»» Good afternoon everybody. I have the pleasure of being able to present this year's Health Quality Professional Award. As Dr. Winchester pointed out this morning, the ACC's mission is to transform cardiovascular care and improve heart health around the world. And this is realized through a lot of the work that we do with the cardiovascular team members supporting NCDR and the accreditation services. Each year we gather together to help share best practices, goals for advancing quality, equity and value for our cardiovascular patients. We all of us in the room and those who couldn't attend are the boots on the ground professionals that support the ongoing data collection that's used to help inform policy, guidelines, research and practice changes. Last year was the initial presentation of the Healthcare Quality Professional Award. I was very honored to be recognized in that award. And we are celebrating cardiovascular team members that contribute to the NCDR and accreditation. This year's winner was nominated by a member of her team for her extraordinary work as a subject matter expert, registry manager across multiple specialties, Ms. Serena Felcher has been an RN for over 25 years. She currently is a clinical effectiveness consultant for quality outcomes and analytics at Sutter Medical Center Sacramento, Sutter Health and Vascular Institute. In these roles, Serena oversees implementation, integration and services as support to experts in the cardiovascular, surgical, diagnostic, interventional, radiology services and women's and children's service. Her collaborative work is instrumental for Sutter Health in earning high marks with CMS, prestigious awards, Integrated Healthcare Association, U.S. News World and Report and much more. Serena's accomplishments, resilience and enduring dedication are key strengths that help build a brighter future for Sutter Health as well as all of our patients in cardiovascular. Congratulations again. Thank you. Good afternoon, everyone. Am I audible? Okay. There we go. Good afternoon, everyone. Who's excited to be in sort of sunny Florida? Woo-hoo! But you know, I was thinking about it. Okay. Today's not so beautiful day. Maybe we have greater attendance. Maybe we'll all hang out inside today, and it looks like the weather's going to get better each day. So if you're here this weekend, it's looking gorgeous. I'm very excited to be with you here today. My name is Dr. Olivia Gilbert. I'm an advanced heart failure specialist and oversee quality for our hospital, which is Atrium Health, Wake Forest Baptist in Winston-Salem, North Carolina. Very excited to talk to you about the topic of corporate medicine, big medicine, as we've seen so many merges taking place across the country and what the implications are for our hospital systems, for our providers, for our patients with regard to quality. We have an esteemed panel with us today. I'm very, very excited to have with us. I didn't see which way they came in, so I'll introduce. Starting with Rachel Kiever, she is a medical executive with Janssen Scientific. So grateful to have her with us, coming from Raleigh, North Carolina. And then we have Ginger Briesbach, who is the executive vice president for care transformation with MedAxiom. And then we have Mr. James Reynolds, who is the associate vice president of outcomes and care transformations at Sanger Heart and Vascular in Charlotte, North Carolina. So grateful to have you all with us. So our structure for today will be that I'll just give sort of an introductory talk on the topic, and then we'll jump into a panel discussion with some guided questions. And if you all have questions along the way, just to send those into the portal. And we're hoping for a couple minutes at the end to be able to go through those. So we'll jump into the topic. I have no relevant disclosures to discuss. So our objectives today will be to discuss how best to align corporate goals with patient-directed health care goals, how to identify strategies to uphold quality improvement efforts in the face of corporate change and cost restrictions, and also to recognize tactics to improve provider morale in the face of corporate medicine. Before we jump into that, I'd like to just get a perspective from you all on what your organizations look like. So we'll start with some polling questions. So if you activate through your app and go to the talk and then go to the questions area, you can get to be able to respond to the questions. So we'll start with, how many hospitals are in your practice organization? None, one to five, six to 10, or greater than 10? It's not showing. We might be having a technical issue, in which case we can do it the old-fashioned way. Oh, OK. Here we go. Are you all seeing it now? OK. OK, great. So interestingly, the majority of folks represented are in smaller hospital systems that I would categorize with one to five hospitals and less than I would have thought in the larger conglomeration of hospitals. So really a nice distribution there. And then additionally, some not affiliated with hospitals and more than I would have actually expected. So interesting. We'll go on to our next question. Oops, and I skipped number two. OK, has your organization been through a merger acquisition in the preceding 10 years? Yes, no, or I don't know. OK, so yeah, and this isn't surprising, and this is sort of what this session is intended to talk about is what are the implications of all of these mergers on our outcomes and quality for our patients. So not surprising response there that the majority have undergone that in the last 10 years. OK, we'll go on to the third question. I have a heavy finger today. We'll go back. There we go. Is your organization for profit or nonprofit? A, for profit, B, for nonprofit, and C, for don't know. OK, great, and not surprising that the majority are non-for-profit, but about a fifth being for-profit organizations. So will be interesting to explore and have your all's input and perspectives on this conversation as well. So moving into the inspiration for this talk, many medical practices have transitioned from being independent organizations to hospital-owned models with increased tendencies for corporatization, big medicine. And maybe corporatization isn't the right word to use in the sense that it is actually illegal, technically, in some states to be corporatized in medicine. We'll call it big medicine. There is some perceptions with that, some negative perceptions that this increases overall health care costs without increasing quality. And so that was what motivated us to want to talk about it and look for the pros, cons, and possible solutions. Associated with that, there are reports of increasing medical provider frustration and dissatisfaction resulting from decreased autonomy, as well as pressure to focus on profit margins and less about outcomes. So we'll reflect over the evolving practice of medicine over the past century and just having the perspective that a little over 100 years ago, 80% of medical encounters were house calls, if you can believe that, down to, of course, nearly zero at this point in time. But just reflecting on how much medical practice has changed during that period of time and then in more recent times and pertaining more to cardiology specifically, a decade ago, the majority were private practice. 70% were private practice, where now just a quarter of cardiologists are self-employed. So understanding those rapidly evolving practice patterns that we face. And part of that, this evolving process, a big part of that was the introduction of Medicare and Medicaid in 1965, which had potentially significant outcomes for prolonging life for individuals who may not have had access to medical care previously. We saw an increase in life expectancy during that period of time from 70 to 79 years. There were obviously some fantastic technologies introduced during that period of time known as stents. You guys might have heard of them. And these increased life expectancy, increased population of patients to care for obviously led to massive increases in patient volumes, unfortunately translating to decreased time that providers were able to spend with their patients. And so in came the government's way of trying to limit some of the costs with that. DRGs were introduced. And we saw the beginnings of administrative complexities, increasing administrative complexities in the way that we practice in the face of rapidly increasing medical care, medical patient loads. So with that, with the regulatory and administrative requirements to care for those masses of individuals, I think many in this room have probably seen the statistic of the disproportionate increase in administrative presence in medicine during the period of 1970 to 2010, with MDs growing by 150% and administrators growing by about 3,200%. And it was necessary to overcome the challenges of administrative burdens. And so with that, we see organizations merging, and we see increased administrative involvement in care to be able to promote the most efficient practices to try to contain costs. And following the COVID-19 pandemic, these trends have massively accelerated, as we've all seen. There are so many hospitals that we talked about yesterday during the wonderful session about practicing and upholding quality in the face of limited resources. We heard about all of the hospital closures nationally after COVID, all the numbers of providers leaving, that these are real trends that hospitals are needing to stand together to go on. So not necessarily a bad thing, but we have to understand the implications of it. So we find ourselves in this paradox of corporate medicine, where we have administrators who are trained to focus and optimize profits through capital investment, and providers who are trained to optimize patient well-being through personal investment. And while not always, unfortunately, those two can conflict with each other at times. And so while there are benefits to corporate medicine, with the appropriate delegation of responsibilities where providers can actually focus on their jobs to provide medicine, and administrators can care for medical practices, also that there would be protection from certain types of liability, and that there would be more ability to subspecialize, offer specialized equipment, but that may not be possible for smaller organizations to afford. Concerns with corporate medicine, we've already alluded to several of these, that there can be monetary priorities outweighing quality of care in some circumstances. One meta-analysis actually suggested that there was an increased risk of death for private for-profit hospitals versus not-for-profit, that there are increased costs and marginalization of care with corporate medicine. We see that particularly with retail clinics, which happen to be more distributed in affluent areas. And then we also have that very significant and sensitive issue of physician burnout, especially in this era of increasing acknowledgement of depression and suicidal risk for providers in the current era. With that, we see earlier retirement, substance abuse, that then for our patients can translate into decreased safety, quality, and satisfaction. This is not to say big medicine is bad. It's not. It is our reality. It is the future, and I should say the present, of medicine for a lot of organizations, as you guys have reflected in your polls today. So the intent of today is to bring together thought leaders to be proactive in how we approach big medicine and the ways that we protect quality, uphold, and advocate for it. And so possible solutions from my perspective would be inclusion of providers in management leadership, focusing on performance quality versus productivity-driven compensation, and personalizing quality and outcomes data for individual providers. So with that, we will transition to our esteemed panel, and I'm going to ask them to start with just general perspectives on this topic that they're going to share, and then subsequent to that, we'll go into the guided questions. So I'm going to come sit next to Dr. Kiever and ask her to start for us. Thanks, Dr. Gilbert. First of all, thank you for having us here. I think as cardiologists, this is the meeting where we're probably the most afraid because I look at every person in here, and they know more about quality than I do. I've been practicing for 20 years, and I'd like to think I'm a good doctor in all the words that that means, all the ways that it means to be a good doctor. And yet I know that I personally have struggled with time limitations and ability to deliver on all the metrics as they change each year, as I continue to stay modern despite moving years and years away from training. I will say one of the things I think about, too, is anytime we talk about our health care system, I feel the need to use a different word. We have a health care quilt. I think about the slide that was presented this morning about competencies inside of the quality work and that colorful diagram of people's abilities, right, and where they rank most. And that's true in the health care team. We'll talk a little bit about team-based practice. It's true inside of hospitals. I practiced in particular in a rural area, and we did not always have as many or as trained individuals for certain things. I think about the general surgeons that used to take all the emergencies in the middle of the night, whether that was something they had had subspecialty training for or not. Geographically, that was their job. If someone showed up with a surgical emergency, they did the case, right? That wasn't a proactive quality choice. That was the lay of the land, so to speak. So when I think about the health care quilt, right, because it is patchwork. We have different resources, different connectivity, different training paths, and at times, as we've seen with COVID and the manpower shortage, just lots of holes in the quilt, right? So living in that world and working in that world and then feeling judged I think is a really important conversation to have in this room. But I just want to frame out a couple of things that I think about quality. As a person who's practiced medicine for a long time, I also really understood that I needed to understand about the administration and business of health care if I was to be an effective doctor and took some time and did some extra training in that. Also, I've worked in the insurance world, stood up a physician-led network in Medicaid in my state and the transformation to manage Medicaid and sat doctors down at tables and said, payment, quality, safety, policy, it's all ours. What would we write if we got to choose? And the truth is it's very hard, right? These are all points of tension between resources and quality and time and ability to close some of the important gaps that exist for patients, some of them non-medical, right? So I just think that's important for us to think about. If you look at the arc of my career and the different things that I've done, whether it be straight clinical practice, I came out and actually was a made partner. Remember when that was a thing? I made partner in a prominent large cardiovascular practice. That was incredibly important to me as a professional goal. And then very quickly our practice actually was bought by a health system. And that health system has transformed over the years, bought your health system, has grown. And the folks who put this panel together did not know the Kevin Bacon world that we live in. But one of the early practice managers that I had was James. And really thinking about it, I was part of a multi-specialty practice that had cardiologists, electrophysiologists, interventionalists, cardiothoracic surgeons, vascular surgeons, a very diverse group of trained folks working together for the betterment of patients. But I was solo in my county. And so running a one-man, we still called it that, right? One-man practice, one-woman practice back then. What does that mean to be a satellite clinic? I calved. There were years where I did 100 cases. Your denominator has to be zero. Your numerator has to be zero if your denominator is 100. So thinking about all of those things as we talk about quality today in the room, I just wanna refocus on what was talked about this morning, which is this idea of why. Why are we measuring quality? And I think it really comes down to patient centricity. We're not measuring quality for payment, right? We're not doing it to pat ourselves on the back or to make it that we're competent or able to give good care. We're not doing it for stars. I think sometimes we forget that, right? We're doing it because patients' lives hang in the balance. The quantity and quality of their lives are really affected by these decisions that we make, a lot of them around preventative elements or safety elements of live care. So I think that's just an important piece of how we talk about this. The other thing that I really love to talk about, the how, right? Great quality kind of floats in the flow of healthcare. If I have 15 minutes to see a patient, it takes about 300 clicks. I like to look at my patients in the eye. When I talk to them, I like to be close to them. I like to hear what the family has to say. That's a real challenge for me to do quality documentation in the room. And I think that's been talked about, but I would love for our technology to catch up a little bit and that quality would float as a capture layer above that. I bet everyone in this room would agree with that, right? That the after the fact or in the room quality flow that we have now isn't serving our patients. And we will continue to look at technology that can really help us with this. I think I'm very excited about natural language processing and figuring out how to go into the chart and find those quality measures without you guys having to literally go and find them and maybe without me having to click another time. So hopefully technology and cardiology, that's been true. The technology has helped us, right? So I'm excited and optimistic about that. The other thing I would say is really thinking about quality in terms of what does it teach us about our society? And one of the things that I have the privilege of doing now is working in health equity. And as we look at quality, I'm very clear on one thing. If we want to know what we value, we should look at how we care for humans, right? It's true in our schools, but it's especially true in healthcare. Who's falling behind in health? And I think it's something that maybe you don't even think of as a byproduct of the work you do every day, but we have a scorecard on how we're doing, right? We know that there's disparities in care across our country and not just in cardiovascular disease, but in a lot of different areas. So I really think of this as healthcare has an opportunity to connect us as a country and talk about the things that people need to achieve optimal health, to realize health equity or health justice really, right? And I think that's something that everybody here has started to collect data about as well, these non-medical or social drivers of health. And I think we have an opportunity if we really can capture it and use it to teach ourselves a lot about our systems. What's built into the system that's disadvantaging our patients. Wonderful. That's absolutely beautiful. I'm inspired. Ms. Ginger, we'd love to hear your input and perspective. Fabulous, thank you. So I have the amazing opportunity and the role that I currently live in to basically travel the country and I've been to multiple healthcare organizations, large, small, and I get to, I think the term used earlier, I get to peek under the hood. And I wanna start with the term clinical effectiveness. And I believe that was in the title of our award recipient in the previous session. And that is a term that has made me sit up and listen over the last couple of years. It's something that really resonates with me. And I think many of you in this room hold the answer or at least the whether or not we're clinically effective, you hold that data. So what do I mean by that? Well, I think what we mean by that is are the patients that we're treating, are they receiving the care in a way that we're getting the outcomes that we're hoping to achieve? So bringing it back into kind of corporate and big business, big medicine, what does that mean? Well, I've been in large organizations, small organizations that some do much better at this than others. And I would start with we all have the same ingredients. We have doctors, we have patients, we have administration and in business pieces, we have the same guidelines. So we're all working off the same roadmap. Why are outcomes so different? And I don't know, maybe, and I do think there's probably, there's something can definitely be said as we vertically integrate and our organizations get larger, we oftentimes can lose sight and things can get messed in the layers and the bureaucracy. But I think there's a key framework or there's probably several actually, but there's a few things that I've identified that I think are key to getting that clinical effectiveness we're looking to achieve. One would be the partnership, the true partnership between administration and physician leadership and really integrating that clinical leadership into our business leadership and how we partner together, creating governance and leadership models, that dyad model where we're both responsible for the same outcomes. If I'm not successful, if we're not successfully clinically, none of us are successful. And if we're not successfully business, and business just means we need to be able to keep our lights on, right? We gotta keep our doors open and our ability to care for patients, but we're accountable for those things together. And then we work together to develop our organizational objectives, goals, and then action items or strategies. The reason why I think that's important is because when we start to think about quality and the quality of care we're seeking to achieve, that should tie back into or align with those organizational objectives. When we do that effectively, it creates an environment where we all win when we meet those objectives and we have the ability to advocate, negotiate for the resources and things that we need. So it's this concept of, again, partnering strong with clinical business leadership, but then how does that answer the question of, but we're large? So how do we make large seem small? I've got service lines that have 150 cardiologists in them and we have nine hospitals and 15 hospitals and how do we create an environment where even all of us are taking care of patients on a daily basis? And again, I think we do that through our governance and leadership models and we create that environment of that strong dyad leadership, but in addition to that, we create clinical councils or work groups or areas where we take the cardiologists, the teams, the APPs, the quality, the revenue cycle, we bring them in together around our care objectives and then bringing that performance management in so that they understand what we're seeking to achieve and getting real-time feedback and whether or not we're effective in those areas that allow us to pivot. So again, I see large organizations that do really well and I think those are some of the ingredients that provide that high performance, but I think we can also start, no matter where we live within those organizations, if we kind of understand how do we represent and tie that feedback information as well as our overall objectives and goals, that creates an environment where I think we can take big and make it seem small. Wonderful, thank you. James? I said on the wrong end of the stage. So, I mean, I couldn't agree more with the points that both of you guys have brought up. When I think about our organization, I think another key point that I would like to highlight that we've been successful in is really creating the space and the time to talk to our patients, right? And formalizing patient family advisory councils. And those stories can be very powerful when you're advocating for resources within your organization. But starting with the data, as you all know, right? That helps craft a story to garner resources that are needed to support. And so, it's tough to add to the commentary that you've had, but I truly believe in dyad models. Strong physician leadership is crucial. Bringing people in, and it's teams, it's administrative teams, as you mentioned, that do include clinicians, right? At multiple different levels. Physicians, PAs across the board, because they're all gonna have unique perspectives as to how we take care of patients. And then lastly, think about, in my mind, value creation, right? And that is the cost and the quality, right? So both of those components together. So from where I sit, I have to be thoughtful in resource distribution because I want to ensure the same high quality heart failure care that happens coming out of Wake Forest Baptist is the same experience that people get in Union, which is a smaller hospital, 150 miles away. And how do we start creating those mechanisms and models for that? And I think when you combine that with strong leadership, multidisciplinary teams, right? Across the organization, then it can become a powerful story for change. Wonderful. Well, that gives us their individual perspectives from different areas of practice, administration, organization, national organization, and then from a physician perspective. So I'm going to pose a couple of questions to them and ask that they just give their responses. And then if we have time at the end, we'll open up to the audience. So I'll start with a two-part question. So how can we better align corporate goals with patient-directed healthcare goals? And the second part of the question is, should quality metrics be changed to better align these goals? Do you want to? Go ahead. Well, okay. You know, I think this is a really interesting question. And if you want to make yourself better in healthcare, I strongly encourage you to get inside the machine that creates metrics for quality. Because if you start to understand the process that happens at CMS and how metrics float down, how they get chosen, how they get prioritized, it really is an eye-opener. Because what we realize is we would like to measure a lot of things that are very hard to measure. And most of what we're doing sometimes is that surrogate or sort of process measure, and would love to get much more into what really matters, outcomes. I will say there's a particular hospital in the state I live in who's decided their goal is going to be actually mortality and the highest mortality zip code they serve as their only metric for the year. So that's bold, right? Because we are all so kind of almost, I won't say addicted, but dependent on the middle steps. And I think we can spend a lot of time, attention, and resources inside the middle steps. If you ask patients what they care about, if we're getting patients to choose goals, I think they would choose something very different. I'll give an example. This is the unintended consequences, right? So we have created this holy grail of diabetes care management called the hemoglobin A1C. And what's fascinating, if you actually look at it from a science perspective, we've gotten disconnected. So microvascular disease actually is dependent on hemoglobin A1C, but macrovascular disease or care is actually A1C independent. And so we've taken this idea of good diabetes care or a healthy measure of diabetes outcomes as a lab and really applied it in places it doesn't apply. So I think that's really the challenge. And so when we teach our patients that A1C is the thing that matters and they still have a heart attack and then we have to sit down and explain to them, well, actually your A1C has been great. You've met all the goals, but there's things that happen inside diabetes that don't actually depend on how great your glucose control is. That's a hard conversation because we've really created something, held something up to the patient that would drive outcomes when it really scientifically doesn't. And so there are lots of examples of that where we have to kind of go on the backside and say, well, we measured that because it's easy to measure. It is important. It's part of diabetes care, but really we'd like you to be doing these other things as well. And so I think if patients chose, they would choose less heart attacks, right? They wouldn't choose a specific lab. And I think that's where the reality of where we are in medicine right now is we have to think about thinking of our patients as partners in a really powerful way. And I will say I've seen a trend in the last year that really heartens me. And that is actually including patients as part of the authors and publications on research, right? Even the research work that we do should include our patients because if we're trying to change or understand healthcare and we don't have a patient involved, we're already off track. Wonderful. Ms. Jenner. Yeah, that's fabulous. And I completely agree and actually appreciated what James mentioned too, related to patient family advisory and getting patients involved and letting them look under our hood with the way we deliver care and some of our operations and decisions around that. Now, when it comes to quality metrics, there are some that are handed to us that are complex, but because it is hard to measure, we have to pick the ones that are measurable, which oftentimes are, maybe they're not even great surrogates, but we think they're surrogates for quality. So there are areas where we're just gonna have to measure the readmissions and the high level mortality that doesn't tell us the story, right? It just gives us a number. But I think in addition to that, I'm gonna take you back to kind of those high performing organizations that seem to be a more clinically effective than others in addition to those, they're also choosing meaningful metrics that are specific for them, that are identified by their care teams based on their objectives and their goals and the processes and the ways they're gonna get there are owned by those teams. So you may have your mortalities and your readmissions. And again, those things are important. We're measured externally on them, but for team engagement and to help promote team pride, allowing them to kind of focus on some areas that they have identified and then taking a one step further, pulling your patients in and finding out what's really important to those patients. So again, give you an example. Example, and I'm sure this is one that many of you have been looking through or managing through, but a KI in our cath labs, we can pick that as a measure. There's a lot of factors behind that that go into where we land on that. And so having, taking that topic and bringing in the appropriate stakeholders and helping them identify and understand and then create the action items around that, create it, and then when you start to see improvement and can tie that back into your actual patient care delivery, because those are patients I took care of, that creates an environment for ownership and value, which I think is one of the areas when we start talking about burnout. We're not afraid to work hard. We all work hard. That's not it. I think it's when we become just, we're no longer attached to how we provide value back. And I think we can use our quality initiatives and then again, bringing them into our teams that are delivering the care can create an environment not only to get the outcomes you're seeking to achieve, but also looking to engage your teams and improve some of that personal professional engagement that it seems like is a big gap right now. That is so beautiful. And it's just resonating so deeply with me that I have to just share the example of being in a heart failure clinic. And one of the questions that I've just implemented into my standard questioning for patients are what is your goal for being here in this clinic? What is it that I can help you achieve? And the broad array of responses is remarkable, number one, but it does restore that humanity, that connection, that shared vision and goal that we're on the same page to be able to achieve what's important to them. And it takes less than five seconds to ask them, but has been really meaningful for me, so meaningful as a provider just to incorporate that simple question into office visits. So thank you for saying that. That's beautiful. Yes. Well, and thank you for sharing that example, but this might be crossing kind of questions a little bit, but I think some of the things that we just talked about is how do we create time to facilitate those conversations? How do we think about having that as a standard of our question? How do we reduce the 300 clicks that I have to do within 15 minutes so I can actually look at my patient and ask them the question? Right? So I think we'll probably talk a little bit more in the burnout question section, but those are the things that I think about just sitting here and listening to you guys on stage. But I think it's probably a time for revision and patient advocacy. I think we have to bring them into the picture and really understand what people want and what their goals are. And that likely won't show up on a spreadsheet somewhere, but if we can figure out how to make that happen, then that would be fantastic as well. Great. Well, we'll move on to our second question. So how do we uphold quality improvement efforts in the face of corporate bureaucracy? So we'll go ahead and start with James on this one. Persistence, dogged persistence. I spoke a little bit ago about thinking about the value proposition, right? So the value proposition for the patient, for the clinician, for the organization. And when you can start to create, with data, alignment of those things, then you can really move the needle on quality improvement initiatives within an individual service line or an organization abroad. And I think we talked about how sometimes we have to think outside the box from our care delivery models and how do we make sure that we have the right people at the table? How do we make sure that we have the supporting cast of characters, right? So, you know, the clicks and how do we make sure that from a, you know, from a corporate perspective, teammates don't become line items on a sheet of paper, because to uphold a quality improvement effort, you know, if we start cutting out baseline teammates, I believe there was a talk on, you know, data collection in a time of, you know, minimized resources. If you start cutting out those components, then that yields, you know, greater burden for clinicians, so. I completely agree. Completely agree. A couple other thoughts. One would be, and I will say I've been saying this for the last 20 years to anybody that listened to me, and it comes to that dogged leadership, and I'm just, I'm not, I'm not going to let it go, but that's if we do what's right for our patients, the business will fall in line behind it. And so I think it's, I think that's very much true in my current world. I would also say, though, in addition to that, we have to learn how to quantify it. And at the end of the day, when margins are tight, in some cases they're negative, and you've all lived this, right? You get the mandate from executive administration or senior administration, you've got to cut 5% out of your budget, and we have, where do we go, I mean, we're already lean. And so when it comes to how, and we can't be clinically effective if we're not doing quality improvement. That's one of the pieces of constantly looking to improve. So when we do do quality improvement, which we should be doing almost every day and have our different initiatives we're working on, we need to also be able to quantify the economic impact, whether that's through revenue enhancements, as I have to put my business head on, cost avoidance through better care, the revenue enhancement through being more accessible and getting more patients in that deserve our care, quality of care, cost avoidance through taking care of better care of our patients and managing them in lower cost settings or avoiding EDs or avoiding readmissions. And the good news is for much of the work that we do, if you dig in and get into some of the research, there's examples of dollars saved and revenue generated out there that you can take and apply to your projects. And when you start applying dollars to the outcomes you're seeking to achieve and then show how you're going to use your resources to get you there, that starts to get the attention of your administrative team. And because you're doing clinically quality improvement work and we're making ourselves more clinically effective, I'm telling you, go back and use that word. I love it. It resonates with everybody you talk to. You make yourselves more clinically effective, you get the attention of your clinical leadership. So again, I think we have to get better at tying in that ROI and the value proposition. But that's another great reason why we come together to network, because if you've done this project over here and you saved this much or found that much, I can apply that. Apply those things to what you're looking to do and develop those little business plans, pro formas, and I think you'll be amazed at the level of engagement you'll get with some of your leadership that has to sign off on the resources. And I just have to give the example and shout out, and thank you so much for talking about that translation of the quality improvement to a value. Because it's so important for us to understand that unfortunately or fortunately is the common language, the common denominator. And so us learning to speak that language empowers us as providers to get what we feel we need for our patients. But the example I wanted to share was actually here at the ACC Summit. One of our T32 fellows, Dr. Raquel Hammonds, presented a poster today that showed variable outcomes for heart failure patients on cardiology versus non-cardiology services and took that to our administration. And actually with that, we were able to hire two positions for navigators just because of the information that was relayed in her quality improvement project. So it is real that we can translate the value of those efforts into real change. So I just wanted to give her a shout out for that very proposition with her project. I won't say anything else because you guys have covered it beautifully. Thank you, Ginger and James. But I will say, physicians in particular have multiple layers of bureaucracy. So it is inside the health system. And I have to do a module about how far a ladder should be away from the wall. It's not just quality. We have incredible regulatory pressure and documentation that happens. And I will just stop here and call out our college because what they have done with trying to gain control over maintenance of certification and board certification and recertification is another example of how we win together as cardiologists, cardiothoracic surgeons, really understanding that one of the biggest assets in all of these pieces of work is time. So anything that our college does to protect our time really lends me the ability to have a conversation about a project that might make patient care better. So it's not just at the health system level, it's across the board for regulatory pressures for time. Great. Okay, so our third question, how does corporatization of academic centers affect academic quality improvement pursuits? Who would like to kick this one off? I guess I'll start. And I would say our relationship is too new that I don't know yet how it's going to work out for us. I think it's like most things, it can be good or it can be bad. I think if we are working to uphold the mission that has been put forth by the organization and have our partners be the academic arm, I think that there's going to be a value in the research component and setting aside, once again, that time and that space and a model for clinicians to explore and answer those questions. We've chatted about this previously, though, academics for somebody that's an operational minded guy and corporate guy, like, well, now I know something and it's better than what we were doing, so now I've got to change it. So, you know, there's change management, but I think as we get better at being the implementation arm, I think it can be a really nice, beautiful synergy that really drives change. Great. I completely agree. And I've seen it. I've seen it actually go both ways. I've seen where the new partnership, again, creates more silos and challenges and not taking advantage of the bigger organization. And what I mean by that is where, you know, I'll go back to actually one more thought after this. What I mean by that is when it is done well and it's a true partnership collaboration, it actually, I think, you know, all rising tides raise all ships. We have access to larger patient populations for our research and our academics. We have the sophistication and of the actual academic piece that can flow across our entire organization. So we have the ability of our patients that may have been in a community program before now has access to some of those higher level, more advanced therapies that sometimes we see in the academic centers. And so when it's done well, I would actually say it can be very synergistic and be more than additive and create even higher value for our patients. But you have to go into it deliberate in that way to assure that that happens versus what sometimes can happen if we just, if it's a business transaction, it just turns into more silos and silos and things. So again, I think it can very much be a win-win if we set it up right. Wonderful. Dr. Kiefer? I'll just add academic medical centers have always had a reputation for giving people that sense of protected time and personal mission, whether their mission be research or teaching or working in quality improvement, working inside the medical staff of their academic medical center. And I think one of the dangers, I think, of this more uniform individual productivity measure for physicians, PAs, nurse practitioners, pharmacists, everyone's being valued on an individual productivity model, which really can be tough to balance with the dedicated time. In particular, I think teaching, teaching the next generation of healthcare providers. We know how complicated things are. We've been talking about it for days now, right? But thinking about new learners and them having dedicated time for that, teaching folks how to be part of the quality process. I heard some talk today about, you know, in our plenary session about how do we actually make this more part of the curriculum. And I think having folks who can model that and having them have the dedicated time to translate that knowledge to the next generation, I think, is important. And even understanding, you know, what the metrics of comparison are. I know we're going through this whole transformation of are we a Vizient Center or are we a Premier Center now? You know, this idea of academic versus non-academic medicine. So understanding sort of what the new standards of comparison are as we're evolving and changing and have to revisit and think about those things. Okay, last question. And we've got five minutes for this one. So that's about one minute each and then maybe we can squeeze in an audience question. So how can we improve provider morale in the face of corporate medicine? Ginger, do you want to start this one? I think it goes back to that broad representation and engagement and tying our team into the broader value of who we are. So mission and vision is really important. We go in lots of places and everyone, I get a different answer when it comes to what's your vision? What's the organization's vision? A lot of times it's I don't really know. And so if we don't understand where we're going or where we fit in or what the value is we're creating, it's really easy to get disengaged. And it oftentimes creates an environment where I really don't feel safe because I don't understand where I fit. So I think it's vision and mission and understanding what that is, even defining it at the cardiovascular service line level and what is our goal. And that allows everyone to have a common, feel like they're all commonly tied together. And then that second piece is that dissemination of the improvement work and the performance management, getting that information back into the hands of the people that are delivering the care, giving them some resources, but some latitude in looking at new ways to deliver care or optimize the work that they're doing and being part of that work. And then how it all ties back up again into those organizational goals and strategy. And there's a lot in that, but it really comes down to that leadership structure. But allowing that leadership structure to infiltrate into the teams that everyone feels tied back into that bigger purpose, as well as understanding the value that we're achieving and celebrating it. I think that's key in patients and all of those pieces, those are differentiating when it comes to team engagement, physician engagement, and other member, team member type engagement. James? Yeah. No, I would agree. As I touched on before, I think it's also having an appreciation for every teammate that touches a patient or even doesn't touch the patient, right? Because every single person that I work with on a day in and day out basis, they're all part of this care team and they're all driving care forward. From top to bottom, left, right, everybody is. And to your point, when you can create that shared mission and vision and they can feel that connection to patient care, that's very powerful for the team. And the appreciation that, we've said it before on this stage, an FTE might be a line item on a budget, but you got to understand the impact. We talked about how do you unlock your clinical effectiveness? It's appropriately resourcing people to do the things that they want to do and they came to work to do, right? And how do we strip those things that they don't want to do away? I saw this interesting quote and I'll probably mess it up, but it was a provider and they're quoted as saying, COVID was great because I just got to focus on doing what I was trained to do. I didn't have to build, I didn't have to, you know, I was just delivering care the best way that I knew how to do for patients and gosh, it was terrible, but there was part of it that was great. And part of me thinks, how do you get back to that for folks on a daily basis? Dr. Kiever? Yeah, and isn't that even odd to say out loud, right? And I think, you know, but I think there are people who found their purpose, right? So this is the piece where I remind people that we don't just have the corporatization of medicine in a lot of ways from a workflow perspective, we actually have the industrialization of medicine. So people being treated as though they're part of the machine, right? So I really think the issue, you know, is probably more one of moral injury. And I really encourage all the physicians and clinicians that I work with to think of themselves as having their own personal mission statement, their own personal board of directors, running themselves like a business, and then finding a place where they thrive, right? So we talk about belonging, but really, you know, a place where you not just belong, but that you matter and that you flourish. And that's quite individual. And I think that is the challenge when I talk to leaders of corporate healthcare, how do you actually bring out the best in every single person in your organization when you might have 150 plus thousand employees? That's a real challenge. And I think some places are really meeting that challenge. So I think that's really where it comes down to is for people to be on their own mission and groups, right, and very effective groups, that that really is the cure for this. Because I think when people feel like they're put in that box, there's a sense that they've lost their meaningful work. One final note to end on. Do we have time for one question? Okay. Yes, Dr. Gilbert, we have one question. And can you touch on the implications of health systems being purchased by private equity firms whose mission may or may not be healthcare? Ginger? Yeah, we're seeing a lot of that happen. From an organizational perspective. Yeah. In cardiovascular, it's fairly new. Probably within the last two to three years that we're starting to see more of that. But there's lots that have come before us. And maybe I'll go back to almost to the corporatization pros and cons is about the same. There are environments where private equity brings resources and dollars that allow for evolution that wouldn't have happened in the traditional economics of which that organization had found themselves in. So better equipment, better EMR, better resources with the goal to take better care of your patients. Now, the challenge is, is there can be a disconnect. Because at the end of the day, you file it up to ultimate what's owner. And it is a equity model. So I think we don't know what's going to happen yet in cardiovascular. And we'll kind of see what happens and how it evolves over the next few years. But I think the key for effectiveness is going to be making sure that that vision and mission is tied in and is done in a way that it comes together in a positive way. And again, we don't know. And I know there's lots of stories and true stories in other fields where it hasn't gone so well. So I don't know. That's a good question. I'll just add one more piece to the puzzle here. And also the idea of payers buying hospital systems, right? So one of the things that could happen is a wraparound where there's always this tension between payers and the health care systems. And so there could be some mergers in that regard in a new payment model. But I'll just remind everybody that I made an allusion to STARS earlier. But I have that as something I think everyone needs to understand and have on their radar that we have venture capital inside Medicare Advantage. And that is something that if we think about programs that have historically been government programs that we all pay in, if we all look at our pay stub next week, this week, whenever we get paid, we'll see that money going into programs. But we already have venture capital dollars in Medicare Advantage. And so this idea that health care is spinning off dollars for investors, for people who become a Medicare recipient, is something we haven't really talked about as a country. And I think it's a great opportunity for us to think about health care as a business. We all know that. And how comfortable are we with the incentives for the business profit? And I think it does balance against this idea that we also believe health care is a right. And so that tension between profitability and health care as a right is definitely always there. So, well, we will close with that. I absolutely love what Ginger said, just with all of this change, all of these moving parts that we're intentional and focused on the humanity behind it all, ultimately being our North Star for invigorating all of us to do the best that we can do. So thank you all so much for being with us. Really enjoyed this conversation. Thank you.

corporate medicine

provider morale

quality improvement

patient-directed healthcare

administration

physician leadership

economic impact

corporatization

protected time

collaborative approach