Welcome to day three of this wonderful hybrid quality summit meeting in LA. It's so great to see all of your smiling faces that made it through day three for this very early meeting if you're on West Coast time. So thank you all for joining us. We have a very exciting session today and, you know, we would be remiss to not appreciate and pause the impact that the COVID-19 pandemic has had both on us for a health care society but as we're starting to come on to the back end of that, what that's looking like as far as the resources that we're able to have within our organizations. The work that we do is so important at the local level as well as the national level to ensure that our cardiovascular patients are getting evidence-based guideline directed care and all of you virtually as well as those in the audience play such an important role to make sure that you're monitoring and looking at it and partnering with members of the care team that we really wanted to bring this esteemed group of panelists together to be able to share their different perspectives as far as their professional backgrounds and how they can help move the mission forward whenever you get back to your organizations. And before we get into a brief presentation from each of our panelists, I would like to make sure that at the end of it, we will have a small, we'll have a surprise or recognition that we want to make sure that everybody stays on for after we get through our panel discussions as well as our Q&A. So without further ado, I would like to introduce Dr. Stephen Bradley. He is the Associate Director of Healthcare Delivery Innovation at Alina Health in Minneapolis. I'm sorry, what? Oh, Health in Minneapolis Heart Institution. You heard him speak at the opening yesterday. He is the chair of the ACC NCDR Oversight Committee and we're excited to have him leading our efforts. Stephen? Good morning. I can't remember who it was I was speaking with recently, we were talking about post-COVID and I'll admit, it still feels a little early to write the book on it. I don't think we're quite past, we're still suffering, we're still getting through and there's a lot of changes that we're getting through, but it is time to start thinking about how we rebuild, but I think it's first important to think about what did happen? What did we suffer? What have we gone through? And I recall just the moment that the world shut down, we were supposed to, our family were supposed to be going on vacation and literally that vacation ended. All of a sudden, all of us are being called to think about how we can support this change and how we were going to have to deliver healthcare. And as a cardiovascular doctor, I knew that there were going to be a lot of changes that I was involved in, in terms of how we provided care. How do we care for patients who need elective procedures? How do we care for patients who need emergent procedures when we have patients who are in the hospital that have different needs than we're used to? And the impacts were profound. We know that the impact of COVID-19 resulted in delayed elective cardiovascular procedures. We know that that had impacts on patient outcomes. We had severe supply chain disruption that we continue to see. I feel like just about every other week, I get a new email from my health system about some shortage of some other therapy that's important in our care that has implications about how we provide care. We had delayed and deferred emergency care. We saw these trends from Deepak Bhat published in Jack and also in Open Heart in terms of the number of emergent cardiovascular procedures that occurred immediately after COVID-19. And this had tremendous impacts on our care for patients with cardiovascular disease. This wasn't just limited to emergency procedures. This was also for elective cardioversions and elective coronary angiograms. As a result of the changes in the care we were providing, there were tremendous changes in our cardiovascular teams. So our cardiovascular teams during COVID, those of us that were almost entirely involved in cardiovascular care were now involved in other aspects of care and intensive care units. We had nurses who predominant work was in quality improvement who are now being asked to come back and provide clinical care because there was a tremendous demand for people to serve people in beds. And so we had team members who were doing different work than previously. Because of the transitions, we also had a tremendous number of team members who were furloughed, laid off, or their work hours reduced due to low volume in the traditional care that they provided, the traditional aspects of work that they did. And they were also transitioned from their usual work in registry and accreditation work to direct patient care. And as we've come out of this now, there's been this other factor of the great resignation. So people took a look, took an opportunity to say, all right, we've been through a lot. This is a nice moment for me to re-evaluate where I am in my career and how I'd like to move forward. And there are people who determined that they've gotten to a point in their career that it was time to transition to something different, be it resignation truly or be it early retirement earlier than they anticipated. As a result, oftentimes, those are people who are rather advanced in their careers. And it opened up advancement opportunities for other people to move into leadership opportunities that perhaps were less direct patient-facing and more overseeing teams and helping lead our care delivery teams. But as a result, we had fewer people at the patient bedside. And this has had continued impact on how we provide patient care. So we're here to make the case for, as we continue to come back out of what we've been through, how do we make the case for registry and accreditation participation? I think it's helpful to frame the registries and frame accreditation in terms of what are the goals and what are the objectives, what are we trying to achieve with the registries and accreditation. And so these are the NCDR strategic aims and goals and the overarching mission. The mission of NCDR is to improve patient care and heart health through trusted real world evidence. That's central mission. That central mission is a true mission for all care delivery organizations is to improve patient care and improve patient health. And we're here to do that through trusted real world evidence. And NCDR is working to think about how can we continue to rebuild that team while understanding ways in which it has impacts on the care team. How can we reduce the burden of data collection while exploring additional sources of data to increase the value to our stakeholders? If we understand how other aspects of data, be it cost or patient reported health status measures to understand the longitudinal aspect of patient care and patient outcomes, that may have additional value to our stakeholders including health systems, payers, and industry. We can promote local, regional, national, and international quality improvement, again central to the mission of most care delivery organizations. And we can support population health management through advocacy and generalizable information. Accreditation service, the focus is on transforming cardiovascular care by helping create communities of excellence. So the goal of strengthening the value of accreditation services, easing the efficiency of accreditation and recreditation, maintaining a sustainable portfolio, and continuous quality improvement. Central again to the missions of care delivery organizations as they look to meet the needs of their patients. And so we can make a very strong argument for why this cardiovascular team, why our group as an organization and the people that are sitting in this room are central to the mission of the care delivery organization. So again, coming back to that concept, I really think that that north star in care delivery of achieving high quality care using the Institute of Medicine goals of timely, safe, effective, efficient patient center and equitable care, or you can use value, again that concept of achieving better outcomes at lower cost or similar outcomes at lower cost to improve the value of our care. And then finally, that quadruple aim of improving the well-being of our teams as we provide this care to our patients. Recognizing that north star clearly, the missions of NCDR and the missions of accreditation services are directly aligned with that north star in care delivery. So we can make a very strong argument for why this cardiovascular team is important. Another important component of understanding cost of quality comes back to how we make this argument to our financial overlords. I'm again borrowing from the Simpsons, similar to yesterday, but how do we go to those people who pay the bills and make the argument for the cost of the work that we do? Because honestly, oftentimes all they see is the cost for the work we do rather than the value we provide. And the challenge is that it's very easy to see the cost of what we do. It's oftentimes difficult to see the cost of poor quality. The cost of poor quality includes internal failure costs, external failure costs, and what do I mean by that? So the cost of providing bad care is not just the harm that's done to the patient, but there's true financial cost to that. We saw that yesterday in the example that Dr. Masudi gave of the acute kidney injury work and the reduction in acute kidney injury and the resultant reduction in cost through reduced length of stay and the complications associated with that. We can make the exact same case for reduce the bleed and the work of bleeding efforts to reduce the risk of bleeding after procedures in the cath lab. A bleeding episode at a minimal estimate costs $12,000 per episode. If you reduce the episodes that occur, that has a true cost reduction. And so there is cost savings attributed to the work we do. It's not just about that North Star of care delivery, but we can also make the argument to those people who write the bills for the work that's done that there is a tremendous cost of poor quality. The other, those are the internal failure costs. There's an external failure cost as well as we think about how we move towards public reporting and measures that the public see in understanding how we as healthcare delivery organizations achieve the goals and the outcomes that we achieve. There's a tremendous influence on patient perception and the public perception about you as a healthcare delivery organization if you do or do not achieve good outcomes for your patients. And there's the cost of good quality. That's the work that we do. But I think we need to make a strong argument about how the work that we do is actually less costly than the cost of poor quality, particularly if we focus on that North Star of achieving high quality for our patients. So if that is a framework for our discussion, our panel, I look forward to the remainder of our discussion. And thank you again for being here with us today. Thank you. Thank you for the first presentation. That was wonderful. Next, we're going to have Jessie Dunn, who is a clinical pharmacist specialist at Oregon Health and Science University. So many people don't often realize all the things that a pharmacist does. It's kind of been an evolving career for both myself and many in my profession. And so I'm just going to spend a little bit of time on how a pharmacist can contribute to quality measures that are already going on within a facility, both inpatient and outpatient. So focusing on MI care, and there's a plethora of other places we can work, but MI is pretty well spelled out. So at the time of admission in a person who has an acute MI, we are starting antiplatelet therapies, we're anticoagulating, we're maybe doing thrombolytics if we're in a rural place. We have cath lab meds and complication management across the stay of the inpatient admission. Then it comes time to discharge a patient. So we have guideline-directed therapies that we know decrease the progression of the damage to the myocardium, that improve these patients' outcomes, that keep them out of the hospital and help to get them more functional in their everyday life. But longitudinally, we have to also think about how did they get there to the point of having an MI in the first place? So this brings up other opportunities for a pharmacist to be involved in. Smoking cessation, diabetes management, hyperlipidemia, hypertension, and weight loss are all areas that we operate on in a very regular basis, both in a cardiology clinic and in primary care clinics across the nation. So the role of the pharmacist, we do have a little bit of a unique training. And it's not just the meds and the side effects. But really focus is making sure that information is accurate across the way. Medication reconciliation, while a very simple task for some, is a very complicated task for others. So knowing that patients are seeing many, many physicians with many sub-specialties and knowing exactly what the patient is taking that may be contributing to poor health is super important. And something that I think a pharmacist is really the only person who focuses in on and really drills down on. And then choosing patient-selected medications so that we know what the patient's specific goals of health are, how they feel to it. Some patients have side effects you can't predict, and they're that rare unicorn. And it does happen. So tailoring their therapies to progress down a better path rather than giving them more side effects is important. As we've learned with this COVID-19 pandemic and some of the new therapies, drug interactions are kind of spectacular with some of the things that these patients get started on. And the complications as a result have been huge. We educate the medical staff. We educate the patients on the levels that they need to see, which are very different levels. And being able to translate for the person who's actually receiving that information is something we actually are trained specifically on. We monitor and adjust meds and tweak meds all of the time. And we find side effects because our job is to look at the meds first. So we do this across the spectrum and provide helpful little tidbits here and there. But in addition to all of this, it's also on us to help to look at the medications in developing our protocols and developing our various procedures that get the right meds to the patient at the right times. This might mean formatting notes and order sets specifically so that we are starting the right meds on the patient. It might mean monitoring these medications over time and making sure that we aren't having adverse effects as a result of the medications we're using in an everyday basis. In this particular facility, they looked at the impact on post-M.I. patients who had PCI and the impact on discharge prescriptions. And they found that clinical pharmacists who participated at the time of discharge in a good medication reconciliation, deciding what meds from prior to admission to continue, which ones to stop. And then going through a pre-prescribed checklist based on the patient's presentation, they were able to see that there's several meds that got omitted, particularly things like beta blockers and ACE inhibitors, ARBs if indicated. And they were able to increase the guideline-directed medication therapy out the door for these patients. It wasn't powered enough unfortunately to look at big heart outcomes like readmissions. But if we can at least get patients out the door on the right meds, potentially based on other work, we can have an improvement on impact. This other study that operated on looked at modifiable risk factors. So going back to patients come in for a reason, they had their M.I., they were able to show that these patients when they received discharge medication reconciliation and education, and then every three-month disease state follow-up with the pharmacist clinic were on more guideline-directed therapy at one and two years out compared with those who didn't get those services. In this particular country they actually are only allowed to write prescriptions for every three months. So the pharmacists in these clinics took over their every three-month refills in doing on-site clinic visits. So this really provides an opportunity for pharmacists to supplement when there's areas where we maybe don't have good physician recruitment in rural areas. We maybe are understaffed in various ways because we can't hire enough APPs or get other clinic visits opened up because the docs are already booked. So I feel this is a good opportunity for pharmacists to step up and help provide improved quality of care for our long-term patients. So we can do discharge prescription review. We can do discharge follow-up phone visits or clinic visits in that one week or even just a couple days post-discharge. We can do disease state management to prevent further recurrences for these same patients. And then there's the medication adherence aspect. This is probably a good 50% of my day, finding out ways for costs. Why did the patient stop it? Could they not afford it? Are their co-pays too high? Did their insurance need a PA and nobody realized it happened until the patient is already home from the hospital? And then just translating all of our higher level education and reasoning for doing this to patient-speak, to the layperson. If they don't understand why this is important for them to continue those meds, they don't. And so this is a good opportunity to involve your pharmacist in this care. »» Thank you, Jessie. »» And next, we'd like to welcome Jesus Navarro. He is a nurse practitioner at Loma Linda University. Help. »» Well, good morning. It's lovely to be here in Los Angeles. All right. Well, I'd like to tell you a little bit about my experience working as a nurse practitioner in cardiology and some of the things that we have learned during COVID, before COVID, during COVID, and things that we have done to help improve patient outcomes. So I predominantly work for a cardiology service that we are very busy. We have a total of three teams. And in rebuilding this CV team during COVID, I mean, we had a lot of trouble. Just like in nursing, we had a lot of shortages. We had a lot of people, you know, kind of take a look at their careers and see if this is something that they wanted to continue doing, especially in the wake of COVID. But luckily, we went from a provider service of three APPs to now, as you can see, we have a total of ten APPs. So we've been able to build a pretty good team, and we've had some good success. We are a seven-day-a-week service, and we cover the cardiology service as a primary care service. So we do everything from education, diabetes management, cardiac issues, et cetera. And the good thing about our service particularly, or the APP role in cardiology setting, in the inpatient setting, is we are able to ensure a continuity of care. So we are able to see the same patient for multiple days and see them from when they come in at the beginning of admission all the way through discharge and be able to be involved in their care. We have a patient-centered care approach where we take the patient and, you know, we work towards our goal. We use a lot of guideline-directed miracle therapy, and we take their goals into consideration when we are planning their care. We implement a lot of QI projects in our care, and we have wonderful physician collaboration. Some of the patients that we take care of in this APP service are intermediate to lower acuity admissions, low-risk endstemies, heart failure, and pre- and post-procedures. For the most part, I would say about 80% of our service is heart failure management. So why the APP and the benefits of it in the CV team and in the inpatient role is, like I described before, the continuity of care. We make sure that we see the patient from the very beginning to the very end. We take a look at how they're responding to certain medications, their education, and we work with them to improve their outcomes. We do focus heavily on education, and we work alongside many of the interdisciplinary team, such as case managers, social workers, nutrition, educators, because those are some of the important things that are going to help keep the patients at home and out of the hospital. Otherwise, we work very closely with pharmacists as well. We implemented a meds-to-beds program, very similar to what Jesse was talking about, where we ensure that the medications are accurate. They should be on what they need to be on. Guidelines are being followed. Compliance and coverage. Coverage is one of the biggest barriers for some of our patients, where we can prescribe them a million different types of medications, but if there aren't ways for them to be able to afford these medications, then that becomes a problem. In this setting as well, we are able to follow up with them in a close setting, where we can discharge them and have them see one of our APPs in the clinic and typically the appointment time is less than five days after hospital discharge. So this has really decreased the hospital readmission rate. And we are very heavily involved as well in certain protocols and we are part of the cardiac rehab referral team. So we were able to see before the APP started with the cardiac rehab referrals, we went from a 58% referral rate to an 86%, greater than 86% rate. And 98% guideline-directed compliance with discharge in heart failure patients. Thank you very much. »» Thanks. Thank you. Thank you, Jesus. Our final presenter to wrap up our care team presentation today is Ginger Beesbrock. She is a physician associate and executive VP for the care transformation at MedAxiom. »» Thank you very much. I appreciate again the opportunity to be here and honored to be part of this panel for a couple reasons. One, because the value of the team, and I'm going to talk a little bit about that here in just a minute. And then two, as a great example of the work and the effectiveness of the work that can be done when we institute a team-based care model. So I'm going to start talking just a little bit about the role of the physician assistant slash or associate. It was funny because Andrea asked me earlier when she was talking about introductions, she mentioned physician associate. And I thought, wow, I guess that is what I am. But if your head is spinning, I know my head is spinning because we have had a lot of changes over the last few years related to is it physician assistant, is it physician associate, nurse practitioner, our scope of practice, our practice autonomy, and it's all, a lot of it is at the state level, license level. There's just been a lot of work in this space or a lot of changes in this space. And so it does, I think it is important to every so often kind of come back and review where we're at, especially given your environment and your location. So just a little bit about PA. So PA, physician associate, was a recent name change I believe last spring. Historically, we were physician assistants. We're licensed clinicians who practice medicine in every specialty and setting. So from an education perspective, the master's degree, historically there were, originally if you go back, it's been around for about probably close to 40 years at this point. There were some bachelor degree programs, but at this point, I think most everything is master's degree. It includes didactic training, clinical training, the education. Our education is actually focused on primary care, which is a little bit different than some of the nurse practitioner tracks. Ours are pretty standard. But then we can specialize. So once we come out of training, we have the ability through either some additional fellowship training, there are some fellowships for PAs, or on-the-job training, we have the opportunity then to specialize. Our license lives at the state level. And we do have to have certification. So when you see that PA-C, that means we passed our boards and we have to retake those boards at this point. I think it's every 10 years. And that's, again, all based on that primary care type training. So that's a little bit about PA, just to get you up to speed on what's happening there in 2022. Now I want to transition and talk about team-based care and the value of the different types of expertise that you see on this panel, and that probably you all have access to within your organizations. My current role is being part of MedAxium. And I've been doing a lot of work in the space of what I'll call clinical effectiveness. And so, again, I would imagine most of you, when you think about your organizations, you've got physicians, you've got RNs, and other nursing team members. You probably have nurse practitioners and some physician assistants, associates. Most of us have access to pharmacists or we see pharmacists on our teams. But I was in a few years ago, I was giving a talk on team-based care, and I had a physician raise his hand. And the question that he relayed to me that has stuck with me to this day and will continue is that, Ginger, we have all of those things, but this whole concept of team-based care is elusive. I'm not seeing how those things can effectively come together to provide better patient care. It's just, it feels like we're all doing our work, but we haven't really developed that team where we feel like we're doing that work together and lockstep with each other, and then can see the outcomes of the work that we're doing. And to me, that's the definition of clinical effectiveness. It's our ability to take the ingredients we all have access to, we all have access to guideline-driven medical therapy and what we should be doing with our guidelines, and have we put our teams and we have created the infrastructure to allow us to know what we need to be doing as part of my portion of the team, how we work together, and how we bring that together to ultimately provide high-quality care to our patients. And you all have a bird's-eye view into our degree of clinical effectiveness. When you think about our registry and all the different things that we measure, what we're measuring is our degree of clinical effectiveness. Have our teams come together? Have our processes come together? And are we effective in the way we deliver care for the outcomes we're looking for? I don't think anybody would argue that we don't want to maintain our patients and provide the best quality care to every single patient that enters into our door. But things like COVID, things like the acuity level of our patients, if I go back 20 years, I remember when I was working originally clinically, would have been back in, let's see, I graduated in 98. Kind of our general rule of thumb is if the patient was 80 or older, we typically didn't take those patients to the cath lab. That was in the era of the original drug-eluting stents. And we talked a little bit yesterday in the keynote about some of the history and where we've been. Fast forward to 2022, our patients are incredibly complex. And the things and the medications and the procedures and the things that we're doing is incredibly complex. And we can't do that without a team that comes around these patients and the way we deliver our care. And I think there's a lot of factors that have come into play that make it really hard to do the right thing, which then leads us back to are we really clinically effective and have what we need to do that work. So let's talk about team. So I would implore what I have put in front of you is a framework to think about how we put our teams together and starting with the patient care objectives. So what are the things that our patients need? And actually, in thinking about Jesse's presentation, she did a great job of outlining from like an ischemia patient what needs to happen at admission, what needs to happen during the hospital stay in the procedural area, what needs to happen at discharge, and what needs to happen longitudinally. What are all those things that need to happen? And then start to define the who, the what, the how in order to, again, create that clinical effectiveness. Jesus did a great job of providing when we bring a team together, the degree of clinical effectiveness. So he described, I don't remember the statistics, but it was good, related to your cardiac rehab referral rate and your discharge medication adherence rate and getting those follow-up visits intact at the time that the patient's going home or scheduled. And it has to do with creating that infrastructure. So that infrastructure starts with the patient, starts with the care objective that needs to be met, then we develop what are our clinical standards, so what are the things we all agree on that this is how we're going to manage this patient population? What are the protocols? We start to get those things written down and create some protocols and policies, and then how does it fit into the bigger pathway of how these patients and how we deliver care throughout that episode or throughout that stay. So once you've done that work, we can start applying who are the people based on license, based on skill sets, expertise? What is the IT that's needed? So how do we use our EMR, our order sets, our clinical decision support tools? How do we create and make that easy for the right thing and to allow us as teams to do the right thing? So again, patient focus, what's the objective? What are the initiatives that need to happen? And then how do we resource that or put your operational head on and how do you come together? So I would kind of thinking about that framework, and again, most of yours perspective, you get to see that degree of clinical effectiveness. How effective are we in that care that we deliver? And you all kind of manage our scorecard, right? You see those areas of opportunity. So this is just an example where we have these metrics, and when you start to think about where the care is delivered that affects that metric, very little of our care happens in the procedural space. It happens before the procedure, and it happens after the procedure. So when you start to apply kind of that framework that I just described to the things that you're all seeing, start to think about this is the care objective. This is the metric that I'm measuring or that's been measured. This is where we land. Where does this portion of the care get delivered? Who are the people that are involved in delivering that care? And then how do we empower those people or go back and create an environment through good feedback and that kind of thing to empower them to understand their degree of effectiveness and how we need to optimize ourselves to be more effective? So let me just say one last thing. If we take this and bring it back to, Dr. Bradley mentioned a lot about how we've had so much turnover. I mean, we are in staffing crisis mode. We just came through COVID. We have issues around, I don't know, a single hospital organization that's not having financial issues. We're having burnout issues, clinician well-being, team-based care, team well-being, all of this turnover and attrition, and we are in a tough spot right now. And I would argue one of the things that we can do to begin to stabilize this is to go back to the basics, back to the objective of care that we're trying to achieve and get the people that are working really hard to do that work, get them the tools and the resources that they need in order to be more effective or know that they're effective in the work that we're doing. When you start to dig into some of the clinician well-being work, and that, again, includes everybody on the team, a lot of that has to do with, are we tied into the value of the work that we're providing? Are we leaving our job every day because it was so hard to get that work done and not feeling effective or not feeling like I was able to be successful? This sort of a framework and then applying the feedback that we learned from our data and our metrics, that can be very empowering to the team. So again, as you start to think about where are our opportunities, who's the team, what processes, procedures, policies, standard work do we have in place, and then how can we give them the tools and the resources they need to be effective in their job? And I guarantee that will go a long way to begin to increase your morale and help us feel like we're tied back into that objective and the value of the work that we're doing. And again, at the end of the day, it's about that patient and our ability to provide that care in a clinically effective sort of way. Thank you. I think that lays the stage to have a pretty robust panel conversation here next. We wanted to make sure everybody was aware of the various professions. And as you guys are thinking about your questions, type them in the app because once we get through a few panel discussions, we will open it up for Q&A, so go ahead and start submitting those. I would like to start off with the first question is, with the workforce challenges that the healthcare industry is navigating, how can your professions partner with those to ensure that we are continuing to deliver high quality care whenever we see people in unexpected roles? Who would like to start? I should just keep looking the other direction and just pretend like I'm looking. So sorry, so how do we continue to ensure that we provide high quality care when we see people in unexpected roles? You know, that's a fantastic question, and I can relate that directly to something we're going through in my own health system. The Union for Nurses in the state of Minnesota actually has a strike ongoing this week at 15 hospitals in the state of Minnesota, and as a result, it's caused a lot of disruption in terms of people working in unfamiliar roles. On Monday, I was on the floor in our cardiovascular unit, essentially acting as a nurse for a half an hour because we needed to make sure that we had a presence of clinicians. And I can guarantee you, the quality of care is not the same with me acting as a nurse. But you still need to understand, I think it gets back to Ginger's concept about putting the patient first and understanding the need for roles, protocols, processes, and even if the people change, how do we continue to leverage those protocols and processes to optimize our patient care, and I think that's a central component. If you have a strong component of protocols, processes to achieve that goal, even as people change in positions, they can understand what they're supposed to be following in care, so I think that's a, I would offer that as a central component of ensuring that you have a strong foundational approach to the management of that patient, recognizing that at the end of the day, it's still optimal to have the right people in the right positions. We actually struggled in our facility with getting patients their follow-up visits, and how do we see them in the first week? And in light of us having our team out, I actually had to step up and take on doing the one-week follow-up visits for a short time period and doing med titrations. And I've seen this in other facilities before, a prior place I had worked at, we actually cut our readmissions in half for our post MI patients by doing follow-up visits and the discharge med reconciliation and doing all of these pieces because we were in a facility that was very tight with our resident staffing, and they were being pulled to new services and so there were fewer on service at a time. And then the nursing shortage, even at that time pre-COVID was still very present and palpable and a lot of the discharge education had previously fallen on them. And so we took on that piece as well just to do what was right for the patient as Ginger was talking about. So it's something we all have to, I guess, pivot and find new ways to work around. »» Yeah. So this has been an issue, it sounds like, at every hospital and every facility. Ours is no different. Specifically with our role, or especially with my role, I've had to provide a lot of the education immediately during admission because we've been short on either nurse educators or nursing staff. Maybe we have nurses that work in specific units now floating over to our cardiovascular unit. So working together with the nurses, providing great education for the patients, and ensuring that nothing gets missed. The biggest thing for us is protocols. We have a very good set of protocols that we follow. We have guideline-directed therapy and we ensure that everyone that comes in through our door has a list of what guideline therapy is, what it's there for. And a lot of the times, even if we have nursing from a different unit that comes over to the cardiovascular unit, they are able to ask the unit, hey, in this paper here it says that this medication will help me for this. What about this? And then that's where we get involved and we ensure that we educate and that we provide great quality care regardless of whether being short or not. Wonderful. I think one thing to add, too, especially for those that are in the audience, you know, as a former data coordinator, data abstractor, you guys have the lens of the entire patient care. So whenever the CV operations or your physicians let you know of a change or let you know where there potentially may be a gap, if you're caught up on your abstraction, you can provide real-time feedback as far as where some of the policies may be not, you know, where there could be an educational opportunity so our patients aren't harmed in the care through the staffing transitions that our hospitals are navigating right now. So that would be a good way to partner. I actually would agree 100 percent because one of the things with all this disruption and transition is some of those stone-cold stable metrics that we've seen for the last decade, always stable at the top percentile, we're seeing changes in that. And because of the breakdown and the transition in our staffing and the breakdown of some of our processes and things because of so much of this disruption. And you are the lens back to us or the feedback back to the people that are delivering that care to say, hold on a minute. We got a problem over here. Even though this hasn't been a problem for a decade, it's a problem now. So we need to look into that. So you really do have a pivoted role when it comes to helping those that are delivering better understand where those opportunities are or where those processes that we've always considered stable aren't working anymore. Great. All right, next question. So COVID brought a number of restrictions to the way that we did work as far as spacing limitations and distancing challenges and quite a number of people were then put into a virtual space because they were sent at home as remote workers. It also played a significant impact to the training that's occurred. So our nurses and care team members that have gone through training over the past few years now entering the workforce, they may have a few gaps because their clinicals were done quite a bit differently due to COVID. What are some insights as to how you may want to proactively address some of those gaps? I won't start with you. I was going to say, you look at this direction, I'll just flip that. I can start. I think there's a significant opportunity for what we'll call standard learning. And we sort of, I think, historically have been in the mindset that we sort of come in well-baked. And when I say we, I'll say PAs, but I think it's true for nurse practitioners, pharmacists, nurses, even physicians that are coming out of fellowship training and, you know, coming in and we're ready to hit the ground running and ready to go. And I just kind of outlined even for PAs, we're trained in the primary care model. So I had a month of cardiology didactic, and I had a couple months of clinical, and then I took my first cardiology job. And so the reality is there's a fair amount of on-the-job training that needs to occur. And with my work, having the opportunity to visit lots of organizations across the country, I can confidently tell you we don't do a very good job with that whole onboarding piece, especially in our provider space. We just kind of, well, you go work with somebody and you observe somebody and do some shadowing and you start seeing a few patients and we'll get, you know, after a time, we'll get you up to speed. And what I find is that six to 12 months into that, people are feeling frustrated. They don't feel, we'll go back to that concept of effective. They don't feel effective in their role because they didn't really get what they needed, the tools and resources they needed in order to do that. So I think the college has done a great job a few years ago, came out with a list of competencies. So start with some definitions around what we should know, and then begin to put together sort of those objectives of learning and the resources around how we get that information. I think it's fair, especially because, again, I'll say COVID was a major disruptor, but a lot of the things we might be blaming on COVID, I would suggest, were opportunities before COVID. It just magnified it. It just brought it to the forefront that we probably weren't doing a good job with it even before COVID. And this is another one of those. I will say, though, to Andrea's point, she's absolutely right. A lot of clinical training that our teams that were going through training during COVID didn't happen. It was, well, we can't have you in the hospital because it's COVID and we can't put you in the clinic because the clinic is shut down for a month, but we got to keep you, get you through your training because we need you to graduate. So I would say it is worse now than it was even before. But as you start to think about the onboarding for new team members, I think it's important as administrators and leaders that we put some definitions around what we expect them to know and then get some tools and resources to help get them there. I agree that, you know, I think a lot of these issues were amplified with COVID. Obviously the issues were there. Training, you know, big time on the job training. As a nurse, I can tell you that I would say a lot of the training for me was on the job versus actual school training. And with my NP program, it was no different. I came right at the very beginning or right before COVID. So I was, you know, kind of on the job training. Then I got really busy. So our training got cut short and then there was COVID. So definitely, I think that at least having some basic skill sets and some competencies and some things that, you know, specifically the college has laid out for us to, at a minimum, know these competencies, I think is a great start. But we should definitely continue with our education as far as in the clinical setting. I know that Zoom, you know, the patient interaction and patient experience is definitely not the same on Zoom as you would if you have the person in front of you. But, you know, I think the college has done a great job in setting these competencies and these trainings. I onboarded in a new facility on the opposite side of the country during COVID. I started on February 24th of 2020. And I got a new employee orientation and then started a new job and inpatient as the world shut down. And the only thing I think got me through is I actually was lucky enough to start in a facility that had insanely detailed structure to training checklists. And as much as I rolled my eyes at all of that, it was really helpful. Because I was on one of the units that ended up shutting down half the unit to take care of high-acuity COVID patients. And I wasn't seeing the usual volume of these cardiovascular patients I was expecting to care for. So God bless your checklists as much as we want to roll our eyes at them. God bless structures and training manuals and the cumbersome task that it is to create them. I wouldn't have done well with it. And then I transitioned to a new role with no structure whatsoever about a year later in the ambulatory setting. And I started at the same time as an APP who, God bless her, had no structure. And she was sent home to do virtual visits in her first job after graduating with her PA in licensure. And she came to me one day when she was finally back in clinic. And she said, I need somebody to teach me these things. And so we did use some of the resources from ACC. I pulled out some from my bag of tricks in pharmacy world and we kind of worked together to get her there. But structure, you got to build the structure to have the outcomes. I think these comments are spot on. And I think within my own practice, I'm the director of our inpatient service. And it just occurred to me that I get updates on essentially achieving competency of adequate billing. But we have no formal structure on achieving adequate clinical care. We have our nurse practitioners and PAs that join our group. And we have a range of nurses who have worked on our cardiovascular floors, gone on to get their NP degree, come back, and they're facile from day one. And we have PAs who are straight out of training who really haven't experienced cardiovascular care. And we act like they're the same. We partner them up with people for a certain period of time to get familiarity with how the floors work. But we don't in any way kind of assess, do you have a good understanding of how to care for the most common patients that you're going to care for in the aspects of? And so to me, this is just an eye-opening experience of me as a physician was trained in the adage of see one, do one, teach one is entirely inadequate and harmful as we think about how we create structures for strong team care. So I think these comments are spot on. Well, besides having like thoughts, because I love structure process outcomes, it makes me very cozy. What I'm hearing, at least from the lens of the audience, is one, you can also have structure process within your accreditation team and your data collection team. Because I know whenever I started, I was handed a definition book, because back then is when you printed out the pages. And it was in a binder. And they said, go to it. And I'm like, cool. Right? Like, what do you do with that? So now we have a very robust onboarding, very similar to what you might see on a nursing unit to make sure that people do a good job on the data, because it's so important. So I think that's one thing to take back. I think another thing that I'm hearing is we may get frustrated, especially if we're working remotely at home, that we're not getting feedback or people aren't responding to the emails, even though I've sent it five times. If that resonates with anybody, you can raise your hand. Maybe giving a little bit of grace. Because if we're missing some basic onboarding opportunities with members of the care team, it's more of foundational things that we may be able to do, and approaching it more from a how can I help? Here's resources. Here's what we're graded upon. Or here's what we monitor and how can we help might be a good action item from this group. Barbara, do we have any questions? Yeah, we have a couple questions here. And there's a few that have a theme going, so I'll try to kind of consolidate that. It's really about the relationship with the data abstractor, the registry site manager, as part of the team with the PAs and APPs. How do we engage the site manager, the data abstractor in with this care team? Maybe some of you can share how you've done that on your teams. I agree 100%. In fact, as Andrea was describing, that was going to be another take home for all of you. When I go back to some of my early clinical days, and I feel very blessed for the organizations that I had the opportunity to work in, but one of the key relationships that I had was with our data owner when it came to our registry work. And again, I'm going to go back to that clinical effectiveness. She provided me direct, real-time feedback with my clinical effectiveness and the clinical effectiveness of the team that I was working with. If things didn't get documented, if something didn't get written down, if frankly it didn't get ordered, we had a very, very good first name relationship with that level of feedback. And I think, again, in our days of, number one, scaling. Some of us work for really large programs, and you might have 30 or 40 different people on the team that you would be working with, as well as just the, a lot of us work from home now. We kind of created this, we need this space for clinical, and so we're moving some of the non-patient face-to-face. I would still suggest you're all clinical, because you're giving that feedback. That's such an important portion of our team. But anyway, either way, transition to 2022, we may not all be working in the same space any longer. But I do think first name basis. So if you don't know them, then they for sure don't know you, and you are just an email that showed up in their in-basket, along with the other 55 emails that they got that day. So I would recommend, in fact, for those of you that have the ability to manage onboarding for the new teams, for every member of the team, those face-to-face introductory conversations are really important. And then first name basis, everybody knows your name. It also ties us all back into the value of the care that we're providing, and how we do that together, and how we can't work without each other. So again, I would say it's get to know each other, and create that really strong environment with good, positive feedback, and how we all come together to do that work. In my facility, we've actually created quality meetings that we do quarterly for all of our various programs. So I'm on a first name basis with our Gen Cards PCI MI group, as well as our VAD data outcomes. In fact, Saeed, when he runs the VAD quality improvement work group that we do, he's the showcase. Everybody sees him. It's his data that he's pulling out, and he's uncovering things that we've had some really good quality improvement projects built around. We completely rebuilt our entire anticoagulation pathways, both in the hospital and after discharge, and cut our bleeding rates in half, because the work Saeed was doing. So I think it's really important, as you say, become very familiar. Put them on the pedestal. Let them have their time, and tell us. Because if they don't get that opportunity, we're all missing out. Here's a question. Can you talk about how the care team has evolved and changed with COVID, and what things might have worked well, and what did not? So I guess I could say, were there lessons learned from COVID around the care team function makeup? I could say that some of the things we learned, specifically during COVID, is to work in a more close-knit type teamwork, right? Especially with COVID, at the very beginning, we had patients that were in one unit, and other patients that were in a non-isolation unit. And we had a mixture of different areas that we had to go to. And by working together as a team, and communicating not only once a day or twice a day, but it was typically on the hour of what updates were going on, and how we were improving, or how we were working with these patients. So some of the things that I could say is just teamwork. I think it really increased and enhanced our teamwork and our collaboration. We learned a lot about each other that we didn't know before, and things that we could recognize our strengths, our weaknesses, and be able to utilize that to better take care of our patients. One of the things that we saw and or learned is through that experience, where the difference between the organizations that sort of weathered it with, I'll call it a controlled chaos, is right, things were changing by the day, we didn't know, we didn't have resources, we didn't have supplies, there were a lot of things we had to pivot, and then just chaos. And the difference was a venue in which we come together to communicate, in which we come together to collaborate. And then we have the ability to make decisions that allow us to, you know, it's back to that infrastructure, those decisions that provide definitions around how we're going to do things, what we're going to do, who's going to do it, and then build some of the pathways and things in order to do that. And the organizations that had those things in place prior to that day, when we found out we all had to shut down, this wasn't just going to go away in a week or two, seemed to weather it a little bit better. You know, it was hard on all of us, don't get me wrong, I don't think anybody came through it wishing, you know, not seeing things that they wish they had done differently, but they could quickly get those people together and start to have conversations and make decisions very quickly with how they needed to move forward. And those that didn't have those venues in place, they had to start fresh. And who do we need and how do we get it? And it just created delays and even the effectiveness of their ability to make those decisions and do that. So I would suggest a lot, it has to do with that venue. Jesse mentioned we get together, I don't know, every month or with a group to talk about how we do things and our quality and what's going well and what's not going well. Those are the venues that I think are so important when it comes to our ability to pivot quickly when changes happen and things happen that are not in our control. I think one thing, one gap we found in ours was two of them. We didn't have redundancy in system. So if one person was out because they had COVID, there was nobody else to step in and take on some of those roles. So we learned we had to retrain people kind of as a backup outside of their box and then give regular time doing those roles later on. The other thing is we lost some historical perspective. There was a discussion yesterday about knowing the history of how you became or went down this path on a quality improvement project, but none of that was recorded. And so without that historical record of what has happened and changed over that time, we just lost it and then wasted time recreating the wheel and trying to figure out why did we make this decision in the first place? So good records are weirdly clutch. Well, thank you to our panelists. We've got a couple of minutes left and we're going to move on to an award presentation, but I appreciate each one of you sharing your perspective. Nothing that we do in health care is not without a team. And the more diverse our team is from a professional background, as well as our other D&I efforts, it only is better for our patients and our communities. And I wholeheartedly appreciate each of you sharing your expertise today. Thank you. So I am not sure how many of you are aware, whenever I first came to the NCDR in 2013, I didn't know that I could be a member of the ACC. In 2003, the American College of Cardiology opened up membership to include members of the cardiovascular team. They felt that it was so important to make sure that there was professional representation that they opened it up for many members to join the college. We subsequently we now have member sections and we have a section within the American College of Cardiology that is dedicated only to CV team members. So we look at multiple professions and some of the opportunities that we have to move the college forward as well as our professions forward within the American College of Cardiology. Over the past few months, that section named the CV team section decided to establish a quality, a health care quality professional award. The intent of this award is to recognize members of the CV team that are active within the NCDR as well as the accreditation space. All of you that have volunteered their time over the years in order to move our professions forward in the name of CV quality. And so this year it is with my great honor to recognize Kim Marshall. Kim, can you come up? And as Kim's walking up, I'm like trying not to get all emotional because like Kim's the one person that like you see her and you're just like, Kim! I'm going to brag on Kim just a little bit. So she has been a member of the ACC since 2005. She became an associate, which was not an easy feat in 2015. She has been our nurse planner. So everybody that's gotten the CEUs over the past couple of years, you can thank Kim because she reviewed all of the content to make sure that all of our CEUs we were able to get over the last eight years. And she is also shared as the on the Accreditation Oversight Committee from 2019 to 2022. Kim, you are the model of health care quality. And with that, I'll pull myself together and we will break for the next session. Thank you all for having us today and thank you for all that you've done.

COVID-19

healthcare

teamwork

collaboration

high-quality care

staffing challenges

clear protocols

onboarding and training

communication

data collection