AHA Podcast – Building a Sustainable Perioperative Engine

0:00 Effective surgical services are deeply influenced by efficient processes and

0:05 collaborative cultures. Today we explore what it takes to create a high-performing perioperative infrastructure.

0:14 Hello and welcome to AHA Associates Bringing Value, a podcast from the American Hospital Association. In this

0:20 series of podcasts, we speak with AHA associate program business partners, check out on their healthcare

0:25 initiatives and learn how they support AHA hospital and health system members. I’m Kathleen Wessel, vice president of

0:31 business management and operations with the AHA. And today I am joined by Steven Lever from Carilion Clinic and by Barbara

0:38 McClenathan and Joan Cox who join us from Surgical Directions. Join us as we

0:44 unpack improving surgical operations. Stephen, Barb, Joan, welcome to the podcast.

0:50 Thank you. Thank you. Thank you. Before we start, um, I want to introduce everyone to the audience. Can you each

0:56 share a bit about your career journey? Um, some key points about your current roles and how your background was

1:03 instrumental in this collaboration. And let’s start with you, Stephen. Hi. So, I’m Steven Leverne. I am the

1:09 vice president for the department of surgery and anesthesia at Carilion Clinic. Uh, I have been a nurse for over

1:15 25 years. I did start when I was 10 years old. So, um, just so we’re clear on that piece. Um, a nurse for

1:23 over 20 uh 25 years. I started my career actually as an even before that in EMS

1:29 which um I was the captain of the rescue squad at a very young age. Um and

1:34 so that drove me to nursing. I met a nurse, married a nurse and went to nursing school. I started out as an LPN

1:42 after I was an EMT or a paramedic. So I became an LPN. Um I took the long

1:48 way to um to a doctoral degree. Um, I started out, as I said, as an LPN, which

1:54 is a certificate program, and then went through an associates program, a bachelor’s program, a master’s program. Um, but all of those things, while it

2:01 was the long pathway to get here, um, I got to meet some enormous

2:07 uh amount of uh educators and some amazing individuals along the way. So it

2:12 it afforded me opportunities to see um how others uh lead whether it’s in the

2:18 classroom um in my masters and my doctoral programs they were all focused on administrative leadership and that

2:26 just allowed me opportunities to be able to dive in with others um in

2:31 an educational role and then take those things and bring it back to where we are here um today. Um a look about a

2:40 year and a half ago I met these uh individuals from Surgical and they’re amazing individuals. um you know

2:47 uh we met as a as a group to start this um this journey and I think all of

2:55 our experiences in the perioperative um the perioperative space um Barb’s

3:01 experience, Joan’s experience, my experience just allowed us to be able to speak openly and freely as leaders

3:08 to be able to develop and design what we wanted to accomplish and then they

3:14 brought tools to help us be able to do that. So, um, that’s a that’s a a long

3:20 journey, but it’s been a very much a worthwhile journey. Joan, would you like to go next?

3:26 Yes. Um, my name is Joan Cox, and I have been a nurse for 38 years, um, a little

3:33 over and my entire career has been spent in perioperative services in some

3:39 capacity. Uh prior to going with Surgical Directions, I um was employed

3:44 with Prisma Health and about the last 10 years at Prisma Health, um my role in

3:52 perioperative administration, I was responsible for standardizing perioperative services across the

3:58 upstate and then eventually across the Midlands working with Surgical

4:04 Directions and along with my experience um at Prisma health. It has aligned me

4:11 to work with other health care systems and hospitals to make improvements and

4:18 work on changing the culture and working on efficiencies and it’s been a great

4:23 experience with Steven and Carilion and Barb. Hi, I’m Barbara McClenathan. I’m the

4:29 vice president of nursing at Surgical Directions and much like my colleagues, I’ve been in the perioperative field for

4:36 greater than 30 years. My uh tenure started at the staff level and I worked

4:43 in organizations up in Western New York and in Florida and I was able to have

4:48 the privilege of leading very large high complexity academic perioperative services and in that I was able to

4:56 promote both operational performance and financial outcomes for my organizations.

5:02 I’ve been with Surgical Directions now for about 13 years and in this role I

5:08 have the ability to work with many hospitals across the nation. We’ve been in over 500 hospitals and we’re able to

5:16 strengthen operations that truly drive sustainable change and profits. And what

5:22 I enjoy most about working with Surgical Directions is I have the direct ability

5:27 to bring surgeons, anesthesia providers, nursing, sterile processing and leaders

5:32 together to mutually develop a unified plan so we really can deliver measurable

5:38 and lasting improvements. What a panel of experts. I am so excited to have you here. Thank you so much. Um

5:45 let’s get started and Stephen, we’ll start with you with the first question. um help us set the stage by sharing some

5:50 of the challenges curling clinic faced that served as the catalyst to enlist support from this team at Surgical

5:56 Directions. So you know it was 5 years ago uh prior

6:02 to the pandemic we had done a lot of internal work to really improve processes and get us into what we

6:08 thought was a really good place. Um like many health systems and many other organizations the pandemic

6:16 created a fracture um it created a fracture in processes efficiencies the

6:22 way we do things um it allowed us to get away from some of those

6:28 standardized processes that we had created previously. Um over time um

6:34 especially in the year before um Joan and Barb and team came in um

6:41 there was an increase in what I would call uh

6:46 behavioral frustration and body frustration. So it you know some people

6:51 are verbal about their frustrations and some they wear it on their body. Um you can see it in the way they carry

6:57 themselves. you can see it in the way that when you’re having a conversation um with them, they may not be, you know,

7:04 not everybody’s going to be direct um and share what’s for, you know, their

7:09 their concerns or their challenges, but um you can hear it in their voice. They’ll come and ask a question and

7:16 and use um different tactics to be able to get that information across. But

7:21 we as leaders, that’s one of the things we really have to do is not only way listen to what we hear, but watch what

7:27 we see. And that that seemed to be increasing more and more over time. Um,

7:33 not only from the physicians, but from the staff. Um, you know, the staff

7:38

would come in and you’re talking about a group of people who are very committed to our community, to our patients. They

7:43

live our values each and every day, but they were frustrated because it’s like they came in and they felt like they

7:49 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 um their room ran a little

7:57 bit later and they’re very supportive of their surgeons and they want to stay as a team and finish taking

8:03 care of the patient that they’re on. Um and so efficiencies was certainly

8:08 suffering there for a while. um when you’re talking about um first case on time starts and turnover times, what are

8:15 the things that that prevent us from doing that? As we know, people can trust

8:20 leadership, they can trust um their peers, but sometimes when you’re trying to solve a problem, you know,

8:27 especially if you’re in in a room of individuals, you may or may not get um

8:32 feedback that truly helps change that process. Sometimes you have to turn away. And that’s one of the things I

8:38 will talk about, you know, as a leader is letting go. In surgery, we’re type A people. Um, so all of my colleagues on

8:45 this call are type A people. Um, and so letting go to be able to allow someone in to help is a huge step. And that’s

8:53 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

8:58 we weren’t seeing. Um, and what we thought were workable approaches,

9:05 it wasn’t working for us. So that that frustration just continued to build and

9:11 um we decided that as an organization we’ve got to do something different. Now what I will say is um and Joan and

9:20 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

9:26 place but we were going from a good place to a great place. So, it’s going from good to great. And sometimes

9:33 that means so much to the staff and to the individuals and those were the problems that that we were

9:40 suffering. There were efficiency problems. Um, and being able to agree on how we solved them, we just were having

9:46 trouble doing that. So, you bring in uh individuals who don’t know the players. they interview um the

9:53 the teams um not knowing them and put together additional teams that that

9:59 really drive um change and that’s what we what we needed to start with and

10:05 when I mentioned earlier about uh Barb and Joan and I um spending quite a bit

10:10 of time and there were a couple other individuals involved um spending time talking about what we wanted. Those were

10:17 the essential things is how do how do we do this so that it’s it doesn’t feel like um you know it doesn’t feel

10:24 threatening. Unfortunately um consulting sometimes has a stigma like other things. It’s like you bring a

10:31 consultant in it’s I’m a bad person. I’m not doing my job. And we really had to from the very beginning um change the

10:37 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

10:44 them in. And I think as you’ll learn through this podcast, we’ve had great successes.

10:49 That’s amazing. Um, so from the Surgical Directions perspective, you know, following your initial assessment of

10:55 Carilion Clinic, how did you start to form a plan and a timeline that built momentum, trust, and buy-in with all

11:01 these stakeholders? Uh I did the assessment at Carilion and during the assessment I was able to

11:08 meet with surgeons, anesthesia providers, nursing staff, leaders and what really struck me was how much

11:14 passion was in that organization. People genuinely cared about doing the great

11:20 work but all that energy wasn’t connected yet and without structure it

11:25 was difficult for them to move in the same direction. And as Stephen mentioned, there were numerous initiatives that came about prior to us

11:32 coming on board. So once the assessment was wrapped up, we sat down together and

11:39 we said, “Okay, okay, where can we make the biggest impact first?” And because we’ve been listening throughout the

11:45 entire process, the themes were really clear and it made it easy to sketch out

11:50 a plan that felt real and doable. So what we did is we kept it straightforward. We built some few

11:57 focused work streams and the work streams were daily operations,

12:02 scheduling, presurgical and scheduling and presurgical optimization, workforce strategy and an anesthesiology

12:10 working group. So we kept the work tight and this helped people see exactly where

12:15 they fit in and that that immediately helped to build trust.

12:20 for the timeline. We wanted to make sure that we would get some early wins on board. So when people

12:28 start to see something improve right away, even if it’s a small thing, even if it’s just coming together for a

12:34 shared goal, the momentum naturally picks up. Then we layered on the bigger

12:40 structural pieces so no one felt overloaded or overwhelmed. And it was over a period of time.

12:47 And I have to say honestly the moment the buy-in really solidified is when we

12:53 put in the governance in place and it was at SSC surgical services executive

12:58 committee. It’s led by a surgeon and an anesthesiologist and it showed everyone

13:04 that decisions would be made. They were transparent. They were data driven and

13:10 they were team led. And it wasn’t dictating. It was not top down. It was

13:15 leadership truly taking the reigns to do what’s best for the organization.

13:20 And I have to say that once the structure was clear, people saw their roles, they saw their feedback being

13:27 reflected in the plan, things started to move. And that’s when the trust came

13:32

about. It came from listening, keeping the plan simple, and making sure that

13:38 every step made sense, really made sense to the people that were doing the work, not just top down.

13:45 Thank you, Barbara. Joan, it sounds like both you and Barbara had some effective tools and

13:50 strategies to get started. Can you talk more about the overall solutions that were implemented at Carilion Clinic and

13:56 how your team empowered long-term sustainable change? Yes, as Barb mentioned, um, one of the,

14:06 you know, as anything in life, one of the main things is, uh, to be successful is building the relationships and the

14:12 trust. And that was a challenge at the beginning. Um,

14:19 we would go to meetings and the staff, you could tell, just like Steven was

14:25 saying earlier, it wasn’t that they were afraid to speak up. I think they just

14:30 did not really know what we were there for. So as time went on and we had what’s

14:37 called the performance improvement teams what Barb was speaking of every meeting

14:43 that we had as we would as we would discuss different processes um for

14:48 instance for their surgical pre-surgical optimization uh performance improvement

14:54 team. We had all the key players there, but they were not really confident in

15:00 sharing the information and feeling like they were in a safe place to talk

15:07 about, you know, what were the obstacles, what were the things that were working well, what were the things that were not working well. And what we

15:15 kept driving was that we had support from top down from the executive

15:23 team all the way through the managers, the leaders there in perioperative

15:28 services. And we just kept driving that that this was going to be a comfortable space to talk and that Steven and

15:36 others, you know, they wanted us to come in and help them with everything

15:41 that we possibly could to be more efficient um and um build that morale.

15:48 And you know, it was amazing to see. It did not take very long for us to see

15:54 that change. Instead of us leading a lot of the performance improvement teams,

15:59 the staff started leading them and they were having fun and it was so rewarding

16:07 to see that in such a short period of time. They saw through the work of the

16:13 SSC backing them. What we would do was we would implement come up with a process

16:18 at the staff level. Then we would present it to SSC for approval and then

16:23 we were ready to put it to action after that. What they saw was it truly

16:30 was happening in that way. SSEC approved it. They were on board with it. They

16:35 supported it and then once the staff started implementing it, they saw the support from the uh leaders and through

16:43 Steven. And so it just it gave them the momentum to continue working on all the

16:49 other processes that we wanted to work on. And it was it was just very

16:54 exciting to see how quickly the morale changed at Carilion. And once that

16:59 happened, you couldn’t stop them. They were they were unstoppable.

17:06 Yeah. I could imagine that level of engagement really does engender more and more participation. Um that’s

17:13 wonderful to hear. Um you Stephen you know let’s discuss some of the outcomes from your organization like what were

17:19 you expecting through this relationship and what are some of the key metrics that you’ve been monitoring since this has happened?

17:26 So when we started this um this journey uh there were a couple things that we wanted to do and that was set up

17:32 our governance structure um which is our surgical services executive committee who now governs um the operative space.

17:41 Um now this is for our for our level one trauma center. This is our um uh our

17:48 biggest location. You know we have multiple hospitals but this is our biggest location. So we went big bang

17:54 and started our process here. Um but some you know some of the metrics we were looking at was our first case on

18:00 time starts. Um we developed a unified definition um that the surgeons

18:06 agreed upon in in the SSC that the staff agreed upon, anesthesia agreed upon and

18:12 from that we went from somewhere around 40% to um now there are days because I

18:18 get a daily report we’re seeing 90% on time starts. Um and so there’s a huge

18:25 improvement there. turnover times. Um, you know, we started out at like 38

18:30 minutes um to impact turn uh turnaround times or turnover times. Um,

18:36 it takes a lot to change that number. So, there are days where we’re sitting down at 33 and 34 minutes, which

18:43 is huge. Some of the other things that we’ve not been able to measure them yet, but we will be the ne um the next time

18:50 our employee engagement survey comes out is really changing the morale and the culture where people feel enabled

18:58 to make change. Um you know, a lot of times there’s a thought process

19:03 that um if a process isn’t working, I’m going to go to my leader and they’re

19:09 going to make that change. the staff have really and I say the staff the staff physicians and the

19:14 anesthesiologists are physicians um but I’ll use the anesthesia group because that’s both

19:19 anesthesiologists and CRNAs but when what’s kind of interesting now is to watch them hold each other accountable

19:25 it’s no longer um this particular person is not getting here on time to be able

19:31 to get in the room on time so I’m going to go I’m going to go tell my manager it’s hey you were supposed to be here at

19:37 this time what happened this morning. So, they’re talking about it together. And prior to this um to this

19:45 journey, I don’t know that people felt enabled or empowered to be able to do

19:50 that or they felt like if they did that it was going to cause a riff in their relationship. We are a very um very much

19:57 a relationship oriented organization because not only I mean the people

20:02 that work here, our community is not I mean it’s a large community but it’s not um it’s not like New York and some

20:10 of these big cities. The people that that work in these hospitals, we’re taking care of our friends, our family,

20:16 our fam our friends families. Um, and so we always want to make sure, you

20:22 know, people always want to make sure their relationships are intact and I think there may have been some

20:28 hesitation because of that. And this has allowed people to really take on a new uh

20:34 a new task of holding each other accountable when these u metrics aren’t happening. So um our top three things um

20:42 that um we included was the governance structure which is our SSC, our

20:47 performance improvement teams for our first case on time starts or turnaround times and then now we’re into a phase

20:53 where we’re really looking at our block scheduling. How do we maximize scheduling so that we can improve access

20:58 for our patients? Maximize the access that we that is available and then where

21:04 do we need to add um you know add staff or resources to be able to

21:11 increase um our access. So, that that fourth piece is important, but that one

21:16 is a longer adventure um just because it’s a it’s a lot to change um

21:22 block schedules um and get people bought into that. But they absolutely have and

21:28 we started our new block on November 3rd and um the first week, you know, there’s

21:34 some ambivalence because change is change is here. I’m not sure if this is going to work. I I don’t know if I

21:39 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

21:45 on it instead of our previous method of group block. But also what you’re what

21:51 you’re seeing is okay, we’re getting in the room on time. Our turn our rooms are turning over um in a timely manner. So

21:58 we’re getting done on time, if not maybe a few minutes early. So these tools that they’ve helped us um implement here,

22:05 just these four things, it’s much more than that. I don’t want to I don’t want to minimize it, but these four key

22:10 things that that we started with, they’re still in place. Um, you know, our performance improvement teams are

22:17 still in place. Um, they’re just uh managed by the staff. Um, and that

22:23 was part of part of the work that was being done was, you know, we have our consultants uh with us. Um, I don’t like

22:30 to call them consultants because they’re our friends. So, our friends here were with us. and how do we transition

22:37 um from our friends um uh owning these committees to our staff owning

22:43 these committees? And they did a very nice job of being able to transition that so that we don’t lose momentum over

22:49 time. Um, and so far it just when you walk up on the fourth floor,

22:56 which is where our OS are, when you see um people walking by with their heads up and that that body language is just so

23:04 different than where we were last January, um the tools, while they sound

23:10 so simple, they’re so impactful. And I promise they’re not simple. There’s a lot of work that goes into those

23:15 schools, but um I think we the successes that we’ve seen so far are

23:22 huge and um it’s made a difference. So um the other piece that I think is

23:28 important is the leaders. Um so the leaders in surgery are systemized. So I

23:34 have two senior directors. Um one that has the Renault campus because that’s two hospitals and one that has the

23:40 regionals. our next biggest hospital is already um put together committees to

23:46 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

23:52 starting to branch them out to other locations so that we can do, you know, have these same successes there. and

23:58 that and that’s been important, but that’s also um it’s a proud moment

24:03 to see that happen in the way that it’s starting to evolve around the organization to um all of our

24:10 facilities. Wonderful advice so far. What additional advice could you give other

24:15 organizations facing similar opportunities and like what expectations should they set for themselves in their

24:22 teams to balance any worries around change and some of the things that you’ve talked about you know this

24:28 outside perspective and insights? One of the things that I I did because

24:33 you say that you’ve got consultants coming in and the immediate um uh visceral reaction is I’m not doing

24:40 my job. I’m not doing a good enough job. um and it creates frustration. So, um I

24:46 put together a um about a 30-minute um presentation that I did for my all of my

24:52 leaders to help them understand what we were doing. And with that, it was we’re

24:58 not going from bad to good, we’re going from good to great. But it also helped them understand

25:04 the wise behind it. Um and it was, you know, it really um was developed to

25:12 to get them excited about it or to start that transition. A 30-minute meeting is not going to necessarily make create

25:19 that excitement because they’re still ambivalence. But that was the start of the conversation. So we started that I

25:24 started that probably 60 days prior to the engagement starting. And then, you

25:30 know, this trickled down to the staff and there’s lots of questions. And so, we had conversations about this daily

25:37 for about two months before the engagement started. So, you have to talk

25:43 it up with your teams and help them understand what it is, why you’re doing it. You know, access, I’ll use the

25:49 access um piece of it. Um we want, you know, we’ll add FTEEs for access, but

25:54 what we want to make sure of is that we have access. We want to be able to care for our patients. Um, and that was one

26:01 of the pieces in there is prior to prior to the pandemic, this is the number of patients that we cared for each year and

26:08 this is the number of FTEEs we had. This this time, you know, we’ve got this number of FTEEs and this is the number

26:15 of patients we’re caring for. So, they don’t necessarily line. How do we get those realigned? And when you

26:20 show data, people really absorb that much differently. Um so having

26:27 those conversations um prior to the engagement um not with everybody I’m

26:32 talking about staff physicians anesthesia um we’re uh we had conversations at our organizational

26:40 leadership um I presented the work that we were going to be doing even there so they had an understanding of what

26:47 was what was going to be happening um and then now we’re sharing those

26:52 successes and the things that we’ve done. So, it’s been a really exciting so far 11-month journey. Actually, it’s

26:59 probably been longer than that, but um we started the actual um

27:06 work in January and it’s been very exciting. So, to wrap to kind of sum

27:11 this up a little bit, um for other leaders who have concerns or how

27:17 do you make this happen? um we as leaders sometimes have to let go and that’s one of the hardest things

27:23 especially with type A personalities and stand back and let others help and

27:30 um having the courage to ask for help is step number one and then having the courage to um to uh or the commitment to

27:38 allow that um that help to make changes is number two. And number three is

27:44 communicate, communicate, communicate. If people don’t know what you’re doing, they think you’re hiding. Be very

27:49 transparent about what’s going on. And once our friends got here, they were

27:54 they were very transparent with their processes and the things that that they were attempting with everyone so that

28:01 everybody knew where we were going. Um and the performance improvement teams were the ones deciding how we were

28:08 going to get there. It was not um myself or any of my leadership team. it was the

28:13 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 um and sometimes

28:21 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

28:28 people from doing their best and then how do you operationalize it with

28:34 this many people because it’s a lot of people every single day. I mean, we’re talking 200 people um between all of all

28:40 of our um staff, physicians, anesthesia,

28:46 uh everybody every single day. It’s about 200 people. So, trying to operationalize something like that is

28:51 not um is not easy, but um communicate and listen. Wonderful advice. Um Barbara and Joan,

28:59 would you like to share any final thoughts? Yeah, thank you.

29:04 you know, as I look back, we still have our engagement. We’re still currently engaged with Carilion and have our

29:10 partnership. And I remember um I saw I

29:16 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

29:21 and um I saw a post that Steven had put um on LinkedIn and it was about the

29:28 partnership and not only that was exactly what he was just talking about the changes he needed to make as a

29:35 leader. I read it and it really hit me because that I realized then, you

29:41 know, we have truly partnered with Carilion and made a difference. And it’s not because of what Surgical

29:47 Directions brought or what Carilion brought, but it’s what we did together. And I reached out to Stephen and I said,

29:53 Stephen, you have made me emotional here at the airport. And it was just um it

30:00 it’s just so rewarding to work with someone like him and his team. Um it was not easy at the beginning. We had a lot

30:07 of obstacles that we had to work through because a lot of the staff you know even

30:12 though they were so prepared um that we were not in coming in to you know take

30:18 jobs or do you know everything totally different because they had a lot of

30:23 great things in place. Um, but I think a lot of it was building trust among

30:29 between us and the team and among themselves. And I will say the last time

30:36 I was at Carilion and I’ve got the privilege of being there next week. Um, but the last time I was at Carilion, we

30:43 were in the surgical services executive committee meeting and not only are they

30:48 working on the things that we put into place, but they’ve also started um creating subgroups on their own. Um,

30:56 okay, we’re going to monitor, we’re going to continue to monitor what physicians are continually to be late

31:03 and what are we going to put in place to alleviate this from continuing. Do we

31:08 take block time? what are we going to do? And so they have on their own um

31:13 implemented subgroups of the SSC. And that to me is just um it’s just a an

31:21 ongoing um you know, it just tells you that Carilion is in the best of hands

31:27 and there’s going to continue to be great things that happen there and I look forward to the continued partnership. So I just had to say my

31:35 final thought is that perioperative change transformation it’s not Disney

31:41 magic it’s discipline it’s structure it’s collaboration

31:46 and when you give your teams a plan a realistic timeline implementing that

31:51 governance structure that truly lets your clinicians lead you get better

31:56 access you get better throughput and truly the long run you get better financial performance and all of the

32:02 things that Stephen mentioned and really importantly is a more engaged workforce.

32:09 And it seems that Carilion truly proved that when everybody pulls in the same

32:14 direction, these results come quickly and I I’m just proud to be a part of that team. Uh it sounds like an amazing

32:21 journey. Um, Stephen, Barbara, Joan, I really want to thank you all for joining me and taking time um to share your

32:29 story with the AHA members. For our listeners, if you’d like to learn more about Surgical Directions or anything

32:36 you’ve heard on this podcast today, please visit us at surgicaldirections.com. If you’d like to learn more about the

32:41 associate program, please visit sponsor.ha.org. This has been AHA Associates Bringing

32:47 Value brought to you by the American Hospital Association. Thanks for listening. [Music]