Gina Schnathorst (Host): We have today a special guest with us, and her name is Rayne Premo. Rayne is our Quality Coordinator for Iowa Specialty Hospitals and Clinics, and she also has three interesting credentials behind her name, and I have no idea what they are. So, Rayne, I am going to you give you the floor and tell us what it is that these credentials mean.

Rayne Premo: Yeah. So, the first set is MLT, which, by trade, I attended laboratory school, so it's a medical laboratory technician. And in my tenure with Iowa Specialty, I spent a solid 15 years in the lab. So, those are the first set. And then when I transitioned into my quality coordinator role right after COVID, I had the opportunity to sit for two certifications in patient and quality world.

So, the CPEPS is a Certified Professional in Patient Safety. And then, the other one is the CPHQ, which is a Certified Professional in Healthcare Quality.

Host: Wonderful. I completely forgot that you had so many years in our lab. It seems like you've always been in the quality role now. And I'm also kind of laughing a little bit because our entire world now is either pre or post-COVID.

Rayne Premo: It truly is.

Host: It's like this is what I did before. And this is what I'm doing after.

Rayne Premo: I think we all kind of needed that shift a little bit afterwards, a refresh.

Host: Exactly, yes. I also have written down here that you've been in healthcare since 2001. And during that time, your role has changed over the years, as we alluded to, but your commitment to doing the right thing at the right time for the patient has not. And I will reiterate that I do feel that is true. Using data to drive positive patient outcomes has become a driving force in your career, true?

Rayne Premo: That is very, very true. I think I was lucky early on in my career in healthcare to work with people who set great examples of that we don't cut corners, that we're here to take care of patients and to really bring it back home to if that was your family member, your spouse, your child, your mother, how would you want the situations handled? And I feel that that's how I have looked at my career ever since I began, no matter what role I'm doing in. And what is it that we need to do to make sure that that patient is taken care of in that moment and then in the continuity of their care?

Host: I think that rolls very well into the next thing that I wanted to just bring up and then I'm going to just let you have the floor. We have just in 2024 alone, which obviously is not over yet, we've had a lot of awards and recognitions. And I think all of those can be tied back in some way, shape, or form to quality if they're not direct quality awards.

For example, we have gotten the Top Hospital for Care Transitions, Top Hospital for Staff Responsiveness, Top Hospital for Physician Communication. We have received three various American Heart Association awards for both facilities, Becker's Top Hospital for Patient Experience, for Quietness, five-star rating from Becker's, and also a Becker's Top Hospital for Nurse Communication. And on top of those, and these two were in 2023, but I feel like this is kind of ongoing. We also have the DNV Orthopedic and Spine Center of Excellence and also the ASMBS Reaccreditation for Iowa Weight Loss in Belmont, which is a huge quality--

Rayne Premo: Yes, those are both accredited programs, yeah.

Host: Yeah. So with all of that being said, is it this week, this National Health Care Quality Week?

Rayne Premo: It is. It's going to be that week of the 20th through the 26th. So, we are really excited. We tend to stay in the background. You don't hear a lot about the actual field of study, shall we say. But people ask me, "Well, who's part of your quality department?" And my first response is always, "You are. Everybody." Quality happens every day in every interaction we have.

When we think about patient experience, it's the things that you do in the background to ensure that that patient has that wow, that they receive the care that they feel they need at the time. And it all starts with what we do in the background to be consistent with how we deliver that care.

Host: I would say that most of the time when somebody thinks about quality, it's probably because there's a misfire at some point. But otherwise, I think you're right. Quality is everybody's responsibility. It's kind of like remember back in the day when our CEO had us put up signs in the patient hallway saying call lights are everyone's responsibility. And because we didn't want patients waiting too long to see what their needs were, everybody was empowered to step into the room and say, is there something I can do for you? I have the time. To me, that's the same thing with quality. We all have a part to play.

Rayne Premo: We do. And when you say empowering our staff, I think that is the key to having a true environment that leads to zero harm. That ultimately is the goal of everybody as an organization in healthcare is to have a zero harm. We want to make sure that you get the care that you need, but at the same time, we want to make sure that We're monitoring all of those metrics and things that will let us know how we're doing and we want to reduce or have zero of those events. And it comes from creating an environment where our staff feel safe to come forward with concerns before they're an issue. And that's really what we have worked to build over the last 10 years or so in our quality environment and our care for our staff and our patients. And I think this ties back to when we made the decision in 2012 to become an accredited organization, which means that we chose to do the extra work to ensure that we are following policy and procedure and best practice and allowing ourselves to be open and have an annual survey.

DNV is our accrediting agency, and they come in every year and they come through all of the departments. And they look at our policies and our procedures and our patient outcomes, and they want to see how we're doing and how are we doing what we are doing and really digging into those processes. And that's where it's full circle back that if you empower your frontline staff to come forward when they see something that could potentially be broken, it allows us to correct it and prevent errors and harm to our patients and our staff.

Host: I'm not going to lie. It's a little scary when we hear that DNV has entered the building.

Rayne Premo: It always amazes me how everybody gets really worried about it. And there is that quality department. There are people who lead the charge, and we all show up, and we're excited and it's the best day and we're ready to go. And everybody else in the building's are just very, very panicky. And we're like, "No, it's fine." We want them to find stuff because that means we can be better and do the right thing. So, we enjoy those surveys.

Host: Yeah. And it is interesting, you know, when they get done with those surveys and then they have the followup and they say, "Okay, well, here's any deficiencies that were found." And then, what do we do? We just put an action plan behind that if there was something that they didn't like.

Rayne Premo: Exactly. One-hundred percent right. You know, we always say they're going to find something. We are human. Everybody does their very best every day, but there's always opportunities for improvement and their purpose is to help us find those. And what we love about DNV is that it is a team effort. It is not a penalty where they are looking to give us a demerit, they're looking to help us improve. And so when they do find those opportunities for us, they're offering suggestions and providing direction and allowing our team and our staff to drive that change and make sure that we're a part of that improvement, not just a directive from somebody else. We have the opportunity to make it ISH, which as we know is, we are very proud of who we are and part of that is our culture. And so, we want to make sure the decisions we make in our process also reflects the culture of Iowa Specialty Hospitals.

Host: I agree with that completely. And we're just a little left of center at Iowa Specialty. I think we always have been. So, we truly, and this has been going on for years, take those opportunities and we call them gifts, right? So, I mean, if we can't fix what we don't know is broken, so really unless it's something absolutely horrible, you know, which is rare, we really need to just take those with open arms and say, "Thank you. We've got this, and we'll make it better. Because ultimately at the end of the day, it's the patients that we care about.

Rayne Premo: The benefits from us taking those opportunities and rolling with them. And that's where we strive to create a culture that is just and fair, which not only for patients, but for the staff that gives them that empowerment to go and identify those things and bring them to us so that we can create those action plans and improve processes. And we're really excited because we had a new event reporting system put in about two years now, we're coming on our two year. And the previous system took almost five years to hit the number of events that were reported into the new system. We're pretty close to hitting, I believe Tom said the six thousand mark in two years. Sounds terrible, right? Like, "Oh, we're reporting all these events, but really it's the empowerment of our staff bringing forward these opportunities for us, that they feel safe and comfortable, that there's not going to be repercussions to be like, "Hey, I think there's something broken here. Can we look at it?" And that's the purpose of the true quality Department, is to look at those processes as they're brought forward and look for those opportunities and identify where the breakdown is, where we can do better. And so, we look forward to the events. I know the rest of our organization sometimes wonders when we're all excited, but, you know, we have found a lot of improvements.

I think you could say we've made a lot of improvements over the last couple of years. And it comes from being able to put numbers to those events and those processes and being able to track and trend. And that's really what leads to change is being able to see the hard concrete data and dig into it and look for where that opportunity truly lies. Is it in a department? Is it a patient demographic that maybe we've overlooked? And so, having that information at our hands is really what is going to continue to push Iowa specialty into the future to be the best of the best, in my opinion.

Host: Yes, yes, I agree. So, you are also, as the quality coordinator, our hospital has a set of pillars that kind of drive the different directions of the hospital, and you are the quality pillar leader, correct?

Rayne Premo: I am as well.

Host: So, let's talk to our audience a little bit about what that means and what kind of work do they do and how do you lead that team. And then, what kind of change do we see as an outcome?

Rayne Premo: As you mentioned, we have our six pillars, quality being one of them. Our team is comprised of our Chief Quality Officer, Cindy Hunter. She's on our senior leadership team. So, she's my direct boss and everything ultimately funnels through her to be approved and shared with board and the rest of the senior leaders. But then, I have peers in my team, Nikki Nachazel, she's our infection preventionist. So, she is looking at all things that make our staff and our patients sick and looking for ways to prevent that. Big areas that we really focus in on are hospital-acquired infections. Those are some of the metrics that are out there on the HospitalCompare websites. You know, preventing a patient from getting a UTI because they came in and had a surgery and had to have some procedures, right? So, looking at ways to prevent those things from happening. Tom is our Emergency Preparedness and Safety Coordinator. So, his role really grew and defined into what it is today, as we mentioned post-COVID, as we really look at those things. And right now is a great example of how his role ties into it as we look at some of these natural disasters that have hit our manufacturers. That's impacting the organization, so how do we handle those situations? And then, obviously myself, as the quality coordinator, I kind of make sure all of their information filters where it needs to go and that we work on it.

We also have Ash Hansen, our HIPAA and Compliance officer. So, he's looking at all those things to keep us safe. And it's not just making sure my information is protected, but it's looking at cyber security. That's really becoming a scary place and to rest assure everybody listening, Iowa's Specialty is at the very top of what needs to be done to protect our information. They're actually going to use us as an example in a tabletop exercise here this month. And so, we're really excited to see what feedback we get from that. And then, all of the department leaders take part in a quality project. They work with their teams to identify those areas that they can drive improvement in. A lot of times, the work crosses the other departments. And so, it's not just, "Oh, this area--" and I like to always pick on the lab because it was my home-- "The lab needs to fix this." Well, usually, it's a lab and registration and maybe a radiology issue because they have to work together to make sure that the patient gets the needs they gave. So, that's where our team comes in and we help them walk through the process, asking the questions that maybe they don't think about having a better understanding on how each of the departments act on their own, and then how they work together for the system. That's the role that we really play. We don't actually tell them how to fix it, we help them find the solution to improve the process for both the department and the patient.

Host: So again, empowering our staff to really dig in.

Rayne Premo: That's really the message.

Host: Yeah, it is.

Rayne Premo: If they feel like they can make the difference to improve their world they're going to, and that ultimately improves everybody else's care too.

Host: Right. So, let's go back and talk accreditation. That's a big word. We're always excited when we hear that we've been reaccredited. And as the marketing director, I'm thrilled to be able to tell the public, you know, "Look what we did." But what does it really mean to Joe Q. Public who might be listening today and wonder, "Okay, that's great, but what does it mean to me?"

Rayne Premo: We all live in the United States where we know that our federal government likes to set regulations. Pick an area. Healthcare is no different than anybody else. What is different with us is that there are different levels available. So, the federal government has its very baseline of regulatory compliance for an organization to exist. We call those the conditions of participation. We have to meet those at the bare minimum and the federal agencies are required to check in on us occasionally. Every three years is required, but there are a lot of healthcare organizations. And so, sometimes you can go almost five years before you're checked.

Well, we are human, and to be human is to err and to slide. And so when you do that, you tend to maybe put things off. And again, they're coming in to find the things that are not being done appropriately. They're not coming in to help improve. They're really truly just checking the box to make sure you are doing what you bare minimally need to do. So, the difference between that and accreditation is that we make a choice to go to another organization who is going to follow those conditions of participation, and then some. So, they're pushing the envelope to how do you make yourself better than everyone else. And that's truly what an accreditation is. You are looking to show that you are doing the extra work for those better outcomes. And so, we went with DNV. That was a choice that we made about 12 years ago. And we haven't looked back. We enjoy working with them. Like you mentioned, they come in every year so that human urge to procrastinate doesn't really get to happen because we have to be on our A game every time.

And so, we made that choice. They come in, they take a little review for us because we are two organizations that work in tandem. We do have to have two surveys, even though we're Iowa Specialty Hospitals and Clinics, we are technically Belmont and Clarion. So, they come in and they're here for a week, and they walk through every policy, procedure, process, department, facility...

Host: Bringing along fine-toothed combs.

Rayne Premo: They do. They ask those questions. And it's a group effort because no one of us knows the answers to everything. And I think it always provides us not only that opportunity for improvement, but I think it also gives us that opportunity to really recognize how good we are. And they offer their kudos whenever they come and visit and the things that they are truly impressed by. And for me, especially as I've grown into my quality coordinator role, it's the awe I have for the other departments and the work that they do every day and just how they know what they know. And they speak to it so eloquently. And I'm over here going, "Wow, I can't believe this is where I get to work."

Host: All right. I have three more questions that I really want to ask you. So, let's get to those before we sign off. What happens after a safety event is reported? I know you talked about RL6. So, all of the staff, myself included, are empowered, which we've talked about, to see something say something, right?

Rayne Premo: Absolutely.

Host: And we submit a form, and then it goes to your, what, RL6 Committee?

Rayne Premo: So, there are six of us, those folks that I mentioned previously that sit on the quality department. We have access to all of the events that are put in. And then, for each of those events, they occur somewhere, right? Like a location. So, those department leaders that where the event occurred, also are notified of these events, and they're the primary investigators to start with. And so, they will look into the situation and determine was it an educational lapse to just need to provide more education to our team on something, did they truly not have the tools and equipment that they needed to do the process? Is it a bigger safety concern that needs to be pushed up through the ranks to our senior leaders to be aware of. Our role in the quality department is to make sure those things happen, and that they're being recorded and that they're being taken action on. So usually, what happens is the department leaders have been great about doing their investigations. And if they need help, they reach out. And they ask, like, "Okay, we've had this situation now four times. I don't know how I can make it better. What can we do?" And then, we pull it together and we do some quality tools to look for the solutions.

Our process internally is we use the PDCA, which is Plan, Do, Check, and Act. And so, we'll go through and we'll identify what the problem is through a root cause analysis, like get down to why this happened. And then from there, what's our plan to improve it? And that's where, again, we come back to the department and the staff involved and ask them, "Okay, we identified this is where the situation truly is starting at. What is it that we need to do to improve upon it? What do you need to be successful in that we can prevent this from happening in the future?"

And so once all of that is done, then they implement whatever it is that they're working on and we continue to monitor those events to see if they're coming in. And if they are, we as the quality team will follow up with those departments and discuss as part of the plan, do, check, and act is to come back and recheck to make sure it's working. And if it's not, we start the process all over again.

Host: I would imagine to the public, knowing this little tidbit of information would be very comforting, because it's very easy to assume that if there are issues in a healthcare situation that, eh, you hope they're being taken care of, but I don't know for sure. So, it's nice to know that these things are being taken seriously and they are being followed up on. And I agree, it also just showing the trends, like if it's trending that there's a certain department who is having more issues or a certain process within a department that, you know, you guys are able to drill down on that and really do some investigation. So, that's great. I love it.

What is the purpose of an internal surveillance walkthrough? So, that's the other process that everybody lives in fear of, it seems like. So, it's not just when DNV shows up on campus, it's also when they hear that the quality department is coming through to do the SIPs inspection.

Rayne Premo: Oh my. We should not be. The goal of our SIPs and audits is to truly look at those regulatory compliance things. Again, we have CMS. That's the conditions of participation. They're important because they are the ones who set the guidelines. But we also have OSHA, you know, they're out there too. And we have to adhere to their regulatory requirements. And most of us in healthcare don't really know what all those are. We just know that there's things in place to protect us. And then if something happens, we go to our leader and HR and life is good. But there's all this stuff that goes on in the background. And so, our purpose of our SIPs is to come out to the departments and we're checking is there anything that could put you in danger? And are we taking action to get it taken care of right away? We'd like to around the season that we are visiting your department. So if it's tornado season, we ask those questions, "Do you know where to go if there's a tornado?" We'll ask about are you aware of what happens in a fire? Where's the closest fire extinguisher? Just to drive home and practice those things that we don't do every day. So if unfortunately, it does happen, you have a little bit of memory to fall back on and be able to access that.

And then, the other part is truly just looking at DNV requirements, policies and procedures, and making sure we're being safe with patient data. In general, just kind of high level overview of everything that happens during a DNV survey, but just specific to that department.

Host: You know, and I'll be the first one to confess that, if you're walking through my department and ask me these questions, that's probably not something that's top of mind for me. I'm busy trying to do my work that I'm getting graded on. And so, knowing where the fire extinguisher is, I'm sure, and I know I've been asked this question, and I panic every time because I think, "Well, I walk by it every day, it's become kind of like wallpaper, but do I know where it is?" I don't know. Where was it? It's a good reminder.

Rayne Premo: And that's our purpose is just to keep you guys safe, and that it's a great opportunity for us to learn, for those departments to learn, and that's really how we want staff to think of it when we do roll in. We're not there to pick on anybody to just provide some guidance and make sure that you have everything you need. Just another way to check in.

Host: I feel like the theme here is that you guys aren't scary on purpose.

Rayne Premo: We're not. We're really, really not. We're here to help.

Host: That's a great viewpoint. My last question. What defines a high reliability organization? What does that mean?

Rayne Premo: So, a high reliability organization has a really big definition, but for me, what it means is that we are consistently having positive outcomes and creating a place where people want to work and practice medicine and receive care. That's really what it means. The ultimate goal is that, you know, we are having zero harm, people are getting what they need, and that we're taking care of everyone. And to be truly high reliability, you do that over and over and over, and just consistently meet those targets.

Host: I will tell you as the marketing director for system, I am out in the public quite a bit. I hear a lot of feedback, and I think we are nailing it. And I don't say that just because I work here. It's because it's truly felt in the communities that we serve, and that's just such a prideful feeling. And I commend you, Rayne, for doing all of the work that you and your team do, because it's a lot. And it makes a huge difference, and everybody sees it. So, thank you.

Rayne Premo: Thank you for that. And I 100% agree that I think by far we are truly an example of what rural healthcare should look like and that we're doing it right.

Host: All right. With that, do you have anything else to offer? Otherwise, we will wrap this up and call it a day.

Rayne Premo: Nope, we're looking forward to celebrating next week and we hope that if anybody ever needs help that they just reach out and give us a buzz. We're always here.

Host: Not scary, helpful.

Rayne Premo: Helpful. Thanks, Gina.

Host: All right. Thanks Rayne, I appreciate you Thank you for listening to Iowa Specialty Hospitals and Clinics ISH DISH Podcast. For more information on the topic we discussed today, visit us on the web at iowaspecialtyhospital.com. There, you can read a transcript of today's episode or previously aired episodes, as well as get the latest news from Iowa Specialty Hospitals and Clinics and explore all of the services that we offer. For the ISH DISH Podcast, I'm Gina. Thanks for tuning in.