Transcription
Hi everyone, my name is Eddie Keshi. I'm the founder and CEO at Rainfall Health. And today on our hosted program series, we have Dr. Herman Kenny that's going to be joining us. All right.
Well, I want to introduce you in here. So, today we have Dr. Dr. Herman Kenny joining us, uh, regional clinical leader for surgical quality and safety at Kaiser Permanente in Northern California. Co-leads the senior surgical care program across 21 medical centers. Uh, sits on the ACS geriatric surgery verification leadership committees and you've been on Becker's podcast. You've been in the general surgery news recently and you're also part of our rain advisory subclinical subcommittee, which we're very grateful for helping, you know, uh, lead the actual clinical foundations on which a lot of the technology and stuff is built on. So, super excited to have you here today.
>> All right. Well, thank you. I'm happy to be here. So, it's uh, I've been working for Kaiser for 26 years now and uh, you know, for eight years I've been doing the work that you talked about, which is um, shifting away from clinical care and doing uh, more quality improvement work and improving surgical outcomes, not just one patient at a time, but for the entire region. And so, I think we've been successful. And more recently, the focus has been on elderly patients um, because they're a separate high-risk category and um, they they come with a lot of um, you know, special needs and uh, we want their outcomes to be just as good as anyone else. So.
>> So, what got you interested in this?
>> Uh, I was uh, you know, I was always interested in quality. Um, I've been doing quality improvement work since 2009, looking at our um, risk-adjusted data and then doing projects to improve that. And then in 2018 um, I applied for and got the leadership role um, for the whole region. And since then, uh, we've been working on improving surgical site infections, mortality, readmission um, and other complications. And then um, in about 2019 or 2020, we started implementing the um, senior surgical care program, which is also known as the geriatric surgery verification program by the American College of Surgeons. Um, and that was this project that we were part of the initial um, group of hospitals that were pilot sites and then after we saw really great results, we decided to expand that and scale it up to all of our hospitals and so that's when I came in to lead that work as well.
Well, I I have heard that I think Kaiser is one of the uh, most verified systems in the country. Is that right?
>> Yes, we have uh, 14 of our 21 hospitals are officially verified at the highest level called comprehensive excellence. And you know, when you look at the entire country, we have almost half of the hospitals um, at this time in the entire country that are verified at that level.
>> That's amazing. So, why why take those additional steps? Why go through that additional bar that you want to meet um, for for this area?
>> Well, we, you know, we have 4.5 million patients in Northern California and we have noticed that 7% of them are 75 and older and 2% of them are 85 and older. So, it's a large population that's only increasing over the years. So, we realize that um, they are um, needing more surgery. They have more um, complicated situations. They're on more medications, they have more risks, they're more frail, and because of that, we needed a system to manage them better so that their outcomes were better, that we were providing goal-concordant care. So, patients who wanted surgery were getting it. Patients who didn't want surgery and wanted alternative treatments were getting that as well. And in that end, when you do all of these things, it turns out that you have better outcomes as well afterwards. So, that was the that was the driving force behind it.
No, that's amazing. And is this verification program, is this something that's recognized um, at a national stage? And who's sort of the the body that oversees it?
>> So, it's the American College of Surgeons, which is the preeminent um, national organization for.
>> where you hold some leadership roles, right?
>> Yeah, I'm on the leadership committee for the um, GSV program. Uh, and so there's a there's a whole group of people from around the country um, mostly in academics um, but other private surgeons and um, community surgeons like myself um, but that they're the ones that came up with the program by reviewing the body of literature that existed at the time, combining it into a large bundle of interventions that would help patients and then packaging it as a as a program. And then we were one of the pilot sites for it. And then afterwards, as I said, we decided to expand it to all of the other hospitals because of the benefits that we were seeing for patients and the system.
No, that's really amazing. Well, let's take a step into the larger picture right now. What's happening not just with healthcare, but um, you know, also these mandatory models that are coming out specifically from uh, CMS, CMMI, which is their innovation group. And there's this really strong push towards quality now actually being a strong pillar of reimbursement as a function of how it leads to outcomes. And I would think a lot of the work that you've done um, from the quality perspective, from the specific geriatric surgery verification program perspective would fold very neatly into some of these areas of focus because even though these include mostly orthopedics, cardio and um, GI, some of the work that you've done sits sort of on top, right? Just at the quality and outcomes level.
So, all of um, all surgical patients um, have the same risks. So, whether you're having cardiac surgery, orthopedic surgery, general surgery, vascular surgery, all of those um, patients are potentially high risk both from their own medical standpoint, but also in the nature of the operations that they're having. So um, so all of the interventions that we have implemented are applicable to all of those different specialties. Um, on top of the ones you mentioned, we um, have urology patients, uh, thoracic surgery, spine surgery, neurosurgery patients. All of those are um, ones that um, have been incorporated into our program and reap the benefits of this for their patients as well.
>> Yeah. So, do you think it makes sense to have these sort of be the requirements, sort of um, helping the guidelines on best practices um, as we not only start off with team transforming episode accountability model this year, but also expanding into some of the aspects of age-friendly measures and the uh, composite joint replacement expanded that kicks off next year. Again, on the mandatory side, would it make sense to have these aspects be included because they're all post-surgical programs?
>> So, all of them are based on the current literature. So, every single intervention that has been recommended as part of these programs has literature to uh, show that it's beneficial. And so, what they've done is put all of these successful interventions together into one package. So um, you know, having it be mandatory, I think is helpful because when you make it voluntary, it's easy to skip certain um, difficult um, aspects of it and um, you don't get the full benefit unless you do as much of it as possible. So, I I do agree with the mandatory nature of it because otherwise um, it's easy to not do it. It's healthcare systems are um, it's difficult to change. It's a It's like turning a cruise ship. So, that's uh, that's something that we've we've known over the years. It's uh, so it so the more um, you have that is um, tied to reimbursement and um, you know, having better quality outcomes as a part of that, I think is all beneficial.
No, that's amazing. So, again, for uh, other folks who don't might not be as immersed in the programs as you are, can you help define like frailty? That's one of the criteria that you focus on and how it might impact these uh, post-surgical episodes as well, surgeries and the patients most importantly themselves.
>> Sure. So, frailty is one of uh, what are called geriatric vulnerabilities. So, patients have u, you know, frailty is a a sign of overall aging and weakness. So, there are you know, 80-year-old patients who are running marathons, but there are 80-year-old patients who can barely walk or bedbound. So, you cannot treat those two patients the same. Now, there are other geriatric vulnerabilities like cognitive impairment um, mobility issues, nutritional um, function um, and those have to be addressed as well. So, the way that we look at it is that you have to do a geriatric assessment, which measures how patients are objectively for all of those different vulnerabilities and frailty is one of those measurements, which is independently tied to um, poorer outcomes. So, the more frail a patient is, the worse their outcomes tend to be after major surgery.
That it's u, just interesting how um, you know, the actual landscape uh, if you really think about value-based care and its history, it's been a promise coming in for about a quarter of a century, right? The last 25 years, we we've heard these aspects come out. And now it seems like with these mandatory models and how they're affecting starting with 750 facilities this year and then every single acute care hospital next year, it has the ability to have this sort of broad sweeping changes that can come in and we can set in some of these best practices that you're talking about up front and center. But as people are sort of getting ready for that, how do we think about not just making it a financial lever that um, folks are uh, like health systems are focused on and not just cost avoidance, but really thinking about more holistically the actual drivers of value, which is going to be the quality, the patient satisfaction, the outcomes, and then costs as a part of it as well.
Right? So, uh, you have to think of it as improving quality will improve cost and not the other way around. So um, when you improve quality, you will decrease cost and part of that is having, you know, these are the components of age-friendly care. So, having better goals of care conversations with patients so that the ones who want surgery and are willing to go through the risk end up having surgery. Ones who um, prefer alternative treatments go in that direction and then for the ones who want to have surgery, they need to be optimized and that may take some time, you know, it's, you know, before our goal was efficiency, getting patients into surgery as quick as possible and I think taking a step back and making sure that patients are optimized before surgery is better and sometimes that takes weeks, sometimes it can take even months, but if you have a patient that's in better shape, if they're nutritionally more sound, if they're able to walk longer distances, if they're off high-risk medications, then u, those patients do better as well. Um, so I think it's, you know, the quality piece of it is tied to cost and as you improve quality, the cost will be better as well.
>> Yeah. So, that's really the strategic benefit would be by investing in better infrastructure, better practices, you're actually driving towards lower cost and better outcomes over.
>> Yes. I mean, you can see just the just having better outcomes reduces your cost, right? Because there's a cost associated with every every infection, every readmission, every um, other complication has a cost associated with it. So, if you prevent those um, then you're saving cost there as well. Now, there are other costs of uh, you know, benefits to patients where if they choose not to have surgery, then you are also um, lowering the cost by having them choose alternative means and um, going going down a different uh, pathway that doesn't carry so much risk for the hospital or the hospital system in terms of cost.
That's such a great point because um, a lot of these in-scope procedures that's coming out from CMS are elective procedures. So, being able to have that conversation and prepare people ahead of time and then also help them select or opt out is a benefit that really in aligns incentives from the patient to the clinician to the provider and then ultimately the pair as well, which is CMS. Right.
>> Yeah, definitely.
>> Yeah. Amazing. Well, one of the things um, I think that'd be helpful is um, even though the T model or these models go post-op, right? 30 days post-op this year and then we have 90 days um, with CGRX next year.
>> Um, a lot of what you're talking about is actually happening in the pre-op side of the equation. What like could you walk us through like a patient journey where it starts and where it.
>> Yeah, absolutely. The the patient journey starts uh, when they first get referred to the surgeon, right? So, the surgeons typically, we you know, we want to take ownership of the process, right? Patients having surgery requires surgeons in the mix. So, it starts there where with goals of care conversations, right? Deciding what a patient wants uh, with the surgery, what they hope to gain from it, whether that's realistic or not, and what the recovery looks like. Um, so all of those things have to be discussed with between the patient and the surgeon and the family. Then, if the patient is um, you know, wants to go ahead with surgery, then it requires this pre-operative evaluation, right? And that includes this geriatric assessment, frailty assessment, etc. And during that evaluation, if there is anything found that um, needs optimization, then that should be done um, pre-operatively as well. And then after surgery, the components that help with the improved care are doing daily assessments to prevent delirium, having geriatric-friendly rooms, making sure that patients get their um, what's called PSSE or um, things like dentures, uh, their glasses, their hearing aids, so that they're not confused when they come out of surgery. And then um, after they go through their hospitalization, at the time of discharge, they should have another assessment to see what sort of um, post-operative care they need, whether it's at home, whether it's at a nursing facility, whether it's in rehab. And we have social workers and patient care coordinators who do a lot of that. And all of these things are to help patients recover better at home so that they're less likely to get readmitted and come back in with some some sort of complication. So, it helps with decreasing length of stay in the hospital as well as decreasing um, the readmission rate for patients.
>> So, both of those are some of the most expensive parts of you know, a post-op.
>> Yeah, absolutely. Every complication, you know, prolongs the stay in the hospital. Each day is expensive. Sometimes patients go to the ICU, that's even more expensive. Uh, and then they if they go home and they come back, you know, it all starts over with them with coming back into the hospital. So, yeah, the more that can be avoided um, the better it is.
>> So, what do you think is the current level of education and understanding that a lot of the decision-makers have right now at the system level about these these sort of items?
>> Um, I think there's, you know, certainly people know that the elderly population is exploding. People know that they're requiring more care. Um, in terms of the nuts and bolts of how to do it, I think is probably less well-known. Um, and there are multiple organizations including the ACS that are spreading the word. CMS is spreading the word. So, I think more of that is coming through, but the, you know, local implementation, I think still is behind and, you know, the more of that we can do, the better.
So, how would we advocate uh, for the patient in like we have a mandate coming down, there are significant dollars and cents that make it actually there is a penalty element, but I like to focus on the upside, right? Like you can think about it as how do we actually invest in better practices, better clinical workflows, better infrastructure to better serve the patient, right?
>> And so, if you have these new dollars that are becoming available, investing them, but then how do you actually get started in that process?
>> Well, I think you have to start with the experts. So, go with the experts that are there and then, you know, we know what to do. It's just it just takes a long time to implement it. U, you've probably heard that it takes 17 years in the healthcare system for something to go from being known to being routine. And so, we have to speed that time up. And luckily, there are plenty of people doing research and putting together these best practices. It's just a matter of following them. There are multiple um, surgical societies that um, put together these recommendations and there are plenty of uh, geriatric societies that do the same. So, the knowledge is there. It's just really a question of how much are systems willing to put in an effort to have the resources there for patients who are considering surgery and going through it.
>> Yeah, that makes a lot of sense. Um, well, right now, what do you think with the AI boom? Is that something that we can leverage at this point in time and to make this process more seamless? Because 17 years, yeah, my sense, it it sounds shockingly, you know, uh, bad to anybody not in healthcare, but in healthcare, I think um, this would be an of course statement, right? Like yes, I'm not surprised it takes that long in a place where even cutting-edge technologies take two years to just go through the process to get uh, into the hospital for the very first time.
>> So, do you think AI is going to change any of this landscape?
>> Yeah, I think definitely AI is changing everything about what we do in all of our lives, right? That's uh, that's the new thing. But um, but I think and I certainly see that there are applications u, you know, already. I'm already using a um, AI scribe when I see patients. So, it saves me time on charting on patients and there are certainly many other um, AI tools that I think are helpful. So, yeah, as AI becomes more the norm, I think that all of us will get used to using it. I think using AI in our clinical practice is very early in its infancy. So, that's something that I think we you know, will become more the norm over the next few years, I would think.
So, do you think there we have the data elements or do we need to also get better about collecting the data so that we can feed the AI? Because AI is only as good as the the data and how we structure it and if we don't do it properly on the clinical side, its use cases are going to be limited as well.
>> Yeah, I think we the AI needs to use, you know, what the current literature states and what are the best practices that needs to be built into it. It needs to have access to patient data to identify who are frail, who are high-risk and then give tailored recommendations to those providers so that we can get real-time recommendations for what can be done, what interventions are missing or could be done to improve care. Uh, I think there's there's a tremendous scope for AI in this space. It's just we're not quite there yet. So, hopefully soon.
We'll we'll get there. Yeah. Um, I'm curious, you know, from our perspective here at Rainfall Health, we take a strong stance on there has to be the strong element of keeping the human in the loop. The clinician needs to be in the driver's seat. The care coordinators, the case managers, the human in the loop elements can be very strong, especially um, AI can supplement them, but really at the heart of it, it is that human-to-human interaction that goes a long way. Um, any any thoughts about that?
>> Yeah, I think again, healthcare is between doctor and patient. That will never change, you know. Well, I hope it never changes, you know. So, but I think that there's a level of trust that patients have in their doctors and that the doctors are looking out for their best interest regardless of the technology that that we use. Um, one of the things that happens to me is I do robotic surgery. And when I explain that to patients, they invariably think that it's a robot doing the surgery. And you know, I have to tell them every single time that no, it's not a robot. It's just a machine that looks like a robot that I use to do the surgery. So, I'm the one doing the surgery. I'm using this tool. But again, that's a technological advance which I think is beneficial, but it requires explanation. And I think the AI tools that we use are going to be something similar, both for clinicians as well as for patients.
>> That that's exciting. Again, that knowledge gap between what the patient is experiencing as well as what the clinician is um, sort of used to in some ways, like how that always goes hand-in-hand from the patient side of the equation. I'm always curious like they are so central to everything that we do on on the healthcare side and yet a lot of the times they get put off to the side as well. Do you think there is this element of like personalization and from the technology perspective as well as like putting them front and center as part of the reimbursement that uh, in the steps that CMS is taking with these mandatory models that might shift how much say and how much um, presence that we can have around an individual patient to help drive each journey as sort of a personalized one.
>> Yeah, absolutely. I think patients certainly want personalization. I mean, I think that's something we see all the time. They don't want to be treated like a number or, you know, just any other patient. So, I think that starts with the conversations between physicians and and the patients. But the system also can help with that. I think, you know, patient education can be uh, tailored to this. I think their experience going through the system can be tailored. A lot of patients feel like they don't get enough from the system. They don't hear, you know, it's hard to connect with with people and, you know, get their questions answered and every patient's journey is different. So, yeah, having tools to help them go through the process on a more personalized basis, I think certainly would be desired by them.
Oh, that's amazing. I do want to go back for a second to one of the things you mentioned. So, delirium, you know, we talked about that as one of the vulnerability factors. Why is it so critical for uh, a mandate like team, like in your opinion?
>> So, delirium is a very difficult complication to both identify and then to deal with. So, um, patients who are elderly have a high risk of delirium um, in general, but they there are also risk factors for it. So, patients have um, underlying dementia or they have cognitive impairment of any kind um, or they're going through a big operation, they get a lot of anesthetic, uh, they can be they're at high risk for delirium afterwards. So, if they get delirium, then um, then their length of stay goes up. They're it's very distressing for their family because they they don't look like the the person that they that they know. Sometimes it's hard to diagnose. There's a very large cost associated with it and there are long-term um, changes. So, patients may not fully functionally recover from the delirium that they may always have some degree of cognitive impairment um, long term. And so, so I think from a cost standpoint and a patient standpoint, I think it's a it's a very big um, you know, complication or problem that needs to be um, resolved or at least improved, you know, as with any other complication.
>> Yeah, absolutely. Well, one of the things that I think strikes me is at the top of the conversation, uh, you were mentioning how these are just best practices. They go, they span across surgeries. And now what we're seeing as these big uh, moves that are happening in healthcare, they're not only limited to just a handful of procedures to start um, but they're also limited to just a few facilities and within those limited to just Medicare right now. Um, does does it make sense for it to go beyond? Does it should it be going broader uh, to the general geriatric population um, and uh, across private payers and across all health systems as well.
>> Yeah, I think ultimately, you know, we have you know, things that are beneficial interventions that are beneficial, we should be um, doing them for all patients that would benefit from them. Now, I think the elderly population has more risk than younger healthier patients. They they generally do very well with surgery, you know, without much uh, much of an intervention. But yeah, certainly I think starting with the elderly population for the reasons we spoke about earlier, I think is a good place to begin. But I wouldn't be opposed to having it go to all patients as well. So.
>> It sounds like it just be better for everybody involved.
>> Yeah, absolutely. I mean, if something's better, we should be doing it for everyone. I couldn't agree more. All right. What what have we not covered? Like what what should we be thinking about generally?
>> I think we should be focused on um, implementation or change management. Uh, that is I think the most difficult piece. You know, having done this in a large healthcare system that even things that are known to be um, beneficial are hard to translate into practice on a daily basis. So, I think it's it's easier to create the technology, but having the technology by itself isn't a guarantee that it will get utilized um, to its full potential. So, I think that not only having the technology, but figuring out how to implement it successfully is the is the biggest challenge I see in this space.
So, what works and what doesn't work in that.
>> What doesn't work is unfortunately making things mandatory, but you know, I think in even though we think that that is the best way of doing it, but you know, we really need to convince people that there are, you know, both patients and clinicians and other providers need to know what the benefits are and once they see what the benefits are, then they will do it themselves, you know, once they have, you know, I I have hundreds of stories of patients who have come back and told us about their experience and how much better it was than what they were doing before. Some people had had, let's say, a knee replacement on one side using our old system and then now they have their knee replacement on the other side with our new system and they tell us it's so much better the way we're doing it now than what we were doing before. So, when patients and surgeons and other people hear that, then they want to do more of this, right? All of us are looking to have the best outcomes. We have nobody wants to have more complications or more issues. They want everyone to have surgery, have a smooth recovery, and then go back to their lives as best they can afterwards.
How do you make it easier to disseminate really complex and ever-changing guidelines?
>> Yeah, it's a it's a challenge. I think most of the time we do it through the surgical societies. Um, you know, doctors tend to rely on their own the leaders in their own field more than anybody else. Um, and so these people who have, you know, established their reputations as being knowledgeable and objective and um, you know, wanting the best for patients as well as their fellow um, physicians. I think those are the places where we start from. So, most societies have um, you know, summaries of care that they that they put through every few years, they update them and and that's what I think what most um, surgeons and other physicians do when they go to conferences every year, they they learn the newest uh, ideas. That's probably the best way to do it. That's why I I'm part of the American College of Surgeons and we do that there.
No, that's amazing. Um, any any other thoughts before we we wrap up?
>> No, I'm I'm glad to hear that. Uh, finally, we're making headway into the healthcare system, right? I mean, I've been doing this for 26 years and some of the things I'm doing now are the same exact thing that I did 26 years ago. Um, but there are things that have changed over the years. You know, when I started, we weren't using an electronic health record, and now we are, and that's that's changed what we are now. I've just started to use the AI scribe, and that's um, helping my practice as well. I I expect that over the next 10 years, probably in the time that I'm still practicing and beyond when I'm just a patient, I think that these tools will help us provide better care overall. And that's what I'm looking forward to.
No, that's pretty amazing. And you know what's interesting for uh, for me specifically, you know, in in the time that we at Rainfall Health have been working to help empower health systems to work better and serve patients, serve clinicians better, um, there there's a culture in different systems and how rapidly everybody um, gravitates towards new technologies and new ways to do things. And you know, u, in your experience, how does that translate? Because everybody wants to do the right thing. Like you said, every single clinician I've ever met, I come from a long line of clinicians myself, and everybody wants to do the right thing. Why does it sometimes take longer in some institutions than it does in others?
>> I think with again, with change management, it uh, you you see different categories of um, implementers, I would say. So, there are early adopters. These are the people that buy the new iPhone every year. And then there are people who are resistors, people who are no matter what you do, they're going to fight it till the end. And then there's a larger group that's in the middle that are open to change, but they want to wait and see, you know, how it progresses. They're not the ones who jump in at the beginning, but if they see something better, they will adopt it. And I think that's the group that we have to focus on, right? The early adopters will take anything and run with it. and and those are great to have on board as well. Um, but the largest group is this people these people in the middle and those are the ones you have to convince that there's something that what you're, you know, what they're intending on doing is better and more efficient, has better outcomes than what they're currently doing, and once they realize that, then they'll make the switch, but it can take a while for them to accept that.
What would you say to that that group right now about about the stuff that we've been talking about?
>> I would say, you know, changes are coming. We you know, we clearly see that there are ways of doing things better than what we were doing before. Um, the technology is there to help us and uh, you know, don't be afraid of it. I think we we still need doctors and to to manage patients, that that's what patients want and uh, these are just tools to help us do things better.
I couldn't agree more. Well, thank you so much for joining us and you know, sharing your insights. Great. We appreciate it. No, >> thank you very much.