Hello, this is Steve Pastoris, Program Director, Critical Care Medicine, and Vice Chair of Education in the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center in New York. I'm delighted to moderate this session on The Future is Now, Creating a Critical Care Organization at Your Institution. The learning objectives for this session are to write a business plan to promote critical care organization development, assess workforce competencies and integrate best practices across intensive care units, review the role of advanced practice providers and nursing leadership in critical care organization development, obtain advice for women considering critical care organization directorship, and finally, to discuss the practicalities and challenges of critical care billing, compliance, and audits. We're delighted to have a distinguished panel of experts, including Curtis Sesler from Virginia Commonwealth University, Ruth Kleinpell from Vanderbilt University, Kristen Price from MD Anderson Cancer Center, and Rupa Kali Seth from Mount Sinai Medical Center in New York City. Good afternoon. I'm Curt Sesler. I'm from Virginia Commonwealth University, where I'm professor of medicine, and I lead a number of the critical care activities there. It's a pleasure to participate in this session today. I appreciate that invitation from the organizers. This is Academic Leaders in Critical Care Medicine, and I've been asked to talk about assessing workforce competencies in physicians and APPs. I have no disclosures related to this presentation, and these are the topics that I'd like to cover some today. So first is to provide a bit of a framework. Many of you are much more used to dealing with sick patients than you are in assessing provider competencies, so we'll provide a little bit of a framework for that. We'll look at the purposes and process for professional practice evaluations. You're probably familiar with these, the OPPEs and the FPPEs, compare a little bit several different provider roles and how that might influence the competencies, and then look at future approaches to assessing competencies. So what exactly is competence? Here it is in the dictionary, competence is the ability to do something successfully or efficiently. I would argue that perhaps you need to be doing both successfully and efficiently. It's considered a set of demonstrable characteristics and skills that enable and improve the efficiency or performance of a job. It sounds straightforward. What's interesting, though, is if you look at actual documents related to competence, there are some slight variations in those themes. For example, one says specific personal characteristics which resulted in effective or superior performance. Another one says something you need to be able to do well in a specific job role. Third is an important skill that is needed to do a job, so now we're talking about skills. Fourth a person's ability or capacity to do a job. Perhaps the best one, I think, is at the NIH in their HR area where they say the basic knowledge, skills, abilities, and behaviors that employees at NIH need to be successful, so terms that you've all heard in many different places. Some people want to distinguish competencies versus skills, so a major difference between skills and competencies is one of scope. Competencies are broader. Skills are more task-specific, and in many cases what we must be competent in, whether it's placing a central line or diagnosing a difficult problem clinically, it incorporates multiple skills and issues to be addressed. Skills are just one of the three facets, and these folks consider the other ones to be knowledge and abilities. If one then extrapolates the competencies discussion more specifically to physicians, I like this discussion, and this was in the American Board of Pediatrics document, so they focus on a number of different factors. First is gathering essential and accurate information, doing an H&P, and ordering appropriate diagnostic studies, so the evaluation part of evaluation management that we do in our patients. Making informed diagnostic and treatment decisions, analyzing and synthesizing information, and also knowing one's limits of knowledge and expertise and when to obtain appropriate consultation. Sometimes this is an important aspect of competencies, especially for our trainees. And then finally developing and carrying out patient care management plans, including prescribing medications, performing procedures, and counseling patients and families, thereby allaying fears and providing comfort. So this is, I think, a fairly comprehensive description of competencies that includes some of the softer components as well that are important. If one looks at ACGME, and this is an area that probably many of you in the audience deal with, you may be program directors or involved in that process, and certainly competencies is of tremendous importance in looking at how our trainees are doing. So you can see here their introductory statement is the core competencies measure a physician's ability to administer a high level of care to diagnose and treat illness, offer and implement strategies to continuously improve patient health and wellness, offer advice and resources to prevent disease in patients, and provide not only physical treatment but emotional support as the patient is cared for by the physician, as is their family. So they touch on, again, a number of different important components. And they describe the six ACGME core competencies that you've all seen, and probably those in academics certainly, and in teaching hospitals, utilized quite frequently in terms of your assessment of trainees. And this includes PBL, or practice-based learning and improvement, patient care and procedural skills, systems-based practice, medical knowledge, interpersonal communication and skills, and professionalism. And we'll come back to these as the framework for assessment of competency in multiple settings. If we look at our APP colleagues, I pulled this off one of the websites related to physician assistant performance. And you can see that the six core competencies are again listed in a little bit different order this time. Actually, I like this one a little bit better in the sense that it starts with patient care first, but it assesses the same factors. So this is really relevant and consistent among all of our different providers who might, in a critical care setting, be able to demonstrate competency in these areas. So how did we get here? So let's look back and we can see, in fact, that if one looks at developing, maintaining competency, this starts back with our training. So in medical school, or PA school, or nurse practitioner school, we receive education and training in many cases, and then far more advanced training in residency and fellowship. Importantly, those bodies have undergone careful scrutiny and accreditation, which is a periodically renewed accreditation for schools and training programs. This is followed by a personal national certifying exam that we all take, regardless of what specialty or what professional category, and then we receive state licensure as we complete our graduation in preparation to enter the workforce. And then finally, wherever we're employed, at whatever health system we are employed, there is an assessment of our privileges. So what do we want to do? What are we applying for? And we'll talk a bit about that. And then a professional practice evaluation, or PPE, that is undertaken, and we can thank the Joint Commission for this. So they have said it's important that we have initial, which is the focused PPE, and ongoing professional evaluations that are structured in some fashion. And in fact, as we look now at the right-hand side of the screen, we can see that this is what is ongoing. So in the middle, really, we have the initial process, going to school, completing residency, passing our exam, having state licensure, and then the scrutiny that comes with being employed at a hospital. But after that, we need to undergo continued training in terms of our medical education and other factors, so with continuing medical education, or CME, and then periodic recertification. Typically, this is every 10 years or so for both PAs as well as NPs and physicians. But with ongoing process, so the maintenance of certification process that's ongoing as well, and then the evaluation performed within your institution, which again is either performance review and the ongoing PPE that we were just talking about. As one enters the workforce, there's a couple of different factors that are assessed in terms of your preparation to enter the workforce and do the work that you plan on doing. First is credentialing, so the process of verifying and assessing the qualifications of an individual practitioner to provide the care or services that they are being hired to provide. And then privileging, so medical staff process looks at your qualifications, your competencies, and ensures that you have the right skills and knowledge to perform the duties that you're being hired to do. When one looks at privileges, most of these are core privileges, so they come with the territory of the training that you've received. You can see some of the examples here from H&P on down to managing emergency situations and performing basic procedures. There may be additional specialty privileges, an example that I like to think about is let's say ECMO, so not necessarily something that everybody who completes a fellowship in critical care medicine might have, the skill set as well as the experience to perform, and that would be an example of specialty privileges that you may also seek. So let's talk a bit about the professional practice evaluation, and this has become part and parcel of what Human Resources does and what supervisors do in terms of their charges in their team taking care of patients in the hospital. So the medical staff is responsible for ensuring that you have initial and ongoing competence, and many of you have received these requests, okay have you done your OPPE evaluation on Dr. X? This is again tied back to the joint commission and they just say you have to do it and we'd like you to look at competency and confirm that your worker is competent, but they don't say exactly how you have to do it. They say that the mechanism is through this professional practice evaluation, the PPE, but they don't say okay here are the criteria that you need to hit, and so that is up to each institution to utilize their skills and develop criteria. As I mentioned earlier, this is either initially, so the focused PPE, or ongoing, so a yearly sort of evaluation performed at least once every 12 months, and these have similar sort of structure, but the focused one has a duration that is determined by what is going on with that individual, what are the risks of their proposed components to their job, and some other factors. So you can see, and when we look at the big picture here of initial training and ongoing recurrent sort of training, PPE does play an important role in that. There are a variety of different methods for assessing performance with PPE, so direct observation is very common, chart review is also quite common, certainly that's the typical review of five charts and see if certain components are present, demonstration of competency including using simulation as well as peer review comments often in a 360 or 270 type of evaluation. The duration of the initial PPE depends upon the privileges as I mentioned as well as training experience. If we look at ongoing professional practice evaluation, there is a similar evaluation process and it focuses on the six core competencies that we've listed before. There is very little to actually guide one out there in critical care medicine and thankfully we've had a recent publication here in 2020 by Michael Sterling and his colleagues which is a guide to performance evaluation for the intensivist and looking at OPPE and FPPE in the ICU and what they conclude is that currently there is no standard process to develop these in critical care medicine. So this is an opportunity for people potentially to evaluate this and draw some relationships to performance and publish because they did a very thorough MEDLINE search and were able to come up with very little on that. What they did in their paper though I thought was very useful and they came up with some ideas, some examples that they use and they're from Emory and in those six key areas and so you can see for patient care and procedural skill, this might be compliance with policy such as bundles, procedural competency with medical knowledge, continuing medical education, multi-source feedback, academic productivity. If we look at PBL, so involvement in quality improvement projects as an example, interpersonal and communication skills, I think they're observed to work effectively within an interprofessional team is important and looking at professionalism and system-based practice. So you can see that there's a variety of different things that can be utilized and in fact you can make up your own of course. What's important I think is also to consider what the roles and duties that the individual has and so you can see we contrasted traditional ICU attending physician duties with a group that we have at our institution which we call the resource intensivist and their role is working closely with a rapid response team with evaluation and stabilization of our patients, supervision of code blue, assist hospital teams and perform procedures. So what are the future directions? I think making it more streamlined, automated, standardized and flexible and you can see some examples here including getting data from EMR, using web-based mobile applications or apps and then utilizing simulation. So in conclusion then, competent providers are critical to the delivery of safe and effective care and the process for developing and assessing competency, it begins in our training and school but is ongoing on a yearly basis, really a continual basis in practice. The FPPE and OPPE are common mechanisms by which this is assessed but I think there's a variety of things that you may be implementing currently and in the future including using mobile apps to get information when and where you need it, automated chart extraction and simulation techniques. Thank you very much. Hi, I'm Ruth Klinepell and I'm delighted to be joining my colleagues today in this session that is focusing on critical care organizational development. I certainly miss the opportunity to be live at Congress this year but look forward to our session which will also have a live question and answer period after all of the individual presentations. So I'll be addressing advanced practice provider and nursing leadership in critical care organization development. I have no disclosures related to the topic except that I believe that ICU teams are best when they are inclusive and include nurse practitioners and physician assistants or advanced practice providers as part of it. So in 2016, the Society of Critical Care Medicine at their Congress launched a task force titled the Academic Leaders in Critical Care Medicine and this group was tasked with developing a series of articles that focused on advancing critical care organizations and they defined critical care organizations as ones that have a governance structure that is headed by an intensivist physician that has governance over majority if not all of the ICUs as well as the operations. I did have the advantage of practicing in one such organization that started out having individual ICUs but then brought together all ICUs under one governance umbrella and so I certainly can attest to the benefits of having that model of care. This was the initial descriptive report that our esteemed moderator for our session, Dr. Steve Pastoris, actually led that really was the impetus for the Society of Critical Care Medicine forming the task force and they did publish a series of articles that were addressing different aspects of critical care organizations in terms of building academic programs, in terms of business case and performance of critical care organizations, as well as related to workforce and workload and burnout prevention with respect to the formation of critical care organizations. I like this model that was published in one of those articles that highlights the relationship of the mission of critical care organizations to value-based care and as highlighted here at the pillars of critical care organizations are really looking at patient safety and quality improvement, looking at aspects related to professional development, research and education and how all of this collectively through the various initiatives that are developed in critical care organizations work to improve patient care as well as outcomes and at the same time looking at reducing costs. With respect to nursing leadership, that definitely is a given with respect to critical care organization as nurses make up the largest workforce in the ICU providing 24-7 care and the role of advanced practice providers, both nurse practitioners and physician assistants as well as even clinical nurse specialists working in the ICU have really started to be integrated at an increased use within critical care organizations. In fact, in that 2015 descriptive review by Dr. Pastoris and colleagues, 63% of the 27 critical care organizations at that time had incorporated the use of advanced practice providers. Their integration as part of the critical care organizations has grown over the years, certainly with respect to having the need to have direct care providers to help manage complex patients as well as contribute to the mission of the critical care organization. However, even today, there still remains uncertainty about really how to best structure advanced practice provider roles to really capitalize on their skill set and promote optimal performance. Now certainly the Society of Critical Care Medicine has been a leader in promoting multidisciplinary teams and including the integration of advanced practice providers, not only with respect to addressing the intensivist shortage, but also because they're able to fill a gap in critical care provider. A recent article just published in December highlighted some of what I consider some key elements for enhancing teams that include advanced practice providers. Some of those considerations are really having clear role expectations for advanced practice providers, ensuring a reasonable workload, adequate staffing, compensation, integrating a professional and structured orientation program and onboarding, and having a mentorship program. This is essential as you onboard and bring in and expand your advanced practice provider team. Certainly looking at having a strong element of collaboration and communication among team members and respect for advanced practice providers as part of a team, and also having a voice at the table. Really utilizing them in key committees and key aspects of the organization is important as well. So certainly both nurse leaders and advanced practice providers play an important role in not only the critical care organization as it develops, but also as it expands and there's more teams brought on board. So I recently had the opportunity to collaborate with five nurse leaders of advanced practice provider teams, and we published an article in December in the American Nurse. And these, I consider them five key leaders in critical care, April Kopp, who is the associate nursing officer and director of the Office of Advanced Practice at Vanderbilt University Medical Center. And then Sue Stempik is the director of advanced practice at Leahy Hospital and Medical Center in Massachusetts. Karina Sukutris is the director of advanced practice at the Hospital of the University of Pennsylvania in Philadelphia. Brittany Broihill is the senior director of advanced practice at Atrium Health in Charlotte, North Carolina. And then Rhonda D'Agostino was the former advanced practice provider director at Memorial Sloan Kettering Cancer Center in New York, and she is currently at Orange Regional Medical Center in Middleton, New York. But I consider them to be leaders in advanced practice, and so we collaborated by looking at some essential aspects for advanced practice provider teams. So certainly first and foremost is having a good awareness of what advanced practice providers are, and that's an important aspect for directors of critical care organizations as well as key leaders to know really what is the role, what is the scope of practice of advanced practice providers. And it's certainly not a physician replacement role, but rather one that enhances the skill sets of the advanced practice nurses and the physician assistants who are healthcare providers first and foremost, have skills related to communication, collaboration, oversight, integration of care between the nursing staff and the medical team, as well as the ability to communicate with families to enhance care. And beyond their immediate patient care responsibilities, they also have a number of skill sets that should be used in critical care organizations involving them in leading initiatives such as new practice guidelines in care or looking at quality improvements or research or really capitalizing on their skill sets related to education to not only be involved with residents and fellow training, but also the bedside nurses. So the five organizations, just to give you an overview of the degree to which they're utilizing advanced practice providers, Lahey Hospital certainly is one like other academic medical centers that employs advanced practice providers. They have over 300 working in a variety of areas, not only in the ICUs, but in specialty areas as well. Memorial Sloan Kettering, with respect to its care, has over 600 APRNs and over 200 PAs who work in various roles and in various departments similar to other organizations. And at Vanderbilt University Medical Center, they have over 1,200 APRNs and 75 physician assistants. I've had the value of being affiliated with Vanderbilt University now for seven years and can really attest to the model that they have served for developing and growing advanced practice provider teams. And all of these organizations, this comes from Lahey Hospital and Medical Center, but all of these organizations have done a great job in promoting the value that their advanced practice provider teams bring to patient care, and that's an important part. Atrium Health, certainly among those that have growing numbers of advanced practice providers, they have over 1,500 within their healthcare system. And then University of Hospital Pennsylvania, a large growing network of hospitals that employ over 1,300 advanced practice providers within their network of hospitals. And so these five organizations shared a number of strategies that they have used to advance their teams. And certainly what has come under clear highlighted through the pandemic is the role that advanced practice providers can play during, not only during the pandemic, but overall to bring to critical care organizations. And one example I wanted to share of really a new model of care that was developed by Lahey Health. During the early part of the pandemic, their clinicians were struggling with trying to keep up with the demands of communicating with families. So they developed a unique communication liaison role and a program that they had over 65 providers from different medical specialties and other clinicians, including advanced practice nurses and psychologists to serve in a role that really was focused simply on communicating with families. So they had these individuals virtually tap into rounds to learn about the individual patients and what would be important points to clarify on clinical calls to family members. Then after rounds, they did check-ins with family members and calls. They also rechecked back with the team in the afternoon for any updates, and then did additional calls for families to really help streamline communications. They highlighted in their recent publications, some of the key aspects of their communication liaison program, really looking at making sure that the liaisons knew the plan of care for the patient. They could communicate that to the family. They could loop back around with the clinical team and ensure adequacy of communication. And then they did documentation in the chart about the degree to which they communicated with families and how that impacted decisions. Well, because of them sharing that, Vanderbilt University Medical Center actually developed a role just in November in their COVID ICU to have a number of advanced practice providers serve as communication liaisons and replicating the Leahy Method. And this definitely served to be beneficial for clinicians as well as family members during the ongoing period of family visitation restrictions. So that's just one example of how advanced practice providers can play unique roles in critical care organizations and develop new models of care. So expanding models of care sometimes are met with challenges. Individuals don't know the role of advanced practice providers or there's resistance or difficulty in onboarding them. And these five organizations highlighted that there's a number of strategies that can be used. Certainly looking at administrative support, building a business case for new roles, ensuring leadership support, and adequate clinical training. Looking at monitoring outcomes of advanced practice providers to showcase the return on investment for bringing on additional roles. And even looking at metrics that are not only traditional metrics, but also those that may be specific to the role of advanced practice nurses, perhaps working in specialty areas of care, perhaps doing specialty areas of services, and even looking at such things as patient satisfaction and staff nurse engagement and retention as well. So in conclusion, I wanted to highlight some of the strategies that critical care organizations can use to enhance the functioning of critical care organizations. We know that nurse leaders, as well as advanced practice providers, are important members of the ICU teams. And they can really help critical care organizations achieve the goals, especially as it relates to enhancing quality, safety, and patient care outcomes, looking at best practices in care. We know the pandemic has brought a lot of challenges to ICU clinicians, but it's also been an opportunity to highlight the contributions of advanced practice providers, as well as to showcase their role in helping to contribute to not only sustainability, but enhancing the operations of critical care organizations. I look forward to the other sessions that are within our focused area of critical care organizations, and we'll look forward to also the dialogue that we'll have as part of the live question and answer as part of this Congress session. Thank you so much for the opportunity to participate. Good afternoon, everyone. I'm delighted to have the opportunity to speak with you virtually today from my office here in the critical care department at MD Anderson Cancer Center. And I'm going to be speaking to you on a topic that I know a little bit about, and that is women in medicine and women with a focus on women in critical care medicine. Unfortunately, our time together is short. I could talk for hours on this subject, but we'll just have to start with beginning with the ugly truth that gender disparity is alive and well in medicine. It's alive and well in critical care medicine, and essentially it's alive and well in many professions, if not all professions, that women have now earned the right to be in. So since this session focuses on the academic leaders and critical care task force members, of which I am one, helping folks design their own critical care organizations within their institutions, I want to hope that you will take from this the importance as you do that of removing the disk from gender disparity. I have nothing to disclose. So we'll start with a few statistics in the beginning. If you look at medical school training, women have now surpassed men in the United States. It's about 50.5% of all U.S. medical students are female. But what happens when they go to residency? Well the data is enormous and sometimes difficult to get, but if you look at the time period from 1991 to 2016, the number of female internal medicine residents, which is of course a pipeline, one of the many pipelines into critical care, it did increase from about 30% to 43%. However, during that same time period, it appeared that the percentage of women pursuing subspecialties was falling at the same time. In academia, women make up only one-third of full-time academic faculty in United States medical schools. If you adjust for age, specialty, and research productivity, only 21, some studies get it closer to 25%, have reached the level of professor. Only 15% are department chairs and only 16% are deans. This is even more pronounced among racial and ethnic minority women. Overall, if you look at the number of male physicians to females, in 2014, males outnumbered females 76 to 24. Over the recent years, it appears that that's improved somewhat to about 64 to 36%. If you look, critical care medicine is one of the specialties that has a lower representation of women, roughly about 30% depending on again the data that you look at because there are many avenues to get to become an intensivist. There's limited data globally, but the trends appear to be similar worldwide. Compensation. In a study in JAMA Internal Medicine in 2016, over 10,000 academic physicians from 24 public medical school salaries were reviewed. The annual salaries of female academic physicians were 8% lower than those of male physicians. The differences in salary persisted at all faculty ranks from clinical instructors all the way up to professors. This gap became wider in specialties such as orthopedic surgery, the surgical subspecialties, OBGYN, and cardiology. This becomes interesting in a second. As far as editorial board representation, in 2011, Ameren and colleagues analyzed the genders of editorial boards in 60 of the top-ranked medical journals. Only 17% of all editorial board members were women and only 15.9 or close to 16 of the editors-in-chief were women. Unfortunately, at the time, critical care had the lowest percentage of women on the editorial boards, which is only 7.3% of all the specialties and that even included orthopedic surgery. Same for authorship. Men produce more peer-reviewed publications and are more likely to be first or senior authors. Filardo and colleagues published an observational study from 1994 to 2014 that compared female first authorship in high-impact medical journals. What they found that there was an increase in that period of time of female first authorship from 27% in 1994 to 37% in 2014. If you follow that data out to more recently, it appears that in several of these journals this has plateaued and in some instances even decreased. If you start to look at the pattern, if the majority of editorial boards are dominated by men, then most of the papers reviewed will be reviewed by men and that would lead to frustration and ultimately less productivity of women researchers. On consensus guidelines, Maeda and colleagues reviewed 413 clinical practice guidelines published between January 2012 and July 2016. Only 25% of authors overall were females and only 13% of authors of clinical guidelines were women. You have to mention two of the glaring examples where women were not represented and I know it's uncomfortable to talk about, but it needs to be looked at so that we don't repeat these mistakes. One was the Berlin Task Force Arts Definition published in JAMA in 2012 and then the Sepsis 3 Task Force which was international and SECM and the European Society were instrumental in publishing that. Unfortunately in that task force it was 19 members, there were no women, there were no underrepresented minorities, and there were no physicians from countries that were low income or middle income. What we're really talking about is gender disparity. I always like to look at the origins of words. Parity comes from the Latin word paritas which means par or equal. It's just a difference or dissimilarity between two things and it comes from the Latin word dis which means non. We're really talking about inequality of women in medicine. Why does it exist? It exists for many, many reasons, but I'm going to talk about four in the time that we have. The biggest one most likely is unconscious bias. There's a lack of mentorship and sponsorship for women and I'll go over the difference between the two. There is a clear difference in how women view themselves and how society views women. Unconscious bias, implicit bias, I hope that many of you are receiving training in your institution on this. It has become hotly discussed in the last few years as well it should. What it is is just prejudice. It could be for or against a thing, a person, or a group that's compared to another one. It's unfair and certain groups of people benefit, certain groups of people are penalized. There are many forms of unconscious bias, not just gender bias, but racial bias and ageism as well. We're focusing today on gender bias, but it's extremely important to recognize the bias in other areas as well. I think this cartoon is probably enough said. Based on your resume, you're not really qualified for the job, but there's just something about you I like. Like begets like, not just in genetics, but also in society. We tend to gravitate toward the people that look like us and that's a problem. In mentorship and sponsorship, very important to understand the difference between the two. Mentorship is synonymous with someone who imports knowledge or wisdom. Mentors can be at any level in the organization. They tend to be more behind the scenes. They offer expertise to a mentee, but they really are not out in public openly supporting their mentees. Sponsorship is different and very important to understand. Sponsorship is public support and it's usually most often by a powerful or more influential person in the organization. They have the ability to recognize untapped potential and have the influence to help advance that person to promotion, to leadership positions, etc. Sponsors are much higher placed within the organization and they do have influence on people's promotion and people's appointments, awards, etc. Most women in the early career tend to have mentors, which is fine, but as they get up to mid-career, what they really need is sponsors. Those are folks that can help them on the path to promotion, etc. Women see themselves very differently than men see themselves. I think you know that. We tend to underestimate our abilities. We are much less likely to apply for a job or a job promotion until we have every single box checked and we think we can qualify for every single aspect of that job or we won't apply. Women take jobs that may be very beneficial to our department, the institution, but they may not really be glamorous or lead to a path to promotion. Society views women still, women who have children, it's a fact, compromised more than men professionally and at home. It is a fact. We are much more likely to be caregivers not only of the children, but of aging parents, much more so than men. Many women take part-time positions or leaves of absence and that can further slow career progression. Then there's not a lot of support for women who put their family first. In fact, there's often a lot of criticism and shame put in. In addition to what we've just talked about, the drivers of gender disparity in critical care in particular are the hours are horrible, as you know, they're long, they're not flexible, it's grueling work, it's emotional, emotionally draining, physically draining. There's a predominance of male leadership and again, like begets like. With a predominance of male leadership, this perpetuates the recruitment, selection and promotion of men over women. There is a lack of women in the leadership roles that can serve as role models for women under them. It creates an impression that women just aren't successful. Why is it important? Well, we know that gender diverse groups collaborate much more effectively. They're more cooperative, they have a more people-oriented work style and they have greater social sensitivity. Peer review publications that have both male and female authors receive more citations than those with single gender uniform authorship and corporations that have more women on their boards of directors demonstrate greater innovation and higher financial returns. How do we get to the path of gender equity? You must acknowledge that gender disparity exists and it does exist and putting one or two folks on a task force doesn't make gender equity. It needs to be ingrained in the fibers of any organization. It must be mainstreamed and it must be acknowledged. The SECM has done a lot in the last couple of years to promote gender equity. Along with the European Society, recently, they declared a commitment to ensure improvements in representation on task force as well as just in general diversity in the field. Dr. Ruth Kleinfeld, who will be speaking, has done a wonderful job and especially during her presidency to bring this to the forefront. Five of the last 10 presidents of the SECM have been women, 12 of the 23 multi-professional counselor women, and then we as members of the Academic Leaders in Critical Care Medicine Task Force, we have to be the ones to champion gender parity as we make recommendations to the newly formed critical care organizations. Recently the AAMC also issued a call to action on gender equity and I'll leave you with the reference there in the interest of time. I want to spend the last two minutes with what we've done at MD Anderson. I think we have a phenomenal program. It is not where we would ultimately like to be, but we have come so far. It started in 2006 when the Office of Women Faculty Programs was established. The mission was to recruit, retain, and promote women faculty. The name changed in 2016 to Women in Minority Faculty Inclusion and then with the new organizational structure we have in the last two years actually, the name changed to Faculty Diversity, Equity, and Inclusion. The mission is still steadfast and that is to promote and enhance diversity, equity, and inclusion throughout the organization. I have to give the credit to Dr. Elizabeth Travis. She's a brilliant researcher. She holds the Maddie Allen Fair Professor Chair in Cancer Research at our institution. She is the Associate Vice President for Faculty Diversity, Equity, and Inclusion. She has been instrumental in getting this program started and following through. I wish I had a lot of time to talk about the many strides that we've made. I have been a part of this since I became chair in 2004, so I was very fortunate enough when this started in 2006 to be involved in it. Just quick snapshots from the annual report. Women faculty at MD Anderson increased from 34 to 40 percent, 31 percent of professors now are women. That exceeds the national benchmark of 25, still entirely too low, but nonetheless an improvement. The percentage of women faculty at the assistant and associate professor level is now pretty close to 50-50 for both. We know with the national data, as you get higher up in the ranks, there's a lower percentage of women. Then, most importantly, the percentage of women faculty in all leadership positions has doubled since 2008. It's gone from 16 percent to 33 percent, and that's significantly higher than the Woeful National Average, which is only 18 percent. I leave you with the website link, also a book that we published in 2008 entitled Legends and Legacies. It looks at personal journeys of women and scientists, women physician and scientists throughout the organization. I think you'll find many of the stories very inspiring. One of the most important things that Liz has done is to sit on every leadership search in the organization. She sits on every search and ensures that there is at least one woman and at least one underserved minority faculty member on the list to be interviewed by a search committee. She works with the chairs of the search committee in order to get that done. In conclusion, I'm going to leave you with a quote. This was from Catherine DeAngelis. Dr. DeAngelis was the first female editor-in-chief of JAMA. She says, by excluding women, we waste half of our genetic pool of intelligence, creativity, and critical insights and experience. Medicine simply cannot afford that loss. Our profession, critical care, cannot afford that loss. If you notice, I haven't mentioned the word pandemic one time, but think about all the things I've just talked to you about and the stress that are burdened and placed on women in critical care. Throw a pandemic in it and now you have women who not only are trying to juggle career, children, elderly parents. Now we have a pandemic and we have to become school teachers and virtual learning experts. I am very concerned that we are going to lose a lot of women with the pandemic. I'm concerned that as this virtual schooling, it will affect the pipeline of young women and underserved minorities who are interested in the STEM fields from having actually access. They'll perhaps fall behind because of all of this. Now more than ever, it's going to be extremely important that all of us look at gender disparity and remove the dis from disparity. Thank you. Hi. My name is Rupa Kolisath. I'm the Director of Critical Care Institute at Mount Sinai Hospital in New York. Today I am talking about critical care billing, doing it right, facing auditing challenges. It is a true life story. I have no disclosures to report. Institute for Critical Care Medicine at Mount Sinai Hospital has nine intensive care units. Anywhere from our bread and butter medical and surgical ICU to transplant ICU, neurosciences ICU, cardiovascular ICU, cardiothoracic, cardiac intensive care unit, and pediatric or two pediatric ICUs are also part of Critical Care Institute, the pediatric intensive care unit and pediatric cardiothoracic intensive care unit. In total, we have 125 ICU beds, 50 full-time faculty in adult and pediatric critical care. We provide 24-7 care. Our faculty have diverse clinical backgrounds such as anesthesiology, cardiology, cardiothoracic surgery, emergency medicine, infectious disease, nephrology, neurology, pulmonology, internal medicine, and thoracic surgery. Institute for Critical Care Medicine, other than providing a care in the ICU, also has a vascular access service that provides peripheral IV accesses to central and permanent catheters, a rapid response team, night intensive discovery service. We have a difficult airway program, a percutaneous tracheostomy team, and also a critical care recovery clinic where we see patients with post-intensive care syndrome. This year has been especially good for our faculty and publications. We have over 80 peer-reviewed articles, and we have one of the largest critical care medicine fellowships in the country. We have 26 fellows in the program, and next year it will expand to a 30-fellow fellowship. In the beginning of this year, we had CMS targeted probe and educate program review, and let's talk a little bit about it. What is NGS? It is a CMS contractor that conducts evaluation and management trainings. These targeted probe and educate program are designed to help providers and suppliers to reduce claim denials and appeals through one-to-one help. It's a very sophisticated way of identifying errors and help correct them through the work done by Medicare administrative contractors. Providers and suppliers who have high claim rates or unusual billing practices have high national error rates and are a financial risk to Medicare, and that is the reason these probe and educate program are in existence. Providers whose claims are compliant with Medicare policy won't be chosen for TPE review. So the common claims. The common claims are signature of certifying physician is not added, which is unusual in the time of electronic medical records. What's more common is that the documentation doesn't prove medical necessity or encounter notes do not support all elements of eligibility. Initial certification or recertification is left out. So to talk about a little bit more in detail about targeted probe and educate process, there are three rounds to the process. The payment error rate needs to be less than a threshold of 15% in order for the provider to be released from the review. Round one and round two are very similar, where NGS requests 20 to 40 medical records for the CPT code being billed for the medical review department to review once they receive the documentation. After the current round is completed, and it all depends on the error rate, a case manager reaches out to schedule an education call. If the error rate is more than 15%, then the provider proceeds to a subsequent round, which is the round two, after 45 to 52 days after the education call, or if the provider refuses to participate. And round three is a little bit different. NGS requests five medical records at a time, and if the provider does not pass, or if the provider passes all five claims at once and the error rate is less than 15%, the provider is released from the review. If the provider does not pass five claims, NGS reaches out to schedule an education call and will request additional five claims, and this will continue up to 40 claims. If at the end of all three rounds, the error rate of the provider is still more than 15%, then the results are referred to CMS to determine next steps. And those steps could be 100% prepaid review, extrapolation, or a referral to a recovery auditor or other action. You most likely are all familiar with the key criteria of EM documentation training, which includes our history, history of present illness, review of systems, past medical, family, and social history, examination of all organ systems and general body, medical decision making, which includes diagnosis and treatment options, labs, data review, chart review, and risk of complications and or morbidity and mortality, and ultimately the total time spent with the patient or counseling or coordinating care. In relation to critical care, the most important is medical necessity. That means high probability of imminent or life-threatening deterioration that requires your undivided attention. There are ICD codes, which are codes bread and butter, 99291, which is 30 to 74 minutes of critical care, and then each additional code of 30 minutes, which is added to the primary code. You can't build 99292 without 99291. And this all depends on a physician's immediate availability to the patient. You can't build time off the unit or floor. And only one physician can build for critical care at a time. Let me share with you our Critical Care Institute's billing process. Our intensivists, who are either both certified in one or two areas, see the patient, they document in the chart, and once they sign their note, it automatically takes them to ChargeCapture, which has ICD codes, or you can add additional ICD codes and bill for an appropriate code, which shows up in your favorites. This really improves billing efficiency so that you don't have to go back and think about which patient you saw and what you should have billed. So you're billing in real time. We underwent a TPE probe that unsettled us a little bit. And ICCM's plan of action, again, ICCM is the Institute for Critical Care Medicine, which includes all the intensive care units under one umbrella. So we engaged key stakeholders, such as hospital central billing office, critical care administrators, our physicians, and the billing team. What is a central billing office? It is a hospital-wide entity that streamlines all billing processes. They negotiate reimbursement with insurances, tie together hospital billing with physician billing, and they also provide customer service for the patient. The benefits are that our revenue cycle processes are automated. It does reduce labor-intensive work and decreases accounts receivable days, which is very important. During our first probe, these are some of the findings. The names are not real names. They are made-up names for the purpose of this presentation. However, the CPT Bills, ICD-10 Codes, CPT Assessed, and ICD-10 Assessed is real data. So in these three reviews, we found that the TPE manager agreed with the CPT Codes Bills, however, did not agree with the critical care time because one of the ICD-10 Codes was missing. So we added that ICD-10 Code and educated our physician. So one of the ICD-10 Codes was to identify dialysis status. In another patient, we changed an ICD Code to link acute on chronic right heart failure, which was documented in the chart. In one of our reviews, the critical care services were solely based on attending documentation, and it did not match a residence note. We usually do not write our note off residence notes because linking of the notes you have to agree to whatever the residence has written or heavily edit that note and there is an opportunity to make mistakes at that point. The key findings were that we should avoid describing the patient as stable if the patient's condition is still critical and if the patient is stable on high dose vasopressor the documentation needs to support that this patient's clinical condition is stable because of the third vasopressor for example that was added to maintain a mean arterial pressure above 65. So these are our scorecard examples, these are actual scorecards that we received from TPE on two positions. So for position one, number of claims requested were 40 and reviewed 35, 34 out of 35 claims were denied with a claim error rate of 85%. Similarly charges were reviewed, reimbursement was reviewed with an error rate of 74.78%. For our second position, again 40 claims were requested, 35 reviewed and 24 of those claims were denied with an error rate of 60%. Reimbursement was reviewed and reimbursement denied was reviewed and with an error rate of 47.85%. At that time we decided, the Critical Care Institute decided that we would hire an outside consultant to guide us in our documentation and look at our documentation going forward. At the same time we started educating our physicians, our ICU directors and even myself started educating physicians doing sample reviews of their medical records as well as sending their medical records for documentation review by an outside consultant. Records, the physicians were guided, the records should contain patient's condition representing critical illness, a description of provider's participation in life-sustaining intervention. For example, I was present and I put the patient on pressure support of 10 and patient was extubated under my direct supervision. Patient developed stridor post-extubation and I gave racemic epi, tried to stabilize the patient's steroids. So that kind of detail in provider documentation. Of course, total provider time spent rendering these critical care services and ICD-10 codes must support the documentation that the physician has in the medical record. This is an example of one of our physician's documentation on the left and our consultant's review of the documentation and helping us change some of our documentation. So our physician wrote in general, no apparent distress. So this was a critically ill patient who was in an ICU after cardiac arrest and aspiration. A lot of critical care effort was being made and discussions with the family were being had regarding moving palliative care upstream. Our consultants added when key recent events, our physician wrote, no adverse events noted overnight. However, the patient was found to have bluish tint around the lips and was minimally responsive. Similarly, in general, our physician wrote no apparent distress and our consultants recommended it should be intubated, minimally responsive, which is true. That was exactly what was happening in our patient, but it was not reflected in our documentation. In neuroexamination, our physician wrote grimaces to central pain. However, our consultant elaborated on that, mentioning open site doesn't follow commands and similarly on skin examination. The main ICU plan, as you can see, details were added regarding our main ICU plan by the consultant. So after education by the outside consultants and our internal education of physicians and short reviews, we had our outside consultants review our records again and 97% of our records were deemed to be accurately documented, which was a very, very fruitful result for us. Some of the improvement, we still had an opportunity for improvement where one, no documented patient instability, but did not substantiate critical care services. Another note, ICD code was not justified by the documentation and one note did not include critical care add-on time when it exceeded 74 minutes. We also have some very important billing features in our EMRs, which led to our success. We have automated coding error alerts, patient demographic error alerts, if there is a duplicate entry or charge entry, it alerts us and tracks any denial charges or recovery payments. So the pillars of successful CCO billing, a knowledgeable critical care billing staff who regularly communicates with the provider. We have our billers working in, though most of our stuff is electronic, but they'll put edit on the charges, review of physician notes, and if they do not think your documentation supports critical care billing, they will inform the physician in real time if any pieces of the documentation are missing. There is a continuous communication with hospital central billing office and we track metrics. We trend reimbursements, we trend denials, and we also have an EMR software with built-in compliance features. I hope this was useful to our viewers as we took this approach very seriously. We didn't want to go into a full-blown CMS audit without trying our best to fix our billing and documentation practices. It was more our documentation practices that needed to be looked at and physician needed to be guided. Thank you for your time. ♪♪ Christina. Hi, this is Steve Pastoris. Thank you to all our speakers today, Dr. Sessler, Price, Kleimpel, and Dr. Collisette. The session is now open for questions. I see a few questions in the chat room. I'll start with the first presentation that Dr. Sessler gave on workforce competency. Quick question on, Kurt, are there any special or unique competencies that you require for the resource intensivist at your critical care organization at Virginia Commonwealth Health System, or are they pretty much similar to the garden variety intensivist competencies in networking in the regular ICUs? Thanks for the question. Our resource intensivists, a lot of what they do is in the rescue mission and out on the floors. The skill set, I think, is really similar, quite honestly. The work itself is a little bit more individual episodes of care rather than longitudinal care. But from the competency standpoint, we really haven't established any different competencies for that group. A lot of them, parenthetically, do both resource intensivist work and ICUs as well. Great, thank you, Kurt. I had a question that was raised by Marilia Diaz-Correa for Dr. Klein-Pell. So she states the following, nursing staff shortage is worse than ever. As a nurse, I know that nurses want to continue taking care of patients, but the fear of getting infected with COVID-19 is greater. Nursing leaders need to take care of their staff nurses in order not to lose them. Dr. Klein-Pell, do you have any advice for us? Yeah, definitely a valid observation that really was exacerbated by the pandemic with respect to nursing shortages. And we see our ICU staff nurses really, at times, you know, having intense work environments and especially with the change in visitation, family members, policies that occurred, you know, having to maintain communication with families and interactions and all of that has been challenging indeed. So interestingly enough, some of the national nursing organizations have, are addressing this with really putting forth measures for looking at altered staffing hours, you know, shorter duration of staffing, having additional staff service support personnel to assist. So we don't have the traditional assignments that we used to have for some of the ICU nurses, but sort of a buddy system versus a one-on-one or one-on-two patient to nurse ratio. Interestingly enough, the applications to nursing schools have increased. So I think the attention, the media attention that individuals have had for all of critical care really, you know, in terms of the value that critical care brings, the career fulfillment, we're hopeful that that will result in not only nurses, but others, you know, looking at the field of critical care as well. Thank you, Ruth. A question from one of our program co-chairs, Jose Diaz Gomez. Dr. Kleinfeld, thank you for sharing your expertise in this subject. Currently, I guess he's talking about at Baylor, we are experiencing, or maybe nationwide, a critical care nursing staffing shortage. In your opinion, are you concerned about a similar situation with our essential nurse practitioners and physician assistant workforce in critical care? And if so, what immediate actions should our critical care organizations take to try to avoid that? Yeah, good observation, Jose, because it is something that we're seeing in nursing, in bedside nursing. But I will tell you that the numbers of advanced practice providers, we are also seeing increased numbers of applicants to programs. So, you know, that has always been a career trajectory for clinical nurses. And in some cases, we see some of our ICU nurses pursue that as a career to work in a nurse practitioner or physician assistant role. So we are hopeful that those numbers will continue. I think nationally, we don't have enough nurse practitioners or physician assistants. So we need to, as societies, we need to be able to support not only development of those roles, but particularly in a critical care organization to support those roles and make sure that it is a satisfying career opportunity for them. Great, thank you again, Ruth. I'm going to throw this question, just a generic question related to staffing and locums issue. And Rupa, Kurt, Kristen, or Ruth, feel free to answer. This is also by one of our program co-chairs, Lillian Imlat. And she states the following, the staffing and locums issues since the pandemic have been interesting. So many are going to the highest bidder, even quitting their jobs or using their paid leave to pick up a contract. It is very hard to staff consistently. Yet having a core team is best for patient care. Any ideas on how we move forward with continued surges across the country? It is a challenging time to be a critical care administrative leader slash employer. So maybe, Rupa, you can start. Thanks, Steve. This is a very good question and very timely question. And I can't help but think about Neil Halpern's tiered model structure article that was published not too long ago. And that's what we are doing at Sinai. We are developing robust tiered structures of peri-op nurses or cardiac gap nurses are pairing up with critical care nurses so that the critical care nurse can be extended over four to six patients rather than our usual one to two ratio. And over time, we have been able to train, put these models in place and have been able to multiply across the health system. But I hear what you're saying. It's extremely difficult. Kristen, are you doing anything different at MD Anderson with regards to staffing in the COVID? We are following the same guidelines of tiered strategies. But what we are seeing very recently is not only nursing, but our respiratory therapists are getting pulled away to travel. And, you know, these are a lot of these people are young. They don't care so much about the benefits long term. They can make a lot of money going elsewhere. And, you know, so that's been hard for us to deal with. I don't think that we've had the numbers that most of you all have had. We've been fortunate in that regard. We've been able to manage it. But we have definitely seen in the last really last couple of weeks kind of an exodus out. And even within the medical center, Jose might be able to comment on that. But within the medical center, there are people offering sign on bonuses and things like that. And it's very attractive to people that are able to, you know, to leave. So I'm hoping that that will sort of die down. But we've been experiencing that firsthand as well. Ruth, how about at Vanderbilt? Well, you know, we have hired on a lot of additional staff. We actually have hired on some of our graduating Masters of Science of Nursing students to work in different roles, for instance, in the COVID testing and vaccine administration. So trying to bolster our numbers is one thing that we have definitely focused on. You know, all of the ICUs at Vanderbilt have traditionally had 24-7 coverage of advanced practice providers. And that remains. And we did have to open up a separate COVID ICU. And many of our providers volunteered to go and work in that unit. I will tell you that, you know, the culture and the camaraderie is really an essential factor. You know, the ICU work environment is our family as well. So, you know, making sure that we have support not only from leadership, but also, you know, a sense of team and a culture that supports one another. And encouraging attention, a special attention to wellness as well. How about at Virginia Commonwealth, Kurt? Are you struggling with the same issue? And how are you addressing it with your senior leadership? Yes, is the answer in terms of seeing the same sort of thing. I know our nursing leadership has been very active in terms of reaching out and trying to recruit. And it is a big challenge. I don't know about any other specific programs that they've been employing. But I know that it has been a struggle. And we're making progress. And hats off to them for their hard work. But I'm afraid it's not going to go away. And I wonder about more national strategies or something else that's beyond each health system or medical center working through it on their own. But actually, some sort of a national strategy that promotes an ability to meet surge. Now, currently, everybody's surging. But early on, that was certainly much more in the way of hot spots where one could direct some of that. Just a thought. But it's a struggle that I think every health system is encountering. Thank you, Kurt. I'm going to switch topics a little bit. Question to Dr. Price from, again, Jose Diaz Gomez. Dr. Price, if a female intensivist wants to pursue a successful academic career, alongside being a very caring parent, what will be your top three advice to achieve a rewarding career while impacting her family life favorably? Yeah, that's a great question. And sort of the, probably my trajectory over the last 28 years. You know, I always tell people, don't be ashamed to put your family first. Put your family first. And look for programs that value work-life balance and family orientation. So, we have a very diverse group in my department. We're small, but we're quite prolific in the child-rearing department. So, it's a friendly environment. I can tell you, when I first started working, if I had to hear one more time, oh, my God, you're pregnant again. I don't know how to prevent that. I heard that so many times, it was just like, you know, now I think it's a friendlier environment, certainly in my department. So, you need to look for places where that's valued and look for leaders who are diverse and who embrace diversity. And don't be afraid to ask for maybe a part-time position. I was really one of the first faculty members in the 90s that asked for and actually did work for a time when my kids were really little part-time. Because I really didn't want to leave. And there were folks that saw the value in my performance and knew that I would probably have a long-term career here. So, you know, and I don't regret that at all. And you can still, I mean, I'm department chair now. So, you know, it can be done. It can't always be done, but it can be done. You have to ask for it. And sometimes you also have to walk away if it's not what you want. So, those are kind of the things I try to advise women, you know, look for. And I think that things are going to change probably going forward. You know, it's a whole different generation. Their medical school training, a lot different than ours. You know, I don't know. I do worry about the long hours that we endured without even question. And now, you know, they're like, well, why did you work that much? So I think that maybe it will go more to, you know, shift work, which I really didn't want for an academic critical care department. You know, I believe in doing the hard work and having protected time where you can pursue other interests, research, education, et cetera. And so I don't know what it's going to look like in the future. I'm sure everybody will figure it out. Don't be afraid to ask for, you know, what you deserve. And that is to be able to balance motherhood and being a physician. It's a privilege for both. Honey, I was having this conversation with my wife, I mean, this morning over breakfast in preparation for this session. And I said, we have two women leaders who are going to be talking. And I said, you know, we thank our blessings for having adult children now out in California. And I said, well, if this happened now when the kids were very little, what would we have done? And her immediate answer is, I would have had to quit. And I said, but why not me? And she said, nah, you're just too busy and crazy. You won't know how to take care of them. And I said, no, but that's not, you know, that's, I mean, if I could, I would. So, but anyway, Rupa, what would be your suggestion? I'm listening to this. And Kristen, I relate to your presentation. I loved it. And for me, I've been here at Mount Sinai for 20 years. I have three kids. And my youngest is young. So I think a good partner and good babysitter go a very long way. And things you need to do factually and things that you can negotiate. I'll say at Mount Sinai, I've been fortunate enough to have good mentors and sponsors. Very valid point you made there. And I've been supported through my multiple pregnancies and moves. And sometimes, you know, babysitters have their own issues. They have their own children. And I've been able to go home. I live very close by. And exactly what you said, an organization that supports you. And it really makes a difference when you are a female or a woman leader in medicine, that you do have a mentor and you do have a sponsor. So thank you for your talk. And thank you for this question. Ruth, feel free to comment as well on your take on this issue. Well, you know, certainly, it's you do want to be able to succeed in your profession and to be involved. But at the same time, having family should be a priority as well. You know, my husband and I have one child. So we don't have to juggle so much. But, you know, you still have to sacrifice. And it's really looking at how to do that best within your family network and having support and having support with your colleagues as well. Great. Another question for Dr. Price. There are publications regarding the unique value of female professionals in executive roles. Which interventions are necessary to ensure appropriate recognition of leadership potential in early career or even since medical school or graduate training? I think that's where the sponsorship really comes in, really has a very valuable role. And it's not we as leaders have to recognize that. And we have, you know, again, like I said in my talk, we tend to gravitate towards those that look and act and think like us, right? And so we need to broaden our scope, get to know the people that we serve, see the potential in folks that maybe you might not have, you know? And that's where if we can help them get sponsors within the organization that really can promote, you know, a sponsor is somebody that's going to talk very favorably about you when you're not in the room, right, when there's other people in the room. I think there's a lot of more pull within the institution as far as advancing people up for, you know, ultimately leadership positions. And I'll say there's still we still have a long way to go for women representation at high executive leadership levels in medicine and beyond. But I think it starts with those of us that have the opportunity to be in those positions to look for it and to be able to see the potential and sponsor those people. I think that's really the key. I think that's the one point I was trying to make that mentorship is wonderful too, but it's really the sponsorship that can get folks ahead if they want to pursue leadership positions. I think you're muted. Great. Thank you, Kristen. A question for Rupa related to billing and auditing. Is there any advice or suggestion that you can give to those organizations that don't have maybe the luxury or financial ability to get outside consultant help to review and audit and, you know, properly bill so that they don't get audited? Is there any key advice that you can for those that are not as resourced as Mount Sinai, for example? So ICU directors could take on that responsibility and educate their faculty and they could be trained. And initially, that's exactly what we did before hiring an outside consultant. It takes time to get a consultant and for the review to happen. And we were in the middle of the audit. So a lot of responsibility. I gave a lot of talks. I had my directors give a lot of talks and do audits and individually on one-on-one educate our faculty. Great. I don't see any more questions in the chat box. But if any of our panelists are interested in further discussing, you know, a specific area related to their talk in the context of critical care organizations, I would certainly welcome that. We did not have the presentation by Dr. Billman on the business and value performance of creating a CCO. But for those of us that have been established critical care organizations, maybe I'll throw this to Kurt to start. I mean, what were the points that you had to sell to your administrators at the start of the planning stages when you were designing your critical care center in Virginia? Yeah, that's a great question. And it is certainly a very challenging prospect in terms of particularly academic medical centers where you've got pre-existing strong departments. And so, in our case, it really was a balance where there was not an attempt to move towards a separate department of critical care, for example, at our institution, but a collaborative sort of process. I would say that the biggest challenge related to that is that balance and traditional balance of power being within academic departments in terms of hiring and firing and other sort of performance evaluation and so on. So it is a little bit of a matrix in terms of us being the horizontal member that connects the ivory towers of departments to a certain extent. And so, I think feeling the way through what was going to be possible and what wasn't and trying to seek as much of a win-win in terms of organizing the intensivists to work together and commonalities, and in particular launching the resource intensivist program, but at the same time recognizing that collaboration with departmental leadership was gonna be absolutely critical. Yeah, and Kristen, I know you've been department chair now since 2004 or five. I mean, so you actually had early in the curve you're establishing your critical care department at MD Anderson. Can you share any of the key attributes that you felt were integral to how your department took shape within your cancer center? Yeah, you're muted, Kristen. Oh, sorry, sorry. Yeah, it's been a bit of a journey. When I first joined in the early 90s, it was all totally separate. I was in the pulmonary section, we ran the medical ICU and the anesthesiologist ran the surgical ICU, totally separate. And then in 97, we sort of were building a new building and the ICU was being built. And so that was when the critical care department was sort of formed. And I did the majority of my work in the pulmonary section in critical care, so it was kind of a natural progression. So we moved under, and here our divisions are higher than our department. So our division is the division of anesthesiology, critical care and pain medicine. So we're a department within that division and that's kind of how it was born. And probably the biggest, a big challenge is that, we're an academic critical care department and our sole function is in the ICU, now in the COVID ICU as well, but we don't have a clinic, we don't have an outpatient area. But yet the ICU is an inpatient unit and that traditionally has been under the umbrella of operations and nursing, et cetera. So it's been a bit of a challenge trying to navigate that as we've gotten new leadership along the way, higher level senior leadership. So whenever a new leader comes in, things get changed. And so that's been difficult because in some ways, we really don't have, sometimes I think I don't have control of anything and other days, we feel like we do. So it's still a work in progress, I would say, because now we have a new inpatient leadership structure that now we fall, the operations of the unit fall under that structure. But the academic side, of course, is still within our department. So, but it's working and we make it work and there's challenges with everything. So, but that's kind of the way we, and we only have one ICU, that's the other difference in our institution. We have one 52 bed cancer combined med surg ICU and we do have a separate unit that we've built out for COVID. But it's not like we have, a cardiac unit and a neuro unit. And so it's been a little bit easier in that sense that we're sort of just one ICU. And it's been a little bit easier to navigate that way, so. Rupa can probably share her own experience. She's been the Institute Director of Critical Care at Mount Sinai, a very large integrated healthcare network. So maybe Rupa, you can share your experience in terms of how you molded things together, preceded by Andy Leibovitz, but how did you now move forward with your strategic planning and coordination of care and critical care at Mount Sinai? As Kurt said, and so Kristen, a lot of collaboration. It was not an easy road, a lot of challenges because departments are established and taking part of, or part of their division or critical care and putting it into a funds flow institute was a little bit hard on everybody over years, five years. A lot of collaboration, tender, loving care, assuring we are not taking things away. We are actually enhancing the individual departments. We still have challenges. There is always one challenge that comes every few months, but that's what we do. Try to collaborate, move people along and see if we can continue to move forward. For the Institute, we developed different teams too. Rapid response team, for example, didn't exist before the Institute came into the picture. So in saving lives across all specialties, across all departments, vascular access service, from peripheral lines, central lines to permanent catheters did not exist. If you needed a permanent catheter, you had to wait in line for a week or so. We do our permanent catheters within two business days. So a lot of other services, we brought in a weaning program. Anybody's patient that needs to be weaned, we will wean that patient, enroll a patient in a program. So moving palliative care upstream. So a lot of different programs were infused. That actually got the buy-in of different departments. Great. Speaking about another large group of providers that help us a lot are the APPs and PAs. And I know in larger organizations, including ours, where we have a vast number of APPs and PAs, departments of advanced providers have already been set up. Ruth, can you speak to the value of APP departments and also the value of APP training programs in critical care to help in hopefully retaining some of our mid and senior APPs in critical care? We lose three or four a year now, and we have our own APP training program, but it's a limited number of trainees in that program. But this department of APP, I think, has done a huge service for us in molding the group together and making sure that we're able to retain the workforce. Can you speak to that? Yeah, thanks, Steve. And it's something that we have seen develop over the past several years, that as the numbers of advanced practice providers within an organization, particularly critical care, increase, there is a need to have leadership among the advanced practice providers to serve in a number of ways to help support with onboarding and orientation and ongoing credentialing and serving on the medical staff in the medical staff office and reviewing applicants and all of that is really an essential piece. And I have been at several organizations where they first started by having what they call lead, lead advanced practice providers that sort of serve over teams. And then as the numbers continue to grow, those leads roles then form into assistant directors and associate directors and vice presidents of advanced practice. At Vanderbilt, we have over 1,200 advanced practice providers, and we have an office of advanced practice that has staff that really help to organize all kinds of details with respect to advanced practice providers. It's really an essential aspect to have some formation, some organizational structure as the numbers continue to grow and really leads to success as well. Kurt, how about at Virginia Commonwealth in terms of like the APP and PA setup and how they integrate with the physician intensivist in your group? I'd like us to move a little bit more aggressively forward with, I guess, a higher level of critical care oversight related to that. In other words, we do have a growing number of APPs and we've certainly increased the number pretty dramatically in our medical ICU. And yeah, I think there is an opportunity for there to be a bit more in terms of tying that together. Our focus, I guess, a little bit has been on the physician side of the provider piece and that within each ICU, and we have five core adult ICUs that are 15 to 35 bed units each, maybe adding 110 beds or something like that. So within those units, they largely handle that. I think there's more opportunity that we could have that more of an interplay between mobile units. So we've made progress, but I think it is still an opportunity for us to move forward. Yeah, we have found our APPs and PAs to be extremely valuable. I don't know how we would operate every day without them. I mean, from not only caring for patients in the unit, but participating in care of patients on the COVID wards to rapid response team and all the specialized RRTs that we have all over the place and coordinating all of that, our APPs have been integral. What we have found over the years is just getting them involved with the fellowship program as well, even giving lectures, participating in our didactic conferences has been very good and participating in research activities. So we've had APPs presenting at meetings like CHEST or SCCM, ATS. So I think getting them interested in other activities besides just patient care molds them eventually to either becoming an administrative leader, a nursery APP researcher. So I think those are certainly attributes that we have found crucial. And we were so happy to see some of them actually move on to advanced roles and not only in the organization, but also elsewhere. So maybe Ruth, you can speak to that as well. Well, just the value that they bring to ensuring best practices in the ICU, implementing guideline care, doing quality improvement initiatives. It's just a valuable component that some ICUs don't really capitalize on their skillsets. Some just utilize them to fill the schedule to manage patients. And you need to really have different opportunities for the career development of the advanced practice provider. So engaging those who have interest in different aspects, such as leading quality improvements, implementing research, revising unit-based protocols, those types of things are an important piece as well. And even new models of care. I mentioned in my talk that communication liaison role that was developed at Lahey Health just due to the pandemic, but we've adapted that where both the physicians and the advanced practice providers and physicians who don't work in the ICU are calling families. And then that has really evolved as a really supportive initiative. And it started with several of our advanced practice providers networking with the advanced practice provider at Lahey as they started to roll it out. So I think involving them nationally, you mentioned having them present at conferences, that's an essential aspect as well, because then they get ideas from others that they network and meet and they're presenting, they're publishing, that brings attention and visibility back to the organization. So it's a definite strength to involve them in many aspects. Great, thank you, Ruth. I wanna read out a comment from Sidra Ishaki. She says, great to see gender equity being discussed on this global forum. We still have miles to go before gender parity becomes a reality. Thank you, SCCM. So Kristen, you wanna just add on to that? Yeah, and I think that it's been recognized and steps are always being taken to improve this. We do have a long way to go. I think I like to be optimistic and that will ultimately get there, but it's going to take not just the women, it takes the men to recognize and be a part of the solution. It's very important that we have a group at MD Anderson that's now including administrators and we often invite the men to the events because we could sit around and talk about it all day, but if you incorporate the male leaders, it really does make a big difference and a big light has been shined on. You can see through, I would encourage if you can to go to our website for especially some of the junior faculty out there because there really are great programs that can be done to help. And we have made progress, not as much as we would have liked, but it's a work in progress. And so you have to be able to acknowledge it, and move from there and not just talk about it, do something about it. Here's a comment from Lori Shutter, Neurocritical Care, who's on the Board of Regents with me, said, this is more of a statement than a question. The comment made regarding if a female intensivist wants to pursue a successful academic career alongside being a very caring parent applies to male intensivists as well as females. This is not an issue. This is not an issue unique to male, to an issue unique to females. So just a comment on the side to maybe try to balance a little bit the pendulum. But question for Rupa just came up. What is the best way to ensure proper billing practices when working or documenting alongside APPs? That's one. And secondly, what is the best strategy to carry out team building conversations when you are confronting peers who routinely undermine the APP role? Thank you all for a great discussion. So Rupa, what do you think is the best way to ensure proper billing practices when working or documenting alongside APPs? So it's a very good question. As you may already know this, in certain institutions, APPs do bill. And when APPs bill, physicians' part becomes very small. So at Mount Sinai Hospital, our APPs do not bill. It's only the critical care physicians that bill for all our critical care services. The receipts collected by an intensivist are much higher than receipts collected by... Receipts collected by an intensivist, I got a little distracted, are much higher than APP. So it was a business decision for us. Kurt, on your side. I put my hand up because I had a couple of different things that I wanted to mention. I think the billing and interaction with the intensivist and the physician provider with the APP provider is a wonderful relationship, first of all. And it has been discussed earlier. And like Ruth, I think a lot of our APPs have really taken that leadership mantle and done wonderful things in a teaching hospital. They play actually quite a big role in terms of teaching our interns and basic procedures and things of that nature. The billing is a challenge, isn't it? Because otherwise, if they don't bill at all, it's a clear-cut cost center as opposed to revenue. And yes, it is only 85% in terms of a 99291, for example. The documentation is on, we really have to be careful as I understand it, because if an APP has left a note to you in order to bill independently as a co-managing physician, you cannot refer back to their note, you can't co-sign it. And you also have to be careful in terms of procedures. If a APP supervises an intern, for example, you should not bill for it in terms of the provider side of things. So it's, I feel very happy with what we've done in the medical ICU. My earlier comments were kind of like local throughout all the institutions. I wanted, while I've got the chair, so to speak, to make a comment, I wanted to come back to some of the comments regarding gender in the ICU and just make an observation in our ICU setting. We have five adult ICUs and five, four medical directors and several associate medical directors in addition. And we've, in the past couple of years, have doubled the number of women who are medical directors from two out of five now to four out of five of the medical directors are women at our place. So, and my wife is, who is a physician, would be very happy for me to continue to be very supportive of this because it's an important piece. Thank you, Kurt. Another question related to coding by Beth Taylor, who is also one of our program chairs for this year. Our ICU has a coder assigned to our unit. In fact, her desk is in the unit. This allows her in real time of her review to approach a physician to clarify certain points in their note prior to billing. This has seemed to work better than sending queries to the MD electronically per the coder. I get that, by the way, every other day. The coder works for an outside group hired by the hospital. Is this becoming more common? I guess I'll address it to Rupa. Yeah, you know, you're absolutely right. So we have both. We have the hospital query individuals who every alternate day send us queries to fix our documentation. But Critical Care Institute, we have our own two coders. So they put an edit on every charge that goes reviews and they review documentation. And that's another step we put in place when we went through an audit and they'll send our physicians a nice note saying that their documentation needs to be enhanced before the bill goes out. So it's a very, they provide a very important service for us across all ICUs and services. Great, thank you, Rupa. Question, I guess for Ruth, from Shirley Chang. Thank you all for your informative lectures. Dr. Klein-Powell, have you seen or foresee issues of competition for procedures and clinical experience between physician trainees and APPs as well as their trainees? And how do you balance this? Great, thanks, Shirley, for that question. And I'm sending best regards your way. You know, I think early on when the advanced practice provider role was evolving, there was concern about that in terms of procedures being in competition, especially in academic teaching institutions. But looking at some organizations obviously have a focus on balancing that so that the needs of the fellows and residents are met and at the same time having advanced practice providers perhaps involved in different types of skills. For instance, being the responders on the rapid response team and having them serve in terms of IV access teams and really carving out a niche for them so that it's not a situation where when a procedure needs to be done, there's sort of debate about, well, whose turn is it next? So that is something that needs to obviously be addressed, but there are nice models of care out there. And this gives me the opportunity to put a pitch in for the Society of Critical Care Medicine second edition of integrating advanced practice providers in the ICU, which was published last year. And it really is a nice reference. It has chapters related not only to billing, but procedures and competencies. And so I have to highlight that as well. Great, thank you, Ruth. Another question raised by Lillian Imlett, one of our chairs, program chairs. We all want to be better and more efficient at billing documentation. What suggestions do you have for improving the speed by which you provide feedback and re-education for providers? For example, ensuring that we capture as much as possible. Billing code should be done by billers and documentation should be done by providers. Is that the best mode? Yes, yes. Billing should be done by billers, they know best. We do have charge capture where all the billing codes are listed. And sometimes we miscode and our coder will capture it and make an edit to it. Yes, and provider documentation is becoming so much more important, not only for billing collection purposes, but also what we are communicating to. And we will be communicating to our families with Cures Act in March, or late March, where our medical records are going to be available to patients and patients' families. So in that respect, appropriate documentation is more important than ever. Great, thank you, Rupa. Dr. Diaz-Gomez, I guess, is addressing a question to me related to what is my opinion about extending the CCO concept framework to larger community hospitals across the U.S.? And thank you for that question, Jose. Yes, we are intending to do that. When we started with our descriptive report back in 2015, we only identified 27 large critical care organizations, which many of you are active members of. That has grown, but it still represents barely a percent of the entire country. Places in Europe and Canada are much more integrated in the critical care networks, but that's also because they have very different systems of providing healthcare. So we are, with SCCM's blessing, going to transform the ALCCM into a CAG, or Knowledge and Education Group, hopefully sometime next year. And that will open up this network of providers and leaders in critical care to actually allow larger community hospitals who have currently a setup but are not academic in the strict sense of being academic to partake in that organization and in that knowledge education group. So more to come in the coming year or so. So thank you again for that question. Well, and Steve, we really have to take this opportunity to acknowledge all the work that you have done in helping to lead the work on critical care organizations because you're one of the leaders that has helped with reviews and publications and presentations. And we really do appreciate all your work in this space. Thank you. Thank you. Another coding billing question. We have faced billing issues with inpatient malnutrition. This is from Beth Taylor, one of our co-chairs, with updated definitions of inpatient malnutrition from guiding organizations. The dietician documentation provides a supporting documentation in most cases that leads to a positive end to an inquiry. If the MD makes the diagnosis that is not supported by the dietician, it may fail. This is just one example where it may be beneficial for the interprofessional team to work together for billing documentation, build off the MD, but supported by others. Do you think this may be a future model maybe to pull supporting documentation into the MD's note and other strategies? It's a very, very interesting question because it is already happening. So our nutritionists who write their note and various degrees of malnutrition, it gets pulled, in the world of EMR, it gets pulled into the problem list and it also get pulled into our billing coding charge capture. So all these notes are linked and our clinical data science folks have done a phenomenal job that when a dietician writes a note, it gives them a score for malnutrition, calculating various labs on a patient as well as documentation. So it is already happening. Thank you, Rupa. Just a question, one of the final questions for everyone in the panel, again by Lily and Imlet. As leaders, this COVID pandemic has been an ultra marathon for all of you to lead with integrity and to foster wellness and resilience and efficiency in a very hard year. Can you give one pearl that you have learned this past year? Start with Kristen. One pearl during the COVID pandemic that you would try to impart to our attendees from your experience. You're muted. Okay, I'm always amazed at how resilient people are in the times of such incredible stress. And so one thing that we've done is to really, even though it's virtual, we still have our faculty meetings once a week so that we can kind of go down the roster and just check in with people. What are you doing? What's working? What's not working? And it's incredibly stressful. From the beginning when we didn't know how many patients we would get, the PPE issues, just in general. And you really see the resilience in an intensivist because our guys really rose up. I mean, it was our department. It was stressful, but everybody just said, okay, we're gonna do whatever it needs to be done. Some people haven't worked on the COVID unit, but they've covered the regular unit. And it's just been, I would just say, it's been a privilege to lead that, to number one, see the dedication that intensivists have. And it's particularly different in a cancer hospital, I think, because all of our patients are very ill anyway. And then to be able to recognize how stress does affect some people in different ways. So to really keep an open dialogue with your peers and your faculty just to talk about things, because we don't see each other as much as we used to. You don't have that go to the break room, get some coffee and talk. So I don't know if that's a pearl, but just the importance of communication among ourselves and taking care of each other, and even when things were really bad. How about you, Rupa? Just a quick 20 second response. We've been at this for a year, and perhaps we have another four months, five months to go. And what I've noticed, other than what Kristen has already said, our teams have done a phenomenal job. But a lot, I think now it's time for kindness. People are tired, though they're resilient, they're tired, they're upset. They see no end in sight. And I think we as leaders need to understand where our faculty or fellows, what they are feeling and help them get through this, even if sometimes they don't do things the way we would like them to do. So a little bit more understanding and kindness would go, I think, very far. Okay, well, we're closing in on the hour. I just want to thank all our panelists and excellent leaders for their wonderful talks and availability for this Q&A. And I want to thank the attendees as well for their wonderful questions. So we hope you can stick around for the business meetings of SCCM and the convocation this afternoon. So thank you all again, and stay well and be well. Thank you. Bye, everybody. Bye. Thank you. Good to see you.

workforce competencies

critical care organizations

nursing leadership

advanced practice providers

gender equity in medicine

assessing competencies

physicians

role expectations

collaboration

gender disparities in medicine

diversity and inclusion

central billing office

billing processes

reimbursement

customer service