Transcription
Welcome to another episode of Israel the Leader podcast. [music] And this is the last episode for this season. And I'm excited to bring back Carrie and John because we set it off in part one. We're going to set it off again in part two. While we're talking about volume-based versus value-based medicine. [music] And since we are respiratory therapists, we're going to go ahead and apply that to respiratory [music] therapy. Carrie, go ahead and say hi to the people.
>> Hello. Um, my name is Carrie McClure and I am a clinical supervisor in the metro Atlanta area. I have a bachelor's degree in respiratory care and a master's in business administration. [music] My background is in ICU critical care, emergency room, neonatal intensive care, and labor and delivery. And I started in leadership in [music] 2021 and I love it. It's my favorite thing.
>> [music]
>> Good. John.
>> Thanks, Hans. Uh, John Fischer, registered respiratory therapist, EMT as well. Uh, got my degree in cardiopulmonary science. Um, most of my time at the clinical bedside was uh predominantly children's uh pediatric hospital. [music] So, um, mixed variety of different different roles from clinical education to, um, uh, full-time with air and ground transport. So [music] um, definitely excited to be here and continue with uh on from our previous episode [music] talking about value and volume-based care. So, thanks again for this opportunity.
>> All right, let's get into it. Part one, we exposed the problem that we can't continue the way we are doing it. We talked about it. Everybody now is thinking about it. But how are we going to help the leaders? How are we going to get the feel some tips in part two to actually start moving and having better conversations to move from a volume-based task-driven into a value-based? At first, it comes from the top. It comes from us. Come from the leaders. First question for the team. What mindset do we think leaders must shift from to start shifting from task-based, volume-based to value-based? It comes from us. So as a leader who's probably listening to this podcast, give them some practical tips to start at least shifting their mindset from what we've been taught: more patient, more volume, more task, equipped productivity. So let's go ahead. Let's tackle that part.
>> So I'm going to say empowering them to use clinical judgment. Um, you know, of course, we want, you know, to use protocols. We know that protocol-based therapy produces the best outcomes. But, you know, value-based care is, you know, right treatment, right patient, right time. And, you know, we want leaders to empower their clinicians to use clinical judgment. Know when the protocol, when you need to go by the protocol, and know when you don't, know when the protocol is no longer applicable or when something is not indicated. So, anything John, you want to add to that?
>> Um, I mean, I think it's it's it's a top-down thing, right? I mean, we're not going to have a culture change happen with, you know, a flock of new grads coming out of school. Um, but the flock of new grads are absolutely influenced by the environment that they go to work in right out of school, right? So, um, I I I mean, I think that leaders, whether that be the clinical educators, whether that be supervisors, whether that be department heads, there there needs to be an incentive to not focus as much on what you're doing, but why you're doing it, right? I mean, I think that's what protocols are, but unfortunately, you know, there's there's always that off-protocol like, well, this doc wants to go off protocol. I might be in I what I what I want is a world where RTs are called to evaluate, not called to do. Um, and and I think that's a top-down uh approach that is only driven from from within the leadership.
>> Absolutely. So one of the questions that we talked at the ARC is we all we are actually excited about moving towards value.
>> But how do we transition from our organization still looking at volume because we we need the volume. We need people to to show up. So do we is it to have a good mixture of volume and value or how do you how how can we start making that change? How do we how can one clinician or one department be the trendsetter and why what would be the best step to start that movement? So when you're you're saying volume, we're we're talking like productivity, right? So I productivity matters for sure, but that's not the whole story. And this there's there needs to be a second question and doesn't need to be just how productive were you, but what happened because of that productivity? So there needs to be that needs to be two parts. It needs to be were you productive and what happened because of it? Because it, you know, that's where the value is created is in what happened. So, you know, I think it's it's important but it's incomplete.
>> I like that.
>> It's were you productive, but what happened when you were productive? Oh, this is good. This is really good. John, what do you think about that?
>> Yeah, I mean, I mean, think about think about if cardiology was only evaluated off of how many cuts they made, right? How many incisions they made or
>> you know, think if, um, you know, for instance, I if, uh, they were only evaluated on how many EKGs were done, right? It's the full it's the full procedure and the value that they're they're assessed on, right? All those things are important. Obviously, you need the 12 lead. You got to have the cut if you're doing surgery. But what's the end goal? The end goal is is someone's life was saved,
>> right? That that's why they are are, you know, massive when it comes to the ROI for hospitals is they're not they're not being evaluated on necessarily what they're doing, but it's the the extraordinary outcomes that happen as a result of it. Respiratory is in the same position, right? I mean, how many areas can we influence? We we talked about this in episode one. It's a slippery slope balancing. Do we have volume? Volume protects us, right? We got to be able to have things to do, but at the same time, we don't want to get rid of uh things to do because we're running protocols and we're getting patients discharged faster. I think being having an overemphasis on the assessment,
>> yes,
>> which what is what leads to the outcome and the outcome being a good one. Um, we we need to be involved in the full continuation aspect of a patient's journey in the hospital from the ED to the time they go home. Not just on task-based things, just a treatment. It's what's the result of that treatment.
>> Uh, Carrie brought this up in her first appearance, uh, and I wanted to bring it back. What is the relationship between clinical assessment, protocol, and increasing value? Because now we just we just had those three, we just talked about all three of them in the same conver the same answer. So, how important is it for clinical assessment to be right, and do we follow the protocol to the letter, to the tea, and will that have a positive impact on bringing more value to the conversation?
>> Well, better clinical decision-making is going to result in better patient outcomes. You know, I I think that, you know, that's where
>> the capability of the therapist and understanding disease management, pulmonary disease management, and, you know, and and trusting their assessment skills is really essential to value-based care. You know, I this is, you know, one of the things that we've talked about over and over again is, you know, where are those critical thinking skills going? And, you know, now they need to be empowered to use them because it it's definitely going to matter if if we're going to pivot in this direction. What are your thoughts, John? I mean, I I think, you know, just as we kind of talked it at first is, you know, how how do we get there? I think it starts with
>> setting the foundation of our departments.
>> Um, when, you know, one of the questions that I have is, you know, from you guys's is uh experience at the hospital. What is a check-off for when a new graduate is ready to go? Right? They they come in, they get hired out of school. What is the check-off to say, "All right, you're cleared to run and have your own assignment. Go have fun and save some lives." What does that look like for you guys?
>> So, you want to go first, Carrie?
>> Yeah, I'll go first. So, you know, of course, there's the, you know, orientation, there's the computer-based modules, a trillion computer-based modules that have to be done. you know, there's um protocol classes, there's equipment orientation, you know, knowing where supplies are. Then, you know, you get to the patient bedside and there's a whole task list of things that have to be assembled and completed. Do you know how to put the ventilator together? Do you know how to put the heated high flow together? You know, do you know how to, you know, do a ventilator assessment? you know, do you know how to draw off an arterial line? I mean, there's all of these tasks, but the problem is that none of those things tell us how capable somebody is of doing a job.
>> Bam.
>> And clinical capability is what is really important. Competency says, I can do this task. Capability says I know what to do when this task is no longer applicable to this patient. So that's that's my soapbox on that. [laughter]
>> That's your question and your answer.
>> Yeah.
>> Yeah. What do you think, man?
>> Uh, while she was giving the answer, then the problem actually came to wow. This is what it is. We we are task-oriented.
>> Yes. Yes.
>> So we we need to start we need to shift it from the root and and how what Carrie said is we need to have capable clinicians to know what else do I need to do when that task is no longer applicable to that patient.
>> Yes.
>> Wow. And and you're right. And and now going back to what we just talked about, how do we how can we stop time for that transition? It's like we are drinking from water holes. It's coming out at 1,000 miles an hour. Can we say, "Okay, stop now. Let's let's reset." Or do we slowly redirect the efforts and redirect how we think and one skill at a time, one value at a time? Because I'm still it's still to me, just to be a just to play devil's advocate. I think it's a little far-fetched for some or some leaders will probably be listening, "Man, this is great. This is great talk, but but right now I'm sitting on on third events. Right now, we I'm I'm short-staffed right now. This is everything that I need to do, but this is great, but how do how do we switch that?" And same thing for us. And at the bedside, we have, you know, 15, 20 uh new grads coming in per year, but by the time by the time they get off, we need them to get come off and and hit the ground running. So, it's it's how do we start that? How do we how do we pivot?
>> So, you know, we know that COVID really hurt the capability as far as our profession as a whole. A lot of very experienced clinicians left the field or transitioned to other roles. And so that really put us at a disadvantage um, you know, across respiratory care and not just respiratory, you know, healthcare in general. And, you know, I I I haven't said this much, but, you know, it has led me to wonder or question if it's something that organizations are going to be able to do without funding. You know, with COVID, there was all, you know, all the money was the the system was flooded with money, you know, for resources, but we haven't funded recovery for that. And, you know, I'm starting to question, you know, do we need to fund recovery? Because we need time and resources to build that capability back up at the bedside. And I I just, I'm starting to wonder if that's something the organizations are going to be able to manage on their own. So, um, you know, because you have to have something to build off of. And, um,
>> yeah,
>> you know, it almost reminds me of back in in after World War II, you know, with the Marshall Plan, you know, Europe realized that, you know, they were going to need to rebuild, you know, the foundation for, you know, them to be able to be successful. That that was a agreed upon thing. And and I just, I'm kind of wondering if healthcare doesn't need its own Marshall Plan. Um, I I just, that's my concern is just having the resources to do what needs to be done.
>> Wow. This uh, yeah, this is a critical junction.
>> Yeah.
>> But it has to start though. But in the meantime, I mean, at the end of the day, we we can't we we can't put a pause on things. So I think Hans, one of the things that you're asking is like, how do we do this right now? We can't put a stop on on everyday care at the hospital. So where does where do we start initiating this change? And I mean, I think number one, it has to be expected from leaders that our our our departments will need to progress. Um, but I think too, I mean, this is a great opportunity to start empowering students, right?
>> Yes.
>> Um, getting involved in respiratory programs, um, is I think a great place because you're fostering the future, uh, in those programs. Um, you know, we can't, you're not going to, you probably aren't going to change the mind of somebody that's been doing this for 35 years. Um, you might, you might heck, man, you might you might excite somebody at the tail end of their careers. Who knows? I hope so. But I think if we take the leadership and then we take the up-and-coming and we really focus in on what's not the right now, but what's the future opportunity for respiratory care, and once those those two meet, being the that new graduate graduates and becomes an RT, they're they're seeing eye to eye on what the future is for that department with that that that leader who's also embraced these things. Um, it's not going to be an overnight change, but I think this is, uh, you know, keep rowing,
>> right? Eventually we're going to get there. Um, and, you know, respiratory is behind in it, but I think that we're we're not too far behind. I think we still have opportunity for recovery for sure.
>> But you know, I I think we also need to agree upon what are we rowing towards.
>> Yep.
>> Because, you know, there needs to be an ultimate goal, like what metrics are we rowing towards? Because in order to know where to go, I mean, in order to start, you have to know where you're going to end. So I I think that having a shared goal is for respiratory and um, and, you know, moving forward is going to be really important.
>> Here's the question. Who sets that goal? Who sets the tone? Who sets the direction where we need to go?
>> I think that's going to depend on organizations and in general. And and we talked about this in the last episode about knowing what your organization's issues are and where they where respiratory can contribute. And, you know, that is going to require conversations with administrative leadership to say, you know, where, how can our discipline help solve this hospital's problems.
>> Yeah. I think another question to bank off that too is just, or more a little bit more granular on it. Where do we not impact a hospital's metrics?
>> Nowhere.
>> Exactly. We talked about we talked about this last last episode, right? Is that I mean, it's it's it's respit. Yes, it's a little bit of shame on on us for not seeing these things, but at the end of the day, like there's also an outside side that you got to look at, like why haven't we been picked up on these things? I mean, we drive so many areas that impact the hospital's metrics, whether it come to length of stay, throughput, doctor disposition time, you know, avoidable admissions, all these things they talk about every single day. And and and why hasn't respiratory been like, man, we're we're in every single one of these categories. And I think
>> we truly embedded in operations because that that's the key.
>> Yep.
>> Is, you know, all of you know nursing, radiology, laboratory, care coordination, you know, all these other disciplines have dashboard metrics that make them a part of the operational structure of an organization. How many of us have that? I mean, you know, if you don't have metrics that you're accountable to, then you're not embedded in operations, which means that, you know, you don't have a choice but to be at the mercy of administration. It it kind of, you know, it it really puts you at a disadvantage. So your conversations about resources become very different than say, you know, radiology or the cath lab or, you know, one of one of those other um places in the hospital. So I think that that's key. You have to embed yourself in operations.
>> Yeah.
>> So here's another question I want us to talk about to help a leader who's watching this. How can they we help them define value of respiratory therapy department to their CEO or CFO? It goes right along with having the right metrics. So let's just say, you know, um, a leader for respiratory therapy finally gets a face-to-face impromptu with a CFO with somebody from the C-suite, say, "Hey, you know, how's the team doing? What do you need from us? What do you need from what can we do for the department right now to help you all move in a better direction?" Do you think some some of our leaders could actually hold a conversation like that with a C-suite leader?
>> I mean, I think a lot of the responses unfortunately in in that question are going to be that that um, you're a treatment department, right? We do treatments, we assess ventilator patients, right? But I think really, it's going to be from a top-down mind shift to say, we're a performance operational improvement department. That's the new mindset.
>> Say that, say that, say that again, John, say that again.
>> So we're a a a a performance operational improvement department, not a treatment task-based department. And I think that once we we have to first understand that ourselves, there this has to be a growth and empowerment within our own society before we can go have this conversation with anybody.
>> Yes. And, you know, and I think another thing that happens along with it, I mean, I remember when back when I was a clinical educator, one one of the things that that the most proud I saw that I ever was in those that role was when I saw a culture change happen where RTs were fighting in rounds, like, "No, we're on protocol," right? I mean, or when I had RTs that used to sit back and wait to be told what to do. Instead, now they're going and telling the providers what they have done, right? And absolutely.
>> And look, contrary to what some may think, providers want that.
>> They do.
>> You got you got one attendant, one fellow working overnight in the ICU. Dude, there's nothing better than having be like, "Oh, thank goodness, man. We we're we're pumped that we have XYZ working tonight as RT in the unit, right?"
>> They get excited about that stuff when they but they also let it be known when it's not that that RT that they want, right? So, I mean, um, we have an opportunity, but it has to be first embraced, empowered, and motivated from within our own organizations and departments before it's ever going to be appreciated from from those above us. I mean, you know, there is a certain amount of strategic thinking that I think leadership requires. Now, you know, a manager runs a department. A strategic thinker makes sure that department stays relevant. And that's that's what needs to happen because, you know, we we said this last time that, you know, there are organizations where respiratory is becoming less relevant. That's not necessarily a reflection of of the leader. You know, I don't know the operational decisions behind some of those things, but, you know, once again, this goes back to being embedded in operations and the importance of that. So, trying to see how to ask the next question. How can if somebody's been in leadership for a long period of time for over a decade,
>> have they been exposed to that type of thinking, that type of conversation, that type of data? Um, the fact that we are saying that respiratory is part of every operation of the h of the hospital? Some of our leaders probably can't fend them understanding what are we talking about. So for that leader, can we discuss a few of those operations where respiratory is embedded but yet feel silent?
>> So that's why they don't see the value in that.
>> Oh, yeah.
>> Measuring value. What are we measuring to determine value? Mhm. I I don't, again, going back to it, is what what are we preventing? At times it's it's the prevention and not the cure. So
>> right.
>> Like, for example, with with throughput, how can how can a therapist or a leader of a department understand that respiratory matters when it comes through when it comes to patient flow within a hospital? Because we're just saying that you're in the ED, like the the disjointment from the ED to the floor to the ICU to the discharge. How can how can we help leaders see the bigger picture?
>> Well, honestly, I think picking one specific thing that is an issue and working to solve that one specific thing. And, you know, like take ER admissions. You know, I know one thing that, you know, has become a topic of conversation is soft admissions in the ED. Providers that are not really, you know, that are kind of admitting a patient because they're not completely confident in the fact that, you know, the patient could be discharged home. And so they're, you know, not sure. And so they're like, "Well, I'm just going to go ahead and admit this patient." But, you know, I think that and then it becomes a length of stay issue because then eventually, you know, their their stay increases. This I I see this frequently in the CHF COPD overlap patients.
>> Yep.
>> Um, that is a really difficult population of patient to manage. And, you know, that patients don't suffer one comorbidity at a time. They they're all, you know, you don't have a CHF exacerbation on Monday and a COPD exacerbation on Tuesday. It's a delicate balancing act. And a lot of times, you know, what happens is these patients get admitted when occasionally maybe they could go home, um, but, you know, the provider doesn't feel confident. So I think picking one thing and and showing how you have impacted that one thing, um, and do that one thing at a time. you know, we didn't get here overnight. It's going to take time to fix, but I think if we're moving that direction, um, I I think that just, you know, taking it one step at a time might be the way to do it.
>> You're talking about in focusing on areas that that we're already embedded, but maybe not being involved in that metric capture.
>> Yes. Mhm.
>> I mean, I I I think I think that to summarize this, it's only two areas, right? Um, and I think it can kind of bring light to this. There's two areas, you know, I I travel all over, you know, the up and down the US. Um, currently, and and one of the things that I see is I see ERs and I see acute care wards are areas where respiratory may or may not be present.
>> Yes.
>> All right. Where respiratory is always present is the ICU.
>> Where the ventilators are,
>> right? Where our productivity is weighed heavier,
>> right?
>> So maybe maybe it's a a a realignment of what weight productivity carries.
>> Yes.
>> Um, I think that the ED is an area where we actually have a lot in common with emergency medicine as respiratory therapy. Emergency medicine also is looked at as a call center for hospitals. Yes.
>> All right. Uh, that DRG don't kick in till they get on the floor. Right.
>> So I I think the ER is an absolute breeding ground for respiratory success because it provides a unique opportunity for respiratory assessments to be ordered.
>> Yes.
>> For respiratory evaluations to be appreciated. I think standardizing and protocolizing a scoring system that helps align everyone understands that a nine means moderate or a 12 means severe. Everybody's on the same page, but it be respiratory-focused and driven. Um, and I think it has to start there, honestly, because it's going to be continued to the floor once in if and when that patient does get admitted. The ER is a great foundation for RT. And and also where could we potentially impact metrics that are currently being captured within the emergency department? ED length of stay, ED boarding, uh, avoidable admissions. Here's a big one, a real big one. Doctor, doctor disposition.
>> There are there are physicians that are reminded daily of that they need to pick up the pace.
>> They need to see more patients. they need to get patient uh that their their disposition or their decisions to be to be made made more more quickly, right? Well, you know what happens there is you got one or two EDs that are covering or even mid-level advanced providers that are covering a whole wing of an ER, right? And then, you know, heaven forbid a trauma shows up, everything comes on a hole, right? So, empowering that RT evaluation and assessment to lead to the best therapy and the best therapy being, "Hey, at the end of that therapy, a decision can be made, right? Do are we staying and playing or are we treating the street? Get them out." Right? So, um, I think that respiratory's ability to lead to that decision faster is already present. It's just us doing it.
>> Yeah. And
>> wow, that's good.
>> ization piece is is super important because I think that and I love the scoring system because I think then there you have a reliable clinical assessment that a physician can look at and say, "Okay, well, this patient came in as a nine. Now they're a seven." You know, I I think that them being able to see that it kind of reminds me in a way of the pediatric respiratory score that used to be, you know, really relevant. You know, it was it was a standardized assessment and it scored out. So, you know, everybody kind of knew where that patient was. And I mean, I think that that is is really a good idea to making sure that, you know, you're making a decision in a in a reasonably quick amount of time. You know, you're not dragging that out.
>> Yeah. So, here's the question, right? So, in the meantime, who collects this data? So we need to come up with our own dashboard, our own subset of data collection to start validating the value that we're bringing because at the end of the day, same thing like when you have a patient experience where we have all those scoring from for patient-facing, but they'll tell you, "Well, respiratory doesn't get it," but we actually part of the whole care plan, part of the whole care team. So do we now work with a quality department? And not every hospital have a quality team and quality department. So, who's going to help a small RT department who is watching this podcast and was like, "Man, it's all great, but we how do I collect this data and how do I interpret this data to show that we we are valuable?"
>> Go to the departments that already give it.
>> Yeah. I mean, if you have an electronic medical record, I promise you
>> somebody somebody's doing it.
>> Somebody has
>> a dashboard that probably has some of the data that you yourself are needing to have. Like care coordination, for example,
>> you know, care coordination is going to have length of stay. They're they may even have vent days. Like they they are all over that. So, you know, it could be that you're just going to pluck some of what is, you know, already in existence on somebody else's dashboard on onto your own. You know, I would encourage people
>> to show where we are on that dashboard. I mean, that's that's the thing. If they're already doing it, and they're so, I I can go online right now to cms.gov and I can pull every single hospital in the United States's ER length of stay data. Every one of them. I can look at their COPD readmission data. It's live, right? Why? So, so if you find out who's doing it, it's also that's the perfect opportunity to say, "Hey, respiratory, we're we are absolutely contributing directly to the success of that score. We need to be involved in this."
>> It's it's not just about finding the person that does it. It's also about speaking up for our place on that that dashboard as well.
>> Yeah. And I mean, and asking to have something built. I mean, I I promise you that, you know, everybody now is on the electronic medical record. There is a way to get data. I mean, for sure, because more than you know, just respiratory therapy has to keep up with those metrics.
>> Yep.
>> John, you said something on the first episode, uh, and I need to find that clickbait and repost it. Most dashboards for the RT department show how busy we are,
>> but not how effective we are.
>> So I'm going to shoot some metrics, and you could tell us, or Carrie could jump in as well. How can we shift the mindset of that metrics to show instead of showing how busy we are and convert that conversation to how effective it is, like productivity? How can a leader now see productivity on more of being effective instead of being busy?
>> Length of stay. Yes.
>> I I have an RT-driven protocol that I'm being productive. I have the volume, if you will, of that that says this is what my RTs are doing, right? So, we're not substituting volume, but where I bring value into that is to say, our R our respiratory-driven protocol keeps patients from getting stuck on the floors. Instead, your therapy is is contributing to a next step and a next step and a next step. I mean, imagine if we did resuscitations the way that we practice respiratory care. Patients would never get chest compression stopped. It just keep on going, right? Uh, instead, it's like there there needs to be it's it's I've done this, I'm moving to this. I've done this, I'm moving to this, right? There's an there's an assessment at the end, not at the beginning, at the end of what we're doing that then leads to the next step. Right? Do I do I rapidly need to progress or elevate care, or is it time to start deescalating care? Don't let the patients get trapped in treatment world. Instead, have throughput as the focal point of of everything we're doing. Like, what is what are you what are you doing right now that is going to lead to the next decision, next step, the next discharge?
>> Because I think clinical stewardship needs to be,
>> you know, needs to be the goal. You know, I think that's so true.
>> I think I could see that for acute care. How is that conversation translating to the ICU? This is where our heaviest productivity numbers or the heaviest weight of what we do.
>> Days. Do we want do we so now again going back to it, do we want to have less vent days? I mean, I think less ventilator days, reintubation rates. I think the focus once again, and I think this is everybody that's trying to lean back towards the tasks because you're thinking, man, I need this volume, you know, I need this volume to justify having staffing. But I think that everybody is forgetting that, you know, if your value is in what you're doing and how well you're doing it, then it becomes less important to justify people for tasks because now you've demonstrated value and outcomes. So, I'm going to say your favorite thing, your return on investment becomes having people that can do these things to improve your outcomes.
>> I think I think I think I think we can bring some reality to this too, right? I mean, if we start initiating protocols that have RTs, you know, evaluating ventilator weaning readiness, I don't think that we're going to have a red all of a sudden a magical reduction in ventilators.
>> No, there's going to vents. Yeah.
>> Yeah. There's going to be vents, right? Um, I do think that what it what this will do is this will help eliminate, um, uh, non-productive productivity.
>> Yes.
>> Um, well,
>> say that again. Say that again.
>> I think I think that what we're trying to do here is not focusing on limiting or reducing vent days. It's great, right? Ventilator readiness and reading weaning readiness evaluations are great. I think really what we're trying to do here is to help standardize, um, a way to prevent non-productive productivity.
>> Yes.
>> I like that. Non-productive productivity.
>> Yeah. So, we'll take that.
>> Yeah. I mean, we'll we'll take, uh, chest percussion for an example.
>> CPPT. Uh, I know at one point we eliminated it as an airway clearance therapy for non-bronchiectasis/non-CF patients, right? Um, and we focused more on airway clearance techniques, getting the patients up, being more ambulatory, um, and we eliminated chest percussion because it doesn't it's not doing anything. The patient's on a ventilator, it's not doing anything.
>> Right.
>> Um, and we that was 153 hours a week that was eliminated in RT volume, like work productivity stuff. But what happened is productivity didn't go down because it opened up opportunities for RT to run ventilator weaning protocols. It opened up opportunities for RTs to be available for CT. It opened up opportunities for, um, more airway clearance evaluations to take place. It invol It opened up opportunities for respiratory therapy to be where they belong, and that's in rounds in the ICU.
>> Yes. Yes. They're they're so busy doing non-productive productivity tasks that they're not participating in rounds where all these true decisions are being made, where our value can truly be heard, right? Um, I mean, I don't think that a physician's job or a nurse practitioner's job or, we'll take nursing. I don't think a nurse's job is going to be at risk because they're a one-to-one assignment in the ICU.
>> They're on a one-to-one assignment in the ICU because the patient warrants a one-to-one assignment in the ICU,
>> right? Um, so, you know, one nurse may have one ventilator patient in a shift, but why does respiratory have 14?
>> Right?
>> Right. Because it's just, well, they're just going and doing vent checks. That term drives me crazy. Right. It's that you got to go back to assessing ventilator patients, right? You got to go and your respiratory therapist should be full of weaning, evaluations of weaning. And I think this is where there is some collaboration with nursing and respiratory. Um, you know, I know that the ventilated weaning protocol, um, back when I saw one time that the nursing had a ventilator weaning readiness evaluation, it was separate than the RT departments.
>> I was like, "Stop, you know,"
>> time out here for a second, right?
>> So, what happens is if the nurse is not on on on the same page as RT,
>> it's postponing ventilator weaning readiness, right? If if if RT's over here weaning the rate, and RT is down over here running their protocol, and the patient now is it on a CPAP pressure support, but the nurse has it started dexamethasone. So now we now instead of extubating, now we're waiting. Right.
>> So instead, I I I think there is times that I think that this will be important that respiratory takes the bull by the horns and just and and does drive some things on their own to show their value. But I do think there are certain situations, you know, particularly the ICU, where a good strong collaboration and partnership of RNRT is invaluable.
>> ICU mobility is a huge quality measure that is
>> will, you know, speed up
>> patients healing, you know, faster than anything. I mean, we know that like it, you know, that that's an incredible thing to be able to do. And but, you know, like you said, if you're doing unproductive work, then where is time for things like ICU mobility? Because that takes, you know, of moving a vented patient takes respiratory therapy.
>> Yep.
>> So, you know, then you can't focus on the true quality things. I agree a thousand percent. So should a leader now looking at this start playing being very smart out inside the box and see how to redistribute or reclassify non-productive productive work
>> I think
>> to allow us to have the time for what truly matters? How and because you still have to color inside the lines that or organizations are putting.
>> We do.
>> We do. So how do we how do we navigate that? Do we need to partner up with the finance team? Doing to partner up with with the revenue team to see, okay, if we shift the weight from from assets and shuts to allow us to carry the productivity that we have, then could create the time like going to rounds, for example, till this day, rounds is just RT time, which doesn't give us any
>> doesn't show the value when it comes to productivity. There's a lot of stuff that we do that is needed.
>> Yeah.
>> But we just do RT time for it. Early mobility. So
>> how can or is this something that our field needs to start coming together? Okay. These are the new standards that we are doing that we need to now impose on the finance committee. How do we how do we get there? Because it it needs to happen. How do we how do we get there? So before we even talk about headcount, um, you know, because I I think when you start approaching C-suite, you know, that's automatically the assumption. So be take take all of that out of the equation. And I'm going to say the thing that u is is probably going to fire up the respiratory community, but yes, clinical activity time matters, but so does workload distribution. And if your clinical activity time or your RVUs are not appropriately weighted, you can have patients that are high acuity with lower clinical activity time or RVU counts that really take up a lot of time. And you can also have the reverse situation. You can have, you know, high CAT counts and not really very much work. So, you know, if you have a therapist in, you know, in an acute care area, and, you know, say you have, I don't know, six BIDs, and, you know, of that six BIDs, two of those are Q6. Well, you know, your first round is going to be a little bit heavy, but your second round, like on dayshift or and night shift, there's two treatments or two therapies. So, what is that person going to do for the other eight hours or, you know, nine hours of a shift?
>> That's the reality. That's what we face.
>> Reality. So like at that point, can you redistribute the workload? Can that person now go to the ICU to help transport patients? Can they participate in ICU mobility? Can they, you know, help out or, you know, do home O2 evaluations to discharge patients? you know, I mean, I feel like not that everybody has to be busy every second of every shift. That, you know, that's not good either. Um, you don't want to make people feel that way. But I think realistically looking at the workload distribution is something that we have not done. And I think we have blindly trusted a number and we have added or taken away staffing based on that one specific thing without actually looking where is the work and what is the work. So, you know, I think that needs to be taken into consideration before headcount because you may look at your workload distribution and say, "Man, I don't I may not need all these people on this shift, you know, or I I just think that that stewardship alone is important because that demonstrates trust when it comes to resource allocation." And you want to show your administrative team that you know you are using good judgment and you are exercising stewardship when it comes to staffing resources, and you don't want your therapist there just doing low-value or unproductive work just to have them there. That's not benefiting anybody.
>> Because because as as clinicians, what what are they thinking needs to happen when going to value-based would be if to make sure everybody get the right treatment, the protocol, the assessment, the early mobility if it calls for 50 therapists on the on a 12-hour shift
>> to create the value. That's what we need to do.
>> Right.
>> That's the expectation from the clinician.
>> Mhm. Mhm.
>> Realistically, that that is not going to fly
>> right?
>> with any C-suite if we're going to say that you on the floors and you have that, that's not going to fly. But so
>> that that that was a good point. Workload distribution. That's very important. So how do we shift it?
>> But also, we we've been in the we in this seat now, Carrie. We talk about this all the time, right? And when we when we used to work together and as as our role, y, as supervisor, my role at times as RTs, we are very rigid into being flexible within that 12-hour shift.
>> Yes.
>> If if this is if you if you are giving that floor, we are extremely rigid to say, "Hey, like you mentioned, I could now start doing home O2 valves or or I could because right now we are still task-oriented. We are given those that's that stack of paper and we're just going to focus on that."
>> Yes. That that was a very good point. That was a very good. But it's also going to be hard. That's a that's a culture that we need to shift from.
>> It is. And and, you know, and it it's hard for, and I can speak from experience here. It it's when you start shifting that thinking, it it is hard for teams to accept that that's what you're doing. And, you know, then this is where the conversations about, you know, readiness-based versus volume-based, um, areas, uh, become important because you you can't really reliably flex from a a readiness-based area. If that person is sharing a volume-based area, if they're having to be, you know, spread out to that area, because inevitably, you're going to, if you flex somebody, you're going to pull from your readiness base. But once again, you know, these conversations and these points are much easier to make when it comes to resource allocation with finance if you've just proven, "Well, I need for this person to not be in productivity numbers because I cannot flex them. It doesn't matter if they're zero patients or a thousand. Like, I cannot get rid of the this person today." You know, if you can show why, it's a completely different conversation.
>> Yeah. I think we definitely have more work to do.
>> Yes.
>> There's a lot more work to do to get us there.
>> Yes.
>> John, what you got for us, man? What are you thinking about?
>> I mean, I just think the biggest thing is is us stop defending status quo.
>> Yes, Lord. Yes.
>> I mean, you know, the these conversations eventually just got to be focused purely on empowerment of not where we are and what we do. I just feel like we we get stuck a lot of times defending what we do.
>> Yes.
>> Like why while respiratory belongs here, right? But instead, like we need to move past that. It should already be a given, right? We need to focus more on what would happen like what what would we do if if in 10 years we look back and we say RT is twice as, um, you know, your level of performance is twice as valued in 10 years it is today. Right? What would that look like for our team? Right? And, um, moving towards the, you know, the pro, but the the provider, the practitioner mindset of, you know, we don't have to have a master's degree, uh, or an advanced practice degree to do a very good job at the bedside, right? So, um, I mean, that that's just kind of where where I sit a lot of these things, and and and what the opportunity is in front of us is that it's it's literally a a boost to the ne completely next level and where we honestly belong, um, as a practice already, and it just kind of provides us to have the embracement, I think needed from
The key decision makers at the hospitals to you know fully understand that. Wow, that's a lot. That's a lot. Um, we need we need to find a way to to recap everything for those leaders as we try to close this.
If you had to give three advice to a respiratory therapy manager, director, shift supervisor, somebody who is in a position of power to make change to move the needle slowly towards value-based. What would those tips be?
I'd say empowering your clinical team to work at the top of their scope, sharpen their assessment skills, um, and trust their capability, trust what they know. Um you know I would say to look beyond productivity reports. Um start asking the question of what what what is value? What is what is the value that you know or what are the issues that hospitals are trying to solve and and how can we contribute to that and add value to that? Um gosh, those are the big one. And def dashboard metrics for sure. I I would definitely encourage everybody to pull for that. Um maybe before anything else, see if if you can pull together some kind of dashboard metric.
How about you, John?
Is your department a reflection of you?
Yeah. Oh, yeah. John, we're trying we're trying to wrap this up. I I I guess I
Go ahead.
No, I'm saying you're asking the questions, right?
Yeah.
I mean,
you want to think you want to think about this is you're you're saying, "Hey, you know, what are some questions for leaders?"
Right. Here we go. Is your department a reflection of you? It's got to start it's got to start somewhere, man. Um, if you want a progressive, critically thinking, autonomously driven respiratory department, you have to be empowered as a leader to be the exact same thing.
Yep.
That's things, man. That's things big time. No, I mean, you know, at the at the end of the day, this is not really I mean, I mean, do we need to really honestly be sitting back having a conversation of of justifying whether respatory care is important or not? Of course, it is. But why? Every anybody and everybody that's in a leadership role, ask yourself this question and be able to answer the question. Sit back and think about why you are important. And I think ultimately a lot of times we find ourselves kind of going back to why we chose to go into respatory school in the first place. Where did we become so non-complacent, right? So um it it at the end of the day like you came out of school and you just kind of got stuck in a rut. That's fine. It happens. But like if we're talking about moving forward, we got to stop we got to stop paying attention back there. We got to start focusing on what's in front of us.
And I think the easiest way to do that is to ask simply, is your department a reflection of you? And if it is the things that you want to fix, you you also have to be the driver of those changes as well.
That's good. That's good. Let's close with those rapid fire questions real quick. What is one outdated artsy practice that we need to stop tomorrow?
Caster and productivity.
I kind of knew I was going to go there. How about for you, John? I mean [laughter] like
one outdated practice that we need to stop tomorrow morning if we can probably say we're not going to do this again. Which one it would be tomorrow morning for us to stop doing?
Vilator checks.
Okay,
that's John's trigger word.
Hey man, look I need I need patient ventilator assessments, man. I don't need checks. All right. And and look, these these ideas and these things we're talking about, they start with changing the way people think about what they're doing.
Absolutely.
If if you're hearing check, check check, that's what you're going to do.
And other disciplines do too. And I've been about that and I'm trying to change my verbiage as well.
Yeah. Just change the way you think, change the way you talk, change the way you carry yourself. Right. That starts with what you're doing. Imagine, Hans, imagine if every one of your RTS went in tomorrow and said, "I got 12 ventilators to assess this morning." How pumped up would you be as a leader about your department? If that's the mindset and that's the way your staff,
Mhm.
Yeah.
What is one metric every RC leader should know or start paying more attention to?
Start paying more attention to ventilator days,
you said. Yeah. I mean, I I think I think total length of stay is a big one. Um especially in the balance between Medicare and Medicaid. I think especially in the days we are in now where there's been such a massive Medicaid cut that's happened. length of stay is going to be an invaluable number that we have to focus on because once that they exceed those those uh that 72 hours it becomes now back up for negotiation of what that reimbursement is going to look like. So I think building and structurizing and structuring protocols and activity that help drive length of stay and shorten the total length of stay all that's going to do is just help highlight where respiratory is bringing financial value to the hospital. And I mean if you take a deeper dive into you know obviously we impact length of stay
um you know in a big way but it there are also variables there that are kind of out of our control. So you know once respiratory as a service line kind of comes off or the patient stabilizes um back to their baseline. you know, how long between that time and the time the patient actually discharges from the hospital.
That's a really good point. So, you're talking about when the [clears throat] COPD exacerbation is at baseline, but they're still they still have two plus pitting edema, right? So, they're still doing fluid diuresis management, right? Does respiratory potentially fall off of the capture once they're at respiratory baseline? But then the I think that's a great point, Carrie. Honestly. Yeah,
it is.
Yeah.
What is one prediction you have for the field within the next 10 to 15 years? Are we going to make it or going to be progressive? Or are we at risk of seeing some stagnation in respiratory care?
Well, I'm going to speak positively into the world. I'm I'm going to manifest this. Um, I think that and I hope and pray that respiratory will not be known for what they do but for the decisions they make and the outcomes they impact. That's what I want to see.
How about you, John? What do you see? What do you see in the next 10 to 15 years?
Um, yeah. I mean I I I would I would like to just say man my I would echo 100% of what Carrie just said right um the where I would like to see things move towards is that there is uh kind of a holistic embracement from the field to want to be better right um and that respiratory is a respiratory practitioner mindset
yes
you know work force at the hospital where we're getting called for consultations, not called for treatments.
Yep.
Well, team, we did it again. Yeah, that was great. Um, so to wrap this up, right, I think what I would tell any leaders right now as we're trying to move from volume based to value based one, it's going to be difficult.
Yeah,
it is ingrained in us. Mhm.
Vet checks, treatment, treatment counts and we we are count taskdriven oriented is ingrained in us. But like like John said for to all my leaders, the department should be representation of you should be representation of me. And actually this podcast is now firing me up to go back and and do better. find me up to go back and and see how can we now change the culture of ty approach. Uh Carrie said a lot of both all of us the conver was great because Krie talked about workload distribution. We do have the numbers but if we're not distributing in the right way to allow us to within that 12 hours to provide like John said a holistic approach to the care that we give to bring value within those 12 hours. we still going to be stuck into a task mindset mentality. This was a great conversation. Uh there's not not not a better way for me to close session one volume base versus valuebased. And definitely Carrie John, [music] thank you for your time. We will talk soon. Thank you, man. Much guys. [music] All right. Thanks. Bye.
Bye.