SCCM Resource Library-Unexpected Challenges in Leading a CCO

Video Transcription

Hello, everybody. I welcome you to the 51st Critical Care Congress. We were supposed to meet in sunny Puerto Rico, however, we couldn't because of the obvious reasons.  Hopefully, we will be in person next year, and I look forward to that day. My topic today is unexpected challenges in leading a critical care organization.  This is something I've lived through for the last six years as a leader of a critical care organization, and I have gained insight into what works and what doesn't.  And I will be sharing my experience with you. My name is Rupa Kohli Seth, and I'm the director of Institute for Critical Care Medicine at Mount Sinai Health System.  ICCM is home to 21 ICUs across seven hospitals, and we have one of the largest critical care fellowships in the country.  I'm both certified and a tenured professor in the Department of Surgery with over 20 years of experience in critical care. I have nothing to disclose.  So what is a critical care organization, and why do we even need one? A CCO is defined by having a physician leader and governance of at least the majority of ICUs.  The benefits of having a CCO span through clinical, operational, quality, education, and research areas.  Developing one results in having coordinated critical care processes, patient safety, quality  initiatives, reduction in wasteful practices, streamlining hospital throughput, unifying education, training, and research, and as we saw during COVID pandemic, scale up high  intensity staffing expeditiously during crisis. All of these work areas work together under one entity, improving patient care and ultimately our patient experience.  There's several advantages to having a unified critical care organization, and these span through patients, hospital health systems, and for our faculty.  So the advantages for the patients include clinical innovation and equitable care through the continuum of their care.  Patient safety, quality initiatives that boost their clinical experience. If patients have complex medical conditions, processes are already in place for interdisciplinary  specialties to collaborate on treatment plans. During the time of emergency or crisis, organizations are quickly able to scale up bed capacity  and staffing to meet the needs of our patients. For our health system and hospitals, critical care organization works as a matrix and bridges the gap between various departments.  Organizations such as personnel can be flexible and adapt to current needs across all critical care spaces.  There is containment of cost by centralizing the purchasing process for equipment and other resources. ICUs have similar resources, technologies, and equipment.  And there is a defined accountability to critical care as a specialty. For our faculty, there is advocacy within the leadership.  And it is especially appealing to the intensivist as opposed to relying on each department for unique critical care needs.  Faculty contracts can be aligned and equitable across all critical care spaces. And this leads to recruitment, retention, and satisfaction of intensivists.  And also the intensivists have the opportunity to collaborate with their colleagues who are often from wide range of clinical specialties.  There are opportunities for compelling research and a centralized research team to assist faculty in their studies.  It definitely decreases turnover and perhaps decreases burnout as well. Critical care organizations are unique in that they operate both horizontally and vertically  within a hospital health system or regional hospital ICU network. Workflows and processes, accountability and quality, incentives and compensation packages,  and resources are distributed horizontally across all ICUs in various departments and critical care teams.  And they also function vertically within the hospital or health system network by boosting economy of scale, providing value-based care, and defined responsibility.  There are several challenges of establishing a critical care organization. And during this session, I'll guide you through some of them that may come up while creating,  enhancing, or expanding one of your CCOs. So when a CCO is being established, there are many clinical, cultural, and financial shifts that occur.  So anticipating and addressing these challenges early on can make the process go relatively smoother.  Clinical transformation requires coordinated processes, developing trackable benchmarks, promoting great clinicians into leadership positions, and sharing clinical data often  as the proof is in the numbers, and ensuring data is a very powerful tool. And using these tools while adjusting clinical processes will ensure equitable patient care in all ICUs.  I think the greatest challenge in getting people on board is your cultural transformation. A few tools to ease this transition would be to identify dysfunctional culture and try  to address it early on so that it doesn't spread. I recommend developing teams across several specialties to promote collaboration of faculty  and staff across several departments, and also provide resources and personnel to make the transition easy.  Lastly, set achievable goals so that the CCOs experience success early on. Cultural transformation really just takes time, so expect to chip it at slowly.  Financial transformation may be the most crucial piece. If the CCO is able to manage the financial responsibility of critical care, then clinical  transformation and cultural transformation will likely come along with it. This takes a lot of coordination with the departments, which we'll discuss on a later slide.  A faculty compensation model based on performance and a detailed budget will need to be developed to share with leadership.  Lastly, by having governance over the finances, you have the ability to develop patient-centered incentives that will reward faculty for boosting patient care and quality.  To make all of these transformations happen, the unwavering support and buy-in of the senior  leadership, such as your chief executive officer or dean of the medical school or the president of your health system, is necessary.  In order to receive and maintain this level of commitment from your leadership, outlining the benefits of a CCO would have for your organization, establishing benchmarks and  goals for yourself, and sharing data-driven updates on your progress regularly is of paramount importance.  It is particularly helpful to coordinate regular meetings with leadership to check in and receive feedback.  When creating a CCO within an established organization, it's natural for the departments to have discomfort and it should be anticipated.  By introducing a critical care organization, departments will potentially lose autonomy over the ICU faculty and the revenue that goes along with it.  To avoid a lot of this friction, I suggest meeting with departmental chairs individually and outlining the benefits for the health system on a macro level and what the benefits  would be for the unique department. In these conversations, establishing a financial incentive for the department, such as a memorandum  of understanding or some kind of departmental tax, perhaps may be required. Lastly, develop quality initiatives that will also benefit the departments, such as reducing  your hospital-acquired infections, reducing length of stay, your respiratory failure pathway, timely tracheostomies, and a reduction in excess days.  So it's a win-win for department and health system to have a critical care organization.  So the most important piece of your critical care organization is your critical care faculty. So buy-in from faculty is imperative.  Meet with faculty both individually and as a group to discuss why being part of a CCO is beneficial to them.  Transparently sharing progress and data with faculty on a regular basis will keep them engaged.  Being part of a CCO would give faculty a competitive, equitable salary and opportunities for quality incentive bonuses. Career growth opportunities and leadership positions.  Access to critical care-specific personnel, including assistance in their research, developing  programs that they feel passionate about, such as global health program, having a critical  care-specific advocacy pathway in leadership, and also the wellness and appreciation initiatives that meet the unique need of our intensivists.  Once there is a meeting of the minds or buy-in from all necessary stakeholders, the next step  would be to enhance the CCO by integrating vertically within the hospital and the health system and collaborating with various departments.  I would start by developing teams that provide critical care outside of the ICUs as continuum of care, one of the major pillars on value-based care.  So such teams could be a rapid response team that provides care to our patients on the floors or step-down units, a vascular access service that not only serves adults but pediatric  population too. And outside the ICU weaning program, intensivist-led percutaneous tracheostomy team responds to  a difficult airway by the intensivist and have a critical care recovery clinic. Patient safety and quality outcomes are crucial to the success of the hospital health system  and they often evolve over time. Continuous tracking and adapting to patient safety and quality initiative to meet the needs of the organization.  Provide physician leaders accountability in achieving these goals and tie financial incentives to initiatives that improve patient safety quality and report out this data regularly.  I recommend this on a monthly basis so the faculty staff are aware of their own progress,  of the progress of others and as an organization and hold debriefs and lesson-learned sessions  in an educational and safe way. Being in an intensivist shortage makes physician recruitment a challenge.  So offering competitive and equitable contracts can attract new recruits, providing opportunity  for professional growth and leadership development within a CCO and mentor junior faculty into these positions.  Be up-to-date on the market values, whether you use AAMC or MGMA, on an annual basis and stay consistent with them and identify and develop young leaders, create action plans  for these individuals to grow into a critical position and perhaps have planning and have associate directors in your ICU so you have some kind of succession planning.  While expanding a critical care organization across different hospitals, whether they are  in the health system or a region, there is likely varying processes, cultures, and resources at each institution, and that's what makes those institutions unique.  Similar to establishing a critical care organization, there will need to be a buy-in from health  system leadership, departments, and faculty in these new ICUs, hospitals, and organizations. So again, you'll need clinical, financial, and cultural alignment.  And for clinical alignment, we'll start by evaluating the processes and resources these new areas already have to see what works for them and what can be improved.  And next, consider the established clinical processes that critical organization has already in place and that has proven to be successful and share data with faculty and leadership  in these new areas. If they're lacking resources and training, provide these sites with personal workshop mentorship and some of these things.  You may not be able to bring the resources up tremendously, but you could figure out a way to enhance certain programs.  Next alignment would be working with leadership to ensure a performance-based compensation model.  Meet with current faculty and explain the benefits of the newer compensation model and recruit faculty and oversee their contracts.  And of course, cultural transformation, leverage key stakeholders, find people at these new sites that buy into the vision of a CCO and grant them with leadership positions, such  as site director of your CCO. Utilize support from system leadership and cultural transformation takes the longest amount of time. People innately do not like change.  So, now switching gears a little bit so I could give you real-time scenarios and talk to you about the elements of the Institute for Critical Care Medicine.  In the next few slides, I'll describe our CCO that we have at Mount Sinai Health System and how we evolved and expanded over the last several years.  Our CCO is labeled as an institute. We function as a matrix organization and have governance over all facets of critical care.  This includes clinical processes, operations, quality programs, education, including our fellowship programs, and critical care research.  We are one of the 23 critical care organizations in the United States, one of the two CCOs in the U.S. with a female leader, and the only CCO in the country with oversight of  all adult and pediatric ICUs. We contain the largest adult critical care medicine fellowship and overall critical care fellowship training.  Here is the snapshot of what we looked like in 2016. We were operating exclusively at one hospital where there were five adult ICUs, 70 ICU beds,  21 faculty, no 24-7 coverage in any of the ICUs, and the governance and processes stemmed from various departments.  Our critical care medicine fellowship had 16 fellows, and the administrative work was split between different departments. And this process varied from ICU to ICU.  Faculty were recruited by various departments and were in the ICU only a fraction of their time.  A pulmonologist would do, a pulmonary critical care individual would do pulmonary 75% of their time, and critical care 25% of their time.  There was little to no benchmark on data tracking. Our hospital-acquired infections were the highest in 2016 in our ICUs, and interestingly,  we have less HAIs over the past year with multiple newer ICUs, and our hand hygiene compliance was below our system benchmark. How did we find success?  One of the first initiatives we took on in 2017 was development of a rapid response team  and a vascular access service to provide expertise to patients outside of the ICU and benefit the entire hospital.  The same year, we developed quality metrics based on evidence-based benchmarks of quality patient care, such as HAI, hand hygiene, and reported out on the progress over the course  of the year. So all units and teams were aware of their progress. In 2018, we developed a night intensivist coverage service, providing four intensivists  in-house each night, making us leapfrog compliant. And in 2018, we added more ICUs because our critical care needs were much higher.  We added a transplant ICU and cardiovascular ICU, bringing our total numbers up to seven ICUs and redesigned some of our outdated intensive care units.  In 2020, it all came together. We built upon our firm interest infrastructure to rapidly increase bed capacity and implement  a tiered staffing model that was first put forth by SCCM to combat the initial surge of COVID-19 pandemic.  In 2021, we welcomed pediatric ICUs and incorporated two other campuses into ICCM and staffed these areas 24-7 and expanded our well-established programs to these areas.  And this year, we are pleased to include all the health system ICUs into the Institute for Critical Care Medicine.  We hope to continue to build on our strengths and learn from our challenges to develop integrated approach to take care of critically ill patient across Mount Sinai Health System.  This is a snapshot of the quality initiatives and incentives we developed starting 2016. And they've yielded great success in patient safety and quality and professional development  over the last few years. These annual quality metrics have become an integral part of our CCO for several years, and we continue to progress to better outcomes each year.  Our recent programs such as our wellness committee and our diversity equity inclusion task force  are continuing to grow and will also have lasting impact on healthcare. Our diversity equity inclusion task force was created to examine, develop, and improve  ICCM practices that foster equity and inclusivity of our patients, students, house staff, and colleagues.  ICCM faculty and staff are unique that we are organically diverse, but we also look at patient care recruitment, education, research, and various other processes with DEI lens.  Our critical care medicine fellowship exceeds the specialty's national average for women and URM recruitment.  We have received a GME green rating since 2017 when the data were first presented.  We are a home to three critical care fellowships, making up the largest critical care training program in the country.  We currently have 32 fellows in total, 25 in critical care medicine, five in neurocritical care, and two in critical care anesthesiology.  Our fellowship programs are such a strong pillar of our critical care organization, in that we train our future faculty and leaders.  In the midst of an intensivist shortage, we have bright new physicians already in the pipeline in our network, many of whom we hope to recruit and keep.  So I summarized our trajectory over the last years. We've grown a lot in a short period of time and have developed and expanded excellent  patient care to many patients across our health system and perhaps even beyond. To sum this up, in 2017, we were in a single hospital with 70 ICU beds, 21 faculty, one  fellowship and had different processes and critical care. There was no ICU with 24-7 coverage. In 2022, we are in seven hospitals. We have 21 intensive care units with 264 ICU beds.  We have a little more than 100 faculty that provide 24-7 coverage for all our ICUs. We have 32 fellows and three fellowships, and we have consolidated processes across  Mount Sinai Health System. We've expanded our critical care teams and quality initiatives in all the other ICUs. I thank you for your time and attention.

Video Summary

In this video transcript, Dr. Rupa Kohli Seth, Director of the Institute for Critical Care Medicine at Mount Sinai Health System, discusses the unexpected challenges in leading a critical care organization. She highlights the benefits of having a unified critical care organization, including coordinated processes, patient safety, quality initiatives, streamlined hospital throughput, and unified education and research. Dr. Seth outlines the advantages for patients, hospitals, and faculty, such as clinical innovation, equitable care, containment of costs, and recruitment and retention of intensivists. She also discusses the challenges of establishing a critical care organization, emphasizing the importance of clinical, cultural, and financial transformations, as well as buy-in from senior leadership. Dr. Seth shares her experience in expanding and enhancing the critical care organization at Mount Sinai Health System, including developing quality initiatives, recruiting faculty, and integrating vertically within the hospital and health system. She highlights the success they've achieved through these initiatives and their focus on patient safety, quality outcomes, diversity, equity, and inclusion, and fellowship training. Dr. Seth concludes by summarizing the growth and expansion of the critical care organization at Mount Sinai Health System in recent years.

Asset Subtitle

Administration, Professional Development and Education, 2022

Asset Caption

In recent years, mandates to improve healthcare quality and safety have created new challenges for hospitals in the United States. Medical centers now place great emphasis on redesigning healthcare delivery and improving their systems and quality of care to ensure broad-based safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity. Critical care leaders are being challenged to address the rising patient demand for critical care services, the intensivist workforce shortage, education of new generations of critical care medicine physicians and advanced practice providers. Critical care leaders are being asked to standardize care and technologies in hospitals with many ICUs, optimize ICU integration in inpatient care and hospital throughput, and participate in quality assurance, cost control, research, and fundraising initiatives. In response, medical centers are developing new organizational models—critical care organizations (CCOs) of centers, institutes, and service lines—to provide nimble and flexible suprastructures across their entire organizations.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Administration

Tag Healthcare Delivery

Year 2022

Keywords

critical care organization

coordinated processes

patient safety

quality initiatives

streamlined hospital throughput

unified education and research

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