Good morning. So my task today is to talk about not that we don't need critical care leaders, of course we do, but we probably have too many, and it's costly, and we should change the paradigm. Just by way of disclosure, I have my own academic bias. I'm a big proponent of integration of critical care. So whether you call yourselves a critical care department, a service line, a critical care center, an institute, or an operations committee, the whole idea is that it probably is much better and more efficient if you have critical care units integrated under one governance model. So for about six years, I co-chaired with Vlad Kvetan, and later on with John Arapello at Mount Sinai, the academic leaders in critical care medicine. This was established after our previous past president, Todd Dorman, asked us to set up a task force with a series of consensus papers in trying to push forward the idea of integration of critical care medicine. That has morphed into a knowledge and education group for the Society of Critical Care Medicine. For those of you who might be interested in joining, feel free to do so. So my main arguments this morning are not that we don't need leaders in critical care, but that we probably have too many, and it's costly. It results in inefficiencies, conflicting strategies, increases cost when you have so many middle layers. And I will propose to you that a leaner governance model, i.e. an integrated critical care organization, center, or institute, leads to increased efficiency, clearer delineation of responsibilities, faster responses, as I'll show in some examples, to emergent situations, and that integrated critical care organizations or service lines led by physician leaders are the way forward to lead critical care now and into the future. So we heard earlier that much of the literature, as it specifically addresses leadership and conflict management in the ICU, really pertains more for what I call managing day-to-day tasks in the ICU, whether it's directing, staffing, budgeting, controlling, and having some sort of like a vision for your current and future demands. A lot of it is really more like managing day-to-day with maybe a little glimpse into what you should do in the near future. If you look at this leadership review, again, it focuses on leader behaviors, such as, okay, they have a good personality, they're approachable, they make good decisions at the bedside, they have excellent clinical skills, but if you look carefully, they don't really talk about the organizational structure of critical care that somebody as a leader should be doing and not managing day-to-day. So there's no question that a robust leadership structure is needed in critical care, not only to streamline communication, efficient workflow, coordination of various teams, effective decision-making, quality improvement, using our resources well, educating and mentoring our multidisciplinary staff, if our overarching goal is to provide guidance, support, and direction to staff to ensure optimal patient care and cohesive team dynamic. But it should probably not be at the expense of having too many and costly leaders. The problems with too many leaders in critical care is that management can sometimes be ineffective. Decision-making is slow. There's communication breakdown, as you'll see in the cartoon on the left. There are redundancies and overlap, conflicting strategies. Who's in charge? Is it the MICU director that proposed this, the surgical ICU, the trauma, the neurosurgical ICU? Nobody seems to be accountable for something happening in critical care within our health care institutions, and it's costly when you have to do all of these layers and correct redundancies and overlaps. So how do you avoid too many mistakes? Well, you need to establish some sort of a very, very good structured hierarchical method. You need to have clarity of roles. Folks have to know what their roles are within the critical care system. Need to empower your team. You need to be flexible. You need to have strategic planning. You can't just look at what's happening this year. You need to forecast what will happen in two to five years. So how do you recreate your leadership structure? This is not easy. We struggled with this for about two and a half years before we became our own critical care center. First, you need to sell it to the administrators. That's very, very important. But you also need to present yourself with a way that you've already predetermined and streamlined how you're going to structure communication and reporting structures with your administrators. You need to have a very agile decision-making process. It can't be that the SIC director is saying one thing, the MICA director is saying another. Neurosciences director wants to do something else, whether it's staffing, buying new technology, or doing something with electronic medical record to increase efficiency. You need to promote an interdisciplinary collaboration if you want to be effective. So how do you streamline this? There are a variety of ways. I think we all know this. We all try to streamline our protocols, practice best practices, optimize our resources, integrate technology with our EMARs and telemedicine, interdisciplinary coordination, focus on outcomes-based approaches rather than volume of patients, and of course, invest in the education, training, and mentoring, not only of our physician leaders, but also of our APP leaders, our respiratory therapy leaders, as well as all the other allied interdisciplinary services. So just to be clear, my central argument is that organizational change in critical care is what's needed, and not too many and too costly leaders, and that integrated critical care is best suited to not only enhance the quality and efficiency of patient care, but it's actually more cost-effective in the long run rather than the traditional conventional siloed ICUs and siloed departments managing those ICUs. This is not a new concept. About 10 years ago, Dr. Scales and Rubenfeld had a nice primer or textbook on organizational change in critical care, forecasting it as the next magic bullet. And they say the innovation that we recognize as modern critical care is less of a technologic creation, but more of an organizational. So already indicating even 10 years ago and maybe even before that with other leaders such as Dr. Fink and others, Dr. Kvetan, for example, they already saw this coming, that we needed to change how we manage and organize critical care. So I put up this cartoon only to suggest that sometimes nobody seems to know, particularly the administrators, as to what ICUs are and what they're doing and how integral they are to what we do in our day-to-day lives. So the traditional model, as we all know, is that critical care is usually a service or division of a department. It's not at par with a non-critical care center or a non-critical care institute, for example, that reports up to hospital administration. So in the traditional model, the MICU and the CCU usually is part of medicine. Trauma and surgical ICUs are in the Department of Surgery, cardiothoracic, and so forth and so on. So you get the picture. What needs to happen is you need to horizontally integrate all of these ICUs into one governance model. And whether you call it an institute, a center, an operations committee, or a department of critical care, that needs to happen in this kind of model. So why the need for governance? I think we heard earlier from Karina that there are just so many things that we do in critical care that our administrators need to know what we do on a day-to-day basis. From running rapid response to standardizing technology, controlling ICU costs, having telemedicine programs, providing 24-7 coverage with in-house attendings, a very large advanced practice provider, workforce, respiratory therapy, nutritionists, there's just so many things that you need to govern. And it's hard to do that when you don't have a centralized way of running things in your institution. So horizontal integration is key, not only within your healthcare system, but to form strategic alliances. So an effective critical care organization has good oversight. It's attentive to system design. It builds coalition. It's accountable and increases efficiencies, largest from the economies of sale. Think about it. If you had a Servo or a 980 ventilator in the MICU, but then they don't use it in the PICU. They use something else in the neurosciences. Look at the amount of cost with the vendors that you're costing the healthcare system. The administrators may not know this until actually they get an inventory of what you have in yours. So we run our own technology division within our critical care center. So we know what gets into our ICUs at our institution and many of the large CCOs that we have in the country so far. So not only is horizontal integration key, but vertical integration as well. So we're not only focused on what happens in the ICU, but when the patients are discharged from the ICU and to home or to rehab or to a post ICU clinic, we're running those patients and working with them very carefully. So we're focusing not only on short term, but also on long term outcomes. All of these leads to lower transaction costs, increased network size. You're letting yourself known throughout the community and maybe to your state, local county and so forth. And though you have increase in market power and of course that brings additional revenue for the institution as well if you become the primary referral center. So what is the critical care organization? We got curious about this six, seven years ago and put out this descriptive report in critical care medicine. We sampled what we thought were institutions that had models of critical care that were running the majority, if not most of their ICUs. There weren't too many. We had about 27 of them in the country. These are the powerhouse centers like Emory, University of Maryland, Mount Sinai, Montefiore, UPMC, Mayo, Cleveland Clinic. They were largely major academic medical centers with more than 500 to 1,000 beds. Majority of them were called by different names, departments, service lines, institutes as I mentioned earlier. We found in their staffing models, and this has to be updated, this is our 2018 survey of all these CCOs, 50 percent of them had in-house 24-7, about two-thirds had advanced practice providers, one in five were having hospitalists in their ICUs, and about one in six. The numbers are probably much larger now. I think more recently in-house coverage is probably closing in to 70, 80 percent at least in the CCOs that we have been looking at more recently. Why the small number? There are many reasons for that. Well historically ICUs are developed within departments as I mentioned. The chairs of the departments are usually reluctant to give up their ICUs for a variety of reasons, potential loss of revenue, billing triage, and so forth. Most of the time critical care is intertwined with other disciplines in terms of leadership and attending staff, so they're not nimble enough. We don't have a unified fellowship track and certification, so each critical care specialist has to be certified in one different board from another, so we don't have a unified system like they do in Europe, for example, or in Asia. Existing departments believe that the intensivist really cannot cross over, so if you're in the MICU you can't really take care of a patient in a cardiothoracic or transplant unit. We have few graduates in critical care. I'm a program director for over 20 years. Even though we try to teach leadership and management skills, not too many of our fellows end up getting enough of that skill set to actually run a critical care organization. And sometimes the hospitals not seeing data for improving care and lessen costs do not always buy into the development of a critical care organization. So what are the keys? As I mentioned earlier, no one size does not fit all. You can't establish a critical care center organization in a month or even a year or even two years, depending on your institution. The keys are to have very strong institutional leadership and support, financial viability, you have to provide high value care, and of course, quality improvement. This was clearly made more evident during the COVID pandemic when some of our CCOs, like Mount Sinai, UPMC, Mayo, were able to, they were so nimble, they were able to ramp up their services and able to respond very quickly with exceptional flexibility during the COVID pandemic. So everyone was getting calls at our centers asking, hey, how are you doing this? How are you ramping up? How are you getting your ventilators and so forth and so on? The CCOs were ready for this and they were prepared to help those states and cities that needed the most help. If you are interested in this topic of critical care organizations, I recommend to use six or seven papers from our task force over the last six years from most recently our flow sizing resources that talks about how you manage critical care during normal, strain, and surge conditions. It's a very helpful resource. We provide toolkits and some resources there that you can use at your respective centers. So in conclusion, I clearly think that too many leaders are costly. They can result in inefficiencies and conflicting strategies, and that a leaner governance model is probably what we need if we want economies of scale. We want increased efficiency. We have clear responsibilities and clear ability to ramp up during emergency situations, and I will propose to you that only an integrated critical care organization, despite being very few right now, with advanced governance led by a physician critical care leader is best suited to improve the quality and efficiency of care and is more cost effective in the long run than the traditional siloed ICUs and departments. Thank you for your attention.

paradigm shift

integrated governance

critical care

efficiency

COVID-19 pandemic