Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations: Influencing Workplace Well-Being in Healthcare. We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning. Thank you for joining us.

Biddison: Hello and welcome. I'm Lee Daugherty Biddison, your host for the Vital Conversations podcast. It's a pleasure to have with me today Dr. Steve Kravet. Steve is the president of Johns Hopkins Community Physicians. He is a clinical professor of medicine and holds the L. Douglas Lee and Barbara Levinson Lee Professorship in Clinical Medicine. Steve, so great to have you with us today.

Dr. Steve Kravet: Thanks, Lee. Great pleasure.

Biddison: I am excited—really thrilled—to have the opportunity to talk with Steve about some of the amazing successes that Johns Hopkins Community Physicians, or JHCP, has had in focusing on enhancing and improving the well-being of their clinical providers. It's been an amazing journey. I've got many friends in the JHCP community and have been thrilled to watch this develop over time and see JHCP stand out as a leader in this space, both within our organization and nationally.
 So Steve, maybe just in laying the groundwork, tell us a little bit about the history of Johns Hopkins Community Physicians. Where did it start? What was the purpose, the goals?

Kravet: Yeah, thanks, Lee. Actually, it's very interesting. The history of JHCP dates back earlier than Johns Hopkins itself, and it has its roots in the military. There was a military hospital—I believe it was the hospital down near Fort McHenry. If you ever visit Fort McHenry, you see pictures about the old military hospital that was originally there to take care of the Merchant Marines. That became a U.S. Public Health Service hospital when it was rebuilt near the Hopkins Homewood campus, Wyman Park. It existed for a few decades until the early days of the Reagan administration, 1982, when all U.S. Public Health Service hospitals around the country were closed for cost-saving measures, except for six. Six of them, instead of closing, were taken over by private organizations. The organization that took over that hospital was called the Wyman Park Medical Associates. Hopkins ultimately acquired the Wyman Park Medical Associates—and so it was the military treatment facility, and then a whole series of outpatient practices that at the time were linked to where military bases existed around this region. There were also a series of HMOs that Hopkins had been involved with starting; those organizations kind of merged into what was formerly the Johns Hopkins Medical Services Corporation in the early 1990s. The organization existed largely as a primary care organization managing practices in the greater Baltimore area and satellite practices near military bases. In the early 2000s, when Bayview’s primary care network merged with the existing Medical Services Corporation, they created a large organization with some consolidation of practices geographically and took the name Johns Hopkins Community Physicians. That was around 2003. In 2010, when Suburban joined the Johns Hopkins family, they had 60 physicians and advanced practice providers—largely specialists. The decision was made to bring them into JHCP because they were community-based. That was the moment when JHCP became a truly multi-specialty organization. Prior to that, we were largely pediatrics, adult medicine, and OB-GYN. With the specialty groups, it opened the doors to JHCP functioning more broadly across larger geographies. With Suburban and Sibley joining, there was a need to grow in the national capital region. That has been the focus of growth over the past 15–16 years. We went from 18 practices to over 50. From 150 providers to over 700. From half a million visits a year to—this year, for the first time—over a million. It’s a force to be reckoned with.

Biddison: It is a force to be reckoned with. And sometimes that rapid growth can be really challenging. But from the outside at least, it feels like JHCP has taken it all in stride. What are some of the challenges through that growth process?

Kravet: Whenever I hear somebody say that—which is so nice to hear—I also think it never feels that way because it’s so hard. Of all the things our leadership teams worry about, it's really the people at the front lines who are trying to deliver care in more and more challenging environments. There are business challenges to growing an organization, but throughout it all, none of us have stopped worrying about what it’s like to wake up every day and provide community-based care across a broad geography. The big questions are: How do you keep people connected to the mission? How do you manage a really broad geography? It’s one thing to walk the halls of a hospital and meet people. It’s much harder when you have a widely distributed organization. Ambulatory medicine is also fast-paced—you can’t step away easily to have conversations. Finances are always a challenge. But I think JHCP has been good stewards financially, benchmarking well and earning the trust to make needed investments. The greatest challenges in recent years have been linked to well-being and workplace safety—things exacerbated by the pandemic. Patients are struggling, and often staff bear the brunt of that. Day in and day out, that takes a toll.

Biddison: Can you say more about how well-being challenges ramped up during the pandemic? And were there specific components of helping teams stay connected that were impacted?

Kravet: Some central services became remote during the pandemic, which was a blessing and a curse. People appreciated flexibility but missed connection. Leaders now try to bring teams together a couple of times a month. Our frontline practices, however, never stopped seeing patients. They were always in person, like hospital-based workers. That created tensions—managing life outside work while still coming in, supporting patients, and navigating their struggles. Another challenge: the explosion of technology and data flow. In primary care especially, the amount of information expected to be managed is huge. Keeping up creates emotional strain for clinicians and workflow strain for teams.

Biddison: How did that stress manifest at the front line?

Kravet: Turnover, for one. Some people nearing the end of their careers found the environment too emotionally taxing. Others with health concerns didn’t feel comfortable in face-to-face care. Some reduced their clinical FTE, which created operational challenges. But enough about challenges—let’s talk about successes.

Biddison: Yes—my favorite part! What did the team do to intervene and improve frontline experience?

Kravet: Engagement has always been essential. Our HR Director, Leslie Rohde, and I have partnered on this, and early on I built a communications team because communication is the lifeblood of any organization. We had amazing engagement campaigns—one called Y5: “Why would you rate JHCP a 5?” People shared what made them feel engaged, and it built momentum. That was around 2017–2018. Each practice has its own culture, and while we emphasize pride in being part of Johns Hopkins Medicine, it’s practice-level culture that drives day-to-day engagement—tools, connection to mission, feeling heard, opportunities to grow. I’m proud of many things:

• Nursing mentorship programs
• Medical assistant externships to hire better and faster
• Programs for joy in medicine—book clubs, monthly excursions, storytelling
• Meraki, an art magazine showcasing staff creativity, started by Alice Lee, now enterprise-wide

We’ve also created opportunities for people to do different things: participate in courses, build Epic templates—small but meaningful ways to add variety and joy. We developed a vision statement: We give our patients and our teams the time and attention needed to achieve their best health. To do that, our teams also need time and attention. A key success was reducing face-to-face clinical time by four hours per week. With support from Kevin Sowers, we calculated the investment and made it happen. It improved retention and recruitment dramatically.

Biddison: I love that balance—honoring the bottom line while investing in clinicians’ ability to thrive. It's brave to invest knowing there’s some revenue impact, but also recognizing the long-term value.

Kravet: Exactly. It’s hard work, but essential. Another example is structured onboarding. Melissa Blakeman created a model to ramp up new clinicians in a defined timeframe—50% full, then 100% full. That consistency reduced the investment required during onboarding and supported non-face-to-face time. All of this comes from hard work across our chiefs and medical directors. They set the tone for well-being and balance.

Biddison: You mentioned Meraki and other creative efforts. I know Alice Lee also worked on the Epic landing page. Can you share about that?

Kravet: Alice recognized we could customize the Epic landing page. Instead of stock photos of cows and UFOs, she coordinated a system for staff across Johns Hopkins Medicine to submit personal art or photos. These now rotate daily, credited to the contributors. It's a simple but powerful way to spark joy and connection.

Biddison: It’s such a lovely way to build community. I hope we can share that more widely. As we wrap up, what are your thoughts on the future of thriving in healthcare?

Kravet: One of the greatest recent sources of joy is ambient documentation technology—it’s been life-changing. It improves patient perception of being heard and reduces typing, allowing more genuine connection. We’re also improving how we use Epic—better messaging workflows, better refill management—reducing burden. Looking ahead, panel size reduction models and hybrid clinical environments will be important. Models like direct primary care, J-Home, and primary virtual care offer heterogeneity in work that improves well-being. We’ll keep expanding those opportunities.

Biddison: I love that. Rethinking the work itself is so important for autonomy and thriving. I'm excited about everything happening in JHCP and the opportunities to partner.

Kravet: I appreciate the chance to share. And I want to reiterate how important the well-being work you lead is. We tap into it constantly. I send providers to you regularly for help and guidance. We are incredibly grateful.

Biddison: Thanks again. It’s been a great conversation. Signing off for the Vital Conversations podcast—this is Lee Daugherty Biddison, your host. Have a great day.

Fowler: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. We welcome your feedback. If there are any topics you'd like to hear about, please email us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Steven J. Kravet, MD, MBA
Professor of Clinical Medicine
Johns Hopkins University School of Medicine 
President, Johns Hopkins Community Physicians

1. Strategic Growth and Expansion: JHCP provides over one million patient visits annually in the mid-Atlantic region.  Maintaining a culture of connection across widespread locations has been a focus of JHCP’s leadership during a rapid expansion.
2. Administrative Time Innovation: Since early 2024, JHCP clinicians have received up to four additional hours weekly for non-face-to-face clinical work, a well-being intervention that has significantly improved retention and recruitment. This time can be used for achieving quality measures or for participating in special projects, and it has led to reduced burnout and increased job satisfaction.  
3. Creative Well-being Initiatives: JHCP has championed creative well-being initiatives, including the Meraki magazine project where staff can share their artwork and poetry. For many, these efforts have fostered a sense of belonging and connection at work.  
4. Technology-Driven Solutions: JHCP has implemented structured onboarding processes for new clinicians, embraced virtual care delivery models for increased access, and adopted technological solutions like Abridge ambient documentation, which providers describe as "life-changing."

• Learn more about JHCP
• View the Meraki online art magazine

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning. Thank you for joining us. Hello and welcome to the Vital Conversations Podcast. I'm your host for today's episode, Lee Daugherty Biddison. I serve as Chief Wellness Officer for Johns Hopkins Medicine, and it is my pleasure to be here today and to welcome Dr. Helen Hughes. Dr. Hughes is Associate Professor in the Department of Pediatrics. She is also the Medical Director of the Office of Telemedicine for Johns Hopkins Medicine and the co-chair of the MyChart Committee for JHM. Welcome, Helen.

Helen Hughes: Thank you. Thanks so much for having me.

Biddison: So excited to have you here today. You've got a lot of big titles that, as a not  IT person, seem very intimidating. Tell me a little bit about what these leadership roles entail and what you're up to in those spaces.

Hughes: Excellent. In my medical director for the Office of Telemedicine hat, we have a fantastic team of around 12 individuals who are in the Office of Johns Hopkins Physicians, which is sort of our strategic growth arm of Johns Hopkins Medicine. And those individuals comprise clinicians, administrative staff, and IT staff, and we're tasked with deploying and managing all of our care delivery that happen through remote technologies. So video visits in the outpatient setting is our most common tool, but really using a lot of different technologies to connect providers and patients at a distance to deliver healthcare. And that office has existed since 2016, so since before COVID. But obviously in 2020 with COVID had a big transformation. And I was lucky to come into the office as an assistant medical director in 2020 and then become the medical director three years ago. So it's a very cool job because I get to sit at the nexus of a lot of different parts of the health system. I work both with the school of medicine and the health system, work with the outpatient settings and the hospitals, work with our legal department, billing, marketing communications. So it's very cool to get to see kind of the breadth and the expertise across the system. The office does not provide any clinical care, but we support the technical infrastructure and the operational infrastructure around telemedicine care. And then my other hat is to co-chair the MyChart committee. So that's under our health IT team coordinating with our CMIO for JHM. There is a governance structure in our Johns Hopkins Epic team, where there are different committees, and one of those committees is our MyChart committee. So we meet a couple of times a month to review any changes that are coming from Epic to MyChart, which is our electronic patient portal, or to review kind of projects where we have to do kind of custom builds to improve our MyChart. So in both roles, I focus on technology that helps give patients access to healthcare, which I'm really passionate about. And so it's been a great, great marriage across the two.

Biddison: Very cool. Well, tell us a little bit about how you got here. How did you, what was the impetus to move into the digital health space?

Hughes: Yeah, so I've been at Hopkins for a long time. I came to medical school here and I always liked a lot of different things and was kind of a generalist. I settled on pediatrics and ended up doing a fellowship in general academic pediatrics, which was sort of a health equity, population health research fellowship and was really passionate about access to care. And around 2016, when I was a chief resident, kind of in the middle of my fellowship, I was working with Tina Chang, who was our department director at the time. And she was saying, you know, Helen, what are you going to do with your life? I was having a really hard time. You know, I thought I was going to do a K path and was having a hard time narrowing down what my interest was going to be. I just had so many different interests and really wanted to find something that I felt was proximate to making care better. And she asked, well, are you interested in telemedicine at all? Because she had this group on the Eastern Shore of Maryland that was kind of a parent advocacy organization that had approached Hopkins to try to increase specialty care access to the Eastern Shore of Maryland for children. And at first I had kind of a negative perception of telemedicine as a primary care provider, sort of like direct to consumer companies that were maybe doing inappropriate care over video and outside of the medical home. But then I started to read about it, and it really started with the Indian Health Service in the 60s and NASA and all sorts of cool groups. And then around the time I was learning about it, the Veterans Administration, you know, did all this stuff to invest in telehealth to increase access for veterans. So it was really a tool to increase access to care for patients that were having trouble accessing care. And in my clinic where I practice in East Baltimore, 90% of my patients have Medicaid as their insurance. Many of them are working multiple jobs, have multiple kids, don't have transportation to appointments. And the idea that I could do an ADHD follow-up or an asthma follow-up over a video and help them avoid all of that inconvenience seemed like it would be amazing. So I thought, yeah, I'll help with this telemedicine project. So I kind of helped get that project off the ground. That was three specialties. Kind of the specialist was the Johns Hopkins Hospital giving subspecialty follow-up visits on the Eastern Shore of Maryland. But at the time, you couldn't bill for that care if the patient was at home. They had to be at a certain originating site, like a health department or a school-based health center. And so it was really hard to operationalize and it kind of felt like a failure. Like we had to get this legal contract, and we only had eight visits in six months. And I was trying to do this school-based health stuff and that wasn't getting off the ground. So by January 2020, I was thinking to myself, this telemedicine stuff's not going anywhere. I think it's the future, but there's too many barriers and it's not financially sustainable, and the logistics are too hard to get the patient at a non-home location. So I was exploring other K options, et cetera. And then on March 16th, there was this email that you had to essentially convert all your outpatient visits to video because of the pandemic. People were saying, oh, didn't you have the telemedicine program, Helen? So I was lucky to help my department, Department of Peds, kind of do that ambulatory transition to telemedicine. And through that, got to know our office better, which kind of led to this more health system role, but it's been awesome because at the end of the day, it really is about right care, right place, right time, like getting the right care to the right place and at the right time efficiently. And it's great to see, in informatics, there's a saying that informatics is 80% sociology. So a lot of informatics is not the tools, like the tools exist. It's more about the operational process, the change management, the policy. And I really like kind of the marriage of all of those things.

Biddison: Fantastic. I was just thinking as you're talking, I was like, oh, we need to have another, today we're talking about digital health, but we need to have another conversation about career path because I think there are lots of people who would really benefit from hearing about even more about your journey because there's so many diverse opportunities in healthcare. I think sometimes from a well-being perspective and professional fulfillment perspective, I often think, are we trying to fit our trainees into very rigid boxes in terms of how care is practiced or care is delivered in any environment? And in fact, your stories are such a wonderful one that there are a whole host of different ways that this can look. And the next opportunity is just around the corner.

Hughes: Yes, yeah, I was very lucky. A lot of it was serendipity, but one of my favorite phrases is luck favors the prepared. So there was certainly a time of me feeling like I'm a failure, I can't commit to anything, but you just got to keep going and kind of follow those sources of light that attract you. And I was lucky that it worked out. But yeah, I love my job, so I'm very happy.

Biddison: Very, very exciting. Well, tell us a little bit about what the priorities are for Johns Hopkins Medicine and what you see happening nationally and globally in the digital health space and the virtual care space. Maybe we could start with sort of, since you got started in this in 2020, a ton has happened over the last five years. Maybe start there and then we can look into the future.

Hughes: Okay, that sounds great. So I'll do it in kind of two venues. So one is outpatient and one is inpatient, although obviously there's intersection between the two. But on the outpatient side, one of the biggest tools is a video encounter. So you're meeting with your doctor over video. It's as if you went in person. They're doing evaluation and management of you, and that can be a build encounter. So it prevents the patient from having to travel to that appointment. And that's really what exponentially grew during COVID. We had 70 video visits per month pre-COVID because of those operational barriers. We went to 90,000 in May of 2020. Now we're at a run rate of about 30,000 per month for the past three to four years. So we've done 2.5 million telemedicine visits in comparison to 800 pre-COVID. So basically the switch was turned on and it certainly receded as the kind of stay-at-home orders went away, but it's about 12% of our outpatient volume, but in some specialties, neurosurgery, neurology, about 25% of those visits via telemedicine. You can't drive in the state of Maryland for six months after you've had a stroke, so the ability for those patients to follow up without burdening their family is really helpful. So that kind of is our bread and butter. And it is constantly at risk from a policy standpoint. We're lucky to be close to D.C. and to be engaged with a number of national groups like the American Telemedicine Association, the Alliance for Connected Care and the AAMC. But for most telemedicine policy that was a barrier pre-COVID, it was kind of waived with the pandemic and then continues to have these cliffs of expiration where Congress has to act again to continue the waivers. There has not been a permanent action to give the ability for providers to be seeing a patient at home for Medicare and Medicaid and to bill for that care without the patient being at another site. So we do a lot of advocacy to try to continue to beat the drama of, this is still important, this is still care that's happening. The next cliff is on September 30th. We're fairly confident there will at least be a three-month extension. We're hopeful that in December of 2025, there will be a permanent or at least two-year extension because it's very confusing for patients and providers when there's news like telehealth's going away on September 30th, when it's been extended every time for the past five years that it's come up, and there's been about five cliffs. So anyway, we're working hard to try to make sure the payment is permanent because without the payment, it really can't be a sustainable mode of care. The second area we're really in the outpatient space focusing around advocacy is around cross-state telehealth. Pre-COVID, to see a patient for a visit over video, the provider needs to be licensed where the patient is located at the time of care. At the beginning of COVID, each state waived their licensure rules for about a year. It's okay to see the patient in our state, especially if it's an established patient. But then all those waivers kind of slowly went away, so right now we're pretty much back to the pre-COVID state where you have to be licensed where the patient is located. It's a challenging issue because it's at the state level, but the Commerce Clause of the Constitution maybe suggests that there is room for federal intervention when it is occurring across state lines.

Biddison: Did you ever think you would know anything about the Commerce Clause in the Constitution?

Hughes: I did not. No, no. Yeah. I mean, you just keep learning and you just keep moving and you definitely learn things that you never thought you would know about. But yeah, we have a great group of like national advocates, some oncologists, geneticists, lawyers, we have kind of a coalition around 100 people who are interested in this issue. And we're hoping we can make a change because it's heartbreaking to get these emails from patients begging to see their provider. And it's really not a Hopkins rule. We're just trying to protect our providers from any negative downstream consequences of seeing a patient in a state without a license. And then the third thing on the outpatient side is around kind of new care models. So remote patient monitoring, for instance, trying to find ways to, rather than just copy-paste, recreating an in-person visit to be remote, instead figuring out ways to help providers care for a larger population and really maximize their time. So for instance, you know, having a cardiologist, have a number of patients who are using remote patient monitoring devices, entering their symptoms, and really elevating the patients who are needing urgent care to be the ones who they interact with rather than just going based on when they happen to be scheduled. And there's a lot of opportunity for AI in that because right now we have, for instance, you can hook up your Apple Watch to MyChart, but all we get is individual heart rates. So when we turned that feature on, we got thousands of regular heart rates a day with no intelligence about what that data meant. You know, was it high, was it low, was it changing? So but you can see once you layer AI onto that, it's going to become easier and easier without a human to kind of feed clinicians actually meaningful information from the remote patient monitoring data.

Biddison: Very cool. You know, it's... We talked a little bit before we jumped on our conversation right now about sort of the meaning of this remote healthcare for patients. And I think that case is, as you've made very, very well, is pretty obvious. But I think you're starting, what you're just saying here is you're really starting to get at what it means for the clinicians. Yes. Who want to be available to the people who need them most, but for whom it is very hard to know who needs them most. And instead, we're just walking through a sort of almost a first come, first serve approach.

Hughes: Yes. Absolutely. And it, you know, the provider, how these tools can positively impact providers, I think happens both across the outpatient and inpatient space. But I'll start on the outpatient side. We did a survey of our providers in 2021. And we asked, so this is just to say that we're at the early stages of this. So we asked providers, in your specialty, what percent of the time do you think it's appropriate to see patients via telemedicine? And what percent of the time do you want to have your schedule be telemedicine into the future if you can still bill for it? And so people answered 0 to 100% of the time. And if you look at specialties, the mean change, so maybe psychiatry said 70% of their schedule, they want to be telemedicine and pediatrics said 20%. But in every specialty, we had a 0 to 100% range. So in every single specialty, there were some people that said, this telemedicine thing is not for me. I don't like it. And then there were some people who said, I want to do it all the time. People will ask us, do you have like a quota for how much telemedicine people should do? And we definitely do not, but for those people who are in the champion group, we hear a ton of benefits kind of to their work-life balance. So in that paper, people were more likely to be younger and female, perhaps having home responsibilities who preferred to do telemedicine. About 60% of people who responded did telemedicine from their home. So they were at home when they were providing that telemedicine care. And you could see how if you ended telemedicine clinic at 5 P.M. and you're at home, it's easier to be at home at 5 P.M. than if you have to kind of travel from the hospital when you ended that video visit. And then we also have a virtual list program that we've been piloting with providers who are predominantly virtual. And we've had a lot of stories, meaningful stories. So one person whose family member had cancer and they were able to move to a different state for a period of time to help their family member while continuing their clinical work. We have another person who moved to Texas to care for an elderly family member and they were able to do their practice 100% remote during that time period. So kind of having that flexibility, you know, there's so little flexibility you have as a clinician when you're in clinic and having that little bit of at least location flexibility has been really helpful. And then on the inpatient side, we are working on both providers seeing patients over video across hospitals, but also a virtual nursing program. And there were a number of, we did like a national tour. We went to five other sites that have virtual nursing programs. And to see these really experienced 30-year MICU nurses be kind of at a centralized nursing, virtual nurse setting. And kind of teleport into these rooms across a 10 hospital system and be able to say, I had back surgery and I've had two knee replacements. I literally cannot be at the bedside anymore, but it's so rewarding for me to get to help all of these new nurses in training across these 10 hospitals, helping to run codes via telemedicine, helping to document, looking at wounds. So it's been really amazing to see kind of... I think when I first started hearing about virtual nursing, I was like, well, how could someone be a virtual nurse? How does that work? But a lot of the cognitive tasks, the mentoring tasks, the paperwork tasks can be taken off the bedside nurse and given to a nurse who's remote. And it's physically hard and from a sensory standpoint, it's hard to be on the floors in an ICU. And so some groups are giving nurses kind of a break. Maybe they have a block schedule where you do time on the floors and then you do virtual nursing. And then other groups have nurses who are 100% virtual, and some groups even have virtual nurses who are working in the inpatient setting who are working from home, which we haven't gone to yet. But the idea of, I know a lot of nurses may go into case management or other kind of desk job type fields, and to be able to tell those people, well, actually, you can still help with the bedside.

Biddison: When we have a lot of... you could still be engaged clinically, yeah. And that's so huge when there's such an incredible demand for nurses.

Hughes: Yeah, they're also discussing kind of multidisciplinary care models or co-caring models where there might be an LPN or, you know, a non-nurse doing some of the tasks to the bedside with a nurse overseeing, and kind of the ability to scale those models when you have a core of people who can function across units or across hospitals is really exciting when we think about the provider and nursing shortages.

Biddison: So as we said, a lot has happened in the last five years. What are the sort of top priorities from your perspective, both for us as an organization and again, nationally, moving forward in the next five to 10 years?

Hughes: Yeah, so I mean, certainly as an organization and nationally from an academic medical center standpoint, I think we are all in a challenging time as academic medical centers, both from a financial standpoint and from a research standpoint in terms of grant funding. I think in terms of scaling, it takes a long time and it's very expensive to build buildings. In terms of scaling care models and shifting the amount of clinical time, how clinical time is delivered, where it's delivered from, there's a lot of opportunity in kind of thinking outside of the box and thinking about virtual care delivery. So I'm pretty optimistic. I mean, the current administration's always been very supportive of telehealth. It's always had bipartisan support. The current leadership at HHS is very supportive and CMS. There have been a number of requests for proposals, requests for information that have come out around decreasing regulatory burdens in healthcare and increasing, essentially trying to address the many challenges we have through technology. So I think the next four years are going to be actually pretty exciting in terms of the goal of really using these tools to solve our most pressing challenges. So that's very exciting. And then on the inpatient side, it'll be very interesting to see. So I would love to see in five years that we have audio-visual equipment that is AI capable in every room in our hospital, across all of our hospitals.

Biddison: That would be amazing.

Hughes: Yes, it's very expensive right now, which is a challenge. But if you think about scaling interventions that work, we did a site visit at a peer hospital who has like a physical virtual care hub that does basically is kind of, you know, big brother for all of their hospitals and their outpatients. So they have kind of AI algorithms to surface someone who's getting sepsis deterioration. And then an experienced nurse kind of from this big brother centralized group can kind of teleport in either via secure chat, via phone, via video, and help that bedside team to say, you know, oh, this patient's deteriorating, rather than an epic alert that is wrong 60% of the time, and then people ignore it.

Biddison: That would make people feel more well, less wrong alerts.

Hughes: Yes, so the marriage of kind of the technology with centralized humans who are experienced, I think has so much potential. Because if you take that 30-year experienced MICU nurse and you put her there with charts and AI intelligence, you're taking the intelligence of the AI plus the intelligence of a nurse who's been in the ICU for 30 years, and then you're getting it to the bedside to a nurse who's maybe been working there for six months. And, you know, we do hear a lot of positive feedback on the virtual nursing side of... It's scary when you're like just out of training and you're there by yourself and the patient's getting sick and maybe your lead nurse is like at another bed and the ability to just put a button, there's like a call button, it's green in the room. And then an experienced person teleports in and it's like, it's okay, this is what you do next. Even if it was a nurse, that would be amazing. I would have loved having a 30-year experience PICU nurse come help me at the bedside. So change management is hard, and technology management is hard, especially when the technology is changing so quickly. For virtual nursing, we started our process for building the program and doing our requests around the IT technology maybe two years ago. By the time we deployed it, the top companies were probably completely different in terms of AI technology and just it's all changing so fast. So it's a little bit paralyzing because you could analyze and analyze and analyze and never do anything because it's hard to commit when the technology changes so fast. But I've been proud of us as an institution for getting about 200 beds live on virtual nursing in the past year. The team did like a four-month rapid implementation at the end of last year and the hope is to expand again this year. So I'm not sure how quickly we'll get to all beds with the audio-video camera, but there's lots of cool nurse-child life, like Howard County doesn't have child life. What if the child life team at the Children's Center can go down to Howard County? What if Florida and Baltimore can have one child life group that helps support both and kind of offloads registration staff, case management, home care, pharmacy? You can kind of see how when you have really good centralized groups and they're able to go across all beds, regardless of where the patient are, you get closer to that kind of right care, right place, right time ability.

Biddison: And more equity across all the sites.

Hughes: Yes, absolutely. You know, one of the things that I've spent some time thinking about and I've talked about with a number of folks is that sometimes when new technologies or new resources become available, the implementation process has a very specific lens, like patient experience or finance or whatever. And I just, you know, kind of as we close our conversation, I just want to say how much I appreciate the fact that the Office of Telemedicine and the Digital Health Group is really thinking about who are all the stakeholders here. Yes, we need to be sure that, you know, we're doing the right thing for our patients, but we also need to be sure that we're taking into account the perspective of the clinicians who are providing the care so that everybody's outcomes are positive for everybody, I guess, is the way that I want to say that. Absolutely. It is the holy grail and rare to find win-wins in this world. And I think from a patient experience, provider experience, healthcare cost quality standpoint, a lot of these innovations are win-win-wins, which is fantastic. So that's part of why I'm so excited to be doing what I'm doing.

Biddison: I don't know a better place to end than right there, Helen. Thank you so much for being with us today and for this amazing conversation. Again, signing off for the Vital Conversations podcast, this is your host, Lee Daugherty Biddison. Thanks for being with us.

Helen Hughes:  Thank you.

Biddison: So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague. And as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

 

 

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning. Thank you for joining us. Hello and welcome to the Vital Conversations Podcast. I'm your host for today's episode, Lee Daugherty Biddison. I serve as Chief Wellness Officer for Johns Hopkins Medicine, and it is my pleasure to be here today and to welcome Dr. Helen Hughes. Dr. Hughes is Associate Professor in the Department of Pediatrics. She is also the Medical Director of the Office of Telemedicine for Johns Hopkins Medicine and the co-chair of the MyChart Committee for JHM. Welcome, Helen.

Helen Hughes: Thank you. Thanks so much for having me.

Biddison: So excited to have you here today. You've got a lot of big titles that, as a not  IT person, seem very intimidating. Tell me a little bit about what these leadership roles entail and what you're up to in those spaces.

Hughes: Excellent. In my medical director for the Office of Telemedicine hat, we have a fantastic team of around 12 individuals who are in the Office of Johns Hopkins Physicians, which is sort of our strategic growth arm of Johns Hopkins Medicine. And those individuals comprise clinicians, administrative staff, and IT staff, and we're tasked with deploying and managing all of our care delivery that happen through remote technologies. So video visits in the outpatient setting is our most common tool, but really using a lot of different technologies to connect providers and patients at a distance to deliver healthcare. And that office has existed since 2016, so since before COVID. But obviously in 2020 with COVID had a big transformation. And I was lucky to come into the office as an assistant medical director in 2020 and then become the medical director three years ago. So it's a very cool job because I get to sit at the nexus of a lot of different parts of the health system. I work both with the school of medicine and the health system, work with the outpatient settings and the hospitals, work with our legal department, billing, marketing communications. So it's very cool to get to see kind of the breadth and the expertise across the system. The office does not provide any clinical care, but we support the technical infrastructure and the operational infrastructure around telemedicine care. And then my other hat is to co-chair the MyChart committee. So that's under our health IT team coordinating with our CMIO for JHM. There is a governance structure in our Johns Hopkins Epic team, where there are different committees, and one of those committees is our MyChart committee. So we meet a couple of times a month to review any changes that are coming from Epic to MyChart, which is our electronic patient portal, or to review kind of projects where we have to do kind of custom builds to improve our MyChart. So in both roles, I focus on technology that helps give patients access to healthcare, which I'm really passionate about. And so it's been a great, great marriage across the two.

Biddison: Very cool. Well, tell us a little bit about how you got here. How did you, what was the impetus to move into the digital health space?

Hughes: Yeah, so I've been at Hopkins for a long time. I came to medical school here and I always liked a lot of different things and was kind of a generalist. I settled on pediatrics and ended up doing a fellowship in general academic pediatrics, which was sort of a health equity, population health research fellowship and was really passionate about access to care. And around 2016, when I was a chief resident, kind of in the middle of my fellowship, I was working with Tina Chang, who was our department director at the time. And she was saying, you know, Helen, what are you going to do with your life? I was having a really hard time. You know, I thought I was going to do a K path and was having a hard time narrowing down what my interest was going to be. I just had so many different interests and really wanted to find something that I felt was proximate to making care better. And she asked, well, are you interested in telemedicine at all? Because she had this group on the Eastern Shore of Maryland that was kind of a parent advocacy organization that had approached Hopkins to try to increase specialty care access to the Eastern Shore of Maryland for children. And at first I had kind of a negative perception of telemedicine as a primary care provider, sort of like direct to consumer companies that were maybe doing inappropriate care over video and outside of the medical home. But then I started to read about it, and it really started with the Indian Health Service in the 60s and NASA and all sorts of cool groups. And then around the time I was learning about it, the Veterans Administration, you know, did all this stuff to invest in telehealth to increase access for veterans. So it was really a tool to increase access to care for patients that were having trouble accessing care. And in my clinic where I practice in East Baltimore, 90% of my patients have Medicaid as their insurance. Many of them are working multiple jobs, have multiple kids, don't have transportation to appointments. And the idea that I could do an ADHD follow-up or an asthma follow-up over a video and help them avoid all of that inconvenience seemed like it would be amazing. So I thought, yeah, I'll help with this telemedicine project. So I kind of helped get that project off the ground. That was three specialties. Kind of the specialist was the Johns Hopkins Hospital giving subspecialty follow-up visits on the Eastern Shore of Maryland. But at the time, you couldn't bill for that care if the patient was at home. They had to be at a certain originating site, like a health department or a school-based health center. And so it was really hard to operationalize and it kind of felt like a failure. Like we had to get this legal contract, and we only had eight visits in six months. And I was trying to do this school-based health stuff and that wasn't getting off the ground. So by January 2020, I was thinking to myself, this telemedicine stuff's not going anywhere. I think it's the future, but there's too many barriers and it's not financially sustainable, and the logistics are too hard to get the patient at a non-home location. So I was exploring other K options, et cetera. And then on March 16th, there was this email that you had to essentially convert all your outpatient visits to video because of the pandemic. People were saying, oh, didn't you have the telemedicine program, Helen? So I was lucky to help my department, Department of Peds, kind of do that ambulatory transition to telemedicine. And through that, got to know our office better, which kind of led to this more health system role, but it's been awesome because at the end of the day, it really is about right care, right place, right time, like getting the right care to the right place and at the right time efficiently. And it's great to see, in informatics, there's a saying that informatics is 80% sociology. So a lot of informatics is not the tools, like the tools exist. It's more about the operational process, the change management, the policy. And I really like kind of the marriage of all of those things.

Biddison: Fantastic. I was just thinking as you're talking, I was like, oh, we need to have another, today we're talking about digital health, but we need to have another conversation about career path because I think there are lots of people who would really benefit from hearing about even more about your journey because there's so many diverse opportunities in healthcare. I think sometimes from a well-being perspective and professional fulfillment perspective, I often think, are we trying to fit our trainees into very rigid boxes in terms of how care is practiced or care is delivered in any environment? And in fact, your stories are such a wonderful one that there are a whole host of different ways that this can look. And the next opportunity is just around the corner.

Hughes: Yes, yeah, I was very lucky. A lot of it was serendipity, but one of my favorite phrases is luck favors the prepared. So there was certainly a time of me feeling like I'm a failure, I can't commit to anything, but you just got to keep going and kind of follow those sources of light that attract you. And I was lucky that it worked out. But yeah, I love my job, so I'm very happy.

Biddison: Very, very exciting. Well, tell us a little bit about what the priorities are for Johns Hopkins Medicine and what you see happening nationally and globally in the digital health space and the virtual care space. Maybe we could start with sort of, since you got started in this in 2020, a ton has happened over the last five years. Maybe start there and then we can look into the future.

Hughes: Okay, that sounds great. So I'll do it in kind of two venues. So one is outpatient and one is inpatient, although obviously there's intersection between the two. But on the outpatient side, one of the biggest tools is a video encounter. So you're meeting with your doctor over video. It's as if you went in person. They're doing evaluation and management of you, and that can be a build encounter. So it prevents the patient from having to travel to that appointment. And that's really what exponentially grew during COVID. We had 70 video visits per month pre-COVID because of those operational barriers. We went to 90,000 in May of 2020. Now we're at a run rate of about 30,000 per month for the past three to four years. So we've done 2.5 million telemedicine visits in comparison to 800 pre-COVID. So basically the switch was turned on and it certainly receded as the kind of stay-at-home orders went away, but it's about 12% of our outpatient volume, but in some specialties, neurosurgery, neurology, about 25% of those visits via telemedicine. You can't drive in the state of Maryland for six months after you've had a stroke, so the ability for those patients to follow up without burdening their family is really helpful. So that kind of is our bread and butter. And it is constantly at risk from a policy standpoint. We're lucky to be close to D.C. and to be engaged with a number of national groups like the American Telemedicine Association, the Alliance for Connected Care and the AAMC. But for most telemedicine policy that was a barrier pre-COVID, it was kind of waived with the pandemic and then continues to have these cliffs of expiration where Congress has to act again to continue the waivers. There has not been a permanent action to give the ability for providers to be seeing a patient at home for Medicare and Medicaid and to bill for that care without the patient being at another site. So we do a lot of advocacy to try to continue to beat the drama of, this is still important, this is still care that's happening. The next cliff is on September 30th. We're fairly confident there will at least be a three-month extension. We're hopeful that in December of 2025, there will be a permanent or at least two-year extension because it's very confusing for patients and providers when there's news like telehealth's going away on September 30th, when it's been extended every time for the past five years that it's come up, and there's been about five cliffs. So anyway, we're working hard to try to make sure the payment is permanent because without the payment, it really can't be a sustainable mode of care. The second area we're really in the outpatient space focusing around advocacy is around cross-state telehealth. Pre-COVID, to see a patient for a visit over video, the provider needs to be licensed where the patient is located at the time of care. At the beginning of COVID, each state waived their licensure rules for about a year. It's okay to see the patient in our state, especially if it's an established patient. But then all those waivers kind of slowly went away, so right now we're pretty much back to the pre-COVID state where you have to be licensed where the patient is located. It's a challenging issue because it's at the state level, but the Commerce Clause of the Constitution maybe suggests that there is room for federal intervention when it is occurring across state lines.

Biddison: Did you ever think you would know anything about the Commerce Clause in the Constitution?

Hughes: I did not. No, no. Yeah. I mean, you just keep learning and you just keep moving and you definitely learn things that you never thought you would know about. But yeah, we have a great group of like national advocates, some oncologists, geneticists, lawyers, we have kind of a coalition around 100 people who are interested in this issue. And we're hoping we can make a change because it's heartbreaking to get these emails from patients begging to see their provider. And it's really not a Hopkins rule. We're just trying to protect our providers from any negative downstream consequences of seeing a patient in a state without a license. And then the third thing on the outpatient side is around kind of new care models. So remote patient monitoring, for instance, trying to find ways to, rather than just copy-paste, recreating an in-person visit to be remote, instead figuring out ways to help providers care for a larger population and really maximize their time. So for instance, you know, having a cardiologist, have a number of patients who are using remote patient monitoring devices, entering their symptoms, and really elevating the patients who are needing urgent care to be the ones who they interact with rather than just going based on when they happen to be scheduled. And there's a lot of opportunity for AI in that because right now we have, for instance, you can hook up your Apple Watch to MyChart, but all we get is individual heart rates. So when we turned that feature on, we got thousands of regular heart rates a day with no intelligence about what that data meant. You know, was it high, was it low, was it changing? So but you can see once you layer AI onto that, it's going to become easier and easier without a human to kind of feed clinicians actually meaningful information from the remote patient monitoring data.

Biddison: Very cool. You know, it's... We talked a little bit before we jumped on our conversation right now about sort of the meaning of this remote healthcare for patients. And I think that case is, as you've made very, very well, is pretty obvious. But I think you're starting, what you're just saying here is you're really starting to get at what it means for the clinicians. Yes. Who want to be available to the people who need them most, but for whom it is very hard to know who needs them most. And instead, we're just walking through a sort of almost a first come, first serve approach.

Hughes: Yes. Absolutely. And it, you know, the provider, how these tools can positively impact providers, I think happens both across the outpatient and inpatient space. But I'll start on the outpatient side. We did a survey of our providers in 2021. And we asked, so this is just to say that we're at the early stages of this. So we asked providers, in your specialty, what percent of the time do you think it's appropriate to see patients via telemedicine? And what percent of the time do you want to have your schedule be telemedicine into the future if you can still bill for it? And so people answered 0 to 100% of the time. And if you look at specialties, the mean change, so maybe psychiatry said 70% of their schedule, they want to be telemedicine and pediatrics said 20%. But in every specialty, we had a 0 to 100% range. So in every single specialty, there were some people that said, this telemedicine thing is not for me. I don't like it. And then there were some people who said, I want to do it all the time. People will ask us, do you have like a quota for how much telemedicine people should do? And we definitely do not, but for those people who are in the champion group, we hear a ton of benefits kind of to their work-life balance. So in that paper, people were more likely to be younger and female, perhaps having home responsibilities who preferred to do telemedicine. About 60% of people who responded did telemedicine from their home. So they were at home when they were providing that telemedicine care. And you could see how if you ended telemedicine clinic at 5 P.M. and you're at home, it's easier to be at home at 5 P.M. than if you have to kind of travel from the hospital when you ended that video visit. And then we also have a virtual list program that we've been piloting with providers who are predominantly virtual. And we've had a lot of stories, meaningful stories. So one person whose family member had cancer and they were able to move to a different state for a period of time to help their family member while continuing their clinical work. We have another person who moved to Texas to care for an elderly family member and they were able to do their practice 100% remote during that time period. So kind of having that flexibility, you know, there's so little flexibility you have as a clinician when you're in clinic and having that little bit of at least location flexibility has been really helpful. And then on the inpatient side, we are working on both providers seeing patients over video across hospitals, but also a virtual nursing program. And there were a number of, we did like a national tour. We went to five other sites that have virtual nursing programs. And to see these really experienced 30-year MICU nurses be kind of at a centralized nursing, virtual nurse setting. And kind of teleport into these rooms across a 10 hospital system and be able to say, I had back surgery and I've had two knee replacements. I literally cannot be at the bedside anymore, but it's so rewarding for me to get to help all of these new nurses in training across these 10 hospitals, helping to run codes via telemedicine, helping to document, looking at wounds. So it's been really amazing to see kind of... I think when I first started hearing about virtual nursing, I was like, well, how could someone be a virtual nurse? How does that work? But a lot of the cognitive tasks, the mentoring tasks, the paperwork tasks can be taken off the bedside nurse and given to a nurse who's remote. And it's physically hard and from a sensory standpoint, it's hard to be on the floors in an ICU. And so some groups are giving nurses kind of a break. Maybe they have a block schedule where you do time on the floors and then you do virtual nursing. And then other groups have nurses who are 100% virtual, and some groups even have virtual nurses who are working in the inpatient setting who are working from home, which we haven't gone to yet. But the idea of, I know a lot of nurses may go into case management or other kind of desk job type fields, and to be able to tell those people, well, actually, you can still help with the bedside.

Biddison: When we have a lot of... you could still be engaged clinically, yeah. And that's so huge when there's such an incredible demand for nurses.

Hughes: Yeah, they're also discussing kind of multidisciplinary care models or co-caring models where there might be an LPN or, you know, a non-nurse doing some of the tasks to the bedside with a nurse overseeing, and kind of the ability to scale those models when you have a core of people who can function across units or across hospitals is really exciting when we think about the provider and nursing shortages.

Biddison: So as we said, a lot has happened in the last five years. What are the sort of top priorities from your perspective, both for us as an organization and again, nationally, moving forward in the next five to 10 years?

Hughes: Yeah, so I mean, certainly as an organization and nationally from an academic medical center standpoint, I think we are all in a challenging time as academic medical centers, both from a financial standpoint and from a research standpoint in terms of grant funding. I think in terms of scaling, it takes a long time and it's very expensive to build buildings. In terms of scaling care models and shifting the amount of clinical time, how clinical time is delivered, where it's delivered from, there's a lot of opportunity in kind of thinking outside of the box and thinking about virtual care delivery. So I'm pretty optimistic. I mean, the current administration's always been very supportive of telehealth. It's always had bipartisan support. The current leadership at HHS is very supportive and CMS. There have been a number of requests for proposals, requests for information that have come out around decreasing regulatory burdens in healthcare and increasing, essentially trying to address the many challenges we have through technology. So I think the next four years are going to be actually pretty exciting in terms of the goal of really using these tools to solve our most pressing challenges. So that's very exciting. And then on the inpatient side, it'll be very interesting to see. So I would love to see in five years that we have audio-visual equipment that is AI capable in every room in our hospital, across all of our hospitals.

Biddison: That would be amazing.

Hughes: Yes, it's very expensive right now, which is a challenge. But if you think about scaling interventions that work, we did a site visit at a peer hospital who has like a physical virtual care hub that does basically is kind of, you know, big brother for all of their hospitals and their outpatients. So they have kind of AI algorithms to surface someone who's getting sepsis deterioration. And then an experienced nurse kind of from this big brother centralized group can kind of teleport in either via secure chat, via phone, via video, and help that bedside team to say, you know, oh, this patient's deteriorating, rather than an epic alert that is wrong 60% of the time, and then people ignore it.

Biddison: That would make people feel more well, less wrong alerts.

Hughes: Yes, so the marriage of kind of the technology with centralized humans who are experienced, I think has so much potential. Because if you take that 30-year experienced MICU nurse and you put her there with charts and AI intelligence, you're taking the intelligence of the AI plus the intelligence of a nurse who's been in the ICU for 30 years, and then you're getting it to the bedside to a nurse who's maybe been working there for six months. And, you know, we do hear a lot of positive feedback on the virtual nursing side of... It's scary when you're like just out of training and you're there by yourself and the patient's getting sick and maybe your lead nurse is like at another bed and the ability to just put a button, there's like a call button, it's green in the room. And then an experienced person teleports in and it's like, it's okay, this is what you do next. Even if it was a nurse, that would be amazing. I would have loved having a 30-year experience PICU nurse come help me at the bedside. So change management is hard, and technology management is hard, especially when the technology is changing so quickly. For virtual nursing, we started our process for building the program and doing our requests around the IT technology maybe two years ago. By the time we deployed it, the top companies were probably completely different in terms of AI technology and just it's all changing so fast. So it's a little bit paralyzing because you could analyze and analyze and analyze and never do anything because it's hard to commit when the technology changes so fast. But I've been proud of us as an institution for getting about 200 beds live on virtual nursing in the past year. The team did like a four-month rapid implementation at the end of last year and the hope is to expand again this year. So I'm not sure how quickly we'll get to all beds with the audio-video camera, but there's lots of cool nurse-child life, like Howard County doesn't have child life. What if the child life team at the Children's Center can go down to Howard County? What if Florida and Baltimore can have one child life group that helps support both and kind of offloads registration staff, case management, home care, pharmacy? You can kind of see how when you have really good centralized groups and they're able to go across all beds, regardless of where the patient are, you get closer to that kind of right care, right place, right time ability.

Biddison: And more equity across all the sites.

Hughes: Yes, absolutely. You know, one of the things that I've spent some time thinking about and I've talked about with a number of folks is that sometimes when new technologies or new resources become available, the implementation process has a very specific lens, like patient experience or finance or whatever. And I just, you know, kind of as we close our conversation, I just want to say how much I appreciate the fact that the Office of Telemedicine and the Digital Health Group is really thinking about who are all the stakeholders here. Yes, we need to be sure that, you know, we're doing the right thing for our patients, but we also need to be sure that we're taking into account the perspective of the clinicians who are providing the care so that everybody's outcomes are positive for everybody, I guess, is the way that I want to say that. Absolutely. It is the holy grail and rare to find win-wins in this world. And I think from a patient experience, provider experience, healthcare cost quality standpoint, a lot of these innovations are win-win-wins, which is fantastic. So that's part of why I'm so excited to be doing what I'm doing.

Biddison: I don't know a better place to end than right there, Helen. Thank you so much for being with us today and for this amazing conversation. Again, signing off for the Vital Conversations podcast, this is your host, Lee Daugherty Biddison. Thanks for being with us.

Helen Hughes:  Thank you.

Biddison: So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague. And as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Dr. Helen Hughes
Associate Professor, Pediatrics
Medical Director, Office of Telemedicine
Johns Hopkins Medicine

1. Growth of Telemedicine - a lot has happened in the last 5 years: Johns Hopkins rapidly scaled from 70 to 90,000 monthly video visits during the pandemic and is now sustaining ~30,000 visits/month, an estimated 12% of our overall outpatient volume.
2. Policy Advocacy is Needed: The future of telemedicine hinges on securing permanent payment structures and resolving inter-state licensing barriers. These are areas where clinician leadership and patient voices are essential.
3. Virtual Nursing as a Workforce Solution: Virtual nursing at Johns Hopkins enables highly experienced nurses to remain engaged in care delivery, supporting professional fulfillment, staffing flexibility and retention. It also supports new nurses as they build confidence and skills.
4. Optimizing Remote Monitoring: Johns Hopkins is using AI-enhanced remote patient monitoring to collect better data and improve the patient experience.

• Groups active in telemedicine and access to care advocacy:
  • American Association of Medical Colleges
  • American Telemedicine Association
  • National Alliance for Connected Care
• Patient impact story: The Long Road to Care: Patient With Rare Cancer Pleads for Cross-State Telehealth Access

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Fowler: Thank you for joining us. Hello and welcome to another episode of our Vital Conversations podcast. I'm Carolyn Cumpsty Fowler and I am delighted today to talk with a colleague, Doctor April Saathoff. April is the vice president and chief nursing information officer at Johns Hopkins Health System. She has 24 years of nursing experience with 21 years focused in clinical informatics. She's certified in healthcare information management systems and nursing informatics and has extensive Severe experience in healthcare technology implementations, strategic planning championing the use of innovative technologies, workflow redesign and building and fostering teams. And she is a fabulous team builder. April is also interested in how healthcare technology can support wellbeing and professional fulfillment. April, I'm delighted to get a chance to talk to you today. Welcome.

Dr. April Saathoff: Thank you so much, Carolyn. What a what a lovely introduction. I'm happy to be here spending some time with you as well today.

Fowler: Thank you. Well, let's start off with some background, and I'd love to invite you to tell our listeners what led you to devote your career to nursing informatics.

Saathoff: I started out my career in pediatrics as a bedside nurse, which I absolutely loved. After a few years, I was looking for a greater challenge and really trying to think of what was the next professional development opportunity for me? The timing of that was fortuitous because the hospital where I worked at that time was kicking off a project related to expanding the current features of the electronic health record, and so, with several health systems and hospitals expanding in that area, they were looking for people to be engaged in that. Of course, being one of the younger nurses on the unit, the older, more seasoned nurses were like, hey, you're the perfect person to do this. They asked me to join the project. Because honestly, no one else was was willing and able to to take it on. I was I was up for a good challenge. I really realized that I was interested in this very early on because developing technologies had that impact of touching every patient in the hospital, the quality, the safety implications, the magnitude of instead of just providing care to four or five patients, having the ability to provide care that essentially touched every patient in the hospital. I think I just realized that the technology was really powerful in where it was going, and I was excited to be a part of that journey. That was the beginning of of my career in informatics and keeping the patient still at the center of any technology decision making, that philosophy, that passion of nursing, why I became a nurse that stuck with me into my informatics practice today as well. I love the blending of of both of those things and realizing that technology has that ability to to connect things and make things easier and safer and higher quality. All of that is, is really how my, my passion got me to where I am today.

Fowler: Well, I so appreciate that about you, because so often people think that the tech people are removed from the bedside and are removed from clinical care, but you've made it very clear that your primary focus is on how we improve care to patients.

Saathoff: It's critical really. I think when we're at the table making decisions about how we design things, about how things are displayed, um, not only thinking about the, the direct impact from a care perspective to the patient, but also what is the technology feeling like and how will that potentially be received from the patient perspective? Knowing that they they may be scared, they may be dealing with a new diagnosis or, an overload of, of information related to something that they don't know a few days before hadn't anticipated. Just really keeping that lens and that perspective, both on how to help the nurses support a patient care, as well as help the patients do their reception of the journey. I think that, you know, just remains of critical importance with technology implementations.

Fowler: Great. April, why is it so important now for us to be embracing healthcare technology and innovation in nursing? Say.

Saathoff: I think the pandemic opened everyone's eyes to, um, to how challenging things could be. And, um, you know, it created some ripples that were we're still feeling today. I know that the nursing shortage during the pandemic was estimated to be around 30 percent of need in that area, and while we've seen that figure stabilize some, we're still projected to have nursing shortages of at least 10 percent continuing on into the next decade or so. I think even in addition to just looking at the numbers and percentages of staff, we know our clinicians are burned out and stressed. Our patient care is hard. The patients are sicker. They have more complex needs, and some research estimates that up to 30 percent of health care workers are presently considering leaving the profession. We've got high turnover rates anywhere from 8-37 percent across the United States. As our patients age and they remain complex and their care needs and the coordination of care. They're going to need more support from us. I think the other piece that stands out is that we've got a knowledge gap. We've got a lot of younger nurses that we're happy to support and bring into the profession. But as our nursing population ages out and we have greater percentages of younger nurses, what structures do we have in place, you know, that are sustainable to to help foster their growth and make sure that care remains excellent? That we're taking care of of patients in the way that that we have designed. I think despite all those challenges, we know we've got to continue to provide that high level of care. It's really just not sustainable to keep doing things the way we've always done them. We've got some opportunities that have come up recently with virtual care platforms. Artificial intelligence. Everyone's hearing about that in the news. We've got the way to really harness the power of some of this new technology to relieve some of the burdens that we've been feeling since the pandemic and, even probably before that point, right with overload of of care and the burden of how that feels. We've got the opportunities to take advantage of that now.

Fowler: Well, a lot of exciting opportunities. But perhaps I could ask you to help us understand. Some of the newer advances in informatics and healthcare technology that can, that really have the potential to help us address some of these challenges that we're facing in healthcare and make work easier?

Saathoff: We've seen recently, um, a lot of health systems focusing in on documentation burden. I would say that's work with some new tools that happen to be available in that space that where I see a lot of people going, and trying to trying to wrap their hands around it. I think one of our biggest projects was related to what we called our documentation revamp project at Johns Hopkins, where we asked the nurses for feedback and then translated their frustrations into improvement opportunities that we built into our electronic health record. For example, we added tools to the health record like macros, which essentially allows the nurse to press a button, and then it fills in several documentation rows for common repetitive documentation elements to save the nurse time. We've also worked to automate care plan documentation, which has felt redundant to nursing for years, and now we've built, in a way, for that to be automated so that it will automatically add certain elements to the patient chart and pull documentation into reports, so that we're asking the nurse not to have to document things again, but to really work smarter, more efficiently as it relates to that. We've definitely seen a lot of movement in having tools that allow us to do that. I think another huge example that everyone's been hearing about is artificial intelligence. In particular, one thing that we're using at Johns Hopkins is ambient listening. Essentially it records the conversation between the clinician and the patient, and then the technology analyzes the transcript of that and drafts that into documentation. Then we have the clinician reviewing that and saying, hey, I need to edit this, add a little bit more or this looks good as is, and they can go ahead and save that in the record instead of having to stop and cognitively think and go back through independently and put that energy into the documentation. Our providers have been using that technology for a while now, and we're getting ready to embark onto a pilot with nursing this fall to understand the impact that this technology also has in reducing documentation burdens for nursing. We know that the docs have said this technology really helps reduce their cognitive load and helps them practice more efficiently. They feel like when they leave their shift, they don't feel this sense of just total and complete mental exhaustion. We're really excited to see how that may translate into our nursing staff as well. I would say one other thing stands out and in advancements in technologies, and that is a virtual nursing.

Fowler: Well, you know, I want to talk to you about that, but I'd actually like to go back for a second and ask you, how has the use of ambient listening impacted the relationship between the providers and the patient?

Saathoff: That's a really great question, and that's something that was very positive that came out of the provider feedback from that. Before the provider was standing at the computer entering information, and as they went, sometimes with their backs or their sides facing the patients. Some of the feedback that we've gotten pretty routinely from our providers now is it allows them to truly engage in that face to face moment. They feel like their connection with the patient is deeper, that they have better opportunities to really hear them, to really truly listen to what they're saying and respond in a more involved way. Then they then they had in the past where maybe they were just thinking about the next documentation element or the next field that had to be filled out on the computer screens. Definitely some positive feedback from them in terms of how that's translated as well. It's a great question.

Fowler: Well, and that's wonderful because, you know, obviously, we know from our nursing colleagues that the quality of the relationship between them and the patient is hugely important. They they complain when the busyness of healthcare gets in the way of those relationship, those meaningful relationships that they have with their patients.

Saathoff: I think when when we started putting electronic health records into systems, we were so excited about everything we could possibly collect and how we could report on all that data. We were trying to do the right thing. We built so much in that. Then all of a sudden we once we actually got started using electronic health records and realized, what have we done to ourselves? This overwhelming burden of collecting all this information. Is this truly information we need to collect? Will it really change the outcome for the patient? Who are we collecting this for? Where's the benefit there? Now we've really done a full circle here. Now we're looking at it at what's the most essential information. Then how do we bring joy back to the bedside and and to the patients as well through those encounters. We're that happy balance.

Fowler: Well, April, let's go back to virtual nursing because I know we're both interested in that. Recently you've been overseeing the rolling rollout of virtual nursing at four of our hospitals. Could you start by telling us what you mean by virtual nursing? What it does and what it doesn't mean, both for nurses and for patients.

Saathoff: Happy to, dive into this conversation for sure. A virtual nurse is basically an experienced nurse. Typically that person works directly on the unit where they will be providing virtual care, and they are responsible for delivering care remotely. For Johns Hopkins, this means that nurse will provide care from an office space that is located internally at each hospital, but it is away from the nursing unit. We call that our hive. Which or JHIVE, which stands for Johns Hopkins Integrated Virtual Environment. From the hive, they have access to patient technology that is in the room. There are cameras, speakers, microphones, really sophisticated technology that allows us to see into the room at night. Then that technology integrates with the TVs and the patient room and the virtual nurse from the hive. From their station, they have four monitor screens, headsets, a computer, so they can actually launch virtual visits into the patient room with that technology. They typically do that during the admission process discharges. They use it for patient education. We found that very quickly, the virtual nurse had said, hey, we want to do more things with the patients. How else can we interact with them? What else can we do? We very quickly expanded their role. We've only been live for two months now. In most cases, I think the first unit went live on in the end of March. We're still pretty new in the space, but it's been really nice because even though they are remote, they're still able to deliver that that personal touch of care to the patient. The virtual nurse has a doorbell that they ring into the patient's room. They introduce themselves to the patient and they ask for permission if it's a good time to enter the room, and then once the patient gives them that approval, the camera turns on, the patient can see the virtual nurse on the screen, and then the camera redirects. It's it's facing to the patient so that they can tell that the system is on and functional at that time. You mentioned what does virtual nursing mean and what it doesn't mean. It was very interesting in this project. Just some of what the terminology virtual nursing means to patients and nurses. When we were going live with this technology, obviously we had been invested in the project. We had defined what is a virtual nurse? What does a virtual nurse do? But going into a room and saying to a patient, hey, we have virtual nursing now. The the way that they conceptualize that was was pretty fascinating to me. There was a lot of questions. Well, I don't know if I want a virtual nurse. Is it an avatar? Is this someone who's going to be located in another country who doesn't work on this unit? There was this sense of virtual being either extremely far away, and therefore that person would not be in touch with the way that we deliver care at Johns Hopkins or that it wasn't a real person at all. We had to really adjust our scripts with families and patients so that we would tell them out of the gate so that they had a good understanding of what the platform was. I think on the flip side of that, what we heard from bedside nurses is they felt like the virtual nurse was going to be watching them, monitoring them, critiquing them, that it created a chance they may lose their jobs. Maybe we would start to have more virtual nurses and less bedside nurses. This was all fascinating to us, of course, because that was not in our design. That was definitely not our intent of of this program or the way that we approach that at all. Definitely through this implementation, we've learned better ways to communicate about it and then make sure that we incorporate that into next phases of go live and implementation and training new folks to the program. Because we've learned as we've gone in this regard.

Fowler: Well, you certainly generated a lot of excitement around this, and as I go between the hospitals, I'm hearing them discuss how excited they are about about this launch. But it's change. Change is always frightening for some people. What have you been doing? To reduce those inevitable stresses associated with practice change, and also to generate buy in for virtual nursing within nursing staff specifically.

Saathoff: That's a great question. I think it's always something that needs to be very seriously considered at the start of any big technology project. I would say that overall, the feedback we've gotten from bedside nurses and virtual nurses has been incredibly positive about the new platform. I think that is from the fact that we intentionally recruited and included bedside nurses, patient and family advisers, nursing leaders, quality representatives, our IT partners, educators, anyone that we could possibly think of that would be impacted or influenced by this new technology and the new workflows in any way. We invited them to the table Day 1, as part of our design and build processes to make sure that whatever decisions we were making, we were making the right ones to the best of our ability, directly out of the gate. We wanted this to be intuitive for nursing, for the the virtual nurses that had to learn how to use technology and incorporate a new some new processes, and also for the bedside nurses. We wanted it to be as least disruptive as possible to what they were used to in terms of ways of delivering care. I think that piece was really of critical importance. The very first kickoff to this project that we had, we invited over 180 people from the whole health system. Anyone that you could think of that was involved in any way, shape or form in patient care and supporting patient care. We had a huge conference where we kicked things off. We explained what virtual nursing was and we asked them for feedback. We broke up into work groups. We really started to map out our vision for what this would look like before we even knew a lot about the direction where we were going or a lot about the technology. Again, I think that critical piece of having everybody at the table definitely increased the buy in and let people know what to expect here. I think in terms of supporting the project itself with any technology implementation we have implementation support. But then I think one thing that's continued that has really been pivotal and probably will be with any innovative or disruptive technologies in the future, is the idea of ongoing operational partnership. This isn't the technology where you install it and you support it, and then you're like, I'm done, I'm moving on to the next thing. We really have had to work together with our nursing leadership team, with our virtual nurses, our bedside nurses to understand how the impact is of having this new way of delivering care. It's not just technology, it's also the way that we practice as nurses. That has changed, and we're continuing to evaluate that to see how we can keep doing that better. We found pretty quickly that the virtual nurses said, hey, we're ready for more things, give us more roles and responsibilities, and so we started to interview bedside staff and leadership and the nurses and said, what else can we do? What other work is there to be done where we can keep making things easier for the bedside nurse? What other tasks and responsibilities can you help alleviate from that person and continue to work well together with them to deliver care? I think because of that, they've been able to see very clearly at the beginning and then throughout the stages of this, the inherent benefits that it's bringing to the unit, to the patients, to the bedside staff, so that has allowed us to to really keep moving on this pathway, which is ever evolving.

Fowler: Well, I think when people think about virtual nursing, I think a lot of nurses think about work shifting and who's going to be doing what. But perhaps we could just touch back with the newer nurses. We've talked in several of our podcasts about our concern with new clinicians and the levels of anxiety we're seeing in some of our newer clinicians at the bedside. Could you perhaps talk to us about the potential that virtual nursing has to mentor and support and, frankly, back up some of our newer clinicians as they're growing into their expertise.

Saathoff: There are so many opportunities here. We're actually beginning a phase of our project where we will be having some dedicated focus on mentoring, I think we're calling it coaching. What does that look like and and how does that translate into the use of this new platform? We know that when we look at the literature, there's a ton of benefits for virtual nursing, patients love it, nurses love it, decreases that sense of burnout, the quality metrics. But I think the biggest wins for nursing really is that renewed sense of joy at the bedside because we are doing some of that work shifting that you mentioned. But I think there's also a piece about safety, which to me ties into this concept of mentoring and coaching, where you know that someone else with a certain level of experience has your back. That person is an expert in this space, no matter what it is, there's no judgment there, and that idea that there's a way to connect with someone at any point in time where you need support and be able to get that from this role that's always there for you. Even before we did our big kick off of this particular virtual nursing project, we had nurses in the PICU that developed some virtual support workflows, they found benefits from that, and that was limited to just looking at an online mentoring platform. I think then the questions become, how do you deliver the coaching and the mentoring in a way that still feels comfortable for the newer person? Because they may not feel comfortable going in the room and saying, hi, I'm a brand new nurse and I'm going to have another nurse come in and watch what I'm doing. That you still want to feel confident and that the patient will still trust you. I think those are the questions that we're starting to ask now is, how do we use this new technology that we have where we can provide mentoring in a way that is comfortable and natural and boosts and supports that new bedside nurse without making them feel scared of feeling incompetent or anything along those lines. I'm actually really excited to see where this goes and really continue that journey of this virtual nurse being a sense of support for the bedside nurse, whether they're experienced or not, that mental capacity of I'm here to help support you. I'm going to make sure that everything gets done, I'm going to double check, I'm going to help you do things, but in a positive way, not a I'm watching you, critiquing you way, a beneficial way.

Fowler: I'm here to have your back. You're really describing something which is an environment in which the virtual nurse is part of the nursing team.

Saathoff: Absolutely. We introduced them as being a member of the care team. Intentionally on units where we've got whiteboards that we write patient information, we include the name of the virtual nurse as part of the care team. In some of our areas of implementation where they had the resources to do this, the virtual nurse actually rounds in the morning on the units, and they have some face to face time with the patients so that the patient can see and have that physical sense of connection with the virtual nurse, so that when that person pops up on your television screen later, that's yes, I've already met that person, I know that they're a part of this unit. We have had to be intentional in some of our design related to that but they absolutely are a very pivotal member of the care team now in the areas where we have implemented this.

Fowler: Is the virtual nurse always a virtual nurse, or do you have situations in which your virtual nurse is virtual some shifts and in person other shifts?

Saathoff: That's a great question. There's a lot of flexibility to this platform. We may encounter some nurses who have back injuries that may limit their physical amount of time on the unit, in that case, that person could work all of their shifts as a virtual nurse to relieve that physical burden on them. May help with retention of older staff members who may have some physical limitations. Additionally, we do see some benefit from nurses who have I would say, a certain level of experience so that they can be considered an expert or knowledgeable enough to help provide that level of support that's needed, but that that person, once they have that level of experience under their belt, can act and serve as a virtual nurse. We've got a really nice education program that's been developed with some mentoring and some time with hands on practice and things like that, once that person's undergone that level of competency, then they can take on shifts. What we see a lot of our units doing is we may have someone that works as a virtual nurse for one shift a week, and maybe there are other two shifts a week or bedside shifts. All of our virtual nurses essentially were nurses that came from the units where we implemented the platform, so that we knew that there would already be a sense of trust from the bedside nurses with that person that's serving in the virtual nursing role, as well as the opportunities to be able to answer questions about the workflows on the unit and physician orders and those kinds of things. That was a very intentional part of our design to make sure that person could be seen as that resource and have comfort in that person being a part of the unit team.

Fowler: Great. Well, as you've been talking, April, the connections to well-being have been very clear to me. You mentioned the reduction of cognitive load, we've done podcasts on that. You mentioned joy of work, we've done that, you've talked about safety, we've done that. But perhaps we can transition much more specifically now as we get towards the end of the podcast to talk about what are the well-being impacts of not just virtual nursing, but the technology. What is the potential then of virtual nursing and these other technologies to not only reduce burnout and fatigue, but also really support professional fulfillment and renewed joy?

Saathoff: I think we've got a lot of opportunities with taking a look at some of these newer technologies and identifying to your point, not just relieving the burden of the work, but also helping us achieve excellence in the way that we practice. Bringing information, collaborating with what the information that's in the system, bringing that forward, putting that to the front of our ability to practice and making it more intuitive and easier to pull the information that we need to provide that excellence in the level of care. I think there's opportunity in that space for sure. We're also going to be looking at not only the technology, but the way that we practice and deliver care. That's one thing that's really becoming apparent when we implement these measures. We can't just put a piece of technology in, whether it's software or a new piece of hardware, we have to actually consider how the nurse will integrate this and it may involve changing workflows. For virtual nursing, instead of the bedside nurse doing all of the admission documentation, it was we're going to parse this work up and the physical stuff will be done by the bedside nurse and the administrative work and the screening documentation that'll be done by the virtual nurse. I think we're really going to have to lean into that space of really evaluating not only the technology but the workflows, because there are so many efficiencies that can be gained. I think quality and value can be gained simply by having the right information in the right places at the right time, where we're making decisions and we're also seeing what is the next level of care that we have to provide for this patient. I think in the hospital, outside of the hospital, we're going to have continued opportunities to really see how these types of technology can make a difference and relieve not just the cognitive burden, but then also, I think some of the stress of remembering to do everything and be the best you can possibly be, some of some help in in that regard as well.

Fowler: One of the things we talk about in well-being all the time is one of the biggest predictors of our resiliency as human beings is that since that we have real connection to other people and that they have our backs, I remember early on when the EMRs were introduced, the electronic medical records, people talked so much about how the electronic medical record had damaged the connections. Even though we often would say technology is getting in the way of good connections with people, what you described earlier on didn't seem like that was true if it's done well.

Saathoff: I do feel like we're seeing more opportunities in this space as it relates to technology. I think what we've seen is that at one point in time, I remember estimates as high as 30, 35 percent of a clinician's time was spent documenting. The focus at that point was the clinician facing the computer focused on work that had to get done. Not that it wasn't important work, but it took away from that that element of connecting with the patient that you mentioned. I think then it became clear really quickly that that was a burden, and now there are companies, and with the onset of new technology like artificial intelligence, there's a renewed focus on how do we work in a way that provides relief and that makes it easier so that we're more efficient, more functional, and then also performing in a better way, and especially as it relates to connecting with patients. I know in particular for virtual nursing patients have expressed to us that they feel that the virtual nurse is not rushed, that that person has time to answer all their questions, and that's part of the reason why we're seeing patient satisfaction scores skyrocket in places that have implemented this technology. Because the bedside nurse usually has multiple patients, they've got alarms going off, they know they have to go give pain medicine to a patient down the hall. They have a patient that's getting ready to get discharged, and the transporter has shown up, and they have to go in the room and facilitate that, I think it's that sense of interruptions and the chaos, which is the normal part of being a bedside nurse, that that makes it hard to really be that calming presence that has that time, that can really dedicate, the patients pick up on that too, that the bedside nurse feels that way. We're definitely seeing the benefits and from the patient perspective, that's the feedback they're giving us, is we love the calm perspective, the time that's dedicated to us from the virtual nurse. Then on the flip side of that, from the bedside nurses, we're hearing we actually have time to do more hands on care. We have time to do things that we haven't been able to do in a really long time, and to put more time into things that matter, maybe focusing on some of our quality metrics and measures more. I think it's on both sides of the fence we see that sense of relief and appreciation for the time that's being given back to the bedside nurse, as the virtual nurse takes on some of that role, and that on both sides, they feel like they have the better ability to connect, to be more present, to be more hands on with patients. I think the overwhelming benefits of that we'll continue to see as we evaluate the metrics. We have the tools now to give us back time to engage with the patients in a better way than we've had in the past.

Fowler: Then, of course, reduction in those interruptions at bedside are not only going to reduce the cognitive load, but they're going to reduce the safety risks as well.

Saathoff: Absolutely. I forget what the statistic is that I saw recently, but for every so many interruptions in care, it almost doubled or tripled the amount of risk of there being a patient error that actually occurred. I definitely agree with you on that front.

Fowler: Well, April, it's been wonderful talking to you. Before we wrap up, I would just like to offer you the opportunity to share any last thoughts or words of wisdom with our listeners about information technology or virtual nursing.

Saathoff: I think one thing that I would say that's pretty important as we move into this space where we hear more about artificial intelligence, software and new technologies, sometimes there's a fear in particular of the bedside nurse, and even from some of the informatics nurses I've worked with, they feel like maybe I shouldn't be a part of this work because I don't have experience with artificial intelligence or with this new technology. I would say from my perspective, the opposite is true. We really need people that are workflow experts and experts in their subject matter expertise, experts in being a nurse, experts in being a leader, that all that representation needs to be at the table because we're going to be innovating and designing new ways of delivering care to work with this technology, and those are exactly the experts that we need to have sitting at the table with us. I would just encourage anyone, even if there's a level of fear or a sense of I haven't done this before, really encourage people to embrace it and just jump in and get involved in the work, because everything that you have from a knowledge perspective is invaluable to make sure that we build and design these things in the right way so that we're getting that maximum benefit back from a well-being perspective and a safety perspective and all of the things that we're working so hard to achieve.

Fowler: Well, April, thank you so much. This has been such an interesting conversation and I'm sure our listeners can hear that you are this very inspirational and high energy person. We're so lucky to have you with us at Johns Hopkins, and I hope perhaps at some point you'll come back and talk again about some of the lessons you've learned as you've rolled out more broadly across our health system.

Saathoff: That would be fantastic. I am super excited about the work that's happening in this space. And the more we can learn and share with each other, the better things get, we'd love and welcome that opportunity. Thank you so much, Carolyn.

Fowler: Thank you, April, and thanks to everyone who's been listening. We hope that you enjoyed our conversation today and that you'll come back soon and listen to another one. That's it for today. If you enjoyed what you heard, please share this podcast with a colleague, and as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

April Saathoff, D.N.P., R.N.
Vice President and Chief Nursing Information Officer
Johns Hopkins Health System

1. Innovations are needed to address the projected 10% nursing shortage in the next decade. Dr. Saathoff noted that approximately 30% of healthcare workers are considering leaving the profession, with turnover rates ranging from 8% to 37% across the United States.
2. Technological innovations being implemented at Johns Hopkins include automated care plans, ambient listening technology, and virtual nursing.
3. Virtual nurses at Johns Hopkins are experienced staff members from the same units, helping to maintain trust and care continuity.
4. Hopkins virtual nurses work from a dedicated space called JHIVE (Johns Hopkins Integrated Virtual Environment), using sophisticated technology to interact with patients and care team members remotely.

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare. 

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning. Thank you for joining us.

Fowler: Hello and welcome back to our Vital Conversations podcast. I'm Carolyn Cumpsty Fowler, and I am delighted today to introduce you to a colleague and friend of mine, Dr. Cassie O'Malley. Cassie is the senior director of Well-Being and Innovation at MedStar health. In this role, she is responsible for well-being, programming and integration of over 15,000 nurses, physicians, and advanced practice providers. She focuses on the intersection of mindful work such as breathwork and sound, with innovating the care delivery system to better support clinicians in thriving at work. Cassie is also a coach, educator, and mom of three beautiful girls. Welcome, Cassie.

Dr. Cassie O'Malley: Hi, Carolyn, thank you so much for having me.

Fowler: Well, I am delighted. Before we get into some deeper questions about practice, I just like to invite you to introduce yourself because you've been a nurse, leader and advocate in the wellbeing space for several years. Perhaps you could share how you came to this work and why it's so important to you.

O’Malley: Sure. Thank you. I have been a nurse for about 15 years ish now. I started in oncology, and I think that when I reflect on my work now is absolutely the foundation of how I came to be where I am. I would spend all this time with patients, in oncology, oftentimes your patients are your patients for many years. You get to know them. You get to know them well. You get to know their stories. What I felt I loved so much in my work was helping my peers be able to care for their patients better. I loved being a charge nurse because I felt like I could set up the day to be really great for my team, so that all of the patients on the unit would have a experience where they felt held and supported, rather than their nurses having to frantically run in and out of the room. That was my catalyst, as I then advanced in leadership to think about how I can create the best environment for my teams so that then the patients get the best experience. I took that into to outpatient management and then later into all of clinical practice and education. Each time I took on a larger role, I was thinking about how could I just make the environment better for people. I've always been into my own mindfulness wellbeing work personally. I liked to bring that to people, but I kept seeing that I could bring that to people as much as possible. But if we didn't make the place that they worked better, it didn't matter. That's how I finally landed in this wellbeing role at MedStar health, where, I get to do both and I get to coach people and give them breathwork and sound healing, and I get to help look at the care delivery system so that once people are well, or if they are well, or if they're working towards their wellbeing when they come to work, it supports that doesn't degrade it.

Fowler: I love that you're telling the story because, we've got this really long standing, inculturated belief in nursing that we have to sacrifice ourselves on behalf of our patients. Yet the story you're telling is that really, if we take care of our colleagues and we take care of the practice environment, then that helps us take better care of our patients and their families.

O’Malley: Completely. I mean, I think our patients they know whether we are having a good day or a bad day. They're humans, they see what's happening. I think it's our responsibility as leaders of health care organizations to create environments that make it an optimal place to work so that the patient doesn't have to experience the stress of the clinician because the work environment isn't set up for their success.

Fowler: I know that you and I have had conversations about this that, while it's necessary and important to provide support for individual, physical and mental health, and you definitely do that. We advocate that the real work of transforming organizational well-being lies at that, that intersection of practice delivery or the practice environment and then the healthcare system optimization. Could you walk our listeners through your thinking about that?

O’Malley: I mean, I think that is that's the most critical part of this well-being work that I think it's Phase 2. Phase 1 very much, I think illuminated during the pandemic, where we recognized that clinicians were were working in deep, difficult work. We had to focus on their mental health, their physical health, supporting that. Then we got to this space where and I think what we're in now is that, yes, all of those programs should be foundational. But the true wellbeing work is, as I've said, creating an environment that, um, then supports them when they are taking care of their health or we're supporting them, taking care of their health. I think about things like, for example, virtual nursing across nursing. We've just started to scratch the surface with that. We took it from a task based perspective. We saw a lot of work with admissions and discharges. But if you think about the technology and innovation that we have in this world right now, there is so much potential to integrate something like virtual nursing in a way that A, takes some of the burden off of the teams on the units and like in the patient's room, but then also offers nursing a different role. It's hard to be in the hospital. It's hard to be at the bedside. If you can imagine having this option where maybe one day I'm not at the bedside, but I still get to practice my expertise in a different way. I get to connect with patients in a different way because it's uninterrupted. Think about how many times as a nurse, you go in to talk with a patient, you're going to do something to talk with the patient, and you get interrupted because something more pressing is in the next room. Well, in virtual nursing, you can be with that patient. You can really spend more time connecting to without interruption. Doesn't change the unique and deep need for that in-person physical connection, but it gives a different type of experience for nurses that also allows them to expand their skills and get a little bit of a the physical break.

Fowler: I mean, that combination of being able to really engage in deeply meaningful and connected relationship with patients and that ability to just honor what you need physically, I think is very appealing. I was talking to a group of nurses just about three weeks ago, and a couple of them shared that they'd had injuries at work which weren't that severe, but actually kept them out of physical, in-person nursing. Each one of them shared, I could have been providing care virtually with this fairly minor injury, but I wasn't allowed to be in a clinical setting with it. I thought about what a missed opportunity to have highly motivated and highly skilled clinicians be able to stay in the care space despite that.

O’Malley: I think the other thing too, Carolyn, and you might have to fact check me on on this stat because it's either one percent or 10 percent. But there was a study that came out around, the amount of information that is used in the electronic health record. It was staggering. I really want to say it's one percent, but we again, we may have to fact check that, but only one percent of the information in the medical record is used by clinicians in a 12 hour shift. I mean, when you think about that and think about optimizing the workplace, we've put things into place that are meant to help. Is digitalizing the medical record a positive? Absolutely. It helps us connect care in a different way. However, a lot of times we put things into place without thinking about all the implications that then may cascade or ripple out after it. I think that one too, we've put barriers in some of our optimizations that we now have to go back and really think about what do we need as a necessity and what can we strip away to make the a workplace more accessible.

Fowler: Well, how do we make work easier? We've actually done a couple of podcasts, Cassie on cognitive load and how streamlining our systems and streamlining our processes and getting rid of the redundancies can actually reduce the cognitive burden that we're facing every day.

O’Malley: Definitely.

Fowler: I noticed that you actually haven't used the word nursing wellbeing terribly much after our first couple of conversations. I know that another commitment that we both share as nurse leaders is that we have to focus on interprofessional or total team wellbeing as opposed to just nursing wellbeing.

O’Malley: When I started my current role I actually started in nurse wellbeing and we've expanded so that my role looks at all of clinicians because what we realized was, yes, there are some unique needs that each of the clinical roles has within the healthcare environment. If we focus on them separately, we're never going to achieve complete well-being of our healthcare teams, because the reality is all of our work intersects and not just from a how we care for the patients, but we are with each of the other clinicians all day within our teams. If we're doing these things in separation, then ultimately we're missing this piece of how does the team come together to make sure that the team as an entire unit is well together. Sometimes I think is controversial. I think people very much still believe that nurses have such specific needs that their program needs to be individual physicians needs are so unique that they need to be individual. Same with APS. But the reality is, when it comes down to what people struggle with from a wellbeing perspective, they're all human things. It's not just because you're a nurse or a physician, it's because you're a human right. A lot of what I talk about is people when they have well-being needs, comes down to one of three things connection to self, connection to others, or connection to purpose. Those aren't specific to to the role. They're specific to a human. I think that our goal is really to get people to think a little bit differently and recognize the importance of the whole team working together to be well.

Fowler: I had a sense before the pandemic that we were doing a little better in really moving more strongly into this total team space. Yet, during the pandemic, well, certainly I became aware of increasing isolation and increasing separation between the professional groups. I don't know to what extent it was that self-preservation that comes with burnout or with stress that let me put up the barriers so I can keep myself safe. What's your sense of whether that you saw that happening during the pandemic?

O’Malley: I think you're right. I think we were getting better. You saw a lot of development programs and content before that were focused on interprofessional work. Then I think early in the pandemic, teams came together because it was in that crisis mode where you had no choice but to work together. Then the longer it went on, the more tired and exhausted, and to your point, self preservation people got. The world around us was saying like, stay to yourself, don't be with other people, especially with healthcare because you're exposed to everything. I think the other thing is that with that, healthcare has gotten progressively more difficult. Without purposeful work and support to bring teams together, naturally they start to diverge because they're trying to preserve themselves, so I think that's where we are in this. We have to bring it back together.

Fowler: Well, I think I shared with you that I've had a couple of conversations which troubled me with nurse leaders outside of our two organizations, where it was really a real commitment to keeping it in nursing, so what would you say to nurse leaders who believe that they are protecting nurse well-being efforts by continuing to focus only on nurses?

O’Malley: I think when we've talked about this before, there was this sentiment that maybe they feel like this is it's to keep them safe. I think ultimately, it's the opposite. I think that if we go in this direction of just focusing in on ourselves, we are going to just isolate more. We're going to create a bigger barrier or sever in our relationships with the other clinicians, and not just clinicians, but all people that support the healthcare delivery system. That the reality is, again, you are all working together for the patient, so the more you isolate, the more the challenges are going to grow. Because while the nurses are so often, and I believe strongly or the words you have used beautifully are the connective tissue of an organization, and biased as a nurse, I do fully believe that hospitals and patient care don't run without nursing, and all of those other roles do support the patient care. If we pull away, if we isolate, if we make ourselves just by ourselves, well, then we are creating that separation that ultimately is, I think, going to become a bigger challenge for nursing.

Fowler: Certainly, I've been nursing a lot longer than you, but I think when you and I first started our careers, it was a different world. We were part of teams where people stayed in those teams for years. In those teams, we had more experienced nurses than we had inexperienced nurses, and now that has completely flipped, and I feel really concerned. As a nursing well-being leader, I feel really concerned by the level of anxiety and perhaps self-doubt I observe in many of our new graduates and new clinicians. I worry that there almost have a perception which is like, I just have to survive this and tough it out until I get better clinically, and yet well-being is not about survival. It's about flourishing so that you can flourish as a clinician, as a colleague, as a human being, as a team member.

O’Malley: But don't you think that's how we invite them into nursing. We invite them in and say, oh, this first year is so hard. Just from the moment they're in school to the moment they hit our doors, that's how we frame it. That it's going to be so difficult, and you have to tough it out. I love nursing, and again, historically nursing has been really tough on its newbies, and I think it still is because to your point, the way that people are going to practice in healthcare now is different, like people aren't going to stay on the same unit for 15 years. They're not going to do that, and that gives us this beautiful opportunity to say, people want to keep growing, and shifting, and innovating, and thinking about how to do things differently, so let's use that rather than saying, oh, you're not putting in your time. Shame on you. I had that experience as a young leader, and this was about 15 years ago. But I made a decision after, gosh, I must have been on the floor for about three and a half. I was pushing four years. That wasn't that many, and there was an opening in our organization for an Outpatient Oncology Manager, and I remember my first mentor, who I love deeply. She'd been on the floor for 30 years, so she was not happy with me. It hurt her that I wanted to make that move because she saw a lot in me. She saw I was good with our patient care. I loved oncology nursing and being at the bedside. Again, as I said earlier, I saw beyond what I wanted to do. I'm grateful to have had other people that would have supported that, but I think about that now. People come in to this really difficult healthcare environment, and then if that's what they're met with, I don't know, they might just stop.

Fowler: I think this whole idea of paying your dues, you have to have so many years at the bedside before you can be a leader or if you choose not to leave the bedside and step into leadership, that's wrong too. I think that creating a space where we honor each person's unique journey in nursing and leadership to be able to give their gifts, I think is important. I really worry about the pay your dues concept because I think it's okay for us to say this year is going to be hard. It is going to be hard because there's something about the mental rehearsal to know that it's going to be tough. There are going to be challenges, and yet, I think it's also our responsibility to say, yes, because it's going to be tough and because you're on a steep learning curve, we are going to equip you with some support and some skills to keep yourself in better balance whether it's breath-work and the sound healing you do, whether it's some of the community resiliency work that I do, all of these things are things which are able to say it's "normal" to feel stressed right now. What it's not normal to be is isolated and afraid that you're failing because you're feeling like this.

O’Malley: Yeah, and staying in that heightened stress response. That's what we see so much really. People sit in this fight or flight, and we know this little bit of stress is good for you. That's normal to your point. We need that normal ebb and flow but what we're finding is that people just live in it. I think you guys use something similar, but we use the stress first aid model, and we find so often people just sit in that orange just before crisis section, and I think we need to help people build the skills to bring themselves out of that.

Fowler: Well, and I also think that so often when I talk to nurses, they want to support the well-being efforts, and yet they'll say, we're so busy doing the work of nursing, and with our staffing issues and all of those things, we just don't have the time for it. Yet, as I think about what you just said that living in the edge, that living in the yellow orange space of stress, firstly, it's not good for us. It's not good for our relationships. It's not good for our personal lives, but it's not good for our clinical reasoning and our clinical decision making.

O’Malley: No. I do a lot of work with nurse leaders., and it's so interesting because I think both within my organization, but also more broadly with the consortium and stuff what we hear from people is that the nurse leaders are increasingly more stressed because they are increasingly more consumed both by the difficult nature of the healthcare environment right now, but also that their schedules are booked constantly, so nurse leaders need to be out with their teams. Organizations say they understand that value and they understand well-being, yet nurse leaders are booked from 8:00-5:00 in back to back meetings.

Fowler: The lucky if it's only 8:00-5:00.

O’Malley: Well, right. It's oftentimes more to your point because the 8:00-5:00 is already booked, so the only way then that they can be with their patients and their teams is if they come in at like 6:00 or earlier and then they stay till 6:00 or 7:00. By the way, these people have families. I think that's something that I actually think is critical at this moment is looking at how do we make it okay for nurse leaders to actually be with the people that we need them to be with. I coach a lot of our nurse leaders and constantly I hear about, oh, we get these urgent meetings or somebody will put a meeting in a place that I have blocked and just expect that I'm there, or if I'm a med surg leader, and I have three other peers that are also leaders in my division, all of us have to go to every meeting versus splitting it and then coming together and sharing it, and I think that's something that I feel like we speak about, but in practice we don't actually help people implement.

Fowler: I think that's one huge piece of it, and I think the other piece of it for our colleagues who are nurse leaders, who actually do prioritize spending time with their people. What I've also heard from them is a sense of stress associated with all that they have to listen to, because they care for their people, and they're also aware that their people are suffering, so I've had so many people say to me because I also coach them as do you, I just feel like it's so hard for me to be enough because I'm running from meeting to meeting and then I'm sitting trying to really be fully present and listen to somebody who needs me to listen to them, and I feel like I have a double whammy here, because firstly, I feel like I'm not listening well enough or I'm not able to be what they need on the one hand, and on the other hand, I'm recognizing the fact that this is also stressing me because it's reminding me of two things. Firstly, that somebody else needs my attention somewhere else, and also that I'm not able to do more of this that I know is important, and it feels like this constant tug of war where they're being pulled between these different responsibilities, and I've had this leaders say to me, and they're very self-aware, and I just so appreciate their self-awareness when they say something like, I know that when I'm in this position, I'm not showing up as my best self, and I'm not able to be fully present as a leader in the way that I need to be present.

Fowler: That then is distressing for them again, it's a challenging spiral we're in here.

O’Malley: That's the go back to the connection to self others purpose. They feel like they can't fulfill their actual purpose in their work service life. There's there's a lot of research on self-actualization. That's what brings us to thriving. That's a foundation of positive psychology. Is this concept of being able to self actualize into who and what we're meant to be. For me as a leader if I were to hear that, which we hear all the time, but if one of my direct reports were to say that to me, that's a hard stop. Okay. What do you mean? Because I guarantee you, we can comb through your calendar and find all sorts of stuff that you could either a delegate, maybe. Although what we often hear is I don't want to put burden on my teams. We often think that if we give the meeting or something to someone else, we're creating burden, which isn't always true. Again, ask like a peer if you're going to this, can you give me the cliff notes and I'll take this next one so you can take off. But I think people don't think they have permission to do that. I think as in different layers of leadership, I don't think we do a great job of creating the environment where people feel like they can say no. Let's say I'm with one of my team members and they're really struggling and I need to be present with them. But I have a meeting in five minutes that I feel like I have to get to. I think most people's response is to say, and maybe not most people, but I think there is a there's a population of of leaders out there who will say, I really appreciate you telling me this. Can we continue this conversation at whatever time versus texting whoever is leading that next meeting and saying, listen, I really have to be with my team right now because of the fear.

Fowler: Yeah.

O’Malley: That's what I advocate for people. I'm like, what happens if you don't go to that?

Fowler: Yeah.

O’Malley: They come back to you and you're able to say, Cassie was really struggling or not even Cassie, you could just say one of my team members was struggling. As a leader who believes in creating a workplace where people feel supported and like they can thrive. I couldn't leave this person in that moment.

Fowler: Well, and then ultimately that's all about that deep connection. That that is the biggest supporter of resiliency, knowing that when you are stressed, somebody will sit with you or be with you. Is that the stress first aid. The check in and coordinate must be present. 

O’Malley: Absolutely.

Fowler: Cassie, you had mentioned, consortium, and I know we haven't actually mentioned this. Do you want to say something quickly about the nurse well-being consortium?

O’Malley: That started, I guess it's about three years now. We have about 25 organizations from across the country. They're all nurse leaders in some level of well-being, and we meet quarterly. We're trying to get our footing under us now, to put some structure in there, to start doing more cross collaboration amongst our organizations. but it's just been a really incredible place to meet colleagues across the country doing incredible work and to learn from them and to try implementing things that other people are doing. There's a few good examples within our group where people have heard of something in the consortium and then taken it back to their own organization. Still relatively new. But, you know, I think I see a lot of potential with the incredible people in it.

Fowler: Cassie somebody is in nursing outside of our two organizations and it would be interested in joining the consortium, how should they go about that?

O’Malley: They can e-mail me. I think if you can link my e-mail. Carolyn, I'm happy to talk with anybody who has questions about it or is interested.

Fowler: Well, we'll do that. We'll link that in the podcast notes.

O’Malley: Great.

Fowler: If anybody's interested, we can follow up. Of course, anybody within Johns Hopkins Health System, if you want to know how to do it, just reach out to me and I'll connect you. Let's get back to you for a moment Cassie. As someone who's balancing a leadership role and coaching and educating with parenting, how do you take care of your well-being?

O’Malley: It's been an evolution. I think the first thing that I really had to work on in myself was first acknowledging what I need. I'm one of those, like, many other nurses who tends to just hold on, hold on, hold on until my body says hello. You haven't been listening. Then I get, ill for a while. The first thing was really just checking in with myself, and being aware. Then I started being really intentional about speaking what I need and be setting boundaries. I am really intentional at work with setting boundaries and recognizing my bandwidth and being comfortable and saying no or not right now. Right now doesn't always mean no always. It might mean not right now. I'm also really intentional communicating at home with what I need. I need exercise and I need my morning breathwork and meditation practice. That means I get up early, but it also means that my husband and I split our time so that we can both exercise because we know that if we don't we're angry monsters. It's it takes a lot of self-awareness and it takes a lot of communication. But once I've figured those things out for myself they're kind of non-negotiables because everybody's happier when mom's happy. I think the work thing has been a big deal for me in the being confident in saying no. I think that's a lot of where younger Cassie and probably younger leaders are like, well, I can't say no to that. When I choose to say no to something, I feel confident in why I'm doing it. I feel confident in my own contributions that while somebody may be disappointed, they're not judging me for who I am or my capacity as a leader because I've said no.

Fowler: Well, that's a practice that takes intention and time, doesn't it?

O’Malley: It does. It's been the most important one for me. Because I think I spent a lot of time in my own growth, like fearing what other people might think about me as a leader. I believe this in leading my own team, that if my team sees me do that, they're more likely to do that for themselves. They're more likely to not feel guilty if they have to do. I'll give you an example. We had a big conference that you know about. One of my team members, she had some big thing for her son and she had this discord in her because it was the same day as the conference. The conference is our big thing and and for me, it wasn't even a question. It was like, of course, go with your son don't come here. I know you might want to, but you really would prefer to be with your son, that is the right choice. But as leaders, we need to show people that so that they don't have fear around it.

Fowler: Well, as we get to the end of our time, I'm going to offer you perhaps the last Word. Is there anything else that you'd like to share with our listeners before we wrap up? O’Malley: I know, Carolyn. You've had so many wonderful questions. I think that we live in a world of constant consumption and filling all of our time with work, activities, a million things. I think that we might all be in a better place if we just would take a few moments to step back and give ourselves some space and a little bit of calm. Because I think that's where we get our own biggest insights, our own biggest connection to ourselves and to our purpose is when we're able to just sit and be present with it. I've been offering this challenge across a couple different things. I've been doing recently where just challenging people to sit for seven minutes. It's not even that long. But we tend to say we don't have time. Create seven minutes that you can just sit. You can listen to music if you want to write, great. If you want to read, great. But just sit without social media and e-mail and work and whatever it might be, and just see how that feels. O’Malley: Well, maybe that's the challenge [MUSIC] we'll offer to our listeners as we close out. Please think about giving yourself the gift of seven minutes to spend with yourself. Cassie, it was wonderful spending time with you. I'm so grateful to have you as a colleague and as a fellow advocate in this space. Thank you so much for sharing your wisdom with us today on the podcast.

O’Malley: Thank you so much, Carolyn. It's been such a gift.

Fowler: Thank you.

Fowler: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected] [MUSIC]

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Cassie O'Malley, D.N.P, R.N.
Senior Director of Wellbeing and Innovation
MedStar Health

1. Although there are discipline-specific well-being needs, organizational approaches can transcend these traditional silos, addressing the universal human needs of connection, purpose, and psychological safety that are experienced by all members of the health care team.
2. Leaders need to be visible, accessible, and supportive to their teams. At the same time, leaders can set the tone for boundary setting to reinforce a culture of well-being.
3. In the conversation, Carolyn and Cassie offer these practical interventions:
   1. Leverage virtual nursing to diversify roles and reduce physical strain.
   2. Streamline EHR systems to reduce cognitive load.
   3. Design well-being efforts across disciplines for greater impact.
   4. Encourage leaders to protect time for team engagement.
   5. Promote daily mindfulness as a leadership and team resilience tool.

• Reach Cassie O’Malley directly
• Learn about the National Nurse Wellbeing Consortium
• Learn about Stress First Aid

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler. We're your co-hosts for the Johns Hopkins Office of Well-being's podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare. We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning. Thank you for joining us.

Biddison: Hello and welcome. I'm Lee Daugherty Biddison, chief wellness officer for Johns Hopkins Medicine and your host for this episode of the Vital Conversations podcast. My guest today is my dear friend and colleague Jennifer Katzenstein. Dr. Katzenstein is a board-certified pediatric neuropsychologist and the co-director of the Center for Behavioral Health, director of Psychology, Neuropsychology, and Social Work at Johns Hopkins All Children's Hospital. She also is an associate professor of clinical psychiatry and behavioral sciences in the Johns Hopkins University School of Medicine. She's an international and national speaker on topics ranging from mental health of children to physician wellbeing, and our passions include building behavioral health services for youth and their families, as well as ensuring the well-being of the workforce with a specific focus on workplace violence. Jen, thank you so much for being here today.

Dr. Jennifer Katzenstein: Thanks so much for having me. I'm so excited.

Biddison: I'm really been excited about this conversation, and I would love to just start with, giving you a chance to tell people, what it is you do every day. You've got your fingers in a lot of different pies.

Katzenstein: It has been an interesting evolution over the past few years, especially as we went through the COVID-19 pandemic and I think, society and across the world, people recognize the importance of social interactions and mental health and wellbeing as part of our overall physical health, and that mental health and physical health are truly one. As a neuropsychologist and developing behavioral health services and growing our behavioral health services here at Johns Hopkins All Children's it's really evolved into being very mindful and thoughtful about our team members across every component of the hospital, including our environmental services staff, our dietary staff, our support team members, our medical staff, every nurse, every physician, every person who works here, what their well-being looks like, and the well-being of their family. Because we have been through, especially here in Florida, so many disasters. Last year, we had three hurricanes on the west coast of Florida that significantly impacted our teams. Recognizing that you can't just walk into work and forget about everything that's happening at home, that still continues to impact you, and you have to be taking care of all aspects of yourself in order to be the best possible provider, the best possible team member when you come into work every day. It's evolved from really taking care of our patients and families to taking care of all of our families, regardless of how they present here at the hospital, either as a team member or as a patient or anything else.

Biddison: I can imagine that, let me just say it this way. Traditionally, those two categories of responsibility within an institution are separate. Somebody's responsible for the internal team, somebody's responsible for the patients and their families and you have this unique role where both are drawn together. I'm just curious about your dinner at our family. We do highs and lows, but the pluses and minuses of having this all brought together and where you see the balance falling out.

Katzenstein: That's a great question. I'm trying to think what my highs and lows of dinner last night would have been. Because every day brings those challenges. There's times where our patients are taking more of our attention or taking more of my attention. There maybe are issues or things are going well, but then also our team members are coming to me with their concerns. When you say the word balance, I often think about it as more of a rhythm, because it tends to be more of a flow for me. Nothing's ever 50 over 50. Nothing ever equals out and that beautiful way that I wish it would, but it won't. Some days I have to remind myself of that. Last week, for example, I had probably at least eight of our team members reaching out for support of some type, either for themselves or for a family member for an external referral. As a psychologist myself, I know psychologists, I know what training I like to see. I want our team members to be going to the best possible therapists and counselors in the community. I am looked to to provide those recommendations and I'm super mindful of that because I don't want to necessarily endorse anyone, but I want to make sure our team members are getting the best care, whether that's through EAP or our Rice program or an outside provider. Sometimes it is for me, taking a step back and taking a deep breath when I'm overwhelmed by all the modalities that people can talk to me with. Whether they're e-mailing me, texting me, teasing me, asking for a Zoom meeting or using secure chat. I'm getting all these messages bombarded and I need to take a deep breath just to be like, I can get through it all. This is okay. Figuring out that again, I left that balance word out of my vocabulary because it sets up an unfair expectation in my own head.

Biddison: I love your approach to that, because I do think, in wellbeing in general, there are ebbs and flows and there's the, I've sometimes used this analogy of it's like a hit workout. No one went into healthcare to have a perfectly balanced life. That everything you will get to do, all the things that you want to do every single day calmly and at the perfect time. We came into healthcare because it's meaningful, because we care about people and want to support them, because we're accustomed to hard work. The hit analogy, just as you're talking is the go as hard as you can for a period of time. But remember, you can't continue to do that on an ongoing basis. You have to stop and your body has to recover whatever muscle group you've done your hit workout with that day has to recover. I love that notion. There were some times doing well-being work early on where people just zone out because the idea would be, you just want me to work less, take it easy and chill. That's just not how I'm wired and being able to bring to the conversation. No, go hard, go hard and keep moving forward. Just remember that you have to recover.

Katzenstein: I think that point is so important because anecdotally, it was said to me on Tuesday night out of a place of caring, but it was hard for me to hear that burnout was real, and it was a comment that was made to me about my own behavior. As an oppositional person, maybe by nature, my first thought was, oh yeah, wait and see. Don't tempt me on that. Then I have to take a step back and think about it. Remember, too, that not all those people that see me going hard see me when I'm not going hard. Does that make sense? They don't know that in two weeks I have a two-week vacation coming up where I actually won't have cell service for an entire week.

Biddison: Can I come?

Katzenstein: I'm sorry.

Biddison: Can I come?

Katzenstein: Please come. Oh my goodness, you are so welcome to come. I'm really excited about it. Absolutely. You are invited anywhere that I go. I had to step back and say, we also make a lot of assumptions about the people around us. That was an assumption that I go hard and don't take that recovery piece. Just because you don't see it doesn't mean I'm not doing it in a way that's good for me. I think that's one of the biggest pieces for me in talking with people about their well-being is. I want to be a meditator. I want to do the deep breathing. It's not who I am. As a psychologist, that also goes against all of our coping strategies that we would share with you in the first couple sessions. But I think it's about finding what works for you and what that to your hit analogy work out is you're coming down from that going hard piece, and that doesn't mean it's sitting quietly, breathing or meditating. It's whatever works for you. I want people to hear that more.

Biddison: No, I love that. But it's a challenging journey. I think the other thing very often type A folks in healthcare, we are pretty formulaic. Just tell me what to do. That will make me feel better, or help me to de-stress or whatever, and I'll go check the box. Maybe I'm giving away more of my own personality than all of healthcare, but I think it's not uncommon, for us to have that approach. I think that self-discovery journey is vulnerable and uncomfortable sometimes.

Katzenstein: Absolutely. I think so often, too, to your point about things being formulaic. Our whole futures have been laid out for us. Everything for me, for grad school, what you do for your residency placement, your fellowship placement. It's all a match. You get to give your opinion on it, but there's still a match and so you don't get your full autonomy. Then suddenly we release you into the world and say, Well, go do what you want to do. We haven't allowed our trainees to make those decisions for the past 10 years, and so have we trained them to even be able to say, what do I enjoy? What does make me happy? Have you ever been asked that question?

Biddison: Have it be okay to give your honest answer and not have it be something working 80 hours a week?

Katzenstein: Gosh. The standard question in psychology is, where do you see yourself? If you don't respond academic medical center, then that's a red flag. To your point, that's exactly right. What's the correct answer? Well, the correct answer is whatever is right for you. Sometimes if I'm talking to a trainee about that, they're at a loss because they've never gotten to make that choice independently before.

Biddison: So important to create those spaces Circling back to our earlier comments balancing all of that for the employees with figuring out what this means for patients and families.

Katzenstein: Exactly.

Biddison: I would love too. We've had some conversations outside of this conversation right here about resourcing. By that I mean resourcing the work. I would love for you to just give us your thoughts on what it means to resource appropriately the work that you're describing and that you're overseeing now. How do we know when enough is enough? How do we have those conversations about again the resources that we need be they, human resources or otherwise, to do this work.

Katzenstein: That's a great point. Especially for me, being in behavioral health resourcing for me is brains. It's humans. I don't need fancy equipment. I don't need MRI machines. I don't need all laws. I need a room and a brain. When I think about that, I think about myself and those of my team members that are just stretched, where are so willing and excited to take on new opportunities and new engagements that we have. But then, when is enough enough? When are you at your break, your breaking point? I feel like there's days now where I'm thinking to myself, this is a lot, this is probably not sustainable long term. Then in this funding atmosphere and in this atmosphere, just from a financial viability perspective, how am I going to advocate to have a component of my position or anyone's position, be well-being focused or thinking about how, especially workplace violence prevention that we've been working on so diligently? That is a very emotionally challenging area, but also requires a lot of human resourcing because we need people being able to work on projects and work with challenging patients and families who are in the hospital and in our outpatient care centers. I think that's a harder argument to make sometimes. Like a piece of machinery. An MRI machine comes with a cost, but it also comes with some type of revenue that's going to be associated with that. We in well-being and in workplace violence prevention, that revenue piece is harder to really demonstrate because it's often in that cost savings, retention, having a better workforce.

Biddison: It is tough. There's also a lot of conversations happening in the wellbeing space. Had one of these conversations just a month or two ago about the fact that, we sometimes get trapped into the ROI discussion, like, show me how this is paying for itself or show me, even if it's a cost avoidance strategy and trying to figure out in very complex times how we shift the conversation towards this is just the right thing to do. Even if the cost analysis either can't be worked out because it's so complex or it doesn't fall in our favor, it's still the right thing to do. How do we shift towards that? It's not easy.

Katzenstein: It's so interesting that you bring that up because it's such an easy response sometimes to say, well, what is the ROI? Then we get tied up trying to answer it. For the first time in the five years that I've been director of social work, we have no open social work positions right now. Our retention has been so strong that, knock on wood, I'm knocking on wood for everyone listening, there isn't an opening, and we actually have people who are waiting for a position to open. Isn't that exciting? It's anecdotal. It's not data-driven in the way necessarily, that someone wants to see it in a dashboard or specific metrics. But we've developed a culture over the past five years that gets people coming here, wanting to be here, and staying here, such that I have a staff that isn't run dry, running ragged, trying to cover all of these units with open positions. I'm not stretching the bandwidth or asking for extra shifts, because we're where we need to be, and not incurring the costs of recruiting someone new, and not only having the gap right, but that new recruitment to bring someone in. That has been one of those things I think I need to really highlight a bit more. This is a culture that we've completely overhauled and wow, has it been a success.

Biddison: Absolutely. Well, can we dive into that a little bit?

Katzenstein: I love that.

Biddison: Let's, say one of the other hospitals in our health system or somebody from, I don't know, western Kansas, said, Jen, tell me how you did this. We're struggling to retain social workers. What would be your top two or three things that were really important to that transformation?

Katzenstein: One of, I would say, the most important things we did right off the bat when I ended up in this role was I met with every single social worker individually and talked about what was going well and where they saw challenges and where they saw opportunities, and really sat down once we met with everyone and laid it all out. I'm a big fan. Lee, you've been to my office. There are post-its everywhere. They posted small post-its, line post-its, and we put them all out on the big post-its, and we started to see where could we have some quick wins and show this team that their leadership was dedicated to improving and listening, and then where were things that were going to be longer term plans, and where were things that probably had to? I really dislike using the parking lot terminology, but probably had to be put on hold for a little while. HR at that time gave me a stoplight report. The stoplight report has been something that we do quarterly, where we show our green accomplishments over the past quarter or the past even six months. Yellow are things that are in progress, and red are things that are on our minds, but are posing challenges to get moving right now and we tell them why. Just seeing that and knowing that the concerns that they're bringing to their one-on-ones, they're bringing up on a daily basis that are challenging to their daily life, are still on our radar, I think has been huge, really important. One of the other things right off the bat was just like any team. Some internal communication challenges and really resetting our mantra to be is it kind, necessary, and true? It's on every agenda. Is it kind, necessary, and true? Are we talking about things that need to be talked about? Are we building healthy professional relationships? Then we sat down as a team and said, What are our 10 communication values that we are going to bring every day? Then that was a nice way to hold accountability when we weren't meeting those things, because then the last part of it was really if you were not accountable to the things that we had decided as a team were going to be our communication, we're going to be the values we bring to work every day. Then we had a conversation about it and some people self-selected out of that. For the team to see that we were going to not only listen but hold accountable, I think, completely changed the culture overall.

Biddison: One question that's just running through my mind as you're talking is, is this scalable?

Can you scale the cultural transformation you've just described? I'm just curious about your your thoughts on that.

Katzenstein: There's a couple of things I have in my head often about this. One is managers and those who oversee team members are so important to have some of those skills. Even just a standardization of that, I would love to see every team have their own stoplight report. Is that something that could happen? I think that from a not being in an executive leadership role, but probably understanding maybe that there are challenges to get everyone on that same page. How do you set that expectation with leaders and get the buy in? I think if you can do that, that's magic. Then the other thing, there was a midwestern children's hospital I had heard about during COVID that had put up signs in their staff areas. Just be kind. Part of me wondered, too, if maybe sometimes. Is it that simple? We in Saint Petersburg here, if anyone has been here or you drive around, there's a movement with just happiness signs put up on random light poles. You just might be driving down the street and you see on a street sign or on like a light pole that electrical poles, utility poles, red, yellow happiness sign. It always just makes me wonder because our thoughts are so tied to our behaviors and our emotions, like, is it as simple as just reading be kind or seeing happiness to initiate some type of thought process change. As a psychologist, some type of cognitive behavioral intervention that might be able to set that culture differently. I really would love to study that more closely.

Biddison: Let's do it.

Katzenstein: Right. We should do. It's good to have signage, be kind or I've said this to you before. No one talks to you more than you talk to yourself. Can you change one thought a day about yourself. One time where you got mad at yourself about something, or you were frustrated and said something in your head that you could easily reframe to be kinder or more positive?

Biddison: Oh, I love that thinking. I've got a whiteboard over here and I need to change the mantra on the top. Be kind, go back to the top. Right now it says good things take time.

Katzenstein: Oh, I love that. Every day at 10 A.M. in my phone. To your point earlier, my reminder goes off that says you can do all of this. Just as a reminder, like when you're feeling overwhelmed, but I yeah, maybe it's just that simple.

Biddison: Something that disrupts the train of thoughts that we're struggling to that we probably didn't start. We're triggered by something else and we're struggling to start some some disruption there. Yeah. For sure, I love that. Well, another thing that I was curious about your thoughts on is as you are taking care of this broad spectrum of individuals who engage with all children's, starting from patients at their very earliest to your most senior staff, are there things that a lot of times, I would say, like challenges that we have in our work, relationships or any relationships in our lives or come from experiences that we have in childhood, this very common. You will be able to speak much more succinctly about adverse childhood events than I can. But the whole sort of psychology of that. As we think about engaging with our adult staff. One of the things I've actually given some thought to is should we have a more trauma informed approach to people's burnout, what happened that made them that got them into this cycle of behaving in this way? But my bigger question, and we can absolutely run down that rabbit trail if you want to. But my bigger question is, are there things that are happening as we engage our patients when they're very young or early, or on those future clinicians who are patients now that will make a difference down the line? Specifically in this context.

Katzenstein: I think absolutely. These are so many great questions and so many paths we could take currently. I think about especially this teenage generation right now, who is so mindful of their boundaries and their behavioral health and are really using terminology that we as adults are adopting and makes me think back to my own childhood, like gaslighting, is probably one of my my favorite terms that sometimes when you take a step back and you are reflecting on your own behavior, reflecting on a relationship and the other person's behavior. Our kids are getting better and better at this, and I am so curious to see how it sets them up for the future and how if they're forming just these nice, strong relationships with appropriate boundaries in place and thoughtful conversation surrounding expectations in a relationship, will they be able to carry that over to their work? When I think about for myself, for example and even in my own therapy situations where I'm the patient with my psychologist, who sees me. We talk about family of origin and how each of us is really shaped by the relationships we observe early on and the expectations in those relationships, maybe in our parent's marriage or divorce or next relationship and how we communicate, how we cope and what we see to then be that sets the expectation for what your future relationships look like, whether that is in your personal life, if it's in your work and professional life and how those interact. I do think that the things that we do now make a difference long term. As we talk more about well-being and as our kids and certainly our teenagers are doing such a remarkable job of recognizing their own and defining their own psychological concepts. I am so excited to see how that opportunity can evolve in the future, because this is a generation that has an amazing opportunity to use technology and use the stigma reduction to completely disrupt what we all have been setting as the expectation and for decades in terms of work life integration and how hard you work when you're at work and pushing and pushing and pushing. I think we're coming around to, but they're more ripe to really follow through with.

Biddison: The older generation has to unlearn some things that hopefully are those who follow after us are learning the first time around, for sure.

Katzenstein: Exactly.

Biddison: You mentioned the concept of stigma related to mental health. I'm curious about your perspective on how successful we are being in healthcare, in addressing the stigma of seeking mental health support, especially amongst our employees.

Katzenstein: I think it's evolving certainly over time, at least in my experiences. Certainly, I've seen more and more willingness to have open conversations with me about as a team member, an individual's own emotional and mental well-being about their family members, their kids, and when I used to, and I still do set this boundary. When I'm talking with whether it's a team member whose child I'm seeing in clinic or it's talking to them about these are some good opportunities to enhance your own well-being. Again, EAP rise outside providers. I always say I'm never going to bring this up in front of anyone else, and I'm not going to start the conversation just being super mindful from a privacy perspective. If I'm saying, how are you? I'm truly just asking that. You don't have to dive in and tell me how therapy's going or anything like that. I try to set that expectation really clearly, because I don't ever want anyone to feel put on the spot or feel awkward when you know you're back out in the work environment. But more and more, especially really over the past six months, I'm in situations where I'm like, whoa there's people around. You're going to keep talking to me about this. Like coming up to me and having those conversations and they're like, yeah, yeah, I mean, I talk about it with everyone. I'm like, this, I should be embracing that. Like, this is the stigma reduction, the open conversation, the sharing, the letting everyone know that you're not alone by sharing your own perspective. That's why it's so important for me to share. You think even about my own therapy because you need to see others that are doing it and knowing that it's okay, and it doesn't mean that anything is right or wrong or otherwise. It's just one more way to give yourself the time that you need to recover, and make sure you're getting all of the health pieces that you need to.

Biddison: Which allows you to do your job better and be a be a better partner, be a better parent. All the pieces. Everything's better when it all comes together. Yeah, I love that. I love hearing that. How the environment is changing at all. Children's I think we're having some are making some inroads across the health system, nationally and internationally. But I think it's slow.

Katzenstein: Well, and I think it depends dramatically to when I think just having a positive experience can be so beneficial. But I don't want to be naive that there are still negative experiences that people have had as well. Mental health and access to mental health, especially in Florida, is an incredible challenge. Finding high quality providers that take your insurance is incredibly challenging. If you just keep hitting roadblock after roadblock, that's part of like how the stigma doesn't get reduced because it's causing more frustration and more emotional challenge than getting the help that you need. That's the access piece is something that I'm so mindful of because if you're shopping, you're out shopping for a therapist because you should be considering a relationship, that you should be looking for the right person. It shouldn't. Yeah. The first person you schedule with may not be the right person, and that's okay. If we are again hitting roadblock after roadblock, then you're going to get frustrated. You're going to be exhausted and that's only going to worsen your overall behavioral and mental well-being. That is again, it's really something especially in the state of Florida, where we have challenges with access to high quality mental health care and evidence based intervention that I'm continually monitoring closely.

Biddison: So important, and I think to your point about access, if we can't access the care we need, then there is a piece of the why? Why can't I access this? Why isn't this available? What am I not understanding about? It could lead us down these roads of maybe. Maybe I shouldn't have this if it's so hard to get. Maybe that's not the right thing if nobody's doing it or there are a whole host of ways that thought process can go. I clearly could keep you talking all day. I want to ask at least one more very specific question before we wrap up. That is, as we're talking about access in one of the things that we've talked about a little bit and that you've been working on, is bringing together a variety of different resources into sort of a cohesive network of support structures that all children's. We have something similar in the health system at a sort of a system level called MESH or which stands for mental, emotional and spiritual health. It's a collaborative of folks. But tell us a little bit about that, what that looks like at all children's.

Katzenstein: I was so honored that you invited me to MESH at the system level, because I got to see what y'all were doing. You have the responsibility to bring together all of us across these multiple hospitals and talk about how to coordinate care for our team members and what our teams need and what's happening. As I sat in that first meeting with y'all at the system level, I was thinking, we have all these well-being opportunities and initiatives happening here at All Children's, and we're not bringing them together in a way that we can coordinate, or we can maybe make a grant application or make a philanthropic ask that is cohesive and thoughtful for all of our team members, meshes the perfect opportunity to bring everybody together. I talked with you and Carolyn and then our local executive leadership here and said, I'd love to bring this down here and start our group so that we could be doing the same thing in our hospital and being that entity outside of the system that really is so far away from the rest of the entities in the Mid-Atlantic, sometimes our needs are different. Sometimes the hurricanes make things a little bit more challenging, our disaster efforts that need to be thoughtfully approached here. I really just started talking to everybody who was leading a well-being initiative and said, this is what the system's doing. I'd love to start it here. Do you want to be involved? Even this weekly, I just had two new team members come in who want to be even more engaged. A nursing leader and then a leader from our Office of Medical Education, because these are all of our teams working together, and everybody has input and everybody has phenomenal ideas. But we should be coordinating what's available. It's not just about right listing our well-being resources that are available, but talking about programming and what we can do. Because people are so engaged in the well-being space, came together so easily. I think this June will be our third month with MESH in place. I've been so excited. Our team members have been e-mailing me what they're hearing from their teams, what they're hearing during rounds so that our agenda is robust each week. Yeah, it's been exciting. Sometimes when it comes to these meetings, sometimes it's just having the admin support to have a team site with all the agenda and minutes in one place, and everyone feeling empowered to add to that agenda because it is like a living document, and then really just diving into it and then knowing that the team is so engaged, they're going to follow through with the deliverables in that intermediate time period, too. But that's what we modeled it for, workplace violence as well a workplace violence prevention team, by starting off every meeting with just like, what's the well-being of the teams look like? What are you hearing from your team? What are you hearing across the organization? Then from there, do you have ideas or thoughts, or are there things that we need to be thinking about? Because this occurred to me last month actually. Hurricane season starts for us next week here. Because of the loss and devastation from the last set of storms, I was thinking, gosh, like kids who were displaced, my son never went back to his original school go back to school at his original school next school year. But our kids who were displaced from their homes. We had an enormous amount of families displaced from their homes. Families displaced. Are they going to be panicked? Is the anxiety going to be higher than we've ever seen before heading into the next season? Interestingly, I had a couple parents reach out last week and they said, I think that the talking about Hurricane season is what started these sleep problems.

Biddison: Interesting.

Katzenstein: Even just getting the teams together to say, should we do a Schwartz rounds on recovery and resilience from disaster, maybe not focused so much on storm season, but more focused on how we recover and how we have recovered. That was a whole MESH initiative. I'm really proud of the way the team comes together to think about those things and how we can coordinate across all disciplines to make sure our team members get what they need.

Biddison: I love that, especially as we like you said, feel challenged with access. If we can create that sort of network or safety net of connected support. That's so, so meaningful.

Katzenstein: Thank you to you. Because you brought MESH to us and you brought me to MESH. I can't thank y'all enough for that.

Biddison: Well, it's really amazing to see what you guys have done with it. Like I said, I could keep going all afternoon, but we should probably wrap up. Jen, thank you so much for being here. I really enjoyed our conversation, and I know our listeners will, too. With that, we'll sign off. This is Lee Daugherty Biddison, your host for this episode of Vital Conversations. Thank you to Jen Katzenstein for being here.

Katzenstein: Thanks mate.

Biddison: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about. Please e-mail us at [email protected]

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Jennifer Katzenstein, PhD, ABPP-CN
Director of Psychology, Neuropsychology and Social Work, Co-Director of the Center for Behavioral Health Johns Hopkins All Children’s Hospital

• Petersburg, Florida has faced two consecutive years of major hurricanes. Healthcare workers are affected both professionally and personally, highlighting the need for comprehensive support systems.
• There’s a growing openness among staff at All Children’s to discuss mental health. Their experience shows that by addressing mental health concerns openly, organizations can foster a resilient workplace.
• All Children’s Hospital has high retention and low turnover for social work professionals. Strategies include: individual meetings to foster connection and feedback, “stoplight” reports to identify and address issues early, and communication practices that promote transparency and trust.
• Katzenstein emphasizes the importance of both flexibility and boundaries, creating a sustainable model for staff to have regular access to managers and leaders while protecting personal time.
• Katzenstein prefers the term “work-life rhythm” over “balance.” Working in healthcare requires hard work and the ways we choose to recharge can be very individual. 

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Biddison: Thank you for joining us.

Biddison: Hello and welcome to the Vital Conversations podcast. I'm your host for this episode. My name is Lee Daugherty Biddison and I serve as chief wellness officer for Johns Hopkins Medicine. I'm thrilled to welcome my friend and guest, Dr. John Ripp. John is joining us from the Icahn School of Medicine at Mount Sinai in New York, where he is a professor of medicine and senior associate dean for wellbeing and resilience. He also serves as one of the first chief wellness officers in the country. It's just a pleasure to have. John. Also want to mention, John is the co-founder and co-director of the Collaborative for Healing and Renewal in Medicine or CHARM, which is a wonderful organization that hopefully we'll hear a little bit more about later on. John, welcome.

Dr. John Ripp: Thanks so much. It's great to be here.

Biddison: Well, I am thrilled for this conversation. One of the things I love about doing this podcast is getting to talk to my friends who are doing great work in this area. John, as I was preparing for this podcast, one of the things I reflected on is very early in my role as chief wellness officer, we lost a faculty member to suicide. It was devastating, obviously, for that person's family, but also for the teams. I remember one of the very first people I called actually, was you and said, John tell me what you know. How do we handle this? How do we respond? How do we support our people in this really difficult situation? You were so gracious both in supporting how I was feeling in the moment, but also in helping us think about how we can respond to this as a system. Maybe if you could just comment a little bit on why it's important for us to be thinking in advance of an event where we might unexpectedly lose a colleague. Why it's important for us to be thinking about how we'll handle that. What's the role of the wellbeing office in really trying to tackle that?

Ripp: Thanks, Lee for opening a discussion on such an important issue, one that I think all of us in wellbeing leadership roles either have experienced unfortunately or really sometimes feel like we're kept up at night thinking about this event. When it does happen it really does command everyone's attention appropriately and in a way that really requires a response and requires a response in a time where things feel really emotional and chaotic. I'm reflecting on back all those years when we spoke about this and thinking about my own experiences because we've had a few and it feels very fresh and it's the thing that sticks with you. It's important to have an organized response. I'm not like an emergency management person by background, but when dealing with an event like this, you realize that it's really critical to have a protocol, to have a guidebook, a step by step guide to follow because inevitably there's going to be a lot of voices that are making suggestions or that you need to work with, and there's going to be appropriately, a lot of emotion that often makes it hard to do the work. I completely sympathize with you. I'm feeling it now back to those moments and reminded of my own. Again, thanks for bringing up this important conversation.

Biddison: I love what you're saying about the protocol because I think in particular, as we were trying to move through that situation and provide support and help guide, how do people who are reaching out to us for help. How do they respond? How should we encourage or support or guide our institution respond is that we've got to manage our own emotions. One of the things that I recognized in that situation I mentioned to you and has come up again since is that our own sense of responsibility. I'm a chief wellness officer. I'm supposed to be sure that everybody's okay and somebody was clearly very not okay. How do you manage that experience? Of course it isn't all, but it's absolutely not all about us. But you have that own experience, and you need to be able to. I also protocol, I think, is helpful to help us set aside those spaces and say, now here's what we've got to do. Thought about this and here's what we're going to walk through. Here are the pieces that need to be brought together to provide that support in real time and put ourselves aside in that space. But it's intense for everybody's involved. Maybe, could you talk a little bit about as we think about, we just mentioned a protocol a couple of times. What are the things that should be in that? Like if somebody's listening to this and says, my gosh, we need to do that. What would you say has to be there?

Ripp: Let me answer that. But I can't help but reflect on some of your comments that alluded to that because I often say that when you're in well-being work, if you're a chief wellness officer or healthcare wellbeing leader, you're often involved in the opposite. You're involved in dealing with distress or things that are getting in the way of wellbeing that are inhibiting fulfillment in the workspace. That and I think, you spoke of CHARM and this community of wellbeing leaders that we have it's critical to be able to lean on others and who are doing similar work and particularly in those times where I would say on a regular basis, we're dealing with distress amongst various segments of the workforce. But when it's a sudden tragic death, when it's a suicide, it is going to take a toll on you as an individual. The protocol allows you to lean on that when your head is a buzz with all the many things, the sense of responsibility you alluded to it, the sense of guilt, is there something I could have done that would have prevented this? It's really important to and again, I've learned so much from emergency management people. I've learned a lot from our experience in COVID that there are times where you need to just follow a step by step guide. I'll just share an anecdote with you around a time when I personally and I will answer your question, I promise.

Biddison: We got time.

Ripp: There was a time where I needed to step aside from the role of overseeing the well-being crisis response. It was not a suicide, but it was a sudden death of a faculty member. The story goes like this. It was a day like any other. I was in my office. I was either having meetings or getting some work done. I got a call on my cell phone from the head of a residency training program in a department that one of the faculty members had moments ago been killed suddenly in a car accident. While he was biking and was killed suddenly. Obviously I was very shocked when I heard this. I was like, my goodness. Who was this? The person who called me told me the person's name and I realized it was a good friend of mine. I mean, this was many years ago. I've processed it and our community has rallied around the family. But it was a double loss. It was a loss within my work community. It was a loss within my community of friends. I began to implement the wellbeing response, the protocol, because that's my job. I called a meeting together of the way our protocol works. This is to answer your question is, we have leads that represent all the key resource groups that need to act in the wake of this. We have behavioral health and spiritual care and marketing and communications my office, emergency management and others, and I called the meeting together and I began to run it. I was sharing the story. Then at a certain point, I shared that this is a friend of mine to this group, and I think it was the head of emergency management services who stopped me and said, wait a second. You really shouldn't be running this effort right now. It was like, of course I shouldn't be running this right now. How could I even be doing? To your point, these are incredibly emotional. It's going to take a toll on us no matter what. There are times where we may need to step aside. Having the protocol is really important. I mean, the main elements of the protocol as we have defined them, and we've really modified some great resources. The ACGME has a response to a suicide toolkit that a lot of us are familiar with which really provides a step by step guidance. We modified that a bit based on our own needs in our community. Each time an event happens, which in an institution that has 45,000 employees, unfortunately it happens with some periodicity, you learn from each of them. What we've learned over the years is that there's two main areas of focus. One is messaging, the other is providing support in the form quite honestly, in the immediate term it's less so psychological support because people are not ready to sit down with a therapist within 24 hours. It very well might be spiritual care that they're often extremely helpful. It may be just someone who's skilled at managing a debrief session where we just come together and share our thoughts about the person that we've lost. There's the support elements and then there's the communication elements because inevitably a message needs to be sent and that can be very complicated depending on the circumstance. There's always unique circumstances. Yeah. Who do you send it to? When do you send it? What do you include? What don't you include? Who's been in touch with the family? What is the family? What are the family's wishes? But all that I always say that is good. That's important work to do by group and not by individual because you really need to rely on the sensibilities of a lot of thoughtful people to weigh in on those. Anyway, long answer to your question, but as it relates to the protocol, I mean, it goes beyond just those two domains, but those are the two major domains in our experience.

Biddison: There's so many things I want to ask you, but I want to just pause for a minute on a piece that you shared about your friend who passed. One of the things that we learned in our experience taking so many lessons from you, was that unexpected deaths come in a whole many different varieties, that I think the ones that tend to be I don't know, most talked about perhaps are deaths by suicide. But I think it's also really important for us to remember that sudden death of someone you spend eight hours a day, five days or more a week with over months or years is going to be shocking, regardless of how they died and disruptive and trying to be sure that we acknowledge and appropriate ways the impact of any death and any loss like that, I think, has been incredibly important. Clearly, there are special considerations in the context of a death by suicide. But to your point, we have I think our organizations are of similar size. To your point, statistically speaking, in a group that size, there will be members of the group who pass away for any one of many reasons. Being prepared to support folks in that is just so important. Maybe just a little bit more to go a little deeper on communications, because I think one of our early lessons as an organization was about that it is important to know what not to say as it is to know what to say. Do you want to maybe comment a little bit on that?

Ripp: For sure. It's incredibly complicated for so many reasons. I would say one main reason, it's very easy to get a message wrong in those circumstances. If you're not really thoughtful about what goes in it, if you just. A lot of times there's a sense of urgency to get a message out and it's more than a sense. As you mentioned, each circumstance is unique and they happen with such a large community, they happen. I was thinking about this the other day, 45,000 people. That's like a large town, a small city. These are life events that happen. There's a lot of considerations. Not only is there a sense of urgency, but and we've come up with a couple of almost like questions you ask, like, was this very public knowledge or not? People will die, if it's a car crash, if it's a suicide, if it's a violent death it might be on the news and we've had those experiences. When that's the case, the sense of urgency is dramatically ramped up. Not because you need to notify people, which you do, but there's all this human nature and psychology that begins to set in amongst the community which is natural, and that is that if the institution is not saying something about what just happened, then they must be withholding some information. Actually, in my experience, it's really never the case. There's times where it's the cause of death is not public and the family is really insistent that they don't want you to release the cause of death. Unless you can think of a reason why it's important to do so, which it's hard to imagine. You take into account and respect the wishes of the family. There you may not be giving all the information. Aside from some circumstances like that, you're going to want to relay information. If it's very public it's important to just send the message quickly and it's usually a message just expressing sorrow, but it's important to do so because again, well-being work. It's easy to lose trust in folks, it's very hard to regain or build it. There's that element of it if is it public or not public. I mentioned what are the wishes of the family? When it's a suicide, there's the unique situation related to contagion. There's a known phenomena of suicide contagion where someone who is at risk for suicide, who learns of another one may be become at greater risk. Sharing that information without good reason can actually be hazardous. That's another special circumstance where you need to very carefully think about details within the message. Then I think the last thing I would say is just determining the scope of the audience. If there is a let's say it's a student death, which is going to be very presumably a young person whatever the circumstances, that's going to be very shocking because unexpected and obviously quite sad. In those circumstances, you have to start thinking, we are a school and we are a hospital, and is someone who works 100 miles from here in a hospital that doesn't have students going to know about this, and do they need to know about this? It can be a little bit macabre to like talk about stuff. But it is important we talk about circles of impact. What's the impact? What's the circle of individuals connected to the person who died, who's most impacted? Is there a secondary circle? We use that to inform our thinking about the scope of the audience that we send the message to. We want to get it right. We want to make sure that people who might have heard, who are connected, they hear. Largely again, it's a message of condolence and it's a message of support and comfort and one that has the level of detail that you're comfortable sharing.

Biddison: It's a couple of things come to mind if we could dive a little deeper. One of them is this question about, in the event of a suicide, balancing the wishes of the family, which are incredibly important to honor, and also the experience of that individual's work family, as it were. There can be situations in which a family, says, I don't want anything said, which can leave a real gap for folks in the workspace. That's another one of those situations that I think it's really important. I think in this case, you can't possibly write out all those things in a protocol. But for the design plan you've talked about, you can at least have that group of people who can come together. These are all the folks who help the communications people and leadership folks and emergency management and mental health support coming together to say, how can we navigate this in a way that honors the wishes of a family member, but also respects the needs and experiences of the work group, which I think is just so important. I completely agree with you. One of the other things that I think to your point about the concentric circles is, we have circles and we also have the Matrix. If there is a student who passes well, we know to say something to their classmates, and if you're on a clinical rotation, then maybe to the residents who are on the same clinical rotation, but maybe we don't know whose lab they happen to be volunteering in or which free clinic there. There are these layers of trying to identify networks and to create opportunities for support that can sometimes be a little challenging to tease out.

Ripp: I would say those are steps in the protocol that you mentioned this. One of the steps which it's step, but it's got multiple steps within it is communication with the family, and let's come back to that. Then the other step is like identifying the circle of impact. Part of the work of the group that comes together in response is to say, and in asking, who is the audience to message, you got to say who is this person and who do they interact with? That's why, again, it's really good to have a group of people because between multiple smart people, all the right questions will be asked, like the ones you just asked. Who did they do rotations with? What do they do? Extracurricular and where are they doing research and then the other thing I will say is there's a whole like a continuous improvement element to these responses because my experience is you never quite get it right. There's always something you're like I can't believe we forgot that, and then hopefully you learn. The next time you don't do that again. Keeping in mind that every circumstance is unique. I think that's a critical piece. Then, the bit about, what do you do when the family says, you may not say anything about this, and yet, there's a group that are really in pain, like a group that works in the case of students, maybe they live together and so forth. There's a group that's in pain that you feel a responsibility to address. You know the family is in pain. I do some palliative care, I know your critical care medicine. I try to lean on some of those skills a little bit. I think about the example of the family of a patient who's dying, who says that you cannot tell the patient that they are dying. You cannot tell the patient what their diagnosis is. In palliative care, we try to find a middle ground because oftentimes the patients know, they understand what's happening in themselves. It just creates this, all this tension when everyone's dancing around the issue and not talking about it. There's all belief systems that way in there. But I try to, lean on those skills and say, well, this decision not to share any information about the loved one who just died. Is that a hard and fast? Let's let's have a conversation about it. Let's try, to the best that we can talk to the family and say, and then make a case for why we'd like to share something and explain all the people that are hurting and try to find some middle ground.

Biddison: Absolutely. It's a constant negotiation. But an important one. I'll put you on the spot. I just ask you, are there can you think of a thing or two, could be just at a high level that have ended up in your protocol or your approach that you are at the outset? When you first started in this job, or would never have guessed would have been there?

Ripp: Specifically in in the protocol, like in the response to a something that surprised me about being in there, beforehand.

Biddison: It didn't occur to me that we would need to say this or that spell this out.

Ripp: I would think of that question a little bit of what are the lessons that you've learned because it wouldn't have been a lesson learned if I had thought about it ahead of time. It's so strange reflecting on these events because they happen with some frequency. But a recent one was someone who, was a researcher on a visa. I did not think about, what about first of all, the transfer of the the remains to the family in another country. Then the release and transfer of personal effects. I just did not think about that.

Biddison: Actually it'll be challenging, even if it's somebody who lives three blocks from the hospital.

Ripp: True. But the lesson learned is that, it's lean on your colleagues who have expertise. Like we have some colleagues that their entire work has to do with, visas for our foreign folks who work and do research and learn and so forth. That person was able to figure it all out. I felt very grateful to have that person as part of the team. But that was something I just didn't think about.

Biddison: There's always some nuances. You're absolutely right. I would just say that one of the things that struck us in we recently, did the work of creating a guideline, as an institution. As we shared that internally, it was really, striking the amount of appreciation that was shared. Thank you so much. For just thinking about this, for having a plan. Because, writing it down somewhere. It's not something that can be even coming to this on a podcast, it can be a little awkward. Nobody wants to think about this. Nobody wants to talk about for a good reason. These are really difficult situations. But the more we're willing to, and you have this such experience in this in palliative care. John, for sure willing to face those hard conversations, the more satisfied will be with the outcome and how it went afterwards, as opposed to that. What do we do now? Conversation which can happen if you don't plan.

Ripp: What I will say is, providing guidance during those periods of time. That's actually what I didn't speak to in terms of the structure. This response currently lives under my office, the Office of Wellbeing and Resilience. There's actually the truth is what we do is just, operational oversight and we provide guidance. Ultimately when there's a death in our system or school, there's a need for the immediate leader to have a role, whether it's a dean in a school or a department chair or a division chief or, what have you. That person as the leader of the the circle that's impacted, they have to have a role. In fact, they should be the ones that are that are doing the communication, with their own people. They should be the ones that are present during times to reflect. A lot of what we do is we just provide guidance.

Biddison: It's so important. Thank you.

Ripp: It's for me, I'm always assessing the, extent to which I can step back because this person's got it, they've got to figure it out or the extent to which I need to lead a little more and say, hey, you should have this, you should cancel this meeting, you should have this session, you should send out this, message. It's always figuring out. But what I will say is yes, it's important to send out, notify people that you have a protocol and that, you're there for them should this rare event occur. When it does occur and you're there to support those leaders, there is no group that is more grateful to me in this institution than those who we've provided guidance and support. When someone that reports to them or in their space has died suddenly, and they know they have something they need to do because they're a leader, but it's absolutely not what they've prepared for. For us to be able to do that, those are the folks that are most grateful.

Biddison: That's such an important point. The key role of those trusted communicators and trusted leaders, it wouldn't be effective if we were just to step in and take over for them. Thank you so much for highlighting that. But sometimes the trusted communicators just don't have the words. Being able to to support them and then thinking through how important as wellbeing leaders it is to build the relationships with those local leaders in order to really further the work and effectively support their teams, so important. John, I could keep going for hours, but this has been so helpful. Thank you so much for coming on the podcast and having this conversation and I'm really hoping we can do this again sometime.

Ripp: It's been great. Thanks for again such an important conversation. Thanks for setting it up and inviting me to speak.

Biddison: Well, my deepest heartfelt thanks. For everyone listening, this is Lee Biddison, signing off for the Vital Conversations podcast. Thank you.

Biddison: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e mail us at. [inaudible 00:33:06]

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Jonathan Ripp, M.D., M.P.H.
Senior Associate Dean for Well-Being and Resilience and Chief Wellness Officer
Icahn School of Medicine at Mount Sinai

• Having an agreed-on plan or protocol that serves as a road map to guide the response to an unexpected death is essential, given that emotional circumstances can make decision-making in the immediate response very difficult.
• Communications in the wake of a death require careful consideration of timing, audience, and family wishes. Communication templates can be helpful for leaders to adapt to the circumstances.
• One challenge after a death is identifying “circles of impact” - determining who needs to be notified and supported, considering various connections the individual had within the institution.
• In a health care organization, support teams such as employee assistance and peer responders can provide support to affected individuals and groups. Spiritual Care and Chaplaincy is another important partner that can be critical in the immediate response to an unexpected death.

American Foundation for Suicide Prevention afsp.org

A special note for the Johns Hopkins Medicine Community:  The protocol Guideline for Response to Unexpected Death of a JHM Employee (UED Guideline) can be found in the Hopkins Policy and Document Library (HPO). Specific guidance for learners is handled by the Johns Hopkins University School of Medicine. Questions may be directed to [email protected].

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-beings podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Biddison: Thank you for joining us.

Fowler: Hello and welcome to another episode of Vital Conversations. I'm Carolyn Cumpsty Fowler, and I am delighted today to welcome Doctor Deb Baker as our guest. Deb is the Senior Vice President for Nursing and the Chief Nursing Executive for the Johns Hopkins Health System. She partners with the chief nursing officers and leaders at Johns Hopkins Health System hospitals and outpatient care settings to ensure integration of services and alignment with the health system's strategic goals and their operational and financial objectives. She is accountable for enhancing a healthy clinical practice environment that is patient centered with unsurpassed clinical quality and patient safety, while also providing significant contributions to education and research and ensuring nursing practice at the highest scope of licensure. Doctor Baker has also been a champion for nurse wellbeing and under her leadership, at the beginning of FY 24, Johns Hopkins Nursing adopted a strategic priority for well-being that guides all of us across the health system. Deb, I'm so delighted you're joining us today.

Dr. Deb Baker: Thanks for having me.

Fowler: Can we start off by you telling us a little bit about how your understanding of importance of workplace well-being has changed over the many years you've been a nurse leader at Johns Hopkins?

Baker: Yes. I could say over the span of my career that nurse well-being has evolved and has become sharp focus for me, catapulted by the pandemic. But I think throughout my career, I've always understood that nurses want to be a part of something bigger than themselves. They want to be part of a team, they want to belong and contribute to that mission in caring for patients. How that happens is something that we used to take for granted, happened in one way and it was the best way. The lessons learned since the pandemic are that by us listening to our staff, have taught us a great deal of what we can do to improve the practice environment.

Fowler: I remember how many hours and hours and hours of rounding you did during the pandemic, and that's something you've continued to do to this day. Is that something that you feel really invested in?

Baker: Yes. I have to give you a shout out here, Carolyn, because although I've always been, excuse me, a visible leader, you coached me how to listen. So many times when I was listening to staff very stressed by the pandemic that we were trying to understand every day as it was changing, I always wanted to fix things for them. You taught me to listen, and taught me what they were teaching me and taught me to say, what else, instead of this is what I can do. Because the fundamental need to be heard was so strong and so much a part of their well-being. They needed to know that we were listening, that that was significant, and then that we were going to do things and that if we couldn't fix everything that we were going definitely communicate to them the why we couldn't and when we could. The plan. They're so important to staff. Again, it's that sense of belonging, belonging to a group, belonging to a team, but also belonging to the strategy, belonging to the bumps and the warts. They want to know it all. That level of transparency really needed to happen. It was a significant lesson learned from the pandemic.

Fowler: One of the things I respect so much about your approach to well-being is that you've stay focused on belonging, you've stayed focused on making sure that our nurses have access to the mental and emotional support that they need and the well-being resources, and yet you've kept your eye very firmly in the space of how do we change the nature of the work itself? Like how do we think about what operational things are either supporting a nurse's wellbeing or compromises a nurse's wellbeing? Can you say a little bit more about why that is such a priority for you?

Baker: Yes. Thank you for mentioning that because I think it's significant. It's like the metaphor of building a house on sand. There's probably not an executive in the country running a hospital that hasn't put in programming since the pandemic. What I mean by that is, intentional use of resources to provide respite rooms, counseling and just other programs that help people cope. These things are important, and they need to be present. However, they're not effective if the day to day operational challenges are not dealt with. That's what I learned from the listening sessions that we did. We also asked the staff to bring their solutions. We know that that high reliability component of listening to grassroots and that the experts, the people that do the work every day, that cusp approach was really, really important here because they were going to tell us what they needed. Some of these things seem so routine and not such a big deal, but they're huge and it's about having supplies that you need to care for your patients. That the team shows up. It's not just the nurse bringing the iPad into the room, that the whole team is going to show up and be helpful. Again, that if there are limits in resources or things we can't do, telling them why and then when we can do it, so critical. If we don't take care of those operational challenges, having enough staffing, having enough supplies, listening to their feedback around some broken processes, that any of the programming are the intentional well-being initiatives we put in place just will not stick. This continues to be a daily focus of our team at Hopkins.

Fowler: In fact, it's interesting when you said you have to think beyond the nurse to the whole team. I remember when we were wording our strategic priority for Johns Hopkins Health System, you were very clear that you didn't want the word nurse in the wellbeing objective. In fact, maybe I should just pause for a moment and share with the listeners what our objective is. Would that be helpful, do you think Deb?

Baker: That would be great. Yes. Thank you.

Fowler: Our strategic priority for wellbeing at Johns Hopkins Health System is to invest in best evidence strategies to foster a positive practice environment that supports well-being and professional fulfillment. So two things perhaps we can talk about Deb, one, the focus on practice environment is the primary goal, the positive practice environment, and the other that we chose not to talk about, improving nurse well-being and professional fulfillment in general in our health system.

Baker: Yes, we work in teams. When any part of that team is struggling, the entire team struggles. Nurses traditionally have provided voice, voice for patients, for families, but also for the rest of the team. We thought as nurse leaders, it was really important not just to focus this objective on nursing, but on the team. That healthy work environment that we want to foster has a lot to do with relationships. Those relationships within the team sometimes get stressed, especially when one team member's not able to deliver in a way to the patient that is so important. Nursing finds themselves brokering a lot of this work. We really wanted all of our strategies to be focused on also helping the team. As a nurse executive, I can spend time with our human resources person many hours looking at how we can build pipelines for all of our front line workers regardless of whether they're clinical or non-clinical, because we are an ecosystem that needs to be high functioning in order to care for patients.

Fowler: Ultimately, one of the biggest drivers of our well-being is that sense that we're connected to each other, that we'll be supported by each other.

Baker: Those connections, I think we're getting into the area of mental health and we're talking about that because it's not just the connections I've been talking about in order to deliver care and that operational connection and that trusted relationship. They're important. But the connection that's a little deeper than that is actually more important. That is because if I'm not doing well, I'm going to tell you, and that's where, the mental health of individuals and teams is so important. Having an environment that really says, we want to know when you're not feeling okay, and we want you to tell us if you're worried about anybody on the team not feeling okay, and how can we foster that peer to peer connection where I feel like I belong every day, that people want me here, they'll miss me if I'm not here. Then if I can't be my best self, can I get the help I need? Carolyn, I have to say, the Office of Well-Being, it's a small office, but has made so many connections of all the ways that we can get mental health care within our hospitals. Some of that is, psychiatric care, some of that is support systems, but being able to have connections to those resources, often when people are feeling really bad is when they can't reach out. So fostering those connections and that expectation that we will speak for ourselves and we will speak for each other is really important.

Fowler: I remember us having conversations earlier on about the importance of saying to people, it's okay to not be okay. What's not okay is that is to keep it quiet and to feel shame about that. It's okay to say I need some support to be my best professional self.

Baker: I think that requires a fair amount of willingness to be vulnerable by leaders. It's tough. We're very high risk industries. We have to have high standards and have strong accountability models. But I really do see part of that structure and process that we put in place as leaders to help our teams do their work is to let them know that we know they're going to have bad days and that we are going to make mistakes and that we're vulnerable. I try as best as I can. I tend to have a pretty strong personality and my low voice and everything, but when I'm with teams, I always try to share vulnerable moments that I've had either in the past or currently just so they know because it's it's all true. It's that transparency. It also gives them permission to speak up when they're having a tough time or they're feeling, not prepared to do something that they know they need to do today. I try to be mindful of that, to share that when I can.

Fowler: Well, I think you've done more than just share your thoughts about it. I think you've been very intentional in your work to support leaders, both in being better at supporting their front line staff, but also in looking after their own wellbeing.

Baker: That is a daily challenge, the amount of hours that leaders need to put in to really make sure things go smoothly in a very high, demanding healthcare environment. There's a lot of demand for our care. I would say we're about 40 percent there, the things that we can do, there's a lot of assumptions around how we should work if we really care and testing those assumptions, asking more questions, why can't we job share as nurse managers, why does the manager have to be 24/7? Why can't we share that responsibility with each other? Really asking those tough questions and letting people know that you're not less than because you take breaks and you give yourself space, that you turn it off. Really pushing each other to do that is so important. It's easy to slide back into that, I have to do everything myself mentality. It's intentional, Carolyn. It's certainly still a journey.

Fowler: One of the aspects that I think you've spent a lot of time on recently is this idea of developing the leadership behaviors that support a positive practice environment. Not the pure skills like scheduling and finance and all of those things, but those relational skills. Can you tell us a little bit more about your growing awareness of why that had to be addressed?

Baker: Yes, I think it's in that category of we work from assumptions often and we need to question those assumptions. We have to be curious. Being able to say, I don't know, something is not easy in healthcare. One of the things that it's always so humbling to me that small conversations can create big things. We have a group that meets CNOs across the country. We meet a couple times a year, and we had this very informal discussion after a formal presentation about what are you most concerned about? I brought up that I was most concerned about our nurse managers. I felt like the workforce was really going through a real transformation that we were losing a lot of staff because they're rethinking whether they want to be in healthcare. It was just very hard to be in healthcare. The nurse managers have always borne the brunt of any turnover in their areas. They have a high accountability role with not as much authority as I'd like for them to have. I know they're just so at risk for mental health issues and just burnout. In that discussion the Health Management Academy actually listened very carefully to us having this informal chat and built a whole program around this, really a research program around how can we help nurse managers. In so doing, these young researchers found that there really wasn't much published anything around span of control or any of the just the fundamental things about a nurse manager and what they do. It was really a see one, do one, teach one. A lot of need for research, evidence based understanding of what nurse managers do and how they do it across the country. Then how can hospitals support them? We've been at this work for about five years and it has been incredibly exciting. We actually have done it from the vantage point of listening to our nurse managers. We've had nurse manager cohorts from across the country come together. They have really loved the networking and just the validation of their experience. But we've learned a lot about what we can do to help support them. Some of it really was giving them the skills and exposure to a lot of why things happen in the hospital and how they happen, as well as their ability to be able to manipulate the things that are in their scope and in their purview. It's been a very exciting thing to do. It really has demonstrated that if we can assist our nurse managers to have that voice, to have that agency over their practice, if you will, we can create a healthy work environment for many, including those that they report to.

Fowler: I remember during the pandemic I did a lot of listening sessions as part of our crisis leadership training that we were doing around the health system. The thing that struck me there was how many managers said to us that the hardest thing they were experiencing during those early days, that first summer of the pandemic, was how much listening they had to do to pain and how much listening they had to do to people who were stressed. People actually described. They were describing the technical stresses of leading during the pandemic. But the thing that was getting to them was that sense that they either didn't have the time to listen as much as they needed to, or they didn't have the skills to listen appropriately. You've continued to focus on that. You've continued to focus on these relational competencies.

Baker: Yes. Another lesson learned is that these are not soft skills. These are fundamental skills. It's the old metaphor about putting the oxygen mask on. If we don't help managers to help their staff, then we are creating a cascade of issues that are very problematic. I agree with you. I think our managers were traumatized by a lot, lot that they had to listen to from their staff because their staff were caring for people at home. They were homeschooling their kids, and they were trying to be available in a 24/seven environment. The managers were just absorbing all this stress. By giving them the skills and some of the work that you and I have done together, I think, a really good example is understanding. Again, this is a work in progress. We certainly have not checked anything off the off the list. How to have compassionate accountability is really critical because during the pandemic, we had so many different people working for us coming from contracts and flexible staffing models that the managers lost their core team. That's where the trust is. They became hyper vigilant and less trusting of people's competencies, and of their own. How can we help them restore their expectations, their high quality standards, without feeling that they're overstressing their staff? It really was a paradigm shift, for me as well, to think that by not holding people accountable, we weren't giving them the agency to to have purview over them, to have control over their practice. That was a very big mind shift. We were walking on eggs and so worried about not having enough staff. That we weren't really focusing on the quality of leadership that we were providing in terms of holding people accountable and creating an opportunity for them to be proud of their practice, to belong to something bigger. These were lessons learned. Again, this is the work of every day that we're doing now. I'm sure this time next year we would have learned more about it.

Fowler: I think that's why one of the decisions that we made at the CFO Council, was that we would not have a separate standalone well-being committee for the health system. That we decided to put the the charge for thinking about well-being in the health system into our practice councils, to really connect those dots between if we're investing in positive practice environment, we'll get better well-being, but we'll also get better patient care or we'll get higher levels of engagement and higher levels of satisfaction, both in our patients but also in our nursing staff.

Baker: Yes. I think that that's so critical. When you separate well-being into a committee or a separate priority or structure, then you're saying it's a nice thing to do, as opposed to saying it's critical to everything we do. That people don't listen to what we say. That if we're real influencers, whether we're in an executive role or just a really excellent clinician that has influence over less experienced clinicians, then people are looking at what we do, and that's our practice. We can't be grumpy till 10 a.m. and not be inclusive, but we're so clinically skilled that people put up with it. Those days are gone. We have to model well-being. Just a really quick example is about a year ago, I was rounding on an oncology unit. I remember I would ask about breaks and not just, did you have lunch, like did you eat through charting? Did you really get off the unit and have a break? There were a couple, um, veteran nurses with some very new nurses in the station. The veteran nurses were a little offended with me and they said, Doctor Bake, I don't need, no one needs to tell me when to take a break. I know when to take a break. If I need to do anything, I have people that will back me up, which is awesome. They have trust in their team and could shout out if they needed anything. I'm looking at these new graduates. I said to the veteran nurse, I said, do you think that they take a break if they see you not taking a break? She thought about it and said, oh, I didn't think about that, I've worked all these years to have these relationships work. I can do what I need to do for me and give a shout out, but I guess I'm not explaining that to the people that are coming along. It's exactly right. Those new graduates were not getting along, they weren't taking lunch, or they were eating their lunch while they were chatting because their preceptor didn't do that. I think that that really, in a nutshell, says it all that we have to practice well-being or it's just not going to stick. There's not going to be any stickiness to that healthy work environment.

Fowler: That was what was really interesting to me when you asked me to do that assessment around the health system. I talked to nurse leaders, in fact, inter-professional leaders, about how we influence well-being. What was really striking to me was two things. The first was that I think they didn't fully understand how much power they had to influence well-being. I mean, for better or for worse. They also didn't really understand that we organized well-being. We influence well-being by taking care of the practice of nursing, of the business of nursing. I think so many people have only about two or three people of the 50 something I interviewed, who realized that when we take care of the practice and the business of nursing, we also take care of well-being. It was a fascinating revelation we had, neither of us had thought about, I think.

Baker: That's exactly right. How we started off this podcast when you asked me what's different? That's what was different. It was through your assessment. We're grateful for that survey because it just keeps teaching us. We're still using it. Because again, we made assumptions. Then I've realized in listening to staff, there's a lot we as CNOs for the Johns Hopkins Health System did not know or appreciate. We needed a structured survey. Your expertise actually as a qualitative researcher to explain that to us. Then as a group, prioritize what we need to do first, second, and third. What was very significant was that realization that, boy, what I do every day and how hard it is or how easy it is to to accomplish that, is fundamental to my well-being.

Fowler: Perhaps as we begin to wrap up, can I just ask you to reflect for a couple of minutes on how we make the business case for investing in nursing well-being when we have so many competing financial priorities?

Baker: Yeah. It's an excellent question. I really think it's the long game, if you will. As executives, that's what we have to be able to articulate, and in dollars and cents. An investment in well-being today, can pay huge dividends over time. Really, you don't have to wait too long to be able to realize that those successes. We are fortunate we have chief financial officers that also understand operations. In healthcare, operations are a little messier because we have a very diverse workforce with a wide range of preparation and training and practice. Being able to explain that, what does that mean? What it means is that you have to invest in the early part of people's careers in order for them to have self-agency. When they do and they feel and they know that you care because you're investing, you're asking the questions, you're asking, where do they want to be in a year or two years, and what tools do you need to be able to get there successfully? Then you're investing in retention. The one thing that is really important and many people understand is that retention of talent really is an investment. If you can't do it, it's a huge expense. I always start there. Many CEOs across the country do this. But we also have to be able to challenge the way we deliver care in some of our models. We've been doing it the same way for a very long time. That's how you build the trust with the rest of the executive team, especially when everyone's under financial pressure to say, well, this is what we can do differently because we want to invest in wellness, because we want to add that resource nurse at night shift with the staff that are less experienced, so they're not so anxious. It's always a compromise, it's a give and take. But there are certain things, and we've adopted this language around our financial planning here that are the non-negotiables. I really think investing in well-being of our staff. At Hopkins, it really is around our professional governance model. Our shared governance model, having those listening sessions and having people's voice count, and how it impacts our decisions is really fundamental to that. That is an investment. That's a financial investment to give people time to do that. I'm very well aware of that. It's important. My job as an executive is to really be able to detail and itemize the things that we're doing and the retention that we're really seeing and we are seeing it. It's exciting to invest in something and see that retention of staff that want to be part of the mission.

Fowler: Right. I'm going to ask you one very last quick question Deb, and that is, if you were meeting with CNOs around the country and they would say, Deb, why go to the extent of having a system level strategic priority about well-being for nursing? What would you say to them?

Baker: I would say to them, much of what we've been talking about over the last 30 minutes, and that is having it as a strategic priority keeps it in focus, and again, keeps us disciplined. Make sure that we incorporate well-being into all of our strategic priorities, and that we invest in it. When you don't have it as a strategic priority, then it does slip down to the bottom of the list of focus. I also think another part about keeping a strategic priorities that we're still learning. We're still learning from our staff what we need to do, what we need to pivot, what we need to invest in. We have a long way to go with that. I think it needs to stay a strategic priority, and probably part of our mission.

Fowler: Thank you so much, Deb. In saying goodbye to you, I also wanted to just publicly acknowledge you, both for your leadership in this space, but also for your incredible partnership that you've shown the Office of Well-being and and Well-being colleagues in general across the health system. Thank you for that, Deb.

Baker: Thank you, Carolyn, for everything you've taught me and the small team in the office of Well-Being that, this work that we're doing, we're not providing people soft skills. We're actually providing them survival skills and ways to thrive. Not just survive, but thrive in healthcare and deliver the best care we can. So thank you for your partnership.

Fowler: Thank you. Thank you, everyone for listening to our podcast. We hope that you can take away some of the insights that Deb shared today as we focus on how do we have our workforce thrive at work? That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [inaudible 00:31:10].

[MUSIC]

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Deborah Baker, D.N.P., A.C.N.P., N.E.A.-B.C.
Senior Vice President for Nursing and Chief Nurse Executive 
Johns Hopkins Health System

1. Johns Hopkins Health System Nursing adopted a strategic priority for well-being, which focuses on fostering a positive practice environment. Because we work in teams, the strategic priority is not just for nurses, rather it is intentionally worded to be inclusive of all team members, recognizing the interconnected nature of team well-being.
2. During the COVID-19 pandemic, Dr. Baker learned valuable lessons about listening, moving away from immediately trying to fix problems to truly hearing staff concerns. Sharing plans and progress, being transparent about challenges and explaining “why” have been critically important to well-being.
3. The work of a nurse is hard; adequate supplies, staffing and functional processes are fundamental to well-being. Well-being programming and access to support resources is important, but must coexist with strategies to address operational challenges.
4. Dr. Baker shares insights about supporting nurse managers through skill-building on relational competencies and compassionate accountability, and the need for evidence-based understanding of nurse manager roles.
5. Johns Hopkins embedded well-being into the practice council structure, rather than having a stand-alone well-being committee, signaling the fundamental nature of well-being to delivering patient care and to the practice environment.
6. Investing in well-being can yield long-term benefits for health care organizations, particularly in terms of staff retention and quality of care. Having well-being as a strategic priority keeps the focus, enables investment and allows us to learn from our staff members.  

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Wellbeing's podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Biddison: Thank you for joining us.

Biddison: I'm Lee Biddison, chief wellness officer for Johns Hopkins Medicine and your host for today's episode of the Vital Conversations podcast. Today, I am joined by two colleagues from Johns Hopkins Medicine, Michelle Campbell, who is the Strategic Learning Center senior director and has over 20 years of experience leading ambulatory operations, focusing the last two years on development and dissemination of enterprise-wide training programs to improve EHR efficiency and operational performance. Welcome, Michelle.

Michelle Campbell: Thanks so much, Dr. Biddison.

Biddison: Also with us, Dr. Maura McGuire, executive director for the Office of Johns Hopkins Physician Strategic Learning Center. She directs education and training in Johns Hopkins Community Physicians and works as a primary care internist. She also serves as assistant dean of part-time faculty and is an associate professor of medicine in the Johns Hopkins School of Medicine. Great to have you with us, Maura.

Dr. Maura McGuire: Thanks, Lee.

Biddison: I just want to plunge in to share with our audience some of the amazing things that you all have been doing to really improve our clinicians' experience interfacing with the EHR. I think people think of, in our case, Epic or whatever your EHR is, wherever you are, you hear the word Epic, and it's a dirty word. In many ways people groan, roll their eyes, all those things. You guys have seen this for sure. But it is also an amazing tool. You guys are doing such wonderful work to really help our clinicians move forward in that space. Maybe we could start off just with the basics. Can you tell us a little bit about the Strategic Learning Center? Maura, how about you kick us off?

McGuire: We started the Strategic Learning Center about three years ago to provide some operations-focused education to our ambulatory practices. We've been doing this for a while in our big ambulatory care group. That's Johns Hopkins Community physicians. But we didn't have the same operations-based training for some of our academic practices or our health system practices. We thought wouldn't it be great if we could identify a team to work with teams where we're delivering patient care and provide ongoing coaching around standard operating procedures for patient care in the practices and just help our managers and our physician staff have staff that were trained up to help them do the work they need to do. That's it in a nutshell. We focus on a couple big areas. One is just clinical support staff and that would be medical assistants, nurses, MOX techs, all the people that make things work, making sure that those folks know what they should be doing have standard operating procedures and follow them and then working through Michelle's team to improve epic skills. Epic efficiency is another big one. I'll let Michelle talk about that. Then the other thing that we try to do besides staff education is just billing and coding basics for professional billing just to make sure that people put in a lot of hours, and we want to make sure that they know how to use the existing codes to just capture the value of all the work they do. Those are our big three things.

Biddison: That's fantastic. Anything Michelle, you want to add on that piece?

Campbell: It's been really great to be able to bring this forward to our academic practices, like Maura said, we've been doing it in Johns Hopkins Community Physicians for a long time. You mentioned groaning when you mentioned EHR. I think when you start talking about In-basket, which is where we really started from an efficiency perspective, the groans get even louder. That's all the work you have to do after you finish working. Looking to see where we can standardize workflows so that it's easy and repeatable and where we can engage the team in that work. Really, the goal there was to lessen the burden on the providers. that's been the focus. Our investment initiative has been called the Great Eight, which was a term coined by Dr. Steve Sisson. In this, we had a physician improvement work group that was really looking at how do we tackle this problem. They came up with the eight message types that we could focus on to streamline and places where we could engage the team because we have a lot of people, as Maura mentioned, there's a lot of clinical support staff. Sometimes it doesn't feel like there's enough, but there is clinical support staff. We have CMAs, we have nurses, we have administrative staff supporting care of patients, and how can we really engage everyone in this work, rather than just leaving it to the physician to figure out?

Biddison: Say more about I've heard lots about Great Eight and wonderful feedback, but tell us a little bit more about what the Great Eight program looks like. Do you want to go first, Michelle?

Campbell: Sure. We have tried to tackle this in phases. The interesting thing about In-basket is I think when we went live with Epic 10, 12 years ago, we didn't really know what that work meant. I have to apologize to all of the clinicians out there because I was the one standing up in front of the room saying, it's not any different than the phone calls you get today. It's just the same work coming in a different way. I was so wrong about that. You will self-screen out of waiting on hold on the phone, but not at 10:00 at night when you can just shoot off a message from an e-mail message or a MyChart message. It's so easy to log in and send every thought that you might have, every concern as a patient that you might have. It's so easy to outreach, and that volume of work has exponentially increased and our staffing has probably not kept up with it. I was so wrong about that ten years ago and I apologize to everyone who heard that from me. You know that, and we never really thought about in-basket, like what does that look like? How should you tackle that work? What should the standard operating procedure be? As we've been meeting with clinics there's not been structured standard work development around this. Whereas we have a standard intake process. When you come in where there's a standard check-in process, the MA rooms you and takes your vitals and goes through a standard workflow. There's really no standard workflow around in-basket task management. We started this work back in 2021 with just some really basic workflows, really building off a program that JUCP had done years ago. Having that education and training team, they've been a little bit ahead of us. Really building off of that was just some really easy standard workflows on how to process a prescription refill request, for example. Making sure we're using a standard smart phrase or a standard template, if you will, to tee up information for that physician on when was the last time that prescription was ordered? Does the patient have any refills left? Because if the patient has refills left, that doesn't need to go to the physician. I can just call the patient. When was their last visit? When is their next visit so that you, as the prescriber, have all the information you need at your fingertips in order to say yes or no to that request? We did some really, really basic training. We do not have a great continuing education program around the EMR. There were a lot of new features and functions within Epic that people didn't know about. We spent time just presenting at faculty meetings, doing staff meetings webinars to do a catch-up training. Phase 2 of that program has been our in-basket sprint. That's the fun part. that is a three-month engagement with a division, the Department of Clinic, where we do a really deep dive on what are your what is your message routing look like today. Where are your messages going? Are they going to a pool? Who's in that pool? Is that going to someone else who can triage the message or the messages going direct to the physicians? Then in that case, can we reorganize that so that they're going to support staff first to be triaged? Because what we're finding is patients send all questions in MyChart to like, I need an appointment. How do I get to your office? Can I get a copy of my medical records? I need a copy of my referral. things that physicians don't need to answer and probably aren't the best, aren't best suited to answer. Getting administrative staff to handle the things that they can. We developed a scope of practice document. Our ambulatory directors of nursing got together across the enterprise so that it was consistent across the enterprise of who could do what in terms of responding to messages. Then in that in-basket sprint, we develop message handling guidelines. If you get this message, this is what you do with it and get very specific. That's been really helpful to help the administrative support staff who may never have really been engaged with this work before, give them very clear instructions. Once everybody agrees on what those guidelines are, we do one-on-one coaching with every provider, every staff person involved in In-basket work, so that we can review the guidelines and then make sure they have the Epic tools that they need to be successful in managing those messages.

Biddison: Those guidelines vary by clinic or vary by department. Or how does that work?

Campbell: They can. There are a lot of very similar message scenarios across departments, but you might imagine departments are going to have a lot more prescription refills than a surgical department. A surgical department is going to get a lot of questions about what happens. When is my surgery? What are my pre-op instructions? A lot of post-op questions, wound care, things like that that you're not going to see in a medicine. There's some variability to by and large pretty similar questions. Then where it varies is if I get a scheduling question, am I sending that to a scheduling pool? Am I sending that to Patient Access? Am I sending that to the provider's MOC or a medical office coordinator, which is an administrative person support person? We we definitely allow for that variability. A lot of it's going to depend on the staffing within that department. Some departments have a lot of nursing, and nursing is involved in that message, whether as the first triage person or in a nurse triage pool, where if it needs nursing support, it goes to nursing before the physician. Other departments don't have a lot of nursing in the clinic. It's more administrative staff. The guidelines will vary based on scope of practice.

Biddison: That all sounds great. I can imagine folks getting nervous if they're like, do I have to do this? Just like my colleague in this other department that's totally different from me? Because I think there is a lot and there's pretty good data to suggest that standard workflows are helpful. But if we over-standardize or over-control things that that can actually make things worse. It's great to hear that this wonderful balance of both standardization and flexibility is fantastic. How many clinics have done this?

Campbell: We've gotten through 100 percent of the Johns Hopkins community Physician clinics and about 20 percent of the School of Medicine clinics. Size-wise, the School of Medicine is quite a bit larger in terms of number of locations.

McGuire: That amounts to more than 120 different clinics or departments have done this training, which I think it's really a huge number given the small size of our teams.

Biddison: That is amazing. Tell us what you're hearing about people's experience with it and how it's going. Once you've come and gone, how people are doing? Tell us more about the impact. Maura you want to take that one?

McGuire: We do have a couple of numbers that we've been trying to take a data-oriented approach to just looking at our outcomes. One of the things that we did when we started the program was that we developed a dashboard that looked at a couple of what we call our key performance indicators. There are a couple of things we've been trying to get people to do that we think are simple steps to improve their efficiency. Actually, let me go back to what are the Great Eight. Those are the things that the workgroup that Steve put together identified as tasks that they commonly manage through their in-basket, where they thought they needed some help. The Great Eight are test results, prescription refills, patient medical advice requests and phone calls from patients, appointment requests, referrals and orders, letters and form completion supplies requests. Then finally, we added learning to use Haiku, which, as you know, is our local app for Epic. For then what we did was we went through our in-basket messages themselves and identified the volume in those big buckets. In fact, as the people on Steve's workforce had just imagined the big pieces of the In-basket pie are test results, which is almost a third of almost everybody's in-basket. Prescription refills are big in primary care, less big in some specialties. Patient medical advice requests, though, are also very big. Then the other things like appointment requests, referral requests, letters and supplies or things that staff really have a huge role in managing. We took a look at the pie and then we decided can we find one thing that everybody can do as a team to improve the efficiency of managing that slice of the pie. We looked at, for example, in the results bucket, we've been trying to get people to think about using a quick action, which, as everybody, as every epic user knows, is something that bundles a couple of clicks together into essentially a macro where it's a one-stop completion for what might be a complex task. We're really trying to get providers and staff to identify a couple of common quick actions for their most common results that come into them, whatever their specialty is. Another one is prescription refills, again, very big in primary care. What we've learned is that frequently people don't prescribe patients the maximum number of refills, even for stable medicines. If you have a patient on a stable medication, like maybe a statin for hyperlipidemia, the dose of that changes pretty infrequently. Why not just give that patient the maximum, the 90 or 100-day supply and then give them three or four refills? But it's interesting that that's not a universal workflow. If we're having people call in after six months or even in some cases one month for a refill, that can really increase unnecessary noise in our in-basket. We're just advising; give them a three-by-four refill response. Then for a P-match, those are complicated. patient medical advice requests. Those are our MyChart messages. What we've noticed is that a lot of those include things that really require a physician or a prescriber to respond. But at least a third and sometimes up to a half of them in many audits that we've done are asking for appointment requests, which really don't require the prescriber to get involved at all. Some of them are doing simple things like, hey, I'm coming to see you. Can you put in lab orders? Well, staff can do that. I need help making an appointment for a test that you want me to have done. Staff can do that. I need help printing out my med list. While staff can help patients do that from MyChart. What we've done a lot of work with, and Michelle has really led. This is helping each practice that engages with us. Go through a guidelines work group and develop some standard management approaches for the patient, medical advice requests that come into them in their specialties. Maybe I'll let Michelle talk a little bit more about that. 

Biddison: That'd be great. Michelle, tell us.

Campbell: Sure. We start with an audit. That's the best way we've found to really understand what's going on. We will actually go into Epic and look at the messages that are coming into either that clinical support pool or that physician in-basket directly and grab the general scenario. Is this an appointment request? I need a referral request, etc., and categorize them and look at how the staff handled that message. In a lot of cases, because again, no one sat down and really thought through what this work should look like or the flow should look like. Our clinical support staff was just a pass-through. They're just forwarding the message that they get to the physician and maybe reading them, maybe not and again, because we didn't tell them what to do with it. We will take the message scenario, what happened but what could have happened. We stole this, I think, from Vanderbilt this term that show the message.

Biddison: I love that.

Campbell: It's so good, and we have a whole video series on maturing the message that speaks to why and what this can do. It's really taking that message. How can you add value before you send it to the next person? How can you make it easy for that prescriber to answer that question? It might be calling the patient back to information. It might be I don't need to send this to the provider at all because they're asking for their lab slips that went to Quest. We did a system quick action. With a one click, you can reply back to the patient with screenshot instructions of how they can go into MyChart and find that information and print it out for themselves. That's really been eye-opening, I think, for a lot of groups to understand what my staff can do for me, how my clinical support staff can support me. Then it requires training. You can't just like, turn these guidelines over to your medical office coordinator and say do this without. Then we come behind and really show you how do you search the chart for the information that we're asking you to tee up for the provider? How do you invoke that smart phrase or that template? We put that as a speed button at your fingertips, so you don't have to remember what it is. We set people up for success that way. Then we continue to audit after the fact. Once that training has happened, to see if those workflows are sticking, and then they're Phase 3 of our initiative is really sustainability. We have a small grant that we received from MCI, which is our malpractice insurance carrier, to really help with this sustainability work. We're embedding coaches in the practice. After the sprint, we don't just disappear now, not for everybody, because it's a small grant. But those identify that we're piloting. Hopefully, this will build momentum, and the program will grow. Embedding that coach to continue to regularly audit, look for folks who might need some additional training. In one of our audits, identified a new nurse who had just joined the practice and hadn't really gotten a good orientation on those workflows. We were seeing a lot of errors in how she was handling the messages, per the guidelines. That was a great signal to get in there and do that coaching, and get her on the right track right from the beginning.

Biddison: That's fantastic. It's so exciting to see how these simple, straightforward structures that we really need and often aren't able to do for ourselves can make such a difference. Tell us a little bit about how the work has been received, what people are saying.

Campbell: I think one of the providers, it was really heartwarming to hear he had been receiving all of his messages directly to himself. One of the things we do at the beginning of the sprint is an audit of where messages are routing, because sometimes the epic build gets a little off track, or maybe you didn't realize there was another option. We have quite a few providers who are receiving their own messages, and we were able to switch him so that the pool is receiving the messages. Then what's needs nursing input is going to his nurse, and it's getting triaged appropriately, and he said it has had such an impact on his quality of life. Getting messages on Saturday night at dinner with his family, that he feels he needs to respond to right away because those messages are going to the pool. They're getting triaged appropriate going to his nurse, and he's getting them during work hours, which is really what my chart. Those messages were designed to be handled and responded to during work hours. Not in those off hours in the family time. That was really great to hear.

Biddison: That's fantastic. That promoting work-life balance by working more efficiently is wonderful.

McGuire: Well, I just want to add to that, one of the things that we've been trying to communicate is, what the provider work hours might be like, what prescriber work hours might be like to our staff. Everybody works really hard during their standard workday. But we've been trying to try to figure out how to engage people in this. I think some of our very busy staff might rightly say, well, why should I do more work? I'm already working really hard. We've been trying to connect with people at an emotional level, too. Just sharing. The goal is always to take care of patient needs as quickly as possible. But staff may or may not know that the people that they support are going home, and then after they finish all their notes. One of the things you've been working on is pajama time. We know that the average just say primary care provider puts in one and a half to two hours of after-hours work for every four hours that they see patients. A lot of that happens because of this in-basket work. We've just been trying to communicate with staff in really simple ways that your providers don't stop at 5:00, like maybe you do. They go home and then they open up their computers for another two or three hours, maybe, around midnight, and do a bunch of this work, and we really want to create that feeling that we're a team and we're all in this together. Letting staff give providers feedback. If providers could do a better job of supporting the staff, is there something the staff would like us to share. But also giving providers the chance to coach their staff and really get them involved in making it be a team communication process so we can get the work done, but support each other. I'll show up at work the next day, rested and happy and ready to do another day of care.

Biddison: Makes such a difference. I think it builds cohesion. When we understand what our role is within the team, and sometimes I think the just the pass-through piece, it lacks meaning. But when you know, as a staff member. If I can engage in a way that's meaningful both to the patient and to the rest of the team, that's helpful. That I think can be really impactful. That's really fantastic.

McGuire: Some people are really struggling. One of the other things that Michelle's done is some of the training team have worked individually at the elbow with providers who had huge in baskets with lots of folders and lots of old messages and things that they just couldn't emotionally get around cleaning up and just the work of sitting down with someone and making suggestions, consolidating folders, getting rid of old messages that were already addressed, but just sitting there and then letting someone come in to work the next day with a small, succinct in-basket that they can actually maintain going forward. Those are some of the things that we're also trying to do with this project. It's a culture change. Just saying that over the last couple years, as we've started using Epic, we haven't always done it as well as we could. Learning to do things better and changing the culture from people don't like it to. Boy, this is a great tool. It can help us work together. Get work done in a way that really supports the well-being of everybody, including the patients, including the staff, is something that we've tried to get to.

Biddison: It's fantastic. I love that community building. It's wonderful. Michelle, did you sound like you had something to add?

Campbell: Oh, I was just going to say I so agree with you. I think having the staff have meaningful impact to patient care. It helps them feel part of the team and feel more engaged. We want those folks to be engaged and happy working here because we need them to support our clinics.

Biddison: Absolutely. It sounds like there are a bunch more clinics in the School of Medicine who still need this. Are there other things on the horizon for the Strategic Learning Center in this space or related spaces?

Campbell: I think our motto for FY 25 is moving beyond the in basket and really tackling some other areas of epic efficiency. We are partnering with the clinical education team that's led by Julie Petter, who does all of the epic education to really enhance onboarding. What happens after your initial epic training when you initially get access, and how do we create more options for continuing education and the cadence for learning so that we're not just giving you four or eight hours of epic training and then setting you loose and really helping people understand epic is incredibly powerful, and I think it can be a really incredible tool to help you care for patients. But if you can't find the information and you can't navigate the chart, it's a burden. We want to make it have people enjoy it as the tool that it is, but you need more probably than that initial onboarding training.

Biddison: That totally makes sense.

McGuire: I think also as we implement other tools that are supposed to help us increase our efficiency, just being thoughtful about where people might need help to do the quick implementation thing and then take advantage of them. We just want to be thoughtful and provide more at elbow coaching in the places where people need it. That's something that we're not necessarily well-staffed for, but our strategic learning center could help. Think about the e-consent form that we implemented in the last year. I know a lot of colleagues knew it was easy, but they just couldn't quite get that first consent signed, and they really struggled with it. Just imagine putting a coach in the major or areas just so someone could come and say, I haven't done this before, just walk me through it. One and done. I know you talked about our new AI scribe. That's coming live in one of our podcasts. Another thing that I've heard is really easy, but I can imagine that I and maybe some of my colleagues who are a little more tech challenged might need someone to just sit down there and say, let's do your first note. Let's get you set up just so I don't have to look.

Biddison: Absolutely.

McGuire: I'm seeing patients. I'm just thinking there are other areas where we can be thoughtful as an organization and say we're investing in expensive technology to help us be more efficient. But where will a hand help? Is that something that a group like the Strategic Learning Center should be able to assist with?

Biddison: That's fantastic. We've made the investment, the technology. Now let's get you to where you need to be to really. I think that new technologies can feel a little bit like that black box, and I'm not really sure. How do I get started? For the early adopters, it's perhaps an easy thing to just plunge in. But for the rest of us, it can be a little intimidating. I'm so grateful you guys are there. Well, specifically around Grade 8. Can I ask just quickly if somebody's listening, and it's like, we need this X posthaste in our clinic. How do they reach out?

Campbell: Absolutely. We have an e-mail address In-basket queries at h.edu. Feel free to drop a line. Feel free to reach out to us. I would say myself and Laura, directly, but maybe I shouldn't offer that. But in basket queries, jh.edu, our amazing project manager, Kari Berlet, manages that inbox, and she will reach out and get you set up.

Biddison: Fantastic. Just one more time in basket queries at jh.edu. Great. We'll put that in the notes for the podcast as well, so people will have it. Well, Laura, Michelle, thank you so much for this incredible work. For all that you're doing to support all of our teams and, in turn, all of our patients, it makes such a difference, and we are super grateful. As we wrap up, anything that I didn't ask that I should have before we go?

Campbell: I would just love to say to all of the physicians out there, when we are taking advantage of coaching, I know it feels burdensome to set aside 30 or 60 minutes to sit down with someone, but it can really save you so much time. It's a small investment to save you a huge amount of time after the fact. I've sat down with so many physicians who will say, I don't know why I'm here. I've been using Epic for 10 years. I was told I had to be here and meet with you, and then within five minutes, they're like, well, I didn't know that. Well, why didn't I know that? Well, this is amazing. Trust me, it's worth the time to spend.

Biddison: That's great advice. Laura, any last words?

McGuire: No. I think Michelle's covered it all. Well, thank you both again. For our audience, this has been the Vital Conversations podcast. I'm your host, Lee Biddison. Take care and be well.

Biddison: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Michelle Campbell
Sr. Director, Information Technology
Mercy Medical Center

Maura McGuire, M.D.
Executive Director, Strategic Learning Center
Office of Johns Hopkins Physicians

1. Hopkins established the Strategic Learning Center in 2022 to provide operations-focused education in three main areas: clinical support staff training, EHR efficiency improvement, and billing and coding basics.
2. The JH Strategic Learning Center’s 'Great Eight' initiative helps team members strategically manage in-basket messages. The eight key types of in-basket messages are: test results, prescription refills, patient medical advice requests, appointment requests, referrals, orders, letters, and form completion.
3. One popular and helpful concept is 'maturing the message'. Team members focus on how to add value to the message before forwarding it on to the next person. This practice fosters collaboration and teamwork.
4. The Center continues to support teams through: standardized workflows for prescription refills, quick actions for common results management, message routing optimization to improve provider work-life balance, and audits to identify providers in need of coaching.

• https://www.hopkinsmedicine.org/office-of-johns-hopkins-physicians/education-training
• https://www.hopkinsmedicine.org/office-of-johns-hopkins-physicians/education-training/epicinformatics#great8

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison 

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-being's podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare. 

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning. Thank you for joining us.

[MUSIC]

Biddison: Hello and welcome. This is Lee Daugherty Biddison, and I'm your host for today's episode of the Vital Conversations podcast. My guest today is Dr. Kelvin Hong. Thank you, Kelvin, for being here. Kelvin is a Associate Professor of Radiology and Oncology at Johns Hopkins, and he is also the Executive Vice Chair of the Johns Hopkins Department of Radiology.

Dr. Kelvin Hong: Thank you so much.

Biddison: Grateful to have you with us. What people won't know is that we've just been having a wonderful conversation about travel. But for today our focus for well-being, will actually be on departmental efforts to support the well-being of our clinicians and our faculty, and other members of the department. Kelvin and I, some weeks ago started having some months ago, I guess, by now started having some conversations about what radiology has been doing, to support well-being on a departmental level. Kelvin graciously agreed to come and tell us a little bit about it here and so I'm excited for everybody to get to hear what you-all are working on. But as we maybe get started, Kelvin, if you could tell us a little bit about, the department itself, size, makeup, those kinds of things. People have a vision for what the department looks like and where you're trying to intervene and bring change, and then your approach to thinking about things on a departmental level.

Hong: Fantastic. Thank you so much. Just a little bit of background. The Department of Radiology at Johns Hopkins actually spans across our health system in the Mid-Atlantic. We have representation from all four hospitals, standalone hospitals, actually, we have standalone imaging centers which provides easy access for patients in the Mid-Atlantic region. The five other standalone imaging centers. We have almost 140 faculty and plus about just under 1,000 staffing in employees within the department. The footprint is quite large and notwithstanding, we've got a large training programs or variety. This is a at least operationally a large group. Hence, I think when when the notion of wellness came up and how to represent such a diverse large groups, we struggled, so my Chair Karen Horton and I thought about how we might address this and really heads the Wellness Advisory Council within the health system that frequently, I think it is actually, frequently a person to spearhead the department. Drive for wellness frequently is a person who has specific interests or may have interests or we feel has special interest. But the way we thought about it actually led us to go down the path of having myself, I had this as Executive Vice Chair was the fact that wellness itself is so important, yet I feel, maybe misunderstood and underrepresented or not sufficient weight has been given to this in many departments. It's and again, I don't speak from a seat of criticism, but frequently and it's given to someone who has interest and maybe doesn't have, I think, authority or even the weight or leadership opportunities to enact, change or impact the department in a meaningful way. We felt that it would be helpful that I took the approach. Actually, having taken the role, I actually, have tried to get better understanding of this important role. This led me down to giving recognition that in many departments, organizations that frequently the wellness individual has a large responsibility but is under-resourced and has often times not the knowledge base or the specialized knowledge to take on, I think is such a critical important component of our daily lives professionally and it impacts into our personal lives. I have taken a slightly different role for our department, and that I see it as an important domain that we should focus on and importantly, that it should be evidence-based. Everything else we do in our jobs frequently is evidence-based. We tend to take on wellness almost as if it's a part of another factor that we might, and I just see it as a challenge or problem or component of our workplace that we should tackle in, in a similar manner that we do every other aspect. You had to wait to do some reading and actually found that wellness is not very well understood, at least in the healthcare setting and healthcare workers that not sufficient evidence-base is being published enough. Also to give recognition that each Wellness Officer, wellness individual in each department has unique challenges. From my perspective, my department, department radiologists and radiologists itself has special challenges in wellness that is posed by our specialty on its own. We tend to be individuals that are work quite independently often by themselves. I think the workplace frequently you work in a dark room because light actually distorts diagnostic radiology form. We tend to work in dark rooms. It affects circadian rhythms. Some of us are shift workers. There are a lot of, I think a great representation, a large representation of women as well. Our challenges are a little bit different. But you could say the challenges of our department is similar, that we very distinctly different, say, from the emergency room which is entirely shift work and the challenges are different from surgeons. Hence, I think it's critical that a lot of the wellness challenges and solutions are somewhat unique. I felt we should tackle our problems evidence-based for our department in our constituents. Hence, speaking just from our department, I gave recognition that one, that we needed to have a department based focused approach. The first initiative that we thought about doing is actually, wellness frequently, from my observation is that, I found it less compelling when an individual who wasn't an expert wellness gave lectures or talks or gave advice to faculty meetings or groups about aspects that probably they're not experts on. I just felt it would be disingenuous for me to come up and tell my faculty that I think they need to focus on their sleep or their wellness or the way they tend to their personal lives or their finances and all the other aspects that might challenge what the notion of what wellness is. I felt it was important to arguably get an expert so frequently at least medical experts and I think individuals who work in healthcare, I think, have over time give credence to that. When you speak to experts and their credentials suggest that they have knowledge base or they have the authority to talk about this topic, that you sit up and listen a little bit more carefully. I felt that we could maybe tackle this issue by who should give recommendations, who should advise us and tie to another problem, which I've seemingly encountered once I actually took a look at wellness, was the fact that mental health challenges in our department was not that different from other parts of our health system, but arguably even higher because we work in dark rooms and are isolated frequently. The challenges of all aspects of mental health are being felt throughout our department and some obviously more than others and the vulnerable, and more pressured, frequently don't speak up. Our access to mental healthcare in our region is very challenging. Any parent or individual who has tried to seek mental health access in the last post-COVID era, I can tell you, is surprisingly challenging. Number 1, access to mental healthcare and then even just arguably speaking to someone who may be able to help you with authority is difficult because of the stigma attached to mental health challenges. I thought we just don't even know when we have a problem, we don't know how to get help and we don't know who to talk to, let's try solve that. I've decided to address that by actually having a mental health expert. In our case, I've actually sourced a psychiatrist who is not on faculty outside our health system, who is actually our wellness consultant, who is giving periodic mental health and wellness talks and our faculty meeting, based on, evidence-based guidance and will then guide our faculty and be open hours to talk about confidentiality, if not in small groups of issues that they care about. That could straddle both wellness and mental health or just have access to someone who is an expert to turn to. We've on a retainer sourced person who's going to help our department not to provide mental healthcare, but to be an expert of wellness that actually has the credentials to do so, who has a specific interest in group health. I felt that was a different direction to go in and so we funded that ourselves, and so we are providing a department resource. What evidence-based education surrounding wellness? Number 2, a person who can assist in mental health access and questions related to mental health and just bounce questions, ideas of individuals who find it hard to speak to another individual that they don't have natural access to. Secondly, a different direction of how we want to address wellness was the fact that I think, funding of wellness initiatives is typically in the department ad hoc. I thought we should just go about it and say, how much is wellness cost us? How much do we value it? How much how important is it? Let's put a dollar amount to it and as a pilot for one year, let's put our money to it per individual and give it to them to decide how they might use it. What we did was cut up within the budget, a wellness budget per division and based on the size of division, so per head, and give them that amount of money that they can spend within reason that can master approval through the school of medicine, funding of a process event or initiative that is important to them and have the individuals, is a small group decide what that might be. What has turned out to be, I think it's been really good so far in our department. Using the wellness budget this year, different groups have used the money in different ways. Some groups have elected to get some simple exercise equipment that is placed within the reading room, which is the space in which they all sit in dark corners and cubicles. When they take breaks, they can do exercises or stretching or some type of movement and get out of the chair and move. They have a little clock to things for each person, and everybody moves and almost like a circuit of work and wellness. That we felt was really great. Some groups have decided they want to get on the Baltimore Harbor, pirate ship and take go out as a group because that group specifically valued getting together and celebrating and laughing, and just being off physically campus. These are just examples of how differently people have decided to use their wellness budget. Then obviously there's some cooking lessons, baking, trips, book clubs, dinner, so all different varieties of what they think is important to them. As a outset in the initial pilot, we felt actually it was of value and people have expressed, you unusual it is that we have a wellness budget to the department that actually is individually based. Of course, you could argue what about as a group? I, as a Wellness Officer, still has a small budget to initiate department wide initiatives that we can also do. We're trying to tackle wellness, I think, on a individual group, large group, department level. Then because the notion of team building versus wellness versus just caring can be very hard to distinguish, but I think putting a dollar amount to it and trying to define how we might do this and the fact that we are trying. Again, you can never satisfy everybody, but starting somewhere, putting money to it and making access to someone with credentials of a mental health, person was the first direction to go in. Then thirdly, I've just recognized that people in wellness and even I, as the Wellness Officer, just are not, strictly speaking, probably credentialed or trained enough. I'm going to hopefully get some more training and educate myself to make sure that what we're trying to achieve has value and is evidence-based or has some type of background that our initiatives are not just some essentially arbitrary in that it's organized.

Biddison: There are so many things in what you've just said that are so wonderful and encouraging. There are a couple things that I think really struck me when we talked before, and also when you're talking today. One of them is really about agency and how important agency is for all of us in terms of determining what we need. Just the way that your radiology has honored the agency of the various divisions to choose something that works for their group using their budget, whether it's exercise, because all of these things are associated with well-being. In our office, we joke that everything is a well-being issue. There isn't anything that really doesn't touch the well-being of our workforce. But what one division needs at any given time to get up and move to those components for the group that's in the reading rooms versus another room, another group that really needs the social connection. Just the approach is really I just love that it honors both that diversity of need and the agency of the folks who are engaging to really lay hold of what's most important to them. I have a couple of questions for you. One of them is just around, what has surprised you in this journey of this work in radiology?

Hong: I suppose surprising that the leadership was willing, Number 1, to back it. Again, obviously, I think it takes good leadership to recognize that since we eventually do spend money on it, why don't we just proactively do it and plan it? If you do that, it then needs to go into the budget. That's I think insightful leadership to do this. I was surprised thinking that we might get some resistance of putting this through but we have not. Number 2, that wellness is so different to individuals and the disparate views on wellness. Some people dismiss it all the way to people who crave it and so giving recognition to the fact that everybody approaches wellness to a different degree. But I think the important thing is that when presented they actually all gravitate towards it. Because when you say, you can spend the money anywhere you want, the IO group which has greater bravado, these are people doing procedures every day, decide to go to Topgolf and have a fun day out, which is so different from another group, shows you again that they were very happy to embrace it. But you asked them what they think of wellness, and some people will dismiss it because it is still, I think, uncomfortable to some individuals, and even in this day and age of that the fact that they have wellness needs. Again, I think it's somewhat surprising to me that, given the opportunity, people embraced it. But the notion, like in many, I think, buzzwords in our vernacular now, some of the time that wellness does not get the credit it needs, despite the fact that it's so critical, that it's been surprising. I've been surprised by how it's been received and I think in this next year in the FY25, we'll find that our people are asking for, what are the extremes of what we can do? I think that's will be the next phase of just constraining people, not going off the reserve and making sure that it's well thought out, but I think we have to give recognition. It's been surprising how what wellness means to each individual. I think again, it allows me and I think the department to recognize that the diversity of the needs, why it's so hard to make, it'll work for everybody. We just need to make sure that we have mechanisms and outlets or give the groups sufficient opportunities to try address it in their own way, I think will go a long way. My next step is probably arguing is to quantify this, whether we can measure this and argue this is what is probably more important that we have evidence-based backing of some of these initiatives, because it's actually not in the literature and arguably very important. Probably what I'd like to say is probably the return on investment for creating a wellness budget is that we can maybe measure this. Starting to try and understand some of the survey or quality of life or impact scores that this might be able to be measured. Then to have faculty who may respond better to some of these surveys, given recognition that there might continue some of these innovates they allow them to do whatever they see is valuable to them, since they've chosen to do it, hopefully get us a meaningful data out of this. That's the next stage.

Biddison: Well, folks who are listening can't see me grinning from ear to ear because this measurement thing is a passion of mine. I'm excited to hopefully have more conversations around measurement with you. It's a perfect segue to my next question, which is around, what does success look like? I mean, we think about surveys and things like that and measuring burnout, to fulfillment engagement and those types of things which I think are critical. But are there other components of a successful approach to this that are top of mind for you and for Dr. Horton as you think about this?

Hong: I suppose in the long run, I would love to see this reflected in, obviously the satisfaction surveys and the [inaudible 00:20:55] of the staff, and other standardized surveys that our school and a healthcare system takes, but I'm not sure, it was hard measure. But that would be fantastic to show some impact on those scores and changes. I think just obviously just from a personal level that seemingly the individuals are giving us credit for trying is helpful. I'm hoping that it changes some retention rates that we may be able to see, so multifactorial, but we obviously need to just take cognizant of the fact that sometimes doing the right thing doesn't always have a measurable outcome, so long as it's valued from a positive light. But I'm hoping to see some changes in that and then obviously, if we can use some standardized survey data that will drive this. But I think even the notion that, we are hoping that survey results from XYZ will help to continue the funding of the wellness budget. Hopefully we'll get some positive reaction because again, this is an initiative that we've actually started out with very little asking back, which is unusual in medicine. Typically when things are funded or they're asking for some outlay of work or labor or some effort, that this is seen as a really a freebie. But I think it's obviously a critical component as we as leaders and the workplace should be providing in some way at least give a notion that we think this is important and this impacts how you perform at work, and then hopefully this does have a measurable outcome.

Biddison: Yeah. I completely agree. You mentioned retention which I think is such an important piece of this equation. We work with such amazing colleagues and being able to keep those teams going and supported, and productive in the ways that are meaningful to them not just cogs in a wheel, but in ways that are engaged and meaningful. I think is really important and is has got to be one of our most important returns on investment. You made the point earlier that we're going to spend this money one way or another, why not spend it upfront? When we think about turnover and recruitment and those kind of things which are incredibly costly into these investments that we make, upfront make so much sense in the ROI. We think although to your also earlier point, we really need to do more work to demonstrate that, we think are really worthwhile. Kelvin, thank you so much for taking the time to chat today. It's been such a pleasure. What, didn't I ask you that I should have asked you?

Hong: Oh, no, I think you've covered it all. You've taken on a large challenging job of addressing wellness in a stressed out large scale health system. But nonetheless, I think it's very important. I think we're making headway within all the departments. Again, hopefully, some of these individual experiences can drive, some more standardized approaches throughout our school will certainly help a lot. So appreciate what you do too.

Biddison: Thank you so much and thank you to our listeners for being with us today. See you next time. That's it for today. If you enjoyed what you heard, please share this podcast with a colleague and as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

[MUSIC]

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Kelvin Hong, M.B.B.C.H.
Associate Professor of Radiology and Radiological Science
Executive Vice Chair of Radiology

1. Departments should be proactively investing in well-being. We know the cost of turnover and recruitment, so let’s get ahead of it by investing in strategies that mitigate burnout and promote fulfillment and well-being. A key component of this effort is assigning leadership of well-being to someone with decision and budget authority.
2. In healthcare, our goal is to be evidenced-based in everything we do, so why don’t we treat well-being the same way? We should be investing in well-being training within our departments and bringing in experts to guide us in implementing proven strategies.
3. There is no one-size-fits-all strategy for promoting well-being, across departments, between divisions, and among teams. Allowing individual teams to decide how to spend their budgets, based on what matters most to them, supports autonomy and agency which we know is connected to well-being.
4. We know well-being impacts our experiences at work and in life, but the impact of well-being initiatives may take a while to show in our survey results. So, stay the course, because good things take time.

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Wellbeing's Podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare. 

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning. Thank you for joining us.

Biddison: Hi, I'm Lee Biddison, chief wellness officer for Johns Hopkins Medicine and your host for this episode of our podcast, Vital Conversations Influencing Workplace Well-Being and Healthcare. I'm excited today to introduce my guest, Corey Feist, who is co-founder and CEO of the Dr. Lorna Breen Heroes Foundation. Corey, welcome.

Corey Feist: Thanks for having me, Lee. It's wonderful to be here with you today.

Biddison: So excited to have you on our podcast. Today, we're really hoping to talk about catalyzing transformative change in workplace well-being and doing that on a national level. Obviously, it takes one person to change their space. Corey and I have known each other now for a little while, and Corey is my go big or go home friend and so we're going to take this opportunity to talk about trying to do this on a national level and really make an impact. But before we go there, Corey, for those who are listening, who maybe haven't met you and aren't familiar with the foundation, will you tell us a little bit about yourself and about what the foundation does?

Feist: Sure. Again, it's wonderful to be here with your listeners today. I grew up as a lawyer in healthcare. That's where this began, this journey, in the late 90s, spent time embedded as part of my legal training in law school at, actually, Penn State Hershey Medical Center. It's where I got to see what it might be like to work inside a hospital system. Then I went into private practice after that and then quickly returned inside an academic medical center, which is based in Charlottesville, Virginia, the University of Virginia Health System, where I spent quite a bit of time working on a variety of legal and regulatory issues, which now your listeners are already turning this off so we will quickly move past that in the story. But I had an opportunity to become the general counsel of the organization that employs all the physicians and the advanced practice professionals, called the University of Virginia Physicians Group. I really transitioned to the clinician side of the business of medicine, returned to get my MBA, and then became the CEO of the medical group shortly thereafter. I spent a lot of time over my 20-plus-year career at the University of Virginia Health System, watching the weeds creep in the garden when it comes to administrative burden that's been shifted onto the workforce. I spent quite a bit of time trying to cut back those weeds, whether those weeds were in the form of things like prior authorization or in the forms of the electronic medical record, or just this increasing shift. In the spring of 2020, we experienced a family tragedy when my sister in law, Dr. Lorna Breen, emergency medicine physician in New York City, experienced a mental health episode following COVID and returning to the workplace too soon when she was not at all recovered, but felt compelled to run back into the burning buildings like the firefighters did on 9/11. Lorna's experience quickly moved from her first singular mental health experience to expressing concerns to me and her little sister Jennifer, who's my wife, about the ramifications on her career for obtaining mental health treatment. Shortly thereafter, she died by suicide, and we began to hear from the workforce in droves. The volume of communication that we received after her death on April 26th, 2020, was a tsunami of feedback that I, as a healthcare leader, had never heard or had not maybe realized was under the surface all along, which are these mental health concerns that healthcare professionals have and the really intense stigma around help seeking, let alone getting mental health treatment? That feedback, which continued in earnest for years, was the driver of creating the Dr. Lorna Breen Heroes Foundation, which serves to support the well-being and mental health of healthcare professionals of all types across the country. Our mission is to reduce their burnout, improve their job satisfaction, and we envision a world where seeking mental health treatment is universally viewed as a sign of strength. We've had quite a busy run and impactful run for the last few years, but I think the most important thing for your listeners to know is that healthcare professionals are human, too. That may sound trite, maybe overused, but they're not treated as such when it comes to having to take care of themselves or recognize the humanity and the practice of medicine, and we all need to do a better job, whether those are policymakers or healthcare leaders, or just the general population, recognizing that we desperately need health care professionals to be able to provide this critical infrastructure for health care in the country. In order to do that, a very critical element of it is just recognizing their humanity and supporting them, just as they have supported us their whole career.

Biddison: I love that. There's a lot of talk in training about how we navigate the doctor-patient relationship, and I think that word is key. It's a relationship between two humans, and yes, we as clinicians, as physicians, and advanced practice providers, nurses have a responsibility to our patients. But we do also bring our humanness to that space, and it's so important for us to acknowledge that. Well, this is so deeply personal, as we focus on the mental health space, so deeply personal, and I sometimes struggle to think about how do we take this to this macro level and tackle it in a structural way that's meaningful and still acknowledges that unique personal component. Tell us a little bit about your thinking on that.

Feist: It starts with listening. Sometimes leaders of all flavors start with their mouth when they start with their ears. For me, there is no better example of that than listening, reading, and just the blessing, if you will, that was the feedback after Lorna's death. That Lorna's experience was not an anecdote, but really a very consistent experience by many. When you listen, and then you follow up with a question like this one, Lee, what does it mean for you to feel valued and supported as a clinician in this environment? What you get in response to it is the gold. It is what you need to act on. In some ways, it's just very simple. It's human conversations. It's personal conversations. Unfortunately, those are hard to scale if you will. Everybody in business is trying to scale the solution. It lends itself to scale, but you have to go slow first to go fast if you will. That going slow part is really having these individual conversations. I remember that a key piece of research that came out of the American Medical Association during the COVID-19 pandemic was the survey results from this survey that they administered across all healthcare professionals, all staff, called coping with COVID-19. During that time, one of the big takeaways was that less than, or well, about 50 percent of the healthcare workforce, regardless of role, felt valued and supported by their employer. I think one of the struggles with that, that folks, at least in the conversations I was having, were really struggling with is how do you scale a solution to that? Because it is so personal. But what you can do is you can then train the leadership to have those individual conversations. It's not that leaders necessarily have to act on every single response, but I think when you start to see things and hear things like we've heard over the years, that gives you a direction to focus your energy. It's important to listen, and it's important to focus and tailor your response to what you're hearing. That's been really, in some ways, our approach. The last thing I would just say that I think is also really critical, particularly in healthcare, and for those non-healthcare listeners, healthcare is such a siloed industry. Every specialty, every inpatient unit, outpatient unit, every hospital system is really quite siloed, even if they're in a health system. You often find that the department on the second floor doesn't know what's going on in the department on the fourth floor, and as a patient, you may not see that. But the point in all of that is to say that taking an interdisciplinary approach to this work is absolutely critical. When you start to listen, when you start to then focus, and when you're listening, not just to one singular type of voice, but to all the voices in a hospital system, then you start to be able to craft solutions which will improve the workplace, which ultimately is what we're about because the mental health of healthcare professionals is heavily driven by the workplace environment. It's incumbent on all of us to try to work tirelessly to improve the workplace environment so that healthcare professionals can do what they trained to do, which is take care of patients or do research or teach whatever their flavor, but primarily patient care.

Biddison: So many things to ask you about. One of the things as you're talking about the silos and the interdisciplinary conversations that need to happen, I reflect as a, my background is in pulmonary critical care and internal medicine. Every internist and probably surgeon will tell you that the interactions with the ED is always never what we wanted. There's something they didn't do, and this would have been Lorna. Why didn't Dr. Breen put in a line before they sent this patient up? Why didn't they send this test? Why didn't they do that? Over the years of my practice, I've come to realize that that situational awareness piece is so critical. In an academic environment, I try to bring this up as often as I can when we start getting grumpy about, well, we didn't like that consult that we got, or we didn't like what the editor did, do we know what's going on? It could very well be that patient that didn't have some test sent came up to me quickly because they were chased in the door by three traumas or a call out or things that we don't know about, and working to. People make mistakes. I'm not saying that there's an explanation for everything, but there are an explanation for a lot of things that, if we understood, would make a big difference in how we communicate with and support each other for sure. Let me ask you this. You're talking a lot about listening. I'm curious about 1 or 2 things that maybe surprised you to this point in your journey, things you heard that you thought, I did not see that coming.

Feist: Well, I'm glad we have four hours for the rest of this conversation. The first thing that surprised me is a non-licensed healthcare professional was Lorna's story and Lorna's concern around obtaining mental health treatment, and what the ramifications would do, and how reinforced those concerns are beginning in the earliest days of training medical school, even undergraduate education. Maybe a broad statement there would be, I had no idea about how stigmatized mental health care is within healthcare as a profession, let alone taking a break. I know that there are a lot of professions where, the law, as an example, you have people who go into this because they are very driven people. You're going to get that obviously in health care; it's part of your toolkit for success. What I had no idea about was just how many real penalties or perceived penalties exist for licensed healthcare professionals, doctors, nurses, pharmacists, etc, for doing that. I think that's been a huge part of this work, and it's really driven a huge part of our impact and our solutions at a national level. But I think that for me, that singular issue, it's not just my lack of knowledge. When I talk to healthcare leaders, particularly healthcare leaders who are not physicians or nurses, and you raise this, they look at you like, wait, what? Which was what we were saying to my sister in law when she started to express these concerns to us, wait, at that point, 2020, now 2024. There's a thing called the Americans with Disabilities Act. What do you mean you are penalized for it? I think that's been a huge thing. I'll just share with you. I was recently in a conversation with a staff member as a member of Congress, who was asking us about the Dr. Lorna Breen, Health Care Provider Protection Act, and when I started to bring this up, that staff member actually stopped the entire conversation and she turned her head to the side, and she said, wait, what are you telling me? I said, "Yeah, this is a real thing," and it was not just a singular moment. I think that is one of our biggest surprises, and I would also say on the other side of that in the good news department, now that our foundation has put out a solution set for that, we've put out a toolkit for free for any organization to use, whether that's a hospital for their local credentialing questions, or a or a medical board, or a nursing board, or a pharmacy board, or a dental board. Their willingness to change and act rapidly, use our toolkit, apply for our Badge of Recognition, which is our All in Champions Challenge Badge, which is intended to be and become a visible sign for the workforce of where they're not going to be asked about their prior mental health treatment and diagnosis, which is that big concern. That in a very good way to see that progress so quickly. As you know, healthcare moves at a glacial pace when it comes to changing its behavior. But the reception to that and the speed with which leaders of all makes and models, whether you're a licensing board, executive director or board member, or a hospital CEO, CMO, COO, etc. That's been also similarly important. A big moment and surprise in this.

Biddison: Let's dive a little deeper into the toolkit as to and get you to tell us a little bit more about that. I will say for our listeners who maybe aren't in healthcare or licensed physicians, I have been struck. When I talk about this, what I always say is it really says something to you subconsciously. If you fill out an application for licensure or for credentialing at a hospital, when you're asked about your mental health, immediately after being asked if you are a convicted felon, which is actually the way that it goes often.

Feist: It's unbelievable. It harkens back to this day where folks disconnected mental health from physical health. It harkens back to a day where you were thought of if you had a mental health condition as being less than and in it being criminal, if you will. If you think about that also, Lee, and then how that could translate into how you then view your patients with mental health diagnosis. Then because of all of that layering of individual external stigma, and then this institutionalized stigma that you're experiencing with all these questions, how could you ever see yourself as a patient in need of mental health treatment? There's just too many signals around you that, that is bad and it is, at a minimum career threatening if you were to dare tread into that ground.

Biddison: It's honestly pretty astounding. I think that another question though, that that should be asked and I know that you guys have thought about this is well, Corey, are you saying that it just doesn't matter if people have mental health issues? Our mental health need mental health care. I think this is important because if we're using a biological basis for thinking about mental health or mental illness, then we know you can be impaired by any physiologic disease. You could be impaired by diabetes, you could be impaired by heart disease. Actually it is reasonable and appropriate to say you can be impaired by mental health issues or mental illness. I know that this is not what the foundation is saying. But what do you say to the people who say, well, it doesn't matter?

Feist: What matters? What we want and what matters is that people, whether they have diabetes. I'm so glad you brought that up, whether they have a medical condition or a mental health condition, that they get help. That's what matters. That's what we're trying to inspire and break down any barriers to because, as you know, being treated for any condition can often result in you getting better. It often does. But if you don't treat that diabetes, if you don't treat that macular degeneration or your depression, things can get out of control and be harmful for you and for those around you. I think that's actually the point. The Americans with Disabilities Act allows an employer to ask questions about whether or not an individual is currently impaired, and that's completely appropriate. What's not appropriate is to say, Lee, have you ever gone to therapy in the last 10 years? Now that COVID's happened, I'm not sure I know anybody who hasn't. Any clinician who has to answer that question now is going to be forced to lie. Then you sign on the dotted line that everything in this document that you submitted is truthful. If anything isn't truthful, you can be terminated. Here's an idea. Let's put your entire career on the line for something as trivial as getting yourself taken care of. That's the self-narrative. What we want to do is we want to have people in treatment, and we want that treatment to be whether that be a physical condition or a mental health condition or both. We want people to feel the fact that they can get this treatment without negative repercussions on their ability to have a career and to take safe care of patients.

Biddison: I love that this is so important. Let's go back to the toolkit for a second.

Feist: Sure.

Biddison: We are again talking on this very personal and individual level. What we want to do is create systemic change. One of the ways to do that is by disseminating tools. Can you tell us in a little bit more detail about this tool? I know there are actually other toolkits and resources that the foundation is also promoting.

Feist: Absolutely. Let me just maybe set the table for why this is important. This would be important even if it was just Lorna. It's more important because this is much bigger in scale and impact. The Dr. Lorna Breen Health Care Provider Protection Act was the Federal law that was created after Lorna died. It was the first ever Federal law that created programs to support the mental health of healthcare workers and to reduce suicide. One of the byproducts of that was the American Hospital Associations work with the CDC to publish a suicide prevention guide. In that suicide prevention guide, it identified three key drivers of suicide among health workers, and the first one that they list is the stigma and concern around getting mental health treatment. This was not just Lorna's concern. This applies to all. I want to just to put that into context for a minute. What we have done is we have created tools which are on the drlornabreen.org, which allow organizations to audit questions that they might have on applications. I'll talk about what those applications might be, change those questions and then communicate the changes to those questions. Let's just go back to the top for a second. What we've learned in this work is that healthcare professionals who are licensed and I'm emphasizing a license for a minute are asked questions that are inappropriate. Which are about prior mental health treatment and diagnosis in at least the following areas. When they apply at the state level to be licensed, whether they're a nurse, a pharmacist, a dentist, a doctor, a veterinarian. If they are a doctor or an advanced practice nurse, when they apply to a hospital to obtain what's called credentials to be able to perform um pulmonary critical care as you so, so well do. They are also asked in that same credentialing application, their peers are often asked in a peer reference form questions about, for example, these mental health state or prior mental health treatment and diagnosis. You've got a a licensing level. You got it in a hospital credentialing application which has this little other document called a peer reference form, which means that these peers are getting asked these questions about her. Then you keep going. You wanted to get paid for your work, your insurance company that pays you, your commercial insurance. They're going to have a similar kind of a form. Same questions. Or you wanted to be covered by malpractice insurance. Same thing. You've got these same issues that permeate. Our toolkit has the exact same solution for each one of those because it's the same issue. Audit your questions whether they're on a licensing level or one of these applications change and then communicate. When you do that and you submit those to our foundation for verification, because what we found is that sometimes organizations unintentionally create more of a problem for themselves when they do the work, even though our toolkit is excellent, the people can overthink it and unintentionally create more confusion in their documents. We verify them, we give feedback and then importantly, we give out this All in Champions Challenge badge. The communication part of this, Lee, I think is the longer part because of what we've talked about. This work to build stigma starts at that early age. The work that we need to do to unpack and break down the stigma and stop the stigma needs to be reinforced over and over again, which is why for our foundation, what we've done is on that same website at drlornabreen.org. Every September, we publish what we call the state of the States, which is if you're a doctor, if you're a nurse, if you're a dentist, if you are a pharmacist, you can click on your state on a map of the country and see whether or not we've been able to recognize your state as being free from these questions about prior mental health treatment and diagnosis. It also allows you to click into your state to see whether which hospitals in your state have done this work at a credentialing level. Then our hope is to expand that to insurance companies and others. But the concept is we want to be an impartial source of truth for clinicians, for their families. If their families are hearing something out of their loved one who's a clinician about these concerns, we want to be the source of truth. That would have been incredibly helpful for us as a family, because Lorna was so convinced about the impact on her medical license in New York, and we couldn't dissuade her of that. However, come to find out that Lorna was incorrect about her medical license in New York. In fact, the medical licensing application in New York doesn't even have questions at all about mental health. They were a best practice, and yet she had no idea. When I speak with medical students, when I speak with families of those who have lost loved ones to suicide, I always ask them if they're aware of the rules in their state where they want to be and not one person I've ever talked to and I've talked to. As you know I'm a professional talker, so I talk a lot. No one's been able to answer that question. That tells me that there's an opportunity here to make it clear, because in this context, if we simply communicating what the rules are can be and will be life saving. That's the toolkit. These challenges through our all in coalition, all in well-being first for Healthcare Champions Challenge. Our badge is now benefiting over 1.2 million health workers in the United States, and we've got a lot more to go. I think there's about 15 million health workers in the United States, so that's not a bad impact. That's not a bad start. We need everyone's help.

Biddison: Including Johns Hopkins. We know.

Feist: We rebuilt your help, Lee and everyone else's help. But I will just say, just to inspire you for a moment about this. We had a medical student recently not in Maryland, in another state, that medical student went to the Medical Licensing Board of the state and got the board to change their questions. A medical student is early 20s, not the most on the pecking order of leaders, not the highest. But you know what? Anybody can help make this change. That's inspiring that folks can can make an impact like that.

Biddison: It's totally inspiring, and I will share with our listeners that this is the top of our priority list as a team in the Office of Well-Being this year, so we are very excited to partner with the foundation to get to where we need to be on these important issue. Corey, what haven't I asked you that I should have asked you?

Feist: The Dr. Lorna Breen Health Care Provider Protection Act is up to be reauthorized by Congress. This was first of its kind legislation. It created programs across the country that are benefiting and have benefited thousands of healthcare workers. We we did this in a bipartisan way. We did this with the support of hundreds of organizations across the country. Congress needs to reauthorize the law right now and re-up it, because every law that creates programs has a time bound, the program's all time bound, so we need to extend it for five years and then we need to have it funded every single year. What you haven't asked me is what your listeners can do to help contact Congress. We have had over 13,500 people write messages to members of Congress. We've got again, a tool on our website where we're like, Lowe's of tools. We've got all the tools that you need Home Depot, Lowe's, pick it, pick one. Your local hardware store. We've got them all. But if you go to drlornabreen.org send a message to a member of Congress, it's takes 45 seconds to do it. If you want to use our canned message, if you want to write your own. We've seen hundreds of messages that have been personally tailored, which just reinforce why we do this work. If folks are looking to take further action and support healthcare professionals across the country having Congress reauthorize and fund the Dr. Lorna Breen Health Care Provider Protection Act would be a huge step, and I think what we need to make sure that people understand is that the mental health of our healthcare workforce is worse than any other segment of the workforce in the United States. The Dr. Lorna Breen Health Care Provider Protection Act is just one step in a whole staircase of health policy that we need to create to support health workers. We've got to make sure that members of Congress know that the bill in its first three years had a great impact, but it didn't solve the problem. We've got a lot more a lot more to do. That's the last thing I would just ask for your listeners to make sure that they do, and if they want more information about it, they can contact us through the website as well.

Biddison: Fantastic. I can attest I have used that tool and sent a message to my Congressman senator. It is easy. What's super fast? I'm so grateful to have that just a resource to be able to add my voice. Corey, thank you so much for taking the time to be here today. I've loved our conversation, as always. I know our listeners will have learned a lot, and we are excited to keep track of the foundation and what's happening moving forward.

Feist: It's been wonderful to be here with you, Lee. Your partnership personally, as well as the partnership with Johns Hopkins has been huge for us, and I just want to thank your listeners also for paying attention today and supporting our healthcare workforce. They desperately need it.

Biddison: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

J. Corey Feist, J.D., M.B.A.
Founder and CEO
Dr. Lorna Breen Heroes’ Foundation

1. Lorna Breen died thinking she could not receive mental health treatment because it would put her career at risk. An outpouring of feedback after her death confirmed that this is a common fear among physicians and other clinicians.
2. Questions regarding history of mental health treatment on licensing and credentialing applications is a known contributor to stigma and a barrier to care. Many health care leaders are unaware of the impact of these invasive questions on the health care workforce.
3. Organizations can learn how to audit and change their credentialing processes and advocate for state licensing reform through a toolkit provided by the Dr. Lorna Breen Heroes’ Foundation.
4. Organizations can apply for a recognition badge through the All in Champions Challenge program. The badge is a visible sign to workforce members that their mental health and well-being are priorities.

• Dr. Lorna Breen Heroes’ Foundation
• American Foundation for Suicide Prevention