Kathleen Wessel (Host): Effective surgical services are deeply influenced by efficient processes and collaborative cultures. Today, we explore what it takes to create a high performing perioperative infrastructure. Hello, and welcome to AHA Associates Bringing Value, a podcast from the American Hospital Association. In this series of podcasts, we speak with AHA Associate Program business partners, check in on their healthcare initiatives, and learn how they support AHA hospital and health system members.

I'm Kathleen Wessel, Vice President of Business Management and Operations with the AHA. And today, I am joined by Stephen Lovern from Carilion Clinic and by Barbara McClenathan and Joan Cox, who join us from Surgical Directions. Join us as we impact improving surgical operations. Stephen, Barb, Joan, welcome to the podcast.

Barbara McClenathan, RN, BSN, MBA-HCM, CNOR: Thank you.

Stephen Lovern, DNP, RN, NEA-BC: Thank you.

Joan Stroud Cox, MBA-HCM, BSN: Thank you.

Host: Before we start, I want to introduce everyone to the audience. Can you each share a bit about your career journey, some key points about your current roles, and how your background was instrumental in this collaboration? And let's start with you, Stephen.

Stephen Lovern, DNP, RN, NEA-BC: Hi. So, I'm Stephen Lovern. I am the Vice President for the Department of Surgery and Anesthesia at Carilion Clinic. I have been a nurse for over 25 years. I did start when I was 10 years old. So, a nurse for over 25 years. I started my career actually as an EMS, which I was the captain of the rescue squad at a very young age. And so, that drove me to nursing. I met a nurse, married a nurse, and went to nursing school. I started out as an LPN after I was an EMT or a paramedic. So, I became an LPN.

I took the long way to a doctoral degree. I started out, as I said, as an LPN, which is a certificate program, and then went through an associate's program, a bachelor's program, a master's program. But all of those things, while it was the long pathway to get here, I got to meet some enormous amount of educators and some amazing individuals along the way. So, it afforded me opportunities to see how others lead, whether it's in the classroom. In my master's and my doctoral programs, they were all focused on administrative leadership. And that just allowed me opportunities to be able to dive in with others in an educational role, and then take those things and bring it back to where we are here today.

I look about a year and a half ago, I met these individuals from Surgical Directions and they're amazing individuals. We met as a group to start this journey. And I think all of our experiences in the perioperative space, Barb's experience, Joan's experience, my experience; just allowed us to be able to speak openly and freely as leaders to be able to develop and design what we wanted to accomplish. And then, they brought tools to help us be able to do that. So, that's a long journey, but it's been a very much a worthwhile journey.

Host: Joan, would you like to go next?

Joan Stroud Cox, MBA-HCM, BSN: Yes. My name is Joan Cox, and I have been a nurse for 38 years, a little over. And my entire career has been spent in perioperative services in some capacity. Prior to going with Surgical Directions, I was employed with Prisma Health. And about the last 10 years at Prisma Health, my role in perioperative administration, I was responsible for standardizing perioperative services across the upstate, and then eventually across the Midlands.

Working with Surgical Directions and along with my experience at Prisma Health, it has aligned me to work with other healthcare systems and hospitals to make improvements and work on changing the culture and working on efficiencies. And it's been a great experience with Stephen and Carilion.

Host: And Barb?

Barbara McClenathan, RN, BSN, MBA-HCM, CNOR: Hi, I am Barb McClenathan. I'm the Vice President of Nursing at Surgical Directions. And much like my colleagues, I've been in the perioperative field for greater than 30 years. My tenure started at the staff level, and I worked in organizations up in Western New York and in Florida. And I was able to have the privilege of leading very large, high complexity academic perioperative services.

And in that, I was able to promote both operational performance and financial outcomes for my organization. I've been with Surgical Directions now for about 13 years. And in this role, I have the ability to work with many hospitals across the nation. We've been in over 500 hospitals. And we're able to strengthen operations that truly drive sustainable change and profits.

What I enjoy most about working with Surgical Directions is I have the direct ability to bring surgeons, anesthesia providers, nursing, sterile processing, and leaders together to mutually develop a unified plan so we really can deliver measurable and lasting improvements.

Host: Thank you so much. Let's get started. And Stephen, we'll start with you with the first question. Help us set the stage by sharing some of the challenges Carilion Clinic faced that served as the catalyst to enlist support from this team at Surgical Directions.

Stephen Lovern, DNP, RN, NEA-BC: So, it was five years ago, prior to the pandemic, we had done a lot of internal work to really improve processes and get us into what we thought was a really good place. Like many, many health systems and many, many other organizations, the pandemic created a fracture. It created a fracture in processes, efficiencies, the way we do things. It allowed us to get away from some of those standardized processes that we had created previously.

Over time, especially in the year before Joan and Barb and the team came in, there was an increase in what I would call behavioral frustration and body frustration. So, some people are verbal about their frustrations, and some they wear it on their body. You can see it in the way they carry themselves. You can see it in the way that when you're having a conversation with them, you know, not everybody's going to be direct and share their concerns or their challenges. But you can hear it in their voice. They'll come and ask a question and use different tactics to be able to get that information across.

But we, as leaders, that's one of the things we really have to do, is not only listen to what we hear, but watch what we see. And that seemed to be increasing more and more over time, not only from the physicians but from the staff. The staff would come in and you're talking about a group of people who are very committed to our community, to our patients. They live our values each and every day. But they were frustrated because it's like they came in, and they felt like they couldn't always do their job because there were obstacles. Or at the end of the day, they didn't get to go home on time because their room ran a little bit later. They're very supportive of their surgeons and they want to stay as a team and finish taking care of the patient that they're on. And so, efficiencies was certainly suffering there for a while. When you're talking about first case on-time starts and turnover times, what are the things that prevent us from doing that?

As we know, people can trust leadership, they can trust their peers. But sometimes when you're trying to solve a problem, especially if you're in a room of individuals, you may or may not get feedback that truly helps change that process. Sometimes you have to turn away, and that's one of the things I will talk about as a leader is letting go. In surgery, we're type A people. So, all of my colleagues on this call are type A people. And so, letting go to be able to allow someone in to help is a huge step. And that's what we had to do. We had to bring someone in to hear the things that we weren't hearing or see the things that we weren't seeing. And what we thought were workable approaches, it wasn't working for us. So, that frustration just continued to build. And we decided that as an organization, we've got to do something different.

Now, what I will say is, and Joan and Barb may elaborate a little bit on this, but I think it was not so much that we were going from a bad place to a great place, but we were going from a good place to a great place. So, it's going from good to great. And sometimes, that means so much to the staff and to the individuals and those were the problems that we were suffering. There were efficiency problems. And being able to agree on how we solved them, we just were having trouble doing that. So, you bring in individuals who don't know the players. They interview the teams, not knowing them and put together additional teams that really drive change. And that's what we needed to start with.

And when I mentioned earlier about Barb and Joan and I, spending quite a bit of time and, there were a couple other individuals involved; spending time talking about what we wanted. Those were the essential things is how do we do this so that it doesn't feel threatening. Unfortunately, consulting sometimes has a stigma, like other things. It's like you bring a consultant in, it's, "I'm a bad person, I'm not doing my job." And we really had to, from the very beginning, change the face of that to say, "This is not that anybody's doing a bad job, but we can do a better job." And so, we invited them in. And I think, as you'll learn through this podcast, we've had great successes.

Host: That's amazing. So from the Surgical Directions perspective, following your initial assessment of Carilion Clinic, how did you start to form a plan and a timeline that built momentum, trust, and buy-in with all these stakeholders?

Barbara McClenathan, RN, BSN, MBA-HCM, CNOR: I did the assessment at Carilion. And during the assessment, I was able to meet with surgeons, anesthesia providers, nursing staff, leaders, and what really struck me was how much passion was in that organization. People genuinely cared about doing the great work. But all that energy wasn't connected yet. And without structure, it was difficult for them to move in the same direction. And as Stephen mentioned, there were numerous initiatives that came about prior to us coming on board.

So once the assessment was wrapped up, we sat down together and we said, "Okay. Where can we make the biggest impact first?" And because we've been listening throughout the entire process, the themes were really clear. And it made it easy to sketch out a plan that felt real and doable. So, what we did is we kept it straightforward. We built some few focused work streams, and the work streams were daily operations, scheduling and presurgical optimization, workforce strategy, and an anesthesiology work group. So, we kept the work tight, and this helped people see exactly where they fit in and that immediately helped to build trust.

 For the timeline, we wanted to make sure that we would get some early wins on board. So when people start to see something improve right away, even if it's a small thing, even if it's just coming together for a shared goal, the momentum naturally picks up. Then, we layered on the bigger structural pieces so no one felt overloaded or overwhelmed, and it was over a period of time.

And I have to say honestly, the moment the buy-in really solidified is when we put in the governance in place. And it was the SSEC, Surgical Services Executive Committee. It's led by a surgeon and an anesthesiologist, and it showed everyone that decisions would be made. They were transparent, they were data-driven, and they were team-led. And it wasn't dictating, it was not top-down. It was leadership truly taking the reins to do what's best for the organization.

And I have to say that, once the structure was clear, people saw their roles, they saw their feedback being reflected in the plan, things started to move. And that's when the trust came about. It came from listening, keeping the plan simple and making sure that every step really made sense to the people that were doing the work, not just top-down.

Host: Thank you, Barbara. Joan, it sounds like both you and Barbara had some effective tools and strategies to get started. Can you talk more about the overall solutions that were implemented at Carilion Clinic and how your team empowered long-term sustainable change?

Joan Stroud Cox, MBA-HCM, BSN: Yes. As Barb mentioned, as anything in life, one of the main things to be successful is building the relationships and the trust. And that was a challenge at the beginning. We would go to meetings, and the staff, you could tell, just like Stephen was saying earlier, it wasn't that they were afraid to speak up. I think they just did not really know what we were there for.

So as time went on, we had what's called the performance improvement teams, what Barb was speaking of. Every meeting that we had, as we would discuss different processes, for instance, for their pre-surgical optimization performance improvement team. We had all the key players there, but they were not really confident in sharing the information and feeling like they were in a safe place to talk about, what were the obstacles, what were the things that were working well, what were the things that were not working well?

And what we kept driving was that we had support from top-down, from the executive team all the way through the managers, the leaders there in perioperative services. And we just kept driving that. This was going to be a comfortable space to talk. And that Stephen and others, they wanted us to come in and help them with everything that we possibly could to be more efficient and build that morale. And it was amazing to see. It did not take very long for us to see that change. Instead of us leading a lot of the performance improvement teams, the staff started leading them and they were having fun. And it was so rewarding to see that in such a short period of time. They saw through the work of the SSEC backing them; what we would do is we would come up with a process at the staff level, then we would present it to SSEC for approval, and then we were ready to put it to action after that. What they saw was it truly was happening in that way. SSEC approved it. They were on board with it. They supported it. And then, once the staff started implementing it, they saw the support from the leaders and through Stephen. And so, it gave them the momentum to continue working on all the other processes that we wanted to work on. And it was just very exciting to see how quickly the morale changed at Carilion. And once that happened, you couldn't stop them. They were unstoppable.

Host: Yeah. I could imagine that level of engagement really does engender more and more participation. That's wonderful to hear. Stephen, let's discuss some of the outcomes from your organization. What were you expecting through this relationship and what are some of the key metrics that you've been monitoring since this has happened?

Stephen Lovern, DNP, RN, NEA-BC: So when we started this journey, there were a couple things that we wanted to do and that was set up our governance structure, which is our Surgical Services Executive Committee who now governs the operative space. Now, this is for our level one trauma center. This is our biggest location. We have multiple hospitals, but this is our biggest location. So, we went big bang and started our process here. But you know, some of the metrics we were looking at was our first case on-time starts. We developed a unified definition, that the surgeons agreed upon, and the SSEC and the staff agreed upon, the anesthesia agreed upon. And from that, we went from somewhere around 40% to now there are days, because I get a daily report, we're seeing 90% on-time starts. And so, there's a huge improvement there.

Turnover times, we started out at like 38 minutes. To impact turnaround times or turnover times, it takes a lot to change that number. So, there are days where we're sitting down at 33 and 34 minutes, which is huge. Some of the other things that we've not been able to measure them yet, but we will be the next time our employee engagement survey comes out is, really changing the morale and the culture where people feel enabled to make change.

A lot of times, there's a thought process that, if a process isn't working, "I'm going to go to my leader and they're going to make that change." The staff have really, and I say the staff, the staff physicians and the anesthesiologists, anesthesiologists are physicians, but I'll use the anesthesia group because that's both anesthesiologists and CRNAs. But what's kind of interesting now is to watch them hold each other accountable. It's no longer, "This particular person is not getting here on time to be able to get in the room on time. So, I'm going to go tell my manager." It's, "Hey, you were supposed to be here at this time. What happened this morning?" So, they're talking about it together.

And prior to this journey, I don't know that people felt enabled or empowered to be able to do that, or they felt like if they did that, it was going to cause a riff in their relationship. We are very much a relationship-oriented organization because not only, I mean, the people that work here, our community is not, I mean it's a large community, but it's not like New York and some of these big cities. The people that work in these hospitals, we're taking care of our friends, our family, our friends' families. And so, you know, people always want to make sure their relationships are intact. And I think there may have been some hesitation because of that. And this has allowed people to really take on a new task of holding each other accountable when these metrics aren't happening. So, our top three things that we included was the governance structure, which is our SSEC, our performance improvement teams for our first case on-time starts or turnaround times.

And then, now, we're into a phase where we're really looking at our block scheduling. How do we maximize scheduling so that we can improve access for our patients, maximize the access that is available and then, where do we need to add staff or resources to be able to increase our access?

So, that fourth piece is important, but that one is a longer adventure, just because it's a lot to change block schedules, and get people bought into that. But, they absolutely have. And we started our new block on November 3rd. And the first week, you know, there's some ambivalence because change is here. "I'm not sure if this is going to work. I don't know if I like this." And then, now, it's like, "You know what? With our new blocks, I know the block is mine because it has my name on it," instead of our previous method of group block. But also, what you're seeing is, "Okay, we're getting in the room on time." Our rooms are turning over in a timely manner. So, we're getting done on time, if not maybe a few minutes early. So, these tools that they've helped us implement here just these four things, it's much more than that. I don't want to minimize it. But these four key things that we started with, they're still in place. Our performance improvement teams are still in place. They're just managed by the staff. And that was part of the work that was being done was, we have our consultants with us. I don't like to call them consultants, because they're our friends. So, our friends here were with us. And how do we transition from our friends owning these committees to our staff owning these committees? And they did a very nice job of being able to transition that so that we don't lose momentum over time. And so far, when you walk up on the fourth floor, which is where our ORs are, when you see people walking by with their heads up, and that body language is just so different than where we were last January, the tools, while they sound so simple, they're so impactful. And I promise they're not simple. There's a lot of work that goes into those tools. But I think the successes that we've seen so far are huge. And it's made a difference.

So, the other piece that I think is important is the leaders in surgery are systemized. So, I have two senior directors, one that has the Roanoke campus because that's two hospitals, and one that has the regionals. Our next biggest hospital has already put together committees to implement these tools we learned here. So, it's not just we learned them in this one space and we're going to confine them there. But now, we're starting to branch them out to other locations so that we can have these same successes there. And that's been important. But also, it's a proud moment to see that happen in the way that it's starting to evolve around the organization to all of our facilities.

Host: Wonderful advice so far. What additional advice could you give other organizations facing similar opportunities and like what expectations should they set for themselves and their teams to balance any worries around change and some of the things that you've talked about, this outside perspective and insights?

Stephen Lovern, DNP, RN, NEA-BC: One of the things that I did, because you say that you've got consultants coming in and the immediate visceral reaction is, I'm not doing my job. I'm not doing a good enough job, and it creates frustration. So, I put together about a 30-minute presentation that I did for all of my leaders to help them understand what we were doing. And with that, we're not going from bad to good, we're going from good to great. But it also helped them understand the whys behind it. It really was developed to get them excited about it or to start that transition. A 30-minute meeting's not going to necessarily create that excitement, because there's still ambivalence. But that was the start of the conversation. So, I started that probably 60 days prior to the engagement starting. And then, this trickled down to the staff, and there's lots of questions. And so, we had conversations about this daily for about two months before the engagement started. So, you have to talk it up with your teams and help them understand what it is, why you're doing it.

Access, I'll use the access piece of it. We'll add FTEs for access, but what we want to make sure of is that we have access, we want to be able to care for our patients. And that was one of the pieces in there, is prior to the pandemic, this is the number of patients that we cared for each year, and this is the number of FTEs we had. This time, you know, we've got this number of FTEs and this is the number of patients we're caring for. So, they don't necessarily align. How do we get those realigned? And when you show data, people really absorb that much differently.

So, having those conversations prior to the engagement with everybody, I'm talking about staff, physicians, anesthesia, we had conversations at our organizational leadership. I presented the work that we were going to be doing even there, so they had an understanding of what was going to be happening. And then, now, we're sharing those successes and the things that we've done. So, it's been a really exciting, so far, 11-month journey. Actually, it's probably been longer than that. But we started the actual work in January. And it's been very exciting.

So, to kind of sum this up a little bit, for other leaders who have concerns or how do you make this happen, we as leaders sometimes have to let go, and that's one of the hardest things, especially with type A personalities and stand back and let others help. And having the courage to ask for help is step number one. And then, having the commitment to allow that help to make changes is number two. And number three is communicate, communicate, communicate. If people don't know what you're doing, they think you're hiding. Be very transparent about what's going on. And once our friends got here, they were very transparent with their processes and the things that they were attempting with everyone so that everybody knew where we were going and the performance improvement teams were the ones deciding how we were going to get there. It was not myself or any of my leadership team, it was the frontline staff who were taking on these initiatives and saying, "You know, what would help me be able to do my job better is if I had this." And sometimes you kind of think, "Well, if I had known that before." but it's more than just that one thing. It's the conglomeration of knowing what prevents people from doing their best, and then how do you operationalize it with this many people? Because it's a lot of people every single day. I mean, we're talking 200 people between all of our staff, physicians, anesthesia, everybody, every single day. It's about 200 people. So, trying to operationalize something like that is not easy, but communicate and listen.

Host: Wonderful advice. Barbara and Joan, would you like to share any final thoughts?

Joan Stroud Cox, MBA-HCM, BSN: As I look back, we still have our engagement. We're still currently engaged with Carilion and have our partnership. And I remember I was sitting in the airport, and I have to share this and I'm sure Stephen won't mind, but I was sitting in the airport and I saw a post that Stephen had put on LinkedIn, and it was about the partnership. And not only that was exactly what he was just talking about, about the changes he needed to make as a leader. I read it, and it really hit me because I realized then, you know, we have truly partnered with Carilion and made a difference. And it's not because of what Surgical Directions brought or what Carilion brought, but it's what we did together.

And I reached out to Stephen and I said, "Stephen, you have made me emotional here at the airport." And it's just so rewarding to work with someone like him and his team. It was not easy at the beginning. We had a lot of obstacles that we had to work through. Because a lot of the staff, even though they were so prepared that we were not coming in to, you know, take jobs or do everything totally different because they had a lot of great things in place. But I think a lot of it was building trust between us and the team and among themselves.

And I will say the last time I was at Carilion, and I've got the privilege of being there next week, but the last time I was at Carilion, we were in the Surgical Services Executive Committee meeting. And not only are they working on the things that we put into place, but they've also started creating subgroups on their own. "Okay. We're going to continue to monitor what physicians are continuing like to be late, and what are we going to put in place to alleviate this from continuing. Do we take block time? What are we going to do?" And so, they have, on their own, implemented subgroups of the SSEC. And that to me, it just tells you that Carilion is in the best of hands and there's going to continue to be great things that happen there. And I look forward to the continued partnership.

Barbara McClenathan, RN, BSN, MBA-HCM, CNOR: My final thought is that perioperative change transformation it's not Disney Magic. It's discipline, it's collaboration. And when you give your teams a plan, a realistic timeline, implementing that governance structure that truly lets your clinicians lead, you get better access, you get better throughput and truly, the longer you get better financial performance, and all of the things that Stephen mentioned, and really importantly is a more engaged workforce. And it seems that Carilion truly proved that when everybody pulls in the same directions, these results come quickly. And I'm just proud to be a part of that team.

Host: It sounds like an amazing journey. Stephen and Barbara, Joan, I really want to thank you all for joining me and taking time to share your story with the AHA members. For our listeners, if you'd like to learn more about Surgical Directions or anything you've heard on this podcast today, please visit us at surgicaldirections.com. If you'd like to learn more about the associate program, please visit sponsor.aha.org. This has been AHA Associates Bringing Value, brought to you by the American Hospital Association. Thanks for listening.