colling
Yeah, Nikhil, what I would say is a couple of things, a few things that Kencee mentioned. But also remember, community board members typically are not clinicians, they're not health care employees, so this is a bit of a foreign environment for them. And that's part of the point, right. To have community board members get, you know, to offer a different perspective.

00:04:03:14 - 00:04:22:09
David Colling
But what can happen is, as a board member, you can get pretty overwhelmed pretty quickly with whether it's the acronyms, the accreditation, you know, all the different things Kencee trained on can be pretty overwhelming for community board members. So, I thought it was excellent. And once again, I want to reiterate, it was really a 101. Kencee

00:04:22:09 - 00:04:40:02
David Colling
didn't take any for granted, whether it was an acronym or a word, something need to be defined. It was really quite effective in the way that she approached it. You know, the other thing I think is it helped us continue to elevate quality and safety, you know, as a really important topic for the board. Right? So this is not a sideline.

00:04:40:09 - 00:04:55:17
David Colling
This is a really, really important really the driving force behind the board. You know, maybe besides finance and some other things, you know, a really important piece of piece of the work that we do. So I think there's a couple of things, that I reacted to. And frankly, I've been a board member for, as you mentioned, almost ten years.

00:04:55:19 - 00:05:03:13
David Colling
And I learned a lot. So what does that tell you? Right. So I think it's good for existing board members and new board members.

00:05:03:16 - 00:05:14:01
Kencee K. Graves, M.D.
I think it was a really important launching point for the CMS structural measure that requires patient safety to be part of board meetings. That would have been difficult if we had not done already the Quality 101 session.

00:05:14:03 - 00:05:35:29
Nikhil Baviskar
Thank you for mentioning that. What you're referring to as quapi, we're seeing a lot of folks, other boards that are realizing this is something that has to be integral to the planning process and the strategic planning process. David, I wanted to ask you, a follow up on that. So as the co-chair of the Board Quality and Safety Committee, you said you learned a lot.

00:05:36:01 - 00:05:46:01
Nikhil Baviskar
Do you do you feel like Kencee's presentation sort of set maybe an agenda or help you and your other co-chair plan going forward?

00:05:46:04 - 00:06:02:13
David Colling
Yeah. I mean, again, it gave such a good foundation, and I liked what Kencee said about us all being on the same page. So I do, I think it's set an excellent foundation for the committee moving forward. Got us all kind of in the same spot, whether you'd been there for ten years like myself or whether you're a brand new community board member.

00:06:02:15 - 00:06:19:22
David Colling
You know, the other thing I thought it was nice to, you know, we had it wasn't just board members. It was the clinical and health care staff there as well. I think it's important for them to listen to the dialog, understand that should help them understand kind of that knowledge gap, whether it's quality and safety or whether it's other, you know, board activities.

00:06:19:22 - 00:06:32:15
David Colling
You know, the community board members do need to be constantly reminded of definitions and things that come naturally to clinicians and health care workers, that that we need to continue to, to bridge that knowledge gap. So, yeah, absolutely.

00:06:32:17 - 00:06:43:01
Nikhil Baviskar
So as you know, this podcast will be listened to, by other board members. David, can you give some nuggets of wisdom or some advice to other board members that may be listening?

00:06:43:04 - 00:07:04:06
David Colling
Yeah for sure. So again, going to reiterate 101 basics. You know, don't take anything for granted. Don't make any assumptions. Assume that you're starting with everyone that knows very little about, you know, not necessary quality and safety, but certainly quality and safety in the context of the health care environment. I'd highly recommend making it interactive, almost a Q&A ongoing, right?

00:07:04:06 - 00:07:23:12
David Colling
So in other words, and I think we did that, you know, we never have enough time in our board activities. We probably could even have allotted more time. But as opposed to a report out on a presentation with Q&A at the end, and we did some of this, I would argue we could have even done more with this kind of back and forth discussion with the community board members asking further questions.

00:07:23:16 - 00:07:41:15
David Colling
Kencee being able to elaborate a little bit more, potentially even the health care folks and clinicians in the room adding a little bit of color. And we did some of that but I would encourage that. And once again, I would make sure that you include all certainly all community board members, regardless of tenure. You know, there might be the occasional one that feels like they know it.

00:07:41:15 - 00:08:01:11
David Colling
I'd be amazed if, if a community board member, no matter how long you've been serving didn't learn something from the presentation. And once again, I would say the entire board should be included, that dialog is healthy and I think creates good understanding amongst all parties. And you know, Kencee, you mentioned the podcast that that we kind of did a pre-work.

00:08:01:12 - 00:08:20:28
David Colling
You know, we asked everybody to listen to Jamie's podcast, and I want to say that was about a 30 minute give or take podcast, excellent foundation to reinforce the importance of quality and safety, right? So before we go into the 101 and the teaching piece, get everybody on the same page of the importance of it and the role it plays with the board.

00:08:20:28 - 00:08:29:10
David Colling
So I thought that was excellent. You know, I'll call it pre-work and everyone should kind of be required to listen to that I think prior to the actual presentation itself.

00:08:29:12 - 00:08:46:16
Kencee K. Graves, M.D.
I'm really glad you called out some of the interactive stuff and the keep it fun. I don't know if there's any chief quality officers listening, I do think that's an important piece. And so a couple things that I did that I thought worked really, really well. Survey questions after sections of my presentation. So I would talk about patient safety.

00:08:46:16 - 00:09:04:11
Kencee K. Graves, M.D.
And then I would ask people what it is. And then I would give them four multiple choice questions. Put one in there that was funny. And that kind of thing kept people really engaged. I also put together a laminated front-and-back about what ranking system that we use at the University of Utah, and explained every section of that.

00:09:04:14 - 00:09:23:11
Kencee K. Graves, M.D.
I went through my office and introduced people and talk about what they did, and that's the kind of stuff that people loved. They loved getting to know who their leaders are, and they really liked the human part. And I think that's critical because we're here for humans, right? Like quality care is for humans. And so that was kind of my undertone.

00:09:23:11 - 00:09:24:29
Kencee K. Graves, M.D.
I'm glad David picked up on it.

00:09:25:01 - 00:09:42:16
David Colling
And Nikhil, I'll just add one more comment to that. Yeah, the structure within the organization where quality and safety fits, the different roles. Again, something I kind of knew but didn't know in that level of detail. There's quite a bit more to the quality and safety than many would imagine. So I thought that was know really well done.

00:09:42:16 - 00:09:58:17
David Colling
You know, Kencee, I don't know if I've mentioned it to you, but I think that presentation it's interesting is I went back and reviewed it. That almost needs to be kind of a continuous piece of reference material. I almost feel like I want to make it a little less of a PowerPoint and more of a reference piece. So there's an assignment for you.

00:09:58:17 - 00:10:16:07
David Colling
But, you know, because it is so well done. It should be a continuous reference, you know, that's almost in your little in your toolbox as a community board member, because this is how busy we as committee board members are. You know, we've got our day jobs and we get so focused. So that presentation, which was extremely effective was only a few months ago.

00:10:16:09 - 00:10:30:20
David Colling
But when I reviewed it, you know, even prior to this, discussion, I was like, oh yeah, I need to, you know, keep remembering this kind of thing. So I'm going to be referring back to that pretty regularly. So that might be another piece of advice, you know, use it as an ongoing resource for the for the board.

00:10:30:22 - 00:10:48:28
Kencee K. Graves, M.D.
That's really good advice. And I want to go back to a point you made earlier where our accreditation partner is, that Det Norske Veritas or DNV. They were on site at the end of January. And so I reported that out to the board in February, and I included what DNV stands for and what it means and what they gave us citations on.

00:10:48:28 - 00:11:07:27
Kencee K. Graves, M.D.
And I used graphics to demonstrate kind of each bucket. And I did have people that have worked at the University of Utah in leadership for more than a decade come up and tell me, thank you for doing that, because I think quality is such an alphabet soup that for those of us who work in it, it's easy to forget that it doesn't mean a lot to anybody else.

00:11:07:27 - 00:11:16:23
Kencee K. Graves, M.D.
And so I would just say, I think it's really, really important to continue to revisit those abbreviations that may not land well without an introduction.

00:11:16:25 - 00:11:35:05
David Colling
And Kencee, I would say that the entire clinical or healthcare environment, health care environment is a big alphabet soup. If I had one advice for, you know, the clinical and health care staff, beyond quality and safety, there are acronyms and short you know, wordings used for things that just don't come natural to community board members.

00:11:35:05 - 00:11:38:06
David Colling
So I think that's a good reminder beyond quality and safety as well.

00:11:38:08 - 00:11:59:03
Kencee K. Graves, M.D.
Yeah, I've spent a lot of time talking about what I think chief quality officers should do. But I'll tell you what I think has been valuable to me as interim chief quality officer with a board. The board members ask really good questions. And for me, that is my check on. Am I explaining something well? What does an average patient hear and think and see?

00:11:59:03 - 00:12:17:24
Kencee K. Graves, M.D.
And how do they perceive us through the media? And what does the community say? And that is incredibly valuable because there are not a lot of spaces in my life where I hear that because I work in health care, I work around other doctors and nurses and the community board is my window to what the rest of the world sees when they see our health system.

00:12:17:27 - 00:12:37:28
Nikhil Baviskar
That's very helpful. As you said, the board should reflect the community and that's really important. You know, Kencee or Doctor Graves, I'll ask you just one more thing. For the board members listening, I already asked this to David, but what do you think that the board member should take away when it comes to, you know, working on quality, understanding it and learning about it?

00:12:38:01 - 00:13:01:02
Kencee K. Graves, M.D.
Part of that is, is what I said in that ask questions, stay engaged. And so if you see something or hear something that doesn't make sense, ask about it. The other thing that our board has asked me to do, which I found very, very helpful, is if I bring them a problem they've also asked me to report on who is responsible for it, what is the fix and when do I report back?

00:13:01:05 - 00:13:23:29
Kencee K. Graves, M.D.
And that cadence has kept me giving them information that is meaningful. And then also they've learned to trust the information I bring them. It keeps me honest and keeps a closed loop communication. So I think that's been really good. I do think it's possible to skim over things, and I would just say, I think board members can and should ask really really good questions.

00:13:24:01 - 00:13:35:08
Nikhil Baviskar
Well, thank you both so much for your time. This has been an awesome discussion and we really do hope that you know, your quality journey just continues getting better from here on out. So thank you again.

00:13:35:11 - 00:13:36:04
David Colling
Thank you.

00:13:36:07 - 00:13:38:16
Kencee K. Graves, M.D.
Thank you for having us.

00:13:38:19 - 00:13:47:00
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.