Thank you, Steve. It is an honor to be here right now. So as he said, I'm going to talk to you about how to promote a CCO to your administrators. My disclosures are listed here. You can look like this, because I'm going on to my next slide, because none of them have anything to do with what I'm going to talk about. So disclosures number two, SCCM is, of course, an international organization, but models of critical care vary remarkably widely across the world. And I'm going to acknowledge up front that this is a U.S. and Canadian-centric talk. Some of these lessons might be applicable to different countries, but probably not as many as some other talks that I might give. So this talk is going to include lessons from two different things. As Steve just mentioned, the Academic Leaders in Critical Care Medicine Task Force from SCCM, and also my personal experience from the Emory Critical Care Center, where we have about 80 doctors, 230 APPs, an 11-person administrative team that are sitting over there, 15 ICUs, and three in an affiliate model in six hospitals, with $145 million in billing annually, a tele-ICU that manages patients both within and outside of Emory, and a large multi-professional research and educational footprints, so a combination of global and also local experience. So lesson number one, as I just mentioned, critical care is different in the U.S. because of its structure. So essentially, every academic medical center in the U.S. has departments, and departments are typically specialists where one can train immediately after residency, and it's a sole way of getting into it. There's not five different ways to get into radiology. There's not five different ways to get into psychiatry. One does a residency, and one joins that department. In contrast, in critical care, where there's not one route to specialization, there's multiple routes to do fellowship training in critical care, and no way to specialize immediately after medical school. And by the way, I'm talking about MDs right now, although the CCO certainly has more than one domain to it. Critical care fellowship can be done after surgery, or anesthesia, or pulmonary, or neurology, or emergency medicine, or ID, or renal, or hepatology, or cardiology, or OBGYN. There's a million different ways to get to critical care in the United States, and I say this looking at my good friends from Peru who just came up front in the front. The typical model in departmental-based, in the surgical ICUs, is departmental-based. So a surgical ICU reports to the Department of Surgery. A medical ICU reports to the Department of Medicine. A CT ICU reports to the Department of Anesthesia, et cetera. And in healthcare systems, there's often little to little communication at the bedside level between hospitals, between ICUs. So ultimately, we end up with a siloed approach, a system in which each hospital has different standards, and each ICU within each hospital has different standards, and an ICU reports to a department whose core business is not critical care. And their leadership is going to be focused on their core business, and they're going to have less interest in critical care, because it's not what they do. So I could talk about, I'm in the Department of Surgery, I'm a professor of surgery. The core business of surgery is operating. It's not the ICU. So if I say to the chair of surgery, please tell me what the quality metrics are in the ICU. Tell me length of stay. Tell me severe hypoglycemia. I'll get a look like, what? Let's talk about making sure that the operating rooms stay open, because that's the core business. And so we end up, that's literally the same slide, because I didn't forward it. So if we take that a step further, the ICUs have literally the sickest patients in the hospital, literally the sickest. And it's the second most expensive place after the operating room, focused with the exact same market forces and evolutionary demands as departments in the whole. And yet the prevailing model, which we all know, multiple siloed ICUs leading to variable standards of care, variable quality, minimal financial oversight to assure providers are billing appropriately for the services they provide. So lesson number two, knowing current state is not enough. So Steve asked me to give this talk, and I was going to do current state. It took me three minutes and 52 seconds. So there needs to be a better alternative, because I was talking about how we actually talk about this. How do we form a critical care organization to our administrators? So what's the path forward? It requires vision to see a better way for patients, for members in the entire multi-professional ICU team, and for the health care organization as a whole. So again, I'm going to go back and forth between talking about the academic leaders of critical care medicine, as well as our own experience from Emory. These are just two papers that came from ALCCM, written by an awful lot of people that you see next to me on the podium. So as a nice core structure, what do we have at the center of a CCO? Quality components, value, processes, and structures. At the top of that, you see patient care and safety, quality improvement. At the bottom, not in terms of importance, but this is for an academic CCO, you see professional development, you see research, you see education, you see discovery and innovation. CCOs are not only for academic medical centers. I work in an academic medical center. But if you take any medical center, our first North Star, center of everything, is the patient. Patient care and safety, quality improvement, same quality. And then in a non-academic medical center, education, research, and professional development can play smaller roles. They may or may not be emphasized. The core of patient care is identical, regardless of where we work. So lesson number three, we're talking to our administrators in order to say, we should have a CCO. If you're trying to form a CCO, and you're just trying to justify its continued existence, understand that the administrators that you're talking to are likely going to have a very different way of viewing the world than you will. So a word about administrators. And I say this with the full knowledge that the senior administrator for the Emory Critical Care Center is sitting over there. I'm pointing at her. Administrators are not the enemy. So I'm sure you know people who talk about, oh, the administrators. They're not the enemy. They're not just bean counters. They are not out to get you. It's not personal to you. They are not there to stifle innovation. They are not stupid. And they're not 1,000 other invectives hurled at them. Being in the C-suite doesn't make you a bad person. It makes you have a complementary skill set. Administrators do care about patients. Anybody who says they don't care about patients, it's not true. They really do want to have the best outcomes. It's not okay with them whether your quality is first percentile or 80th percentile. They actually do want the hospital to provide good services. They do not see health care as a business equivalent to any other business. They don't see it like, well, I can work in health care or I can sell soap, whatever. It's just a business. They actually do care about the mission about what we do. But that does not automatically equate to you've got a good idea and it happens. So just because you say, I think we should have CCO, there's an absence of standardization, there's an absence of quality, there's an absence of financial oversight in my hospital, I think there's a better way of doing it, that doesn't equate to it magically happens. So when you're talking to an administrator, you have to remember that they often speak and think in a manner entirely differently from how clinicians speak and think. Some administrators are going to be clinicians, some are not. But their priorities are going to be complementary to yours. It doesn't mean that yours are important and theirs are not. They are complementary. No margin, no mission. You have to make sure that what you're doing is financially viable, you have to make sure that it's going to give good care, and you have to pay attention to the politics involved. The administrators are going to be laser-focused on return on investment. It can't just be, I've got a good idea, okay, well, it's a good idea, let's do it. There has to be a return on investment for everything. They're going to be laser-focused on finances. We've heard again and again through this meeting already about how challenging we are right now in terms of finances, at least in the United States, and from what I talk to around my friends around the world because of COVID. They're going to be focused on it appropriately. You can't lose hundreds of millions of dollars every single year. They will think about competing priorities that you may or may not think about, and they're going to think about the costs, the political costs of a CCO. Because when you do a CCO, it might sound just from the critical care standpoint about being great. And you're likely going to upset some people. Some of those people are going to be the so-called rainmakers. Who makes the money for a healthcare system? It is not critical care. It is procedural-based services, and the more complex the most. Neurosurgeons, transplant surgeons, cardiac surgeons, GI, cath, they're the ones who make the money for the healthcare systems that really support all of us, again, in the United States. And you do not want to really upset the person who's in charge of that. So lesson number four, what is the pitch? In my mind, the concept of why a CCO is better than a siloed approach comes down to two and only two factors, better finances, standardization, slash better quality, slash better care, slash better outcomes. And that's the two core things. Other factors are going to be important to specific audiences. Some people will care about grant funding. Some people will care about multi-professional education. Some people will care about improved well-being for the team. Some people will care about a sense of a belonging. I care about all of them, but the top two are foundational, better finances, standardization leading to better quality, better care, better outcomes. So better finances are there. How does it come in three different ways? It comes in three different ways. Improved collections, decreased labor costs, more efficient care. So financial accountability. In a system where critical care is siloed in multiple different locations, many might not be aware in the slightest, like the chairs and everything else aren't aware about how much time is billed for critical care. They might not know the ratio of critical care to E&M to procedure billing. They might not know how much time a provider is in the ICU. Might be two hours a day, might be 15 hours a day. They might not know if there's a discrepancy. I'm in the ICU 12 to 14 hours a day really taking care of my patients. I'm billing one hour a day. They might not know if there's patients in the ICU who aren't getting billed at all. We're in the ICU and there's no bill. Not going to happen in private practice. It could easily happen if you're salaried. So for financial accountability, if the CCO is responsible for finances, there needs to be clear expectations for how each of these must be set. Our leadership team at Emory can tell you each of these precisely by unit and precisely by provider. So can the medical directors and so can the lead APPs in every single ICU. And so can the individual providers who not only know how much they do, but I know how I compare to Dr. Pastoris and Dr. Moore, et cetera. So here's examples of time accounting. The arrow, by the way, is me. This is time accounting. On the top are MDs and the bottom are APPs from one ICU out of the 15 in the Emory Critical Care Center. So if you look at the top just as an example, blue is critical care time, red is E&M time, green, which there's almost none of for the attendings, is procedural time, and purple is what we call zero charge time, time you spent with the patients but it's not billable. If you look at the bottom for the APPs, there's a lot more purple time. A lot of what the APPs do isn't billable, and it changes. And so what you want to see is that everybody kind of looks the same here. There's a relative similarity between the amount of blue to the amount of red and a number similar of hours per hours per day. And so this is my billing for 29 days, that's the number 29 there, over a quarter, I'm blinded but I know who everybody is, I'm averaging nine hours of billing a day. I'm not in the ICU nine hours a day, I'm in the ICU a lot more than nine hours a day, but not all of my time is billable. A tiny amount of it's not, and I'm there for 12 or 13 or 14 hours a day. And you can see my ratio of critical care to E&M. It's about two to one, that's based on our patient population. Each ICU will look different, it's different sizes, different acuity, but I can tell you that for all 320 of our providers. Financial accountability is a missing bills example. On the left is a day that we had 39 admissions, on the right is a day that we had 40 admissions. On the left, this is before we moved to Epic, we didn't miss a single bill, these are for all the ICUs. And on the right, we missed six bills. And then we can immediately follow up to the ICU and say, why did that patient get admitted and not have a bill? We can look at how we handle extra duty, extra duty is going to cost more, right? And are we doing that with our own people, are we doing that with locums, are we doing that with PRNs? And we can look at this per month, every possible way we have of looking at extra duty so we can be financially accountable. And we can reduce unnecessary tests, and so here we have an incentive based upon decreasing unnecessary chest x-rays. So we don't need to get a chest x-ray on every single patient in the ICU because they're in the ICU, that doesn't make any sense. And so I don't have the names of the specific ICUs here, but we have tiers for reporting and you can see what the fiscal baseline years are, and then what we were the previous month, and are we decreasing the amount of unnecessary x-rays we have, and we can get financial incentives for actually improving care, decreasing costs. Standardization, protocols that can be standardized are standardized. So sepsis is sepsis, ARDS is ARDS, having different protocols between ICUs or in different hospitals that provide the exact same care literally makes no sense, it's more expensive, and it leads to suboptimal outcomes and wasted resources. Some protocols can be standardized by ICU types, some are only within a single ICU because there's a specialized ICU, but it shouldn't be different between weeks. So if I'm on one week, and Dr. Pastore is on the next week, and Dr. Moore is on the following week, we shouldn't practice differently week one, week two, week three. We're in the same ICU with the same patient population, and we should basically do the same thing. We have a quality dashboard, right? This is what a CCO can do. We have 330 or so ICU beds, these are things that we can find on our quality dashboard. So I could tell you in any ICU, what's our nutrition implemented within 48 hours, what's the CLABSI rate, what's severe hypoglycemia, what's the C-diff rate, what's the mortality rate, what's the risk adjusted rate? I can find any of these like this, so do all the medical, the unit medical directors and the lead APPs, and that gets passed along to everybody who works in the ICU so they know exactly what the quality is like in their unit. Here's an example from an ICU that became a COVID ICU. So you see at the top mortality, this is the beginning of COVID, this is like when alpha, now before delta, before Omicron, you see that we see a marked increase in mortality in this ICU that was stable in mortality for months at a time, and then it went way up because of COVID. And I'm superimposing that with the same ICU and their hypoglycemia rate to actually show that while your mortality goes up, your hypoglycemia rate doesn't go up. And so if I look at another ICU, and I see that the mortality went up from COVID, and their hypoglycemia rate also went up because at our worst, we had 11 COVID ICUs, it'd be like, wait a second, what's the problem? None of the other COVID ICUs are having this problem. Here's another thing for blood glucose control. On the left you see hyperglycemia, on the right you see severe hypoglycemia. These are multiple different units. It doesn't matter which unit is which, but if you look at the one in blue, in light blue, on the left, you see it's a small circle. They have the same hyperglycemia rate as everybody else. On the right, their severe hypoglycemia rate is way higher than everybody else's. So that's an opportunity for improvement, which wouldn't be known outside of the setting of a CCO. We know the implications of severe hypoglycemia, and that's something we could fix. Same thing here for risk-adjusted mortality and crude mortality. You can look on the top and see crude mortality, and the bottom you can see risk-adjusted mortality. And you can see why some ICUs have different risk-adjusted mortality. If it's the same type of ICU, if I have six different MICUs, why is one of them fundamentally different from the others? Opportunities for improvement that if you're not in a CCU, CCO, you can't know. Lesson number five, know the showstoppers and be ready to address them. Potential loss of individual program autonomy and visibility to the lighthearted CCO. Attempts at integration in the absence of collaboration may result in failure with people feeling the loss of autonomy, forces them to accept decisions that are not in the best interest of their own ICU or service line or program. So what are the challenges? Culture change is hard. Structural change is hard. It requires a complex transformation from a siloed approach, and it requires strong leadership to convince key stakeholders to undergo organizational changes. You don't just snap your finger and say, this is best for everybody, because of course it is. We're going to have standardized, we're going to have better quality. And everybody will be like, sweet. That's not the way it happens. There's going to be a lot of people who are like, I like it the way it is right now. I don't want to work under the auspices of somebody else. This is a bad thing. Many chairs and department chiefs, et cetera, are going to resist transferring traditional authority and autonomy to the clinical and academic programs of the CCO leadership. You might have a power struggle. And a very powerful chair, again, we talked before about Rainmakers, whose department makes a lot of money for the healthcare system, which a CCO does not, we can meet our budget or exceed our budget, but we're not moneymakers, can torpedo the effort. You have to get the powerful chairs on board. The financial benefits are unequivocally true, but they start as a promissory note. Does the move to the CCU is likely to cause disruptive change initially, but the benefits are seen later. And standardization is good, but it does not inherently lead to improved outcomes or improved quality. You have to prove it. Just to say we do it the same doesn't mean by definition that it's better. It means that you do it the same. So to show the success of a CCO beyond feeling good about yourself, you need data. I've just shown you a bunch of data from Emory. Data's not free, right? I can't just create that data from out of nowhere, the financial reports, the quality reports, and it's a catch-22. You need to spend money in order to show the financial and quality outcome benefits. You need to spend money to ultimately make money and save money, but somebody has to agree to have that financial outlay up front. So I think this is my final slide, and I am right on time, Dr. Pastors. The initial steps of integration, again, this is coming back to the academic leaders of critical care medicine. Four steps within the scope. Introspection. Think about what you want to do and why you want to do it. Outreach. If you do this in an insular fashion, even if everybody in that insular is in critical care, you will fail. You need to reach out to your administrators. You need to reach out to everybody who you touch and get them on board with the concept. Collaboration. By definition, you can go back to where we started. We have trained in multiple, multiple, multiple different fields. MDs, up here, I'm looking at the MDs up here, and I know factually we have people trained in internal medicine, people trained in anesthesiology, people trained in surgery, but it's not just MDs. I'm looking up here, and I'm factually seeing APPs, and an APP can be trained as a nurse practitioner. It can be trained as a physician assistant, and factually, that's not the whole ICU team because, of course, we have nurses, and we have some nurses who are new grads. We have some nurses who have been doing this for 20 years, and we have RTs, and we have nutrition support, and, and, and. You have to get everybody in the multi-professional team on board, and you have to collaborate with everybody outside the multi-professional team. Your friends in surgery. Your friends in blood bank. Your friends in ID. Your friends in renal, et cetera, and your friends in the C-suite. Your chief executive officer. Your chief medical officer. Your chief financial officer. Your chief quality officer. You have a matrix organization. You have tentacles going at it in every single way, and you need to be able to meet with them, and get everybody on board with the fact that this is a better way of doing business, and have continued communication, so ultimately, in conclusion, CCOs are, in fact, great, but just because the concept of a CCO makes sense and may be superior, and I'd make the argument is superior, to current state in many or most hospitals, does not mean that convincing somebody who's going to have complementary priorities is going to be easy. When you talk to somebody in administration, do not talk about, there is this randomized controlled trial, and the relative risk was this. I could talk science. I have a lab. That's the wrong language to speak. You're coming up with an ROI. You have to speak the language of the people that you're speaking to, who are ultimately going to make the structural changes in the financial commitments. You need to be laser focused on a concise message. Ironic that I'm given 20 minutes to talk about laser focus on a concise message, but you cannot give 20 minutes. It's a very concise message. Again, in my mind, two main benefits. Better outcome standardization. Better finances. Better quality. You need to predict the barriers in advance, and have an answer for every one of them. You should never walk into a meeting and have somebody say, have you thought about this? You're like, oh, God, I never thought about that. You should, in advance, know every single thing that somebody is going to, quote unquote, whack you on, know what it is, and be ready to answer to it. Ultimately, culture change and building consensus does take time. Again, you can't just snap your fingers. What I told you about for Emory took 15 years or so to build. It started with Tim Buckman and continued with us and a lot of people in this room, but ultimately, it is, in fact, truly worth it. Thank you.

Critical Care Organization

promoting to administrators

better finances

standardization of care

improved quality and outcomes

culture and structural change