»» Hello everybody. Welcome to the first after-lunch session today. How are we feeling? Hot enough for you? Not hot enough in the rooms, right. Everybody's wearing their sweaters. My name is Tracy Blevins. I'm the Product Manager for Chest Pain Accreditation Certification at HCC. Today it's my pleasure to announce the Hackensack Meridian Healthcare System team, Elizabeth, Jen, Jeannie. They're going to talk to you today about why go it alone for accreditation. Navigate your hospital and ACC accreditation journey. Remember that questions go into the app. And we'll try to get to questions either during the presentation or at the end if we have time. And it's now my pleasure to turn it over to the team. »» Thank you. Thank you, Tracy. First of all, it's my pleasure to represent Hackensack Meridian Health System. I want to say we have 30 plus people here from our team, from our many hospitals. We include our physicians, our advanced practice clinicians, our bedside nurses, our database administrators. So hopefully I haven't left anybody out, but this is really a true team approach and it has been a journey. Okay. So we'll get started. Just want to let you know a little bit about Hackensack Meridian Health. We came together as a network in 2016. We came together as it was a Meridian Legacy Hospital System, about six hospitals, Hackensack University Medical Center, as well as Palisades. We're aligned with two other hospitals, Pasquak Valley and Mountainside in a management alliance. Then JFK joined our organization. So with that being said, it really talks about our journey because separately and independently, many of these hospitals already had attained accreditations. But now we were challenged to truly provide a systems approach. We have 18 hospitals. Within those 18 hospitals, there are three academic medical centers. In New Jersey, we are still a certificate of need state. That's important for the cardiovascular team because in order to be able to provide cardiac surgery, electrophysiology, and structural heart, you must have cardiac surgery onsite. Hence, we do have a cardiac surgical program in our north, Hackensack University Medical Center. We have a cardiac surgical program in our south, Jersey Shore University Medical Center. But unfortunately, JFK at this point in time does not yet have a cardiac surgical program. So part of our strategies is making sure wherever you are entering into our system, we can get you wherever you need to go to be able to provide that level of care. Additionally, we're not just about hospitals. We have a medical school, which we're very, very proud of. We have a big ambulatory footprint, not only just today, but this is someplace where we're actually continuing to build and to grow so that we can support close to home our patients and we can have direct access. There's more than 500 locations where we are. And I think you can see the depth and the breadth of the going from literally the Garden State Parkway up close to New York, way down to Long Beach Island. And this is truly our vision, our mission, and our values and beliefs, and they are aligned with the organization itself. You can see we do not look to just be the best in New Jersey. We are very cognizant of the national landscape. We want to be on the national stage. We want to be able to compare ourselves with national programs. We've got fierce competition not only in our state, but also on the border. We have New York. We have Pennsylvania with outstanding programs. And then as we've mentioned, you know, transforming care and a transformation service is really another word for service lines. Most of you are probably most familiar with that. And our core beliefs are the five Cs, and that's something that everyone who works for Hackensack Meridian Health is expected to live, breathe, and respond every day. And this is our guiding principles. As mentioned, we really have a very heavy focus on quality, access to care, regionalization, opposition of programs. We talk about standardization, standardization of policies, procedures, protocols, job descriptions. We work together as a team because what works at a small community hospital will not be the same when you have to function at the larger tertiary centers. And with that, we also cross-correlate with other service lines. For example, we have a cardio-oncology program, heart attack brain. So we work together so that everything that we do is really as seamless as possible. We are focused on operational excellence through focus on quality. And then this is just another example of our continuum of care. As mentioned, the only surgical programs, which is why they're in the center, is HMC and Jersey Shore. And then you can see how we're focused on from before you're ever sick, focus on prevention, wellness, all the way through that journey of home health care, as well as rehabilitation. We talk about, and we're very lucky to have a Center for Clinical Innovation and Discovery. Great things came out of that center working with our physicians and our teams during the COVID pandemic, as well as a great focus on enhancing those areas of reachers. As I mentioned, really wanting to be a part of every national type of meeting with our specialists, and everyone being able to support the learning that comes from those types of meetings with the team when they come back. And this is, once again, our continuum of care. As mentioned, wherever you enter our system, we want to get you where you need to go and in a timely way. And we're focused on tools that will help streamline that information across the network. It's been a journey in and of itself, taking EPIC across the organization, as well as we are currently working with the development of a true cardiovascular information system that will standardize our PACs, as well as our tools for structured reporting and access across the entire network. So the goal is to have any health care clinicians sitting in a chair be able to pull anything that they need without ever having to move. And we hope to have as few clicks as possible going in and out of the different types of systems. And the CTS is really, and that's what we call ourselves, our Cardiovascular Transformation Service. We are focused on closing the gaps. And that's what this team is all about. You'll hear us talk a lot about the clinicians at the bedside, the advanced practice clinicians working with database administrators, and our physician champions. And nothing was prepared for this talk, to be honest with you, that was just for this. I just pulled the tools that we're currently using. These are our actual tools from our strategic plan, our guiding principles. And I've just highlighted what's applicable to this journey with accreditations. Accreditations have never been about the shingle or saying that you're accredited. It's always been about the process. It's been about the patient. Bringing excellence to the bedside and using standardized critical pathways, guiding principles from our national societies to provide that care. And we definitely, absolutely have demonstrated, not just believed, that if we focus on quality, efficiency comes, as well as cost-effective care. And the one thing that I can say about this model, you know, I was lucky enough to be able to develop this model back in 1994, actually, at University Hospitals of Cleveland. I've had to adapt it and modify it everywhere I've gone based on its culture. But the true difference was being able to have advanced practice clinicians working with patients at the bedside to make a difference in the care while the patient was still there, as opposed to waiting for data to come back and then everybody's trying to make excuses about why this happened, why this didn't happen, so on and so forth. So it's really been the area that's made the difference. And getting our data to be truly what I would say real-time has also been one of the challenges, but it's one of the greatest benefits, to be able to have information long before your data tells you anything. And this is an organizational chart that's literally for discussion purposes only because it's always changing. It's always evolving. But it really shows you that the transformation service is at the top of the organization with reports to the chief physician executive, the chief operating officer, working closely with regional presidents, and the color in green is everything that is quote-unquote CTS, and everything in blue is everything related to hospital operations. And then you can see that I'm lucky enough to not just have for myself a network director, I also have regional directors. And in those regional directors, they are both blue and green, because that's actually how we take strategies and implement into the hospitals. And this is just some examples of the operational excellence, and everything that's highlighted in the light aqua blue color is related to what we're talking about, utilizing this information. And I will also share that the team that's involved with, whether you're working on the data side or you're working on the clinician side, we are the same team that's not just working on accreditation. That's who's developing and merging our clinical policies, procedures, protocols, together with those leaders from those departments in those areas. And we'll talk about more of that later. Literally every manager has to sign off that they've been a part of that policy and procedure, as well as the clinical leads when they were involved in those policies and procedures. We have to ensure that everyone has had input and that what we are putting together is going to work for the organization, as well as bringing it forward when it needs to be readdressed. I think it's also important to mention that with some of the processes that deal with the patient experiences, we also engross ourselves in working with developing those processes, as well as doing them or attempting to do them to see where they go right, where they go wrong, and how we can improve them for the patient care. And everything is done in a multidisciplinary approach. It's not just about the cardiovascular team. We're working across the hospitals. We're working at the corporate levels. We're working at the local hospital levels. Every campus has an acute coronary syndrome committee. Every campus has a heart failure committee. We have different versions of cath lab excellence that incorporate operations, as well as the components that are related to accreditation. And then it's the very same team that's working with our quality officers about U.S. News and World Report. We're very focused on that as an organization. CMS goals and being able to achieve those initiatives with the same team being a part of, they are the go-to for this particular population. And this model is very population-based. It is not unit-based. And these are just some of the collaborative subspecialists. And you'll see as we talk to get putting together a strategic plan, it's something that has to work with all those physician leaders and all those different specialties in alignment with the executive leadership, in alignment with the local hospital administration. And then together, you put forward the new partners of strategy and finance, a true strategic plan. And this is what we're working on right now to take this from 25 through 29. And then as mentioned, you know, this is not just about getting an accreditation. It's really what that provides and what that's saying to your community, your patients, as well as your own team. It's demonstrating you're at the highest level of excellence for that society. So we work with many, ACC, AHA, STS, IAC, so on and so forth. And we truly utilize those standards to develop our tools at the hospital level and working in alignment with our national societies. One thing that I think is probably unique to Hackensack Meridian Health is that two years ago, our physician leaders over every type of discipline were brought together, and it's called sprints. And these sprints were literally essential, viable, minimal essentials, is what they called it. So what do you absolutely have to have for the different kind of program that you are? So it was physician-led, physician-directed. I was able to be there as a participant, but we weren't the people that spoke. And with that being said, in cardiology, what really came out of it is that if we had a cath lab, all cath labs had to be able to achieve accreditation. Additionally, every program had to be chest pain accredited. And if you had a cath lab, you had to achieve the level of at least primary PCI, or you should not exist. And as an example of how we implemented that strategically, we closed a cath lab in January because we recognized in our state, we still have a licensure process, and a CN for cath lab. You needed to have two labs to do elective PCI. We were never going to get there. So we closed a lab. And then standardizing patient care. As far as standardizing patient care, I think I can speak to this a little bit. It's more about the guideline-directed care to optimize medical therapy for the patients. And this is something that we do every day, but the difference is we're not just looking retrospectively back at the patients. We're looking concurrently at what we're doing, and we're there real time at the bedside. We're developing our patient census every morning. We're taking a look at the patients. We're collaborating with physicians, with nurses, with patients, ensuring guideline-driven medicine is on the chart, ensuring standard diagnostic tests, lab tests are on there, making sure that collaboration is complete. And as APNs, we can put any medication that needs to be added when we speak to our providers. We could write notes in regards to what the patient is in need of or why they don't have certain medications. So real-time change, real-time action. The information that's gathered is analyzed also in a real-time function. We can see what's going wrong on our floors with our patients at that time and make actionable change. And we can also validate and work with the process retrospectively to work with the change for individuals, for a process for the hospital, or a process for the system change that's needed. Again, we're closing the gaps both real-time, working with the data to help us validate that those improvements are working. As far as our long-term future with our population-based medicine, we're now at bundles of care, development of care pathways, which, by the way, our accreditations have helped us standardize the care for our care pathways to help them be guideline-driven. This process is moving into our electronic systems like Epic, and we're able to follow the patient through the care that needs to be done through our process mapping, making sure that their echoes are being done, and also monitoring our metrics at the same time because they're embedded into the care pathways. So real-time look at the patient care and change. This helps us with reimbursement, quality of care for the patient, reduction in length of stay. It also helps us with reducing readmission rates greatly in the hospitals. »» And I think those are all things that your hospital's goals are set at as well as your quality departments are focused on, and they're our partners. »» And we also have to remember that, if you can go back just for one more second, that there are, we have to address the patient holistically. It's not just metrics and guideline-driven care. There are also social determinants of health. And when you're working as a network, those could be different in different locations. So when we're working together, these are also areas that we have to discuss. So when we develop protocols or process, we're looking at every area individually and then making our protocols and process so that it works for everyone. Also very important thing. Remember, those who are sick or well today will get sick tomorrow. So community is also a very important part of the care that we're doing. We want to mitigate and prevent illness from happening. And we want to also consider end-of-life issues by having our palliative care and comfort for those who are chronically ill and entering our facility. So these are all the things we're looking at real-time. And just some other examples with the team working. And I'll just give an example, heart failure. You know, we all know that oftentimes the individuals that have chronic heart failure, they're juggling, can they pay for their medicines? Or are they going to pay their gas bill and their mortgage? And so it's understanding and having the clinicians know those programs that are available to be able to get meds to beds, to be able to get a lower cost type of medication on board, as well as offering, even though they would not qualify for a regular home care visit, we are offering home care visits, at least one, to that patient that's a high risk for readmission. And that's on us, but it's really demonstrating we're interested in being sure you have what you need to be able to prevent a readmission, but make sure you're doing okay once you've gone home. And, you know, the other things that we've developed in alignment with this, with each of our hospitals, is we call them stopgap appointments. We all know that the best practice is to have a follow-up appointment within four to seven days. Oftentimes we can't get into those offices within that time frame. So we'll see those patients ourselves with our advanced practice teams. And that's developed differently at each hospital, but it's something that's coordinated throughout the network as one of the goals to help support the patient. Patients get ill. You know, our transformation care services are there to support these patients, but we find that there are multiple consultations that are on board for these patients and that affects the outcomes. Many different providers provide different care and treatment. That also affects what we're doing. So as APNs and the CVS team, we work in collaboration with our physician champions, our database administrators for outcomes and opportunities that we have in order to decrease that variability and work to close the gaps for best patient care. When we do this, we're developing works and standards that go throughout the network. We all communicate with each other. How are we doing this? How are we writing our notes? How are we capturing our data. All of these things allow for the different opinions from the different hospitals and help us to do the best we can for our patients along with the accreditation standards. So this is excellent actually. And as mentioned, it's really dependent on, I say, the three critical team members that are involved in developing this population-based approach across the organization. So we have an APN team, physician champions, and we have database administrators that are involved in managing structural heart to the TBT registry, for example, cardiac surgery, STS, working with our ACC Heart Failure Accreditation. We also work with the AHA's Get With The Guidelines. We are working with other elements right now. We are just launching AFib. It's our newest journey moving towards ACC accreditation for AP. And we've been a part of working with our cath PCI registries, cath lab accreditation for a while. But with each version, you're actually looking at the guidelines and you're pulling to your physicians how do we, and they'll give an example, CCTA, and being prepared for the transition that we all know is coming from diagnostic caths to more advanced imaging. And that's really a team approach. Everyone needs to be working off the same song sheet. There's also something too important to really mention about the structure and what we do. We have structural heart, cardiac surgery, LVADs, EPS. But when we're looking at our policies and protocols, some intertwine with one another. We all work with the departments to ensure that our policies and protocols are unified within the different structures that we have and not just one unit for chest pain or so on and so forth. And that's also done across the network where we can, when we can structure things. And then just as mentioned, you know, we utilize an APN model. And it's really because, you know, in my past experience more than in this organization, there were a lot of these initiatives were held by case managers. And case managers were always leaving notes for physicians. And who knows when they would have an opportunity to get around to that. And it's something that the clinicians knew needed to be changed. And by having an advanced practice clinician that is working in direct partnership with those physician champions, they're able to actually make that change while that patient is in the bed. And then in addition to that, they can contact and they're in a partnership with those physicians. They know who they are. They depend on them for the guidelines. And they actually help them understand what our definitions are. And you know, one of the things that was also important in my career as I moved under this model is that once upon a time I was told if you want to do care management, you have to do case management too. So it really helped my entire team to understand what coding was all about. Taking that 3M course about improving documentation and you learned that oftentimes the key words were missing for the coders because they were describing symptoms as opposed to the words the coders are using to actually, you know, develop how you end up having a case fall into one DRG or another. So it was really a team approach. And being able to have advanced practice clinicians be a partner to your physicians, you're able to achieve those initiatives. And I do have to say that in regards to being like a network or a system working on things, these processes do actually get easier. Your accreditations get easier. The use of your registries, the defining features where you're finding things, way of standardizing. You have a team working together with different ideologies, different ways of processing the way they treat from higher level educational facilities to community-based hospitals, being able to look at everything. And it just becomes easier to be accredited as a system, as a unit and work towards bigger and better goals. This is just an example. I'm not going to read everything on the slide. You could read that on your own time. But as a care coordinator, say for AMI, the AMI patient population, you're in STEMI. Your STEMI patient population is actually the chest pain. You also deal with low risk. You're looking at patients. You're managing the patient real time. It's targeted therapy. You're working with team members, multidisciplinary teams to talk about the different therapies that you have, what's going on, case management, social work, working with the patients, the physicians, understanding the importance of why we're doing what we're doing, building structures, standardized documentation, looking at accreditation, having ACS meetings. So this way, the multidisciplinary team can perform together, working as a unit on problem solving. We work with education, PI, research, pretty much on every committee because you can add a lot of value to your hospital and what you're doing. Just because it's an ACS patient population doesn't mean you can't move those concepts and theories over to other things that are happening in the facility and help them build and do better for standardization and organization. So the accreditation has helped us do all of that, which is a wonderful thing. »» And just to focus on what she mentioned with accreditation, this is just an example of the two tertiary centers and the U.S. New and World Report scorecard. And as everyone may know, five out of five is the highest score. And so, you know, looking at our TAVR performance, we were only three, three out of five. So that became our goal to find out, okay, number one, what's missing? Is there anything that we had as a gap? We learned even though we signed all the papers to publicly report our TAVR TVT information, we had not met the goal of that metric with having the three years of time with a certain kind of a test that was performed. So we had to focus on that. So then we got that achieved. And we determined that we were going to move forward with TAVR accreditation because it would allow us the opportunity to work with a college, get access to best practices across the nation, and be able to hopefully move that needle. So we are happy to report just recently this past spring, both of those campuses did achieve the accreditation for TAVR. And then this is just a little bit more. I'm going to let Jen go ahead and focus on it. These are just examples of that standardization of care. Just standardizing your protocols, your processes, your policies, utilizing evidence-based guidelines and the standards from accreditation in order to build our quality infrastructure to work with multidisciplinary teams in order to make sure that you're not missing any areas when it comes to policies or protocols or order sets. Developing dashboards that we can all monitor with and against each other to see how we're doing and why in order to be able to help each other process improve as we go along. I don't want to repeat myself, but the order sets and protocols and policies that we develop, we all have to come together and talk about the differences in each facility, what could be the same, how you cut the fat out of a legal document because it's becoming a policy, what you can develop into protocols. You're retiring hundreds of things that maybe could cause litigious type of work against you that you're improving for your system. And just to focus on that, in transparency, we retired 716 policies. And that was a team of people that have been working for about three years. I'm being able to read everyone, go through what's alike, what's different, how's this impact me. And, you know, it's actually my job is focused on that. It's focused on standardization. That's why you heard Jen talk about care pathways. We literally, it's been a journey for two years because of our lab moving to high sensitivity troponin and having that process go from hospital to hospital. It was necessary before EPIC would build the program for our network approach. And right now they call it a playground. It's at Jersey Shore. And everyone will learn from the gaps that they found. And then it will go across the network. We have two more that are coming out this year. That's heart failure and COPD. So at the end of the day, they want any patients that has acute coronary syndrome going into any one of our EDs to be treated the same way. You're going to have variation of care because everybody is different. But there are certain things that have to be done that are standards of care. And that's what care pathways help us with. The difference is when they're applied in EPIC, you can add discrete data formats that allow you to get your data that you need for national registries and to also highlight the things that are mandatory for that patient to have along the way in order to ensure best practices taking place. And then I'm sure this is no different than any place else. You know, one of the things I can tell you that's been fantastic about the college is that anything that we've done, we point to our references. And our references are the National Societal Guidelines, you know, very frequently. And this is just more of the same. And I think one of the things that when we have Jeannie give a few pieces of information about the actual data sharing, we have truly enhanced that. Because of this strategic plan and working in a regional approach and then a network approach because each of our regions is very different, you know, just depending and understanding New Jersey with all transparency. You know, we have different models of care. So for example, physicians, just as one example, we have many more employed physicians in our north region. In our central region, we have a lot of lease arrangements. Our south region is fiercely independent. So anybody who went to that most recent talk about putting this kind of accreditation guidelines in contracting, that's really very important because you're dealing with all different types of models. But what we can all standardize on is the ACC or STS metrics. This is the expectation for those populations. And as we've mentioned, you know, this has really been our vision of how we pull the entire cancer evasion service together. But in looking at that, we've actually been able to pull that into how we're actually going to spend our dollars. This helps us not just with the value of that, but the value that each person holds inside of doing these things. And I think that's what opens, you know, our working population's eyes to the need for change and standardization and support of these type of processes. So it's been a systems approach. And I have to say, this is something the college has been very, very helpful with us. Because as I mentioned, some were on different timelines. If they'd already just, and I'll give a great example, our cath lab accreditation, Hackensack University Medical Center last year had just gone through that. And so then here I come along and say, well, now the rest of the network needs to be re-accredited, but I need you to do it again. And you know, just imagine the team, that exasperation, what do you mean? We just finished that. What was great with the college is because they had just visited and physically had been onsite, we just needed to be able to update the data and ensure that anything that was done with the policies and procedures, the protocols, they were a part of it too, to be able to have that same systems approach. And that was a real onsite visit. It wasn't, you know, as doing it remote, which we did have a period of remote during the COVID pandemic. But just as you can see, it's been a system approach for all of these. And that is really, right now, we've just reopened the tool for the chest pain MI. I'm going to turn it over to Jeanne. Hi, I'm Jeanne Chikovas. I work with the manager for the Cardiovascular Registries for Hackensack Meridian Health. A newly appointed position, a position that was identified as needed during this transformation of the CTS cardiac system for the network. We had individual data teams at each of our facilities, and it became important that we brought them out of the individual sites and into a network development. And so my role was we had developed these informal communication groups across the network, but finally appointing me as the key person to serve as the point to bring all members of the data team together. I think we have six to eight hours of meetings a week with the different registries, and they troubleshoot, we provide case reviews, and basic day-to-day management and communication of an entire network and system. I think the most important thing as we look at why go it alone or an accreditation process, the one thing I can unequivocally share for everyone in this room is that what Elizabeth and Jeanne have laid out begins with very strong leadership and a very clear vision that was set out many years ago. I've worked with Elizabeth and Jeanne for over 12 years now, and that vision, bringing it to the Executive Committee of HMH, embraced it, have embraced a continuous quality review across the network, and are very interested in the outcomes, and we report now to them. For the very first time, I was tasked with presenting outcomes for all facilities across the network, beginning with the Executive Committee, and it was very interesting. Just to give you an example of how that went, we looked at metrics identified for process improvement across the network, and the two were the median time and minutes for PCI for STEMI patients and then PCI within 90 minutes. This is just an example, a very brief, abbreviated, straight-to-the-point graph that I was able to present for the Executive Committee, which identified each of our facilities across the network, their performance, individual facility performance, and then again that national benchmarking composite. They're very interested. They look at that data very carefully, comment, make recommendations, have made a recommendation that we move our benchmark to the 75th percentile, then that's communicated outward. So that's how we use that, and again, showing once again network performance, and that went from the Executive Committee down to the Executive Committees at each of the facilities. And so we're ensuring that there's accurate, comprehensive communication across the network and of what we're performing with. »» Yeah. And I mean, this is how we see, okay, well, you're doing 45 minutes. What are you doing differently? What are the dynamics? What's happening there? What could we adapt? What could we change? What could we not add? Because it's just different there. And how can we help the other institutions achieve that specific goal? You know, what could we do to support it? You know, we're at 50th percentile at 63, but we want to be at the 90th percentile. »» And I think the other thing that came out of those presentations to the executive level of the organization and not just the presidents and CMOs, it was stated to me to please take this information as part of the strategic plan to everyone that's involved. So it would be anyone that's a hospital administrative leader, those individuals that are over your quality departments, as well as the cardiovascular team. So as an example, one of the meetings that was just held, there was 136 attendees. And I was asked by my boss, do we really need 136 people? I said, well, you laid out the need to be a part of it. That's what it's going to take. And literally what it allows is when that information like this is shared, everyone's hearing the same thing at the same time across all levels of an organization. And it allows you to then, you know, you're asking questions, just as well, okay, so when was the last harvest? When's the next one due? What are you doing to address this? Immediate questions. Who's the medical director of this hospital? Who's the chief of cardiology? Because what it's going to do is transparency and accountability. I think that the next couple of slides are just overall defect-free care, how we do just in general over from a system perspective. These are things that we worked on early on. They were the most basics of care, you know, your aspirin, your beta blockers, your cardiac rehabs building into the system. Yes, we still have tweaking to do. But you can see that globally we're pretty much at the 75th to 90th percentile for everyone in the institution. That's a testament to the work that somebody is doing here. Jeannie is working fiendishly on educating where we're pulling data from. The staff is working at the bedside with the patient. And you can see as the work goes on that we're all achieving those things from those basic principles. But there's a lot of harder stuff that we're starting to tackle now as a system and get into the weeds to do it. And again, reporting up to our 2024 performance achievement awards across our network. And this is for just PNMI for 2024. Part of the reporting throughout the network, not only at the facility level, but network wide. And I think what was most telling with our executive committee, I don't think they understood what the amount of recognition we were getting at a national level across the network when they started to look at this in that initial presentation of seeing it side by side presented rather than from an individual facility perspective. And then again, our ACC public reporting, that was definitely a strategy of the network that we wanted to be transparent in all of our reporting. Each of our hospital CAGs signed consent forms to release all of our data elements for CathPCI and Chest Pain MI for public re-reporting in CardioSmart Find Your Heart a Home. And this is just showing you our outcomes for our sites for 2023 published in August of 2024 for CathPCI, and then moving on into Chest Pain MI. So again, all this information is shared quarterly with our executive teams. And then moving on, Elizabeth, you wanna take that? Well, I think one of the other elements that was really important is that as a CTS, we were asked, what is our demonstration of excellence? And for us, it was the American College of Cardiology's Heart Care Center. And JFK was our very first Heart Care Center, and now I'm proud to say we have six. And so, the goal is for every one of our programs to be able to meet that level of excellence. And I do have to say, that was probably one of the metrics that the top executive leaders didn't understand what that meant. A lot of these metrics, they just are used to seeing somebody like, as if it's a shingle, so to speak. And then when you explain what each one meant and what you had to achieve, it really made a difference. We had the only six that are in New Jersey. And with all transparency, at the time when we had this measure, there was only 59 in the United States. So that's something that actually they did not recognize, and so I think it's an accolade we're proud of. And there they are. And that is something you do have to do every year, but it keeps everybody on their toes. I mean, I have to say, that's one thing. No one gets to slack off. The next version's coming, and everyone's gonna work together. Now what are you gonna do? And we're busy working on that right now, because we're gonna go to see sneak peeks of the next versions. And this is just a tabulation of some of the accolades that I think we've been able to achieve. And very seriously, we're the ones here representing, but it's the team that's been able to do this. And there are so many that are participants in this team that aren't here, but really, this is about everybody. Everyone absolutely means everything. And we've got 31 plus of you here. So it's really a testament to the team. That's awesome. Awesome people to work with, just great collaboration between everyone. Just makes life a lot easier. And to tell you how it actually does translate into how your organization's gonna spend dollars, I'll just give you this one caveat, because through the PI projects in cath lab accreditation most recently, we discovered we were not reporting accurately with our radiation safety. So it caused Jeanne to work with the physicist to ensure every hospital was doing things correctly. And additionally, when you talked about it in those live meetings with your PI projects, you know, you get into the age of your equipment gets discovered and being able to reduce frames per second to be able to have that ability to still be able to view and reduce that radiation. One of our medical directors clearly came right out and said during that accreditation process, well, I can't go down to 7.5 because I won't be able to see. Well, okay, so Elizabeth, how old is the equipment? And then I had to provide, even though we had a capital plan, what every single hospital's age of the equipment is, because what was said by the very top executives, we may have to bump them up and replace that equipment sooner, because they now recognize the radiation dose and what impact that had on safety for the clinicians in the room, as well as the patients. Okay. Yeah. All right, Elizabeth, so we have tons of questions. We probably will not get to all of them, but we'll try to get them into the app. But I'm going to put Elizabeth on her favorite soapbox that I love to hear. There's a question here that says, how do you get the C-suite buy-in for accreditations when you are already receiving top-level awards in various registries? We hear the argument that it is not revenue-producing and it is too costly. How do you do it? So actually, I'll argue it is revenue-producing, because it actually is demonstrating you doing things in an efficient manager when you're focused on things like same-day discharge. Depending on when you are discharging those patients, you're going to cost more money. If you can get done same day, that's going to be advantageous. We were able to demonstrate through the calculator from the society during our chest pain accreditation that literally the executive was so amazed that the college had brought to us our metrics and actually ensured that we understood what the best way was going to be to incorporate that CCTA into that testing when you should do it. And he said, you got that from accreditation? I said, yes. And so that was pearl number one. And very honestly, you have to take the time to explain to them what it means, because when they understand all the different metrics that are involved, it's really providing perfect care for that heart attack patient. That's what you want to be able to say to your societies. After the pandemic, in transparency, we were getting back on track. They called it re-imagining. The entire organization went to what they called zero-based budgeting. You literally were justifying your existence. I had to justify the existence of the Care Transformation Service, not just mine, but the other three services, oncology, ortho, neuro, as well as cardiovascular. And we focused. I can tell you that slide deck has everything you're seeing related to those accreditations and perfect care. And when they wanted to now focus on US News Report and the other hospital goals, they wanted this team to quote, unquote, pivot. I said, no, I'm not gonna pivot. I am happy to embrace that additionally. But if they don't continue to do what they're currently doing, we will not be achieving what we are currently achieving. And I have to say, we definitely had the medical staff behind us. And one of the leaders at HUMC, the physician leaders of the cath lab, I mean, it was just in the sprints. He's the one I give the credit to, Dr. Badia. With all due respect, he said, you know, I did not know what we weren't doing because I know we've always had a great program, but you've actually, through this accreditation process, had us demonstrate things that we didn't focus on. And so it does improve. I mean, this is all about improvement. Now, accreditation is also focusing on those things that cost money. With readmissions, looking at cardiac rehab, the reduction in readmissions that you have when they have multiple visits, how you're tracking what you're doing, length of stay, same day discharge, all of these things bring back money to the facility, even though it's not directly related to the role. It's justifying the need for the role to keep monitoring and tracking according to those standards in order to be on track to get reimbursed properly. If you haven't seen the return on investment calculators, that'll be in the sneak peek session in this room next. So there's another great question here. Since your APP model is kind of unique, there's two questions in here. How did you get physician buy-in across the entire system for that effort? And was there any physician or administrative resistance to the APP model? So in the early days, yes, to both. As a matter of fact, I can still remember the meeting that was held where I was going up against a very beloved chief medical officer because he was requesting FTEs and so was I. And this is not, I am a nurse by background. I may be master's prepared, but I'm not advanced practice clinician. So in transparency, the president said, Elizabeth, can you take care of X, Y, Z while that patient's in the bed? Yes. Chief medical officer, no, because he had a nurse who was a case manager and they would leave that note for the physicians. I got six FTEs and he didn't get any. And the model's still there. And I will say that the first time that I ever developed this model, I was a pilot project at University Hospitals of Cleveland. And it was when the aggressive care path for the CABG patient population came out. And so I looked at the advisory board, saw that tool, the 10 points, and I went to the clinical nurse specialist in the day who was in the SIC. And I said, can you please tell me where we are on every one of these metrics? And when she came back, that's when I put together this model. And with all transparency, cardiac anesthesia, cardiac surgery, I was given by the chief what he called him the diamond in the rough. He was one of the youngest cardiac surgeons, but we developed three teams, pre-op, inter-op, and post-op. We literally reduced mortality, reduced length of stay, and we literally saved like $45,000. So it was a win, win, win. And that was really a demonstration that this kind of a model would work. And that's really been the foundation of it because I do think that once the C-suite understands what you're trying to do at that point of care, they'll see the difference. And now our lengths of stays are getting shorter and shorter. You've gotta have someone that's able to go see that patient immediately. Think about your PCIs. Most of them are leaving that night. Sometimes they're staying the next day, but you really wanna have someone who's focused to make sure they're on the right medications, we've done the right thing, and they're safe to go home. So this is another great question. So this might be a Jen, Elizabeth answer, but can you speak a little more on how you're analyzing real-time data versus retrospective data review? With our registries, most of the reviews are retrospective, 30, 60 days post-procedure, post-discharge. I'm curious, what are you doing upstream to make process changes real-time? We own our own data. I mean, we're looking at the metrics real-time. We don't go out to other people to communicate all of our data. We don't send it directly to the NCDR to upload and wait for their information. We're tracking it real-time ourself. It does get put into the NCDR, it gets calculated, and we get our quarterly metrics, but we're also monitoring it on a real-time basis. When we have fallouts, our administration is telling us, or our data team is telling us, you know, this patient went home without Plavix, or, you know, I mean, God forbid, we're trying to avoid, but you understand what I'm saying. We're not there seven days a week, 24 hours a day, so we are gonna have to retrospectively review, but concurrently, we can see our trends and how we're doing. Oh, you know, we saw 46 MIs this week. We get census data, and at the end of the day, we get discharge data. You can track what's going on with those patients real-time. You have the metrics, you know what you're identifying, so you're able to see more of a real-time perspective of what's happening. It's with the guidance of the NCDR that we're able to do it real-time, but then when it gets validated and comes through the NCDR, then we have the backing of the national average and the support to what needs to get done for a further change. So that's really how we do it, and we can see it. Oh my goodness, this patient has no beta blocker on here. You know, this group is consistently not supplying this patient with the correct medication. I need to talk to this group, or I need to talk to the chief medical officer. I'm seeing a trend. Nobody is ticking the box in cardiac rehab. Why is this happening? I need to go back to the order sets or report to the section. So it may not be a calculation all the time, but you can see the processes that are identified for metrics being done or not being done, which helps us with process. Because you do have individuals walking the floors. They're able to tell you what's going on. They're seeing the patients, and they're gonna let you know something's up, something's happening. You're not sure exactly why. It may be, just as Jen said, somebody new when the fellows come on every July. You're part of training them also so everyone knows what to look for. Exactly, it's not just us. We're working with other cardiologists, nurse practitioners. We're working with case management, or outcomes nurse practitioners, or physicians, or physician assistants. Anybody who will hear us or listen to us as we're walking down the road, this is what has to be, this is what's going on. I mean, you get the ear, you get the attention. People start thinking about it. I'm like, hey, doctor, doctor, so-and-so, you're missing the reason why you're not putting them on a beta blocker every single time I'm seeing this. Not in front of everybody, but it's, they don't wanna be the one. You know what I mean? Yeah, they're very competitive. And so they're very, you know, so you're working with people, and once there's an awareness, you create that awareness, it spreads like an infection, a good one, but, and it works, you know? And the reason that they're population-based is if a patient ends up being on a unit where, you know, they have heart failure and they're having exacerbation, you wanna make sure that that APN that manages heart failure is alerted that that patient is on that unit. That may not be where that person normally goes. And so that's an additional support, educationally, ensuring the guideline-driven care is also being delivered. And you know, when I first did develop this at University Hospitals of Cleveland, there wasn't a unique program put in place, but, and it was the executive for nursing. Her name was Charlene Phelps, and it was called Partners in Practice. It was a model of delivery that we had that this plan that I was working with really helped support. When you think about Partners in Practice, it's everyone on your team. It's your care technicians, whatever they call them in your organization, in addition to the nurses, advanced practice pharmacists, everyone together focused on a population to really bring best practice guideline-driven care. And nothing is without challenges or problems. It's not perfect. We still have issues and things fall out and things happen. You know, people have other things in their institution, nurse navigators. You have to work with the process that you have, what you have. The availability of people that you have and how you can adapt the process based on accreditation and your metrics to make it work or flow for you. So, I mean, this is a great model because we can produce the real-time change. I can write that prescription if it's not there. I can document why they're not having the medication because I can see it myself. I'm a clinician, I'm a provider. So I can do that to support the team. And I know the accreditation and the standards. If it can't happen that way, you adapt and you work to try to make that process work the best you can while attempting to employ the model that you really want. And to the second question, I don't think I answered that, but I will tell you this, absolutely, you are correct. In the beginning, I did get pushback from physicians because it was viewed, this is a dot-cop. And it wasn't until, you know, I said, that's the whole point of it. I don't want us to be the dot-cop. We're your partner. And truly when they got to know the individual clinician over that population, they now go to them for assistance with this, as opposed to in the beginning. You know, in the very, very beginning, you had to prove it. You know, it really was all about, prove it to me that you're really interested. And when they would see some of the clinicians coming, it was like, you know, here she comes. Where's your dissertation to prove that this is right? But we have the evidence, so our teams back us. And you know, it was the medical director, who is now a medical director of CTS, but at the time he was the chief of cardiothoracic surgery and then a medical director for the service line. He said, are you guys crazy? This is free help. You know, these are people that are here to help you and help our hospital improve. It doesn't cost you a thing. So in transparency, we also train and assist the individual private practice advanced APPs, whether a PA or an APN from our private practice groups, because they're in the hospital too. They are also our partners. They're oftentimes seeing the patient as opposed to that physician. So they are a part of your team. So one of the questions was, where does your CV, APN enter the patient's journey? Do you do both inpatient and outpatient, or how do you key into that patient when they enter? Right now we have to be inpatient, but I'm going to answer this one because I just love the fact that the accreditation allows us and even the NCDR allows us. Well, you moved into this patient with heart failure because of the clinic. Right, and the clinic is one of those things, but we're working with community. We do the education, we're supporting. Where we function most is the beginning to end of patient care. We can come in wherever we need to. You know, if we're there when the patient's coming through the ED with a STEMI, guess what? I'll be down there. I want to watch the process. I want to work. And if they need me to take the patient up, guess what, I can. You know, so, I mean, we can be as involved as we want to be. We can start and end wherever we need to, but rest assured that our hands are in every part of the pot from transition, you know, from coming in to transition out to home. You know, can we be involved in everything? No, but we certainly can communicate and collaborate with everybody from EMS to hospital at home or whatever it is that you want to do. We collaborate, invite them into the multidisciplinary teams, look at what things are happening, and try to support every aspect of what's going on. And in turn, they support us. So the answer is really we get involved everywhere. We want to be involved everywhere we can. We want to support everywhere we can. But our greatest level of function is in the hospital to ensure best practices being done. And when the patient is discharged, they're going home with the proper stuff and things that can prevent them from being readmitted. And I will say one of the testaments that I at least know that there's support for this model at chief medical officers level. I had one at our community hospital go right to my boss and said, Elizabeth needs more FDs because she can't deal with the fact when they're on vacation, they're even at this meeting because things do change at the bedside when they're not there to help support care real time. So I know there's some more questions in the chat. We won't have time to get through them all, but we'll share them with the team and we'll try to get those questions answered for you guys in the app. I would like to thank you guys for your time today. Incredible opportunity to give them what you work with at Hackensack Meridian. Thank you all. Hope to see you later. Thank you all. Thank you.

Hackensack Meridian Healthcare

hospital accreditation

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