Latest / Becker’s Healthcare - Clinical Leadership Podcast / Dr. Heidi Wald, Chief Quality and Safety Officer at Intermountain Health

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Dr. Heidi Wald, Chief Quality and Safety Officer at Intermountain Health · Becker’s Healthcare - Clinical Leadership Podcast

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  - This is the Becker's Healthcare Podcast, created
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  by the team of Becker's Healthcare,
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  Thanks for listening. Now here's the episode.
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  - This is Laura Dedo with the Becker's Healthcare Podcast.
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  I'm thrilled today to be joined by Dr.
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  Heidi Wald, chief Quality
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  and Safety Officer at Intermountain Health.
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  Dr. Wal, it's a pleasure to have you on the podcast today.
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  - Great. Good morning. Nice to be here.
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  - Now I'm really looking forward to our discussion.
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  We'll be talking a lot about quality improvement,
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  especially thinking about the OR and ICU.
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  But before we dive into that discussion,
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  can you tell us a little bit more
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  about yourself and your background?
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  - Sure. I am an internal medicine doc.
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  Um, I am, uh, I have a subspecialty in geriatric medicine
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  and a background in health services research
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  and also health policy.
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  I, uh, spent much of my career in academics until about, uh,
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  five and a half years ago.
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  Um, and that academic career was always actually focused on
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  quality and safety as my area of interest.
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  Uh, I helped run, uh, co-lead for my clinical work, um,
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  and acute care for the elderly inpatient service,
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  where a lot of what we did was focus on
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  mitigating the risks associated with hospitalization
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  and illness in the frail elderly.
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  And that just was a, obviously a natural,
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  my clinical work was a natural connection to patient safety
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  and quality, um,
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  and started to really move, um, through, uh,
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  pilot projects into implementation, science types
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  of research, and then ultimately also into leadership roles
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  in the Department of Medicine where I was at, um, university
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  of Colorado about five years ago, uh,
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  five or five, six years ago.
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  I left there
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  and, uh, took a role,
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  which ultimately ended up being a chief quality
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  and safety officer role at SEL Health.
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  About a year and a half ago, SEL Health merged
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  with Intermountain,
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  and I was honored to take on the lead role, uh, same title,
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  uh, with the much larger organization.
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  - That's amazing to hear.
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  And what a great career journey I could imagine, you know,
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  especially going from, as you were talking about, um,
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  just really some of the projects
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  and initiatives you were doing with the,
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  the elderly population
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  and then into, you know, working
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  with SDL Health and now Intermountain.
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  How has that transition been since merging in
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  with Intermountain and really, um,
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  now having accountabilities over a, a very broad,
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  uh, health system?
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  - Yeah, well, it, it certainly has been a journey.
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  First was the journey from academics, um, into, you know,
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  more operations, um,
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  and then the journey from a, you know,
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  smaller health system, um, to a much larger organization.
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  Uh, so the, you know, what was interesting about
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  the kind of alignment with SEL Health
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  as it integrated inter into Intermountain is in
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  the quality space.
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  We had been on, uh, similar journeys over the past five
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  or six years, I would say.
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  We were taking different approaches, uh, to those journeys.
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  And so a lot of the work of integration
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  has been figuring out how to merge the
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  way we approach things.
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  And that's, you know, that's not easy work,
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  and we feel that, you know, we need
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  to have a one Intermountain approach.
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  It, it's more efficient, more effective, more able
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  to move the needle quickly,
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  and when we need to adjust to improve quality, uh,
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  and, um, improve safety for our patients.
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  - Well, that's great to hear. And can you tell us a little
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  bit about your quality improvement programs?
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  How are you optimizing patient care?
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  - Right, so that is a short question,
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  and there's really not a short answer to it, .
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  So I'd say, you know, we're, it's a pleasure
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  to be in an organization that so
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  prioritizes quality, safety, actually safety, uh,
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  if we think about our fundamentals of care
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  that we focus on at Intermountain, safety, quality,
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  patient experience and equity, and from, you know, uh,
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  and then there are four additional ones,
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  but the ones in the space
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  that I focus on are the first four.
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  Um, and so it's such a, you know, a pleasure, um, to know
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  that our leadership
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  and our, all of our caregivers really prioritize safety
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  and quality and patient experience above all else.
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  Um, uh, not that there aren't other important priorities,
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  and I'll, I'll, I'll loop in their caregiver experience
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  as well, caregiver and a physician and APP experience.
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  But the, um, I, as I was thinking about how to answer
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  that question, I think there are maybe three, um,
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  major points that I wanna make.
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  One is, how do we make big changes
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  and alignment as to, to make sure we're aligned
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  with evidence-based practice, especially
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  as evidence-based practice evolves over time.
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  Um, so that's kind of a macro view.
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  How do you make sure that, you know, you are
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  executing on the best evidence, um, in a way
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  that's consistent across the whole organization.
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  And that's really what Intermountain is known for.
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  That's what, um, Brent James kind of put us on the map for,
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  um, in terms of, you know, establishing
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  clinical leadership that identifies best practice,
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  identifying how to measure that, right?
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  And then looking to make sure that we are doing
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  what we say we're gonna do in terms
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  of meeting those process measures and outcomes
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  and making sure that we're structured,
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  uh, to do that the right way.
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  So that's the, the macro. Um, and we still do that.
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  The way we do that has evolved over time.
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  Um, but the, and I could take, you know, an hour
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  and describe work of many colleagues.
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  Um, uh, but I'll, I'll stop there,
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  but kind of macro, how do we, um, stay aligned
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  as a big organization and move, uh, the needle?
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  The other is, I would say micro Intermountain also is known
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  for being really a strong operating model
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  and baked into the Intermountain operating model is,
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  are the concepts of high reliability, right?
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  How is it that we get the goals of what we're trying
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  to do all the way down to the frontline?
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  Um, how do we have situ situational awareness across the
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  organization on a day-to-day basis?
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  And then how do we improve, right?
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  How do we, if,
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  if the people at the frontline know the goals,
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  they also have to know how those goals relate to them
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  and know, you know, how we're trying
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  to move the needle in their particular area of practice.
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  So, um, and that's the micro, right?
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  There's day-to-day improvement work that just has to happen,
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  um, that, um, comes up in daily work.
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  And then finally, so a macro approach, a micro approach,
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  and then I would say a, um, a commitment to build capacity
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  so that, um, wherever you are in the organization,
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  you have some skills, uh, to identify, you know,
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  when there's an opportunity
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  and how, what is the best way to approach it.
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  And either, you know, doing a small project in the space
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  where you work or kicking it up to, you know, uh, you know,
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  a system level where we need to make a systematic change.
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  So I guess I'd say three main strategies.
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  Um, and there are,
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  and I would be remiss if I didn't add in, um,
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  learning from all of our data.
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  We're just so awash in data
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  and we don't always use it to our best,
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  um, to the best effect.
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  And so we get data from, uh, event reporting, right?
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  We get data from complaints
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  and grievances, patient feedback, um,
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  and figuring out ways to use all of the rich data
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  that we have to, um,
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  gain insights and act on them.
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  - That's amazing to hear. And certainly, you know,
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  it's been impressive to see how the data
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  and technology can really weave into the clinical care.
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  And as you mentioned, um, having a strong culture
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  and approach to doing that, um,
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  certainly makes a difference.
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  I'm wondering from your perspective, what are the strategies
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  that have been most successful in particular
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  with improving patient care in the OR and ICU?
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  - Yeah, so I would say, um, the, uh,
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  ICU, uh,
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  and we've, we've seen some really impressive work out of our
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  critical care units.
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  The one is,
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  the ICU work is incredibly multidisciplinary , right?
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  It's, um, about a team coming together, right?
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  So, um, two, it's about bundles
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  of evidence-based practices, right?
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  What, what do we need to be doing reliably for each patient?
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  And the third thing I, as I was thinking about this,
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  is really how do we use data in our workflow?
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  So a really strong example has been, um, the spread of the
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  practice of low tidal volume ventilation
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  in our intubated patients.
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  And we've, um, with some, um, great clinical leadership
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  have really, you know,
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  provided data in the workflow of the team members, right?
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  And, and that involves respiratory, involves nursing
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  and involves the critical care doc, um, et cetera.
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  You know, how do we use that data, bring it to the bedside
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  so that they, um, can execute on a protocol.
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  Um, another example we're, um, we're having, you know,
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  some great successes, the awake and walking ICU concepts.
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  Um, one of our hospitals, uh, LDS hospital really, um,
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  was a pioneer in this space
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  that is incredibly complex, right?
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  The, you need physical therapy, you need nursing,
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  you need respiratory therapy, um, to, uh, get up, you know,
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  get a patient out of bed, um, uh, lift, lift their sedation,
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  get them out of bed, um, and allow them to be upright, um,
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  and, um, sometimes even take a shower, right?
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  . So, but to do that, right, again,
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  multidisciplinary, um, really
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  what are the evidence-based practices we need
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  to bring to bear?
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  And then how do we support that with the right data, um,
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  to, to help with improvement.
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  And I'd say final area is really making sure
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  that we're leveraging, um, end of life care, um,
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  appropriately in, in patients who are dying, um,
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  and that we are, um, valuing, you know, providing them
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  with, you know, the most effective medical care while
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  they're dying, and that may involve palliative care
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  and may involve referral to hospice.
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  So another space in which we are spending a lot
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  of time thinking about how to improve those connections.
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  Um, in the, or I would say it's really about,
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  um, culture there.
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  A lot of our work in ORs is about culture of safety, right?
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  How do we make sure that the timeout is effective,
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  the briefs and debriefs that, um,
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  the protocols are, are followed.
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  And if, if they are not followed, then anybody in the
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  or, um, is able to stop the line, right?
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  Um, and speak up. And that is hard work, right?
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  You have to talk about safety,
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  safety culture every si single day, day in
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  and day out, um, to really, uh, make sure that
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  that is, that, that folks have that mindfulness that,
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  you know, emerges out of a high reliability organization.
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  - I love that. And I think, as you mentioned, it seems
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  so critical to be able to have, um, that culture in place
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  and, you know, making that change or,
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  or really getting into a space where, um, you know,
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  that all the, um, providers
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  and everybody that you're working with really
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  has, um, that in mind.
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  I can imagine, as you said, it's,
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  it's easier said than done.
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  Um, when you look at having that culture,
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  you've talked a couple of different times about having
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  that information, um, flow down into the front lines and,
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  and really, um, having trust that things are, are, um,
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  the way they're supposed to be.
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  How do you really build that?
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  Um, especially after bringing together two organizations,
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  and for some, you know,
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  there's gonna be some significant changes.
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  Um, what does that look like when you're just starting off
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  and then, um, as you mentioned, a continuous reminders
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  or continuously, um, making sure
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  that that culture is in place?
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  - Well, we're right in the middle of it right now, ,
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  so it's a timely question, right?
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  The, the, when you think about a merger,
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  and I don't know if, uh, your listeners, you know, have,
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  if they're in healthcare, there's chances are they,
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  you know, they might have been involved in a merger,
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  but, you know, there's the, uh, the official, you know, kind
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  of merger period is a, a lot about the back.
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  Well, I, I don't say this in a judgy way, ,
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  but the back office functions, right?
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  Getting HR aligned, getting finance aligned, um, getting,
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  you know, those, um,
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  getting legal aligned and compliance, right?
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  The, um, actual, it takes a while for
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  that alignment to come to the clinical space,
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  and you have to be really committed to it
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  because it is hard.
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  Um, so we are in the middle right now of
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  aligning our safety culture programs, right?
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  We are in the middle right now of aligning our surgical kind
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  of periop services leadership.
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  And so I would say even 18 months in,
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  we're not finished yet, right?
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  And so we're, um, working on that diligently right now.
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  And I think the, the, the reason that we're not done yet is
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  because we're really committed to doing it, right?
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  I think there's a lot of mergers where, um,
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  there's maybe not a commitment to really pushing, um,
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  that alignment to the same degree,
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  but we really are committed to one Intermountain.
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  Um, and so I guess we are for the most part, um,
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  at the frontline clinical, we're still not operating
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  entirely the same, but that is our goal, um, going forward.
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  So anyway, I don't know if that answered your question,
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  Laura , um, but I hope that's helpful.
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  - Yeah, absolutely. Extremely helpful.
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  Um, and definitely great insights to have.
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  Before we wrap up here, I'm wondering,
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  what is your experience implementing enhanced surgical
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  recovery programs and what are the
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  - Results?
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  Yes. So the experience I'm gonna tell you about is the
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  experience, um, from our peaks region, which is Colorado
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  and, uh, eight hospitals in Colorado
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  and Montana, um, from the legacy SEL Health organization.
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  Um, and we really, um, started a, um, diving
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  into the enhanced surgical recovery programs,
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  and we refer to it as, um, E-E-R-A-S in our organization,
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  um, enhanced, uh, enhanced recovery
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  after surgery, um, for, um,
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  because our anesthesia providers were asking for it.
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  Um, and so we have been in this work, um, for,
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  uh, multiple years now.
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  Um, we have, um, uh,
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  so we had great physician champions, um, to lead out,
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  and we, um, we looked at all the protocols,
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  and I think we might have done something a little bit unique
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  in that, um, we did start with one
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  or two types of surgeries.
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  So let's say we started with colorectal,
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  but what we started to do is really think
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  what are the key principles that apply across surgeries?
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  Um, and I would say things like early mobility, um, uh,
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  the approach to pain control, right?
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  Minimizing narcotics when possible,
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  the using the alternatives to opiates, um, the
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  nutritional approaches, right?
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  Um, minimizing the amount of, uh, NPO, um, the, the,
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  um, approach to carbohydrates, et cetera, pre
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  and post the surgery, right?
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  So we found those principles
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  and we decided that was our evidence-based bundle,
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  and how could we apply them across
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  as many surgeries as possible.
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  And so, over several phases of the work at each of our,
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  at all of our hospitals, um, we
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  identified, um, how we could apply those principles, um,
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  more globally, not just, um,
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  procedure by procedure.
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  And my understanding is that
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  that's maybe a little different than
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  how some places are doing it.
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  So at this point, we have 90% of our surgeries,
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  um, in the region are essentially using,
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  uh, eras protocols.
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  The 10% that aren't, are usually urgent or emergent
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  and are not appropriate, um, for, you know, uh,
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  some of that management.
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  Um, in phase one where we were doing just a subset
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  of surgeries, um, we, um,
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  noted an 18% shorter risk adjusted length of stay if, um,
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  the procedure had met the process pass rate, all, all,
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  you know, kind of five, uh, elements of the bundle were met
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  in phase two.
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  Um, another, um, kind of outcome that we had was a, a 16%,
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  um, morphine equivalent unit reduction.
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  And so redu reduction in use of morphine or, or,
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  or morphine equivalents,
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  and that is length of stay adjusted,
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  and that's across all surgeries.
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  Um, and so, you know, we are, and, and,
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  and again, a kind of a similar length of stay reduction
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  as our first phase implementation.
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  So, you know, we, you know, feel
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  that we had great outcomes related to that.
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  It's really just kind of baked in.
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  It's our standard of care now, um, for, um, certainly
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  for all, um, elective surgeries where it's appropriate
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  to apply those principles.
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  And so the, the, the philosophy that we took was really, um,
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  that's, uh, eres is our approach to surgery.
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  We are now working and to the point we,
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  we made earlier about integration, we're now examining if
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  that approach would be best spread across the rest
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  of the organization
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  and comparing, you know, lining up what work has been done,
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  um, in, um, the legacy Intermountain organization.
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  So, so hope that's helpful.
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  - Yeah, that's so interesting to hear.
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  And definitely, um, great to know that, you know,
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  the process is obviously, um, takes a while,
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  but certainly to get everyone on the same page,
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  it seems like it makes a big difference.
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  - Yep, absolutely.
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  Um, and so, and, and you don't wanna change,
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  you don't wanna break processes that are in place, um,
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  you know, just for alignment
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  and yet, you know, at some point, um, it, it,
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  it is, I think something you have
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  to look at if you really wanna operate in the same way,
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  - Way.
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  That makes sense. Dr. Wald, thank you so much
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  for joining us on the podcast today.
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  This has been such a fun and interesting discussion,
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  and I look forward to connecting with you again soon.
• 20:26
  - Wonderful. So nice to chat with you.
• 20:30
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