Piloting Innovative Workforce Support to Put the Focus on Patient Care

00:00:00:12 - 00:00:35:02
Tom Haederle
The federal public health emergency for Covid 19 officially ended 15 months ago, but any health care provider will tell you the official date means little because the pandemic's repercussions for hospital and health system workforces lingers on. It's felt every day, while the great migration out of the health care profession has slowed. It's not over. Nonetheless, caregivers are finding ways to cope and continuing to deliver great patient care.

00:00:35:04 - 00:01:01:16
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Corewell Health, which provides care to a large section of Michigan, also faced a shrinking workforce during the pandemic, as so many providers did. In this podcast, we learn about its response, which can be summed up like this. Instead of saying we'll do more with less by making people work harder, we said, how do we do more with less?

00:01:01:16 - 00:01:06:02
Tom Haederle
By thinking outside the box and reinventing some of the things we did.

00:01:06:04 - 00:01:30:03
Elisa Arespacochaga
Thanks, Tom. I'm Elisa Arespacochaga, vice president of clinical affairs and workforce, and today I'm really excited to have a conversation with Dr. Darryl Elmouchi, Chief Operating Officer of Corewell Health, where he leads strategy, operations and clinical care delivery across 21 hospitals and is dealing with all sorts of challenges related to the workforce and really supporting the teams that, he gets to lead.

00:01:30:05 - 00:01:46:18
Elisa Arespacochaga
And I'm excited to have him share with this group some of the amazing work that they are doing and piloting and innovating to really support their workforce. So to get us started, Darryl, can you tell me a little bit about your background and sort of how you came to this role, from your clinical work?

00:01:46:20 - 00:02:07:20
Darryl Elmouchi, M.D.
Sure. So thanks so much for having me. I'm excited to be here. I am what's called a cardiac electrophysiologist. So a cardiologist who did very specialized procedures for heart rhythms, and never, ever intended to be standing here talking to someone like you. But over the course of many years. And you'll see a theme here when we talk about some of the work we've done.

00:02:07:23 - 00:02:29:10
Darryl Elmouchi, M.D.
I came to see, not only caring for patients being important, but for caring for people that care for patients to be important and really saw a need to make systems better. And so started down that path well over a decade ago and over the course of many years took on different jobs trying to do that. And over the last few years have been really leading all care delivery for Corewell Health.

00:02:29:12 - 00:02:36:03
Darryl Elmouchi, M.D.
if you recall, Corewell Health has actually two health systems emerged about two years ago, Spectrum Health and Beaumont Health, in Michigan.

00:02:36:06 - 00:03:03:27
Elisa Arespacochaga
You're covering not only the entire state, but really trying to make sure you're supporting, to two different teams and bringing those cultures together. So that's, definitely a challenge. And I know we've talked about this. You're facing the same workforce shortages and challenges with turnover and the overall impact on that care team. So not only are you trying to support them, but you're trying to support a team that maybe tired and worn out and needing some, extra supports.

00:03:03:27 - 00:03:17:05
Elisa Arespacochaga
And quite honestly, they're fewer than maybe they were before. So what are some of the biggest challenges you've been seeing? And some of the drivers of dissatisfaction that you really wanted to tackle as you started thinking about this work?

00:03:17:07 - 00:03:47:29
Darryl Elmouchi, M.D.
Yeah, you know, I think you kind of hit it very well. And I'd say a couple of things. Obviously, I think for everyone coming out of Covid, it was just a year or two plus that was incredibly challenging emotionally, physically in every possible way. For caregivers. And then coming out very specifically, we saw, like everyone else, this migration of folks that were no longer in the workforce, whether it was early retirements of nurses or people that came into the workforce and pretty quickly said, I can go do something else that's easier.

00:03:48:01 - 00:04:06:27
Darryl Elmouchi, M.D.
I don't have the calling that I used to have. And so we were trying to do the same amount of work or more with less people. And ultimately that just is a recipe for burnout, and it doesn't work. so we took a multi-pronged approach, and I want to preface this by saying we're on a journey. There's nothing that's perfect.

00:04:06:29 - 00:04:25:21
Darryl Elmouchi, M.D.
But, I really like to pride our teams and some of our leaders because instead of saying, how do we do more with less? By making people work harder, we said, how do we do more with less? By thinking outside the box and reinventing some of the things we did. And I'm really proud with some of the pilots that we've been now starting to scale.

00:04:25:21 - 00:04:27:29
Darryl Elmouchi, M.D.
And I'm happy to share a lot of them, if you'd like.

00:04:28:06 - 00:04:48:12
Elisa Arespacochaga
Absolutely. I know one of the areas you've really, sort of double clicked on is looking for ways to incorporate technology, which is not something that clinicians have, you know, had a real good track record with, let's just put it that way. But looking for ways to incorporate that technology that can reduce the burden, particularly that administrative burden.

00:04:48:12 - 00:05:03:28
Elisa Arespacochaga
That is not why you went into health care. You went into health care to help people. And, you know, typing up their complaint list is not doesn't feel like it's helping them. So what are some of the ways that you have been using technology to really augment the ability of the team?

00:05:04:00 - 00:05:25:08
Darryl Elmouchi, M.D.
Maybe I'll start with nursing because I think probably across the country, that's been the area that's probably been the most challenging in terms of workforce and how hard it is to both hire and continue keeping nurses, as well as attracting new nurses into the field. You know, we've done a lot of things, like many other working on pipelining, partnering with universities and so forth to try to increase the number of nurses in the state.

00:05:25:10 - 00:05:42:11
Darryl Elmouchi, M.D.
But in addition, we had a team that looked at what are our nurses doing, particularly in the hospitals on the floor. What are they doing minute by minute? And how much of that work is really not value at it's not what they went to nursing school for. It's not what we really intended to hire them to do, but they're doing.

00:05:42:11 - 00:05:54:18
Darryl Elmouchi, M.D.
And maybe I'll turn and ask you just a quick question. What percentage of what a nurse does every day in the hospital do you think is really kind of clinical, needing a nurse versus anything else?

00:05:54:20 - 00:06:06:05
Elisa Arespacochaga
Well, I only know the answer because I've heard you talk about this, but I was shocked because I would have thought it would have been in the 70 to 80% range before I heard your, what your study showed.

00:06:06:08 - 00:06:33:07
Darryl Elmouchi, M.D.
So we did very detailed pilots looking on different nursing floors to understand what nurses do. And as it turns out, direct patient care is about 44% of their time, meaning 56% is something other than direct patient care. And even within direct patient care, a large percentage of that is documentation. And that's not necessarily truly direct patient care. But you'd argue that a nurse probably has to document.

00:06:33:09 - 00:07:01:12
Darryl Elmouchi, M.D.
So there's a huge amount of other work. And the hard part about this is that as we learn and we dove into this, that other work isn't work that doesn't have to be done. It absolutely is. It just might not have to be done by a nurse. And so what I would share with you is this if you start thinking about what a nurse does, aside from going in and adjusting medications, giving medications, assessing patients, checking vitals, all the things that clearly are part of a nurse's toolbox.

00:07:01:15 - 00:07:21:20
Darryl Elmouchi, M.D.
There are so many other things that happen that are really challenging for nurses. So think about everything as simple as, you know, a patient wanting a glass of water. That's really important for that patient, for the nurse, probably someone else can do that is going to find supplies on the floor. So many other things that they're coordinating and trying to do that really aren't that helpful.

00:07:21:27 - 00:07:44:10
Darryl Elmouchi, M.D.
So what we ended up doing, and this is a really interesting way that it was piloted, we said, well, is there a way for patients to let us know what they want in a room that uses technology? And by use of that technology, can we use another workforce to do some of that work? And we started this pilot now about two years ago in one of our smaller rural hospitals, and we actually had an Alexa.

00:07:44:10 - 00:08:07:24
Darryl Elmouchi, M.D.
So an Amazon device and a created an interface in an app on Alexa where the patients could talk to that. And the first thing we learned was it totally didn't work. It just didn't work well. Patients, really, it couldn't understand them. The patients themselves really couldn't figure out how to use them very well. So we scrapped that. And we partnered with a local entrepreneur and actually created an app.

00:08:08:01 - 00:08:30:10
Darryl Elmouchi, M.D.
That app can go on a iPad or type a tablet device in a room. The app also we put on nurses workstations and their devices. They carry it around the hospital. And what we learned is that there was a ton of requests or there are a ton of requests, for these nurses. Through this app, we started adding more requests that someone else could do.

00:08:30:12 - 00:08:53:19
Darryl Elmouchi, M.D.
So the second thing we did was we temporarily hired a distinct workforce where we more or less, and for lack of a better term, gamified or Uberized, what they did relative to these other tasks. So if a patient needs a blanket, the patient clicks on the app. They need a blanket. Someone else in the hospital who's hired to do this brings them a blanket, and they could be coming from another unit.

00:08:53:24 - 00:09:15:25
Darryl Elmouchi, M.D.
And that person gets incentives to do more over the course of time. So almost like an Uber driver gets incentive to drive. We started working on this more and more, and we realized that actually the most clicked from the app came not from the patients, but from the nurses themselves when they were tasked with something, when they came by a room, they saw something was needed or asked, and they can actually ask someone else to do it for them.

00:09:15:27 - 00:09:27:23
Darryl Elmouchi, M.D.
And we have now scaled this across multiple, nursing units at large academic thousand plus bed hospitals and in smaller hospitals. And it has been incredibly effective.

00:09:27:26 - 00:09:49:18
Elisa Arespacochaga
I just love this idea. And I especially love that you went back to it. Even after the first version. Didn't quite, do what you needed. I just love the idea of being able to really look for ways to create that delegation chain in a way that doesn't feel like you've got to, you know, then train another workforce and pull them in.

00:09:49:20 - 00:10:14:00
Elisa Arespacochaga
This is work that can be done in a way that that really doesn't put another burden on the nursing team to figure out how to get it done. So can you tell me a little bit about what you're doing to bring some of those teams together, so that you can reduce some of the frictions? I know we often set workflows in health care, and then they are set in concrete and we never move them.

00:10:14:03 - 00:10:25:17
Elisa Arespacochaga
but to try to make the teams more efficient, especially when you're working with maybe people you haven't worked with before or you're trying to do different things with that smaller team.

00:10:25:19 - 00:10:49:10
Darryl Elmouchi, M.D.
Yeah, I love the question. And I say that, you know, if you think about kind of some of the universal challenges in modern health care delivery, one of them is everything's become so big that it becomes more impersonal. Humans are we're just tribal. We like to be around people that we get to know. We understand how they work, how we work, and large hospitals, large clinics, large systems.

00:10:49:15 - 00:11:10:04
Darryl Elmouchi, M.D.
That becomes increasingly challenging. So I'd point that is just one underlying problem that really takes away from the family feeling of things. Number two, as a health system, we had issues with our length of stay. We wanted to work on making our length of stay better. I firmly believe a shorter length of stay improves the patient experience, because they're not waiting for things in the hospital.

00:11:10:04 - 00:11:28:03
Darryl Elmouchi, M.D.
They can be home and not lying in a hospital bed, and it allows us to use our resources more effectively. And as we were looking at both of those problems, we had different teams kind of looking at them. We realized there's a very simple solution, which quite honestly, it's quite possible many of our members have done years ago or never went away from.

00:11:28:07 - 00:12:00:01
Darryl Elmouchi, M.D.
But we started realizing that particularly in our larger hospitals, we had people all over the hospital and very few areas where there were kind of similar people that were working together all the time. And very specifically, this has to do with the move to hospitalist and physicians. So we have large hospitalist program, and we had hospitalist that were in our largest hospitals, you know, over a thousand beds going to 6 or 7 nursing units in a given day around because they were caring for a patient here or a patient there and so forth.

00:12:00:03 - 00:12:32:29
Darryl Elmouchi, M.D.
And as we started working on length of stay and doing what we call care progression rounds, where you have a case manager assigned to a floor, a nursing unit manager assigned to a floor, you realize they'd have to call in the doctor who's running from somewhere different, and that just didn't seem to make sense. And when we started thinking of both of those problems together, we said, you know, the more we can try to cohort patients, doctors, nurses, care managers in the same area, the same unit, the same floor, the more they can work together, not only in this shift or for this week when they're working.

00:12:32:29 - 00:12:49:18
Darryl Elmouchi, M.D.
You know, doctors are often seven days on, seven days off in these areas, but over time, they can develop long term relationships that really help strengthen that bond and have people work together well. And it's been incredibly positive, both from a well-being standpoint and from a length of stay standpoint.

00:12:49:21 - 00:13:07:26
Elisa Arespacochaga
That's awesome. It's, reminds me of one of potentially the Hocus movies that I am a big fan of. But the Apollo 13 and where, you know, Tom Hanks starts talking about, wait, you want to change one of my team members when you know, we know the way, you know the sound of each other's voice, the tone of our voice, how we react and all of those things.

00:13:07:26 - 00:13:33:01
Elisa Arespacochaga
And it's so important to not underestimate the value of that teamwork and that connection among our clinicians, particularly when they are dealing with much more stressful times, patients who are sicker, all of those things that we're seeing now, I think it's really a great approach and, you know, always nice when it also helps reduce length of stay and make the patient experience better.

00:13:33:01 - 00:13:38:24
Elisa Arespacochaga
But I can't imagine it doesn't really make the team members feel really unified as a group.

00:13:38:26 - 00:13:55:24
Darryl Elmouchi, M.D.
Absolutely. And it's such a much more cohesive feeling. And, you know, and I'll be very honest and say that if we look at our particular larger hospitals, somewhere between 50 and 80% of the units were now able to do that. We call it Co-horting. We were 0%, you know, a few years ago. So we've made a lot of progress.

00:13:55:24 - 00:14:05:02
Darryl Elmouchi, M.D.
But there's probably a limit to what you can do just based on the nature of variability within health care. But even that 50 to 80% has made a huge difference.

00:14:05:04 - 00:14:23:15
Elisa Arespacochaga
As you starting to think about this, in especially going into the future and starting to change workflows in the work environment and thinking about the team a little bit differently. I don't know if you've guys coined the term, but I love the idea of someone being an in-box ologist, and I'd love for you to share a little bit about that.

00:14:23:17 - 00:14:41:01
Darryl Elmouchi, M.D.
Yeah, so this one could be one of my favorites. I'm a little biased, as you know, a former practicing physician. So when I started in clinical practice, you know, about 20 years ago, there were no EHRs, at least where I was. and so I was so used to you work, you go home, you work, you go home.

00:14:41:06 - 00:15:04:00
Darryl Elmouchi, M.D.
And when you're home, you could be on call, but you're not finishing notes at 2 a.m.. you're not jumping in the inbox because of alerts and so forth. And nowadays, anyone who works in electronic record, regardless of what it is, is inundated with inbox messages. and that essentially is like your email in basket. But for clinical issues, some of those are very important.

00:15:04:02 - 00:15:25:15
Darryl Elmouchi, M.D.
Some of those are more informational and less important. And it becomes truly overwhelming. And so we started looking and many of the modern EHR vendors, we have to have epic, can give you all sorts of data on what we call pajama time. So how much time clinicians are spending after hours generally when they're home in the in basket.

00:15:25:15 - 00:15:52:15
Darryl Elmouchi, M.D.
And you can look at how much time during say a clinic day they're spending doing things in the, in the in basket and in the E.R.. And it is mind numbingly frightening where we've come. So you talk about burnout amongst the physician and app workforce. It is completely understandable. And you even go a step further. And you say in the beginning of Covid, electronic messages to providers were common, but not commonplace everywhere, all the time they've skyrocketed.

00:15:52:15 - 00:16:11:22
Darryl Elmouchi, M.D.
If you look at data across the country, anywhere from 3 to 6 fold post-Covid. So and that's just new work. You're not getting necessarily paid for it. It's and you're not allocating time for it. So we started looking at what can we do to make life better. And we took it on two paths a technology path and just a rethinking the workflow path.

00:16:11:22 - 00:16:31:06
Darryl Elmouchi, M.D.
And I'll start with the letter first. And we said, you know, there's a lot of stuff that comes to us in basket that absolutely needs a clinical eye on it, but probably can be addressed without the top of license. And our workforce physician looking at each of these. And so we decided to create a pilot. We call this the inboxologist.

00:16:31:06 - 00:16:59:21
Darryl Elmouchi, M.D.
And I'm pretty confident, I don't know that we're the first person to think of this, but we're definitely, I think, the one to coined the term. We actually have a publication coming out, relatively soon on our data for this, for the inboxologist, which is what we call an app, a physician assistant or nurse practitioner specifically hired to manage the inbox of a number of clinicians started with just physicians, but they actually could be managing the inbox of other apps that are in the clinical workforce.

00:16:59:23 - 00:17:25:18
Darryl Elmouchi, M.D.
And the goal was to see, can we decrease the amount of burden on the physicians and apps that they're doing this work for? Can we decrease their pajama time? And our hope was and we this was kind of our underlying assumption that this would improve productivity enough without us asking for anything in return, that it would at least break even and pay for itself, because you have to find something sustainable in this world.

00:17:25:21 - 00:17:42:26
Darryl Elmouchi, M.D.
The second big issue we had with it was, would anyone want to do this? If we're going to advertise for this role, would anyone want to be in the in basket all day as part of their job? Well, we started probably a year and a half ago and I can tell you it has been amazing. So first of all, would anyone want to do this?

00:17:43:02 - 00:18:06:00
Darryl Elmouchi, M.D.
I think I recall us having somewhere like 2 or 3 dozen applicants for the first two open positions. it turns out that, there are a lot of apps that really like this work. They can do this from home. The hours are pretty flexible, and so it's a pretty nice lifestyle work and it's still important work. The second part of it was, can we scale this and make it work?

00:18:06:00 - 00:18:24:10
Darryl Elmouchi, M.D.
And we had a lot of learnings to do because we didn't know. Do you say that one app covers ten doctors, covers five doctors, and it turns out you really have to adjust this based on the panel size of the physician or app, the type of work they do. We really started in primary care thinking that's where the biggest burden was.

00:18:24:12 - 00:18:52:14
Darryl Elmouchi, M.D.
And I can tell you that the data has been absolutely spectacular. I'm going to actually share you our most recent data, which came out about a month ago. So the average physician who is enrolled in this meeting, they have an inbox ologist, spends an average of 77 minutes during daytime hours, less in their invested each day. So an hour and a quarter and 95 minutes less each night of pajama time when they have an inbox.

00:18:52:21 - 00:19:18:07
Darryl Elmouchi, M.D.
Just the work life balance of these providers went from on a scale of 0 to 5, five being the best one from a three to a 4.25, with this being the only intervention. And we've seen a 41% in basket reduction volume. So either it doesn't come to them because it's something the app can be address or when it gets to them, there's a narrative around it where it's very clear kind of where to look and what to do.

00:19:18:14 - 00:19:20:24
Darryl Elmouchi, M.D.
It has been spectacular.

00:19:20:26 - 00:19:23:28
Elisa Arespacochaga
You've given the most of a day back in a week.

00:19:24:03 - 00:19:46:20
Darryl Elmouchi, M.D.
Could you imagine? And I'll share. And so the big thing for, you know, my CFO colleagues, is when you look at this, we also had that idea like, what will happen? How will this work? And so we have now determined that just about everybody who goes through this has enough time on their day where they will see an extra patient in the clinic every day, every few days, what have you.

00:19:46:24 - 00:19:54:03
Darryl Elmouchi, M.D.
And when you add it all up and you also look at decreased turnover, it actually pays for itself and a little bit more.

00:19:54:05 - 00:20:14:03
Elisa Arespacochaga
I love talking to you because you give me so much hope for the work we do in healthcare. Darryl, I can't thank you enough for sharing these great highlights that you're working on, and I hope we can revisit sort of where core well, Health is taking this into the future. I'm super excited. for all the work you're doing and the ability of the rest of the field to, to try taking these on.

00:20:14:07 - 00:20:15:11
Elisa Arespacochaga
Thank you so much.

00:20:15:13 - 00:20:17:27
Darryl Elmouchi, M.D.
Thanks so much for having me. It was a pleasure.

00:20:18:00 - 00:20:26:10
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.