Latest / Becker’s Healthcare - Clinical Leadership Podcast / Transforming Serious Illness Care and High Reliability at Geisinger with Dr. Narayana Murali

Transcript

Transforming Serious Illness Care and High Reliability at Geisinger with Dr. Narayana Murali · Becker’s Healthcare - Clinical Leadership Podcast

• 0:01
  Every year, Becker's annual meeting brings health care
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  leaders together to unpack the most pressing issues
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  facing the industry.
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  And every year, those conversations shift in profound
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  and unexpected ways.
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  This April, more than 3,500
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  health care executives will return to Chicago
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  for Becker's sixteenth annual meeting.
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  795
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  elite speakers will offer new lessons, new case
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  studies, and predictions about what comes next.
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  Join us April 13 through the sixteenth.
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  For the agenda and event details, visit beckershospitalreview.com
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  and click on the events tab in the
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  upper right.
• 0:37
  This is Laura Dirda with the Becker's Healthcare
• 0:40
  podcast. I'm thrilled today to be joined by
• 0:42
  doctor Marley, chief medical officer at Geisinger Clinic.
• 0:45
  Doctor Marley, it's a pleasure to have you
• 0:47
  on the podcast today.
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  Such a pleasure to be here, Laura. Absolutely.
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  Now I'm excited for our conversation because I
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  know Geisinger is such a innovative organization and
• 0:55
  and truly,
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  an area where in health care, you know,
• 0:58
  there's so many opportunities to do things differently
• 1:01
  and use technology as well as transformational efforts.
• 1:04
  And so I'm excited to learn more about
• 1:05
  what you're doing at Geisinger. But before we
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  do, can you introduce yourself and just tell
• 1:09
  us a little bit about the health system?
• 1:11
  Sure.
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  So I am a nephrologist
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  by trade and serve as the chief medical
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  officer at Geisinger Clinic.
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  And Geisinger as an organization is an integrated
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  health system that has a very broad footprint
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  across Pennsylvania.
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  We serve some urban areas, but largely rural
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  communities
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  across
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  Central,
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  Pennsylvania.
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  Today, we care for approximately
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  1,200,000
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  unique lives,
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  across the clinical enterprise. And this would be
• 1:40
  the hospitals. It would be the ambulatory care,
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  the post secured care, the home based services
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  that we provide including our health plan.
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  While that skill gives us opportunity
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  and a responsibility,
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  it
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  lays out the need for us to design
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  care models,
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  that are clinically excellent,
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  but also deeply patient centered
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  with a great focus on zero harm and
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  high reliability
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  where safety is our core value.
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  I hope that that provides you some sense
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  of who we are as an organization.
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  Oh, absolutely. And I I think, you know,
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  having that ability to design those care models,
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  think about clinical excellence, and then really define
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  it as zero harm and high reliability,
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  you know, is truly a huge goal and
• 2:26
  a huge undertaking. And so to see how
• 2:28
  successful
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  that you've been at Geisinger, in achieving those
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  things is is, really inspiring.
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  Now I was wondering wondering if we could
• 2:36
  zero in on the last year or so.
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  Could you tell us about the most important
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  initiative that you led? What did you do,
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  and what were the results?
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  Yeah. So my my role is actually
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  bringing physicians,
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  clinicians,
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  nursing, as well as operational teams altogether and
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  greasing the skits. Right?
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  There are several projects that we've been involved
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  in, whether it is related to access,
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  new patient access, whether it's care redesign,
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  whether it's innovative care models,
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  so on and so forth.
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  But I think the most meaningful initiative for
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  me this past year has been a system
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  wide redesign
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  of our approach to serious and advancing illness.
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  The work is sorted
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  on a very simple but uncomfortable truth.
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  While everyone agrees that advanced care plan conversations
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  are important,
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  they often happen late,
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  are inconsistent,
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  or do not happen at all.
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  Most people want to die at home surrounded
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  by the comfort of their
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  family as well as the familiarity of the
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  home, and yet
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  only a very small fraction of people actually
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  do.
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  This means more to me because I lost
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  my mother this past year and my mother-in-law
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  the year before, both of whom who died
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  at home.
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  For our seniors, that cost
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  of that disconnect
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  between their desires
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  to what really happens
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  is
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  enormous.
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  Too often,
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  we as clinicians
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  fail to involve patients and families early in
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  a shared decision making,
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  and these conversations are hard. They're not easy.
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  They compete with many other clinical priorities in
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  practice.
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  And when they happen too late,
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  patients are deprived of a chance to develop
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  prognostic awareness
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  to reflect on what truly matters to them
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  and shape the care of
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  the process
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  as well as the support to preserve quality
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  of life.
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  So but when it's done well and when
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  it is done early,
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  those conversations change everything.
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  They improve outcomes,
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  related to disability, related to pain,
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  treatment invasiveness. They address mood and psychological distress.
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  And they also actually help families to see
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  death as a non traumatic event,
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  not as a failure and as a natural
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  outcome of serious illness.
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  And so importantly, it reduces
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  unwanted in hospital deaths and very late referrals
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  to hospice where patients can find comfort and
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  improve quality of life.
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  Yet there is a paradox. In our entire
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  country, this paradox exists.
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  Everyone knows that these conversations are important.
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  And when everyone knows these conversations are important
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  and it becomes everyone's job to address it,
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  it becomes no one's job to do it.
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  They go far beyond delivering bad news. Right?
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  They translate directly into medical decisions. They require
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  coordination across settings.
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  And in the absence of clear medical guidelines,
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  clinicians are left to balance between patient autonomy
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  and non maleficience,
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  something we do imperfectly and for that matter
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  the whole country does imperfectly.
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  So we started to establish a very clear
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  baseline
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  and I think it was important for us
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  to know how effective we were,
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  in terms of our advanced care planning
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  with our senior bundles.
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  And what our dashboard showed is that we
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  haven't budged our numbers
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  beyond five percent until a year ago.
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  Those numbers made that very, very real.
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  And so what we did is we looked
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  at it clinically and operationally.
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  We focused on care fragmentation.
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  We focused on patient experience. We focused on
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  end of life outcomes, and we completely redesigned
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  the model end to end.
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  At the core of this model,
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  we have a very high touch,
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  tightly integrated clinical model
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  designed specifically to care for the sickest of
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  our sick.
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  We embedded a very focused team with very
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  deep palliative expertise
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  and clear clinical oversight to partner with patients
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  who have a predicted life expectancy
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  of twelve months or less
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  using a validated predictive tool.
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  The team works alongside with the patient
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  and basically goes throughout the entire last mile
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  of their journey.
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  The role is not scripted at all. It
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  is a series of conversations that happen longitudinally
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  and help patients
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  cope with their serious illness and the enormity
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  of their illness through a continuum of conversations.
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  These conversations are delivered reliably and consistently.
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  And whether the patient's at home or in
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  a post acute setting, it does not matter.
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  This team actually focuses on that.
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  And the intent is very simple. Right? Give
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  patients and families time.
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  Time to cognitively and emotionally
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  understand and process the prognostic information.
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  Time to oscillate
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  naturally
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  between
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  hope and realism and type to adapt.
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  So the work did not happen just like
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  that. It took a village.
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  In fact, it required our ethics teams to
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  come together
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  to review our tools,
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  the College of Health Sciences from the standpoint
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  of cascading education,
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  multidisciplinary
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  clinical teams, specialists in palliative care, the hospital
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  partners, the nurses,
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  and the nursing leaders all stacked hands
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  recognizing both the urgency as well as the
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  complexity of the work.
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  Along the way,
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  we confronted real challenges.
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  Okay. It was difficult to actually cascade that
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  education
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  on dying with dignity
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  because we had imperfect triggers.
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  And the care was very, very fragmented between
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  the inpatient, the outpatient, the post acute, as
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  well as the home settings.
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  So we also had to acknowledge that
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  there was a hard truth.
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  The truth was that we commonly used a
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  surprise question, and the surprise question was asking
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  our physicians and clinicians
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  whether they would be surprised if this patient
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  died in one year. And realized that that
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  was a very imperfect signal when patients and
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  family needed
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  deeper support.
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  So what we did is we pulled in
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  our my care choices team.
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  We helped explore
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  the elements that really matter.
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  We went through that process intentionally
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  and then wanted to get to real change.
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  This far, we've enrolled about 1,800 patients or
• 9:10
  so of the highest risk sickest of the
• 9:13
  six seniors.
• 9:14
  The book focused on exploring their hopes, their
• 9:17
  worries, their grievances,
• 9:19
  their clarity on priorities, as well as building
• 9:22
  coping skills to live with the serious illness
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  at home. And as I said, this is
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  not a single conversation. This is a very
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  iterative process that unfolded over months.
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  And as patients integrated that information,
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  they understood the trajectory of their illness
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  and started to focus on what matters most
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  to them.
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  Those things translated to clear goals and values
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  of shared decision making for them as well
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  as our teams. This was a huge cultural
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  chip. So we started with about a five
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  percent bundle rate,
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  and now we are holding at about forty
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  five to 50% of our identified patients completely
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  engaged in the process.
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  And
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  in the recent snapshot
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  of the thousand or so patients who had
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  been completely engaged,
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  we recognized that close to about a third
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  of them had celestial ascent.
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  And of the third, 50% of them spend
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  their time in hospice with an average hospice
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  time of approximately thirty days. So a significant
• 10:24
  shift from where we were. And this to
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  me was the most meaningful initiative
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  that we've had from my perspective.
• 10:31
  I I know this was a very long
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  response, Laura, but I thought it's important to
• 10:35
  lay out the the elements.
• 10:38
  Yeah. Absolutely. No. That was fantastic. And I
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  really appreciate you going into detail about how
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  you put this together and and why it
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  was so important and critical,
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  because I think it's something that, you know,
• 10:49
  many,
• 10:50
  hospitals and systems overlook or or just continue
• 10:53
  to handle this patient population in the way
• 10:55
  they always did, which is high cost and
• 10:57
  not exactly, as you mentioned, you know, what
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  the patients or families want,
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  in the experience for the the end of
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  their life. And so I know it's so
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  critical having these conversations and putting these systems
• 11:07
  together. And, you know, I I appreciate you
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  also mentioning all the the number of folks
• 11:13
  that are involved in, putting this together, whether
• 11:15
  it's the clinical
• 11:17
  leaders as well as the ethics teams and
• 11:19
  and everybody else just to make sure it's
• 11:21
  done in the right way, in a meaningful
• 11:22
  and a compassionate way too,
• 11:24
  because it's
• 11:25
  a a a very challenging time. I know
• 11:27
  in the patients and live lives of their
• 11:30
  family members too. And so,
• 11:32
  it makes a big difference. Now when you
• 11:34
  think about the future, where do you see
• 11:36
  the, system heading? What are some of the
• 11:38
  big priorities and headwinds that you have your
• 11:39
  eye on for 2026?
• 11:41
  Oh, there are several. But but I think
• 11:44
  I think when I think about it,
• 11:46
  perhaps the most important piece
• 11:48
  for us to scale
• 11:50
  what we need to do as an organization
• 11:53
  is the physician APP alignment.
• 11:55
  Right?
• 11:56
  I think the care team realignment
• 11:59
  and having the teams practice at the top
• 12:01
  of our license is a refrain that we've
• 12:03
  heard for a long time. But in reality,
• 12:05
  that alignment and engagement is probably one of
• 12:08
  our biggest opportunities.
• 12:10
  The other pieces that come along with that
• 12:13
  is workforce sustainability.
• 12:16
  Trying to use data or, you know, what
• 12:18
  is right now the buzzword AI,
• 12:21
  in terms of services.
• 12:24
  Access redesign,
• 12:25
  which is again
• 12:27
  a bread and butter element, but looking to
• 12:29
  figure out how we can actually improve access
• 12:33
  for our new patients and more importantly,
• 12:36
  continuity of care that is not episodic or
• 12:39
  fractured
• 12:40
  is is another element.
• 12:42
  We have other areas that we are working
• 12:45
  on as big ticket,
• 12:46
  issues
• 12:47
  related to clinical pathways,
• 12:50
  having a pharmacy led management,
• 12:52
  and then focusing on patient experience,
• 12:54
  particularly as it relates to their likelihood to
• 12:57
  recommend as the primary signal
• 13:00
  that we follow from the standpoint of care.
• 13:02
  Now none of these topics that I'm sharing
• 13:05
  with you are new topics. These are topics
• 13:08
  that have
• 13:09
  been things that we are working, but we
• 13:12
  are reengineering these all and again to address
• 13:15
  what needs to be done.
• 13:17
  Now in terms of your question related to
• 13:20
  headwinds,
• 13:21
  I think the
• 13:23
  biggest headwinds
• 13:25
  are workforce constraints. Right? The changing mix in
• 13:28
  terms of physicians versus,
• 13:31
  APPs or clinicians,
• 13:33
  and then clinician fatigue. Because now you have
• 13:36
  sicker, older patients in the hospital setting,
• 13:39
  particularly in a rural environment where there are
• 13:41
  also financial challenges and challenges of social determinants
• 13:45
  of health,
• 13:47
  that is substantial.
• 13:49
  That
• 13:50
  is in
• 13:51
  further it is kind of tied in with
• 13:54
  the financial pressures of the decisions that are
• 13:57
  coming down the federal as well as the
• 14:00
  state,
• 14:01
  related regulations
• 14:02
  and support from the standpoint of health care.
• 14:05
  And then aligning
• 14:07
  what is required
• 14:09
  from the standpoint of clinical care with the
• 14:11
  patient,
• 14:11
  and what the patients actually want.
• 14:13
  So so those, I think, are the big
• 14:15
  headwinds that one needs to think through,
• 14:18
  from the health care landscape.
• 14:20
  I love that. I think all those things
• 14:22
  you mentioned are are so critical, and especially
• 14:24
  the workforce piece. That's something I hear time
• 14:26
  and time again from leaders across the board
• 14:28
  who are trying to
• 14:30
  design a system of more collaboration, more alignment,
• 14:33
  more, connecting points between physicians,
• 14:36
  APPs, and and clinicians across the board and,
• 14:39
  you know, their nonclinical counterparts as well to
• 14:41
  make this whole system work.
• 14:43
  I'm curious. What do you think the hardest
• 14:45
  thing you'll have to do in the coming
• 14:47
  year will be?
• 14:48
  That's a tough question because there are so
• 14:50
  many things that are coming down the pipe.
• 14:53
  But I think the most important,
• 14:56
  thing will be driving behavior change at scale.
• 15:00
  At the heart of our mission,
• 15:03
  we have an unwavering commitment to bring high
• 15:05
  reliability,
• 15:07
  which really means we are pursuing
• 15:09
  zero harm and embedding safety in every aspect
• 15:13
  of our care because we believe that that
• 15:15
  is the driver of trust.
• 15:17
  Achieving excellence without exception
• 15:20
  every time is not just an aspiration,
• 15:23
  but it is a core expectation
• 15:25
  of our leadership.
• 15:27
  Our CEO has set the stage in terms
• 15:29
  of what is important,
• 15:32
  and the entire executive leadership team is working
• 15:34
  on excellence without exception.
• 15:37
  And when I mention zero harm, I'm not
• 15:40
  talking about
• 15:42
  zero events,
• 15:44
  but really talking about
• 15:46
  zero errors
• 15:48
  from the standpoint of zero harm. And we
• 15:51
  wish to ensure that every patient, every family,
• 15:54
  every team member can trust
• 15:57
  that their well-being is our highest priority
• 16:00
  And that our systems, our process, and the
• 16:03
  culture are aligned to support
• 16:05
  safe,
• 16:06
  reliable, and exceptional care at every encounter. So
• 16:10
  that probably
• 16:11
  is the biggest piece. All of those are
• 16:14
  behavioral
• 16:15
  change elements
• 16:16
  because it needs
• 16:18
  both our clinicians,
• 16:19
  our nursing teams, as well as our entire
• 16:22
  staff
• 16:23
  to rethink
• 16:24
  long standing habits.
• 16:26
  When do we intervene?
• 16:28
  How do we talk about prognosis?
• 16:30
  How do we define success?
• 16:32
  What really matters?
• 16:34
  How do you understand this from an empathetic
• 16:37
  angle?
• 16:38
  And then stop being heroic or reactive, but
• 16:41
  really focusing on being intentional,
• 16:44
  and anticipating
• 16:46
  care and providing that care
• 16:49
  with hope and compassion.
• 16:50
  So that's really the fundamental change. So changing
• 16:53
  culture is probably the most important thing in
• 16:56
  my mind.
• 16:57
  I love that. And I know much easier
• 16:59
  said than done. And when you look at
• 17:01
  that culture change needing to make the shift
• 17:04
  and wanting to zero in on that high
• 17:06
  reliability,
• 17:07
  zero harm, culture and mission,
• 17:10
  how do you do that,
• 17:12
  in, you know, have that mission out in
• 17:15
  front of folks,
• 17:16
  communicate that, and then really hold that bar
• 17:19
  high, as you're going through these changes in
• 17:21
  in in different
• 17:23
  team members might be in in different places
• 17:25
  in terms of how easily and and quickly
• 17:27
  they can adapt and others who maybe are
• 17:30
  holding on to the way they always had
• 17:31
  done things, differently. So, I'm curious. How do
• 17:34
  you manage all of that, especially in an
• 17:36
  environment as we talked about that, you know,
• 17:38
  finances are tight, a lot of changes in
• 17:41
  all the other dynamics that are happening in
• 17:42
  the health care space today?
• 17:44
  Yeah. As I shared before, our CEO as
• 17:46
  well as the executive leadership team has made
• 17:48
  complete commitment to that. So, basically, we are
• 17:51
  bringing all our leaders for training on HRO
• 17:54
  and zero harm.
• 17:57
  Every staff member with about 1,100
• 17:59
  sessions
• 18:00
  are going to go through this program
• 18:03
  on the education
• 18:04
  as well as understanding
• 18:07
  what this really means and what should be
• 18:10
  the change in the strategic mindset to deliver
• 18:12
  on that.
• 18:13
  But
• 18:14
  rooted in all this is the process of
• 18:16
  just culture and all the safe tenets of
• 18:19
  what a high reliability organization is.
• 18:22
  And so,
• 18:23
  that's really how we're going about the process.
• 18:25
  It's going to be a journey. It's gonna
• 18:27
  be a journey of this next year, but
• 18:29
  that's really the biggest
• 18:31
  area of focus for us as an organization
• 18:34
  for this year towards the end of this
• 18:36
  year.
• 18:37
  Absolutely.
• 18:38
  Makes a ton of sense. Thank you for,
• 18:40
  sharing with us. Now before we wrap up,
• 18:42
  I have one more question. Where do you
• 18:43
  see some of the best opportunities for growth
• 18:45
  in the coming year or two?
• 18:48
  I think I can give a standard
• 18:50
  response of saying that, well, growth can be
• 18:52
  on clinical excellence, it can be on patient
• 18:54
  experience, it can be on value based care.
• 18:56
  But I I really think it is at
• 18:57
  the intersection
• 18:59
  of all these three elements.
• 19:01
  Specifically when I think about it, I think
• 19:04
  that,
• 19:05
  much of the growth has to be in
• 19:06
  home based care models where we can deliver
• 19:09
  better care and better outcomes
• 19:11
  and also on the patient preferences.
• 19:16
  We think that there's opportunity for integration across
• 19:19
  the continuum. I shared with you how fractured
• 19:21
  health care is across the country.
• 19:23
  There is opportunity in terms of partnerships, both
• 19:26
  external and internal.
• 19:28
  We don't need to build every wheel.
• 19:30
  We can buy the wheel off the shelf
• 19:32
  and actually move things faster.
• 19:34
  And then more importantly, developing our leaders as
• 19:38
  well as our teams so that they are
• 19:40
  comfortable
• 19:41
  operating in a space of ambiguity and complexity,
• 19:45
  and also recognize our unwavering commitment to
• 19:49
  high reliability organization
• 19:50
  with safety as its core value.
• 19:53
  Ultimately, the growth for us isn't about size.
• 19:56
  Right? It's really about impact. And if we
• 19:59
  can consistently deliver that care to our patients,
• 20:03
  that we would choose for ourselves and our
• 20:06
  families
• 20:07
  and deliver that excellence without exception,
• 20:09
  we will have succeeded.
• 20:12
  I love that. Thank you so much, doctor
• 20:13
  Murali, for joining us on the podcast today.
• 20:15
  This has been such a fascinating discussion.
• 20:18
  I I really learned a lot, and I
• 20:19
  can tell you're so passionate about what you
• 20:21
  do. So, thank you for the time, and
• 20:23
  I look forward to seeing you as well
• 20:24
  in April. I know you'll be speaking on
• 20:26
  one of our panels at the annual meeting,
• 20:27
  and so it'll be great to catch up
• 20:28
  and dig a little bit deeper into all
• 20:30
  of the things we talked about today.
• 20:32
  Thank you, Laura. You've been exceptional and kind,
• 20:35
  and thanks a million.