Episode 16 : Striking the Right Balance:

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Intro/Outro:
Welcome to the Smart Care Team Spotlight presented by care.ai, the smart care facility, platform company, and leader in AI and ambient intelligence for healthcare. Join Molly McCarthy, former CNO of Microsoft, as she interviews the brightest minds in healthcare about the transformational promise of AI and ambient intelligence for care teams.

Molly McCarthy:
Too often, technology makes caregivers' lives harder, not easier. Time for smart technology to empower care with a more human touch. Today, we have the pleasure of being joined by Doctor Mary Beth Kingston on the Smart Care Team Spotlight. Mary Beth is the Executive Vice President and Chief Nursing Officer at Advocate Health, headquartered in Charlotte, North Carolina, and was appointed to this role following the combination of Atrium Health and Advocate Aurora Health. She previously held roles as CNO for Advocate Aurora Health, and Aurora Health for the past ten years, where she served as a member of the executive leadership team and was responsible for nursing practice and standards as well as patient experience. Prior to joining Aurora Health Care in 2012, she served in a variety of clinical and administrative roles, including system nursing leadership, Vice President of Operations, and president of a healthcare consulting firm. Mary Beth is currently serving on the Board of Trustees of the American Hospital Association, where she chairs the Hospitals Against Violence Advisory Board. She recently also joined the boards of Providence, Saint Joseph's Health, and Mainline Health Systems. Welcome, Mary Beth, and thank you so much for taking time to speak with us today on the Smart Care Team Spotlight.

Mary Beth Kingston:
And thank you for having me, and looking forward to it.

Molly McCarthy:
Great. I'm gonna jump right into our first question. And, Mary Beth, you've experienced health system consolidation throughout your career, an industry trend which certainly seems to be accelerating. And last year, at the end of 2022, Advocate Health combined with Atrium Health and now has a footprint of 67 hospitals across six states, supported by 150,000 employees, including over 42,000 nurses. As you think about the mergers and acquisitions and our nursing leaders, how do we help them interpret what this means for them, their teams, and their patients? And I've got a second part of that question, too. How do you see hospital system mergers and acquisitions impact culture changes and practice standards for nursing?

Mary Beth Kingston:
There are two big questions there. So I'll start first with just the first one. How does this kind of impact nursing? I think for us, one of the really exciting things, particularly for nurses and bedside nurses in direct care roles, was to say, this scale, it's we moved from being, I think, the 10th largest not-for-profit to the third. The fact that we are this big scale gives us the opportunity to really impact nursing and patient care throughout the country, and that kind of excited, that really excited people. So I think that's an important thing is to focus on why you're doing this. I also the scale is one thing, and I also think back to when Advocate and Aurora merged and then the pandemic hit and the things that we were able to do, we would not have been able to do alone. Being able to the way we kept people whole, the way we were able to share staff, depending on where the pandemic was hitting at the time, I think the scale in and of itself is an important piece of it. Also then explaining how we would be looking for synergies, how does coming together improve care in at Advocate Health? One big area that I think people really appreciated was health equity, and that both organizations had this commitment and expertise in that area. And we've invested heavily, and we're building a center, and we'll have a, I think, a tremendous impact looking for those synergies, looking for opportunities for cost reduction. Also, with the cost of care going up, how can what can you consolidate and what can you learn from each other? With that being said, it's changed. There's no two ways about it. But I will tell you, I, I still remember sitting in a group during following the AdvocateAurora merger and folks say I it was a group of ambulatory nurses. And I said, tell me how your life has changed. Raise your hand. Not one person that first year raised their hand. The changes tend to be at different levels within the organization initially, until you start looking at potentially benefits and those kind of things. But it's changed. And so with change does come a little bit of anxiety. So many people will their reporting might change, their scope might change. And that I think is something that we have to pay attention to as nurse leaders is to recognize that, listen to it and really try to make sure that doesn't get in the way. What I found with nurses, though, is that the culture piece is so important, and it's really can be one of the most rewarding, but also one of the most challenging. And many organizations. And we've done them, have done culture assessments to see what where you're together and maybe where you're not.

Mary Beth Kingston:
And it might be something as small as how you communicate things. Do you communicate this way, and who do you direct your communication? So I think that's important. When nursing tends to come together to discuss integration activities, we really do zero in and focus on that foundation of nursing, which is really directing everyone on how are we going to improve care, how are we going to improve the work environment for nursing. So I think nurses really can just get in there and go to that. The other thing that's really important, I think, to remember, is to just agree on some basic principles, because it can be a stressful, exciting and stressful time. So assume good intent. Don't people may not say something, they may not be as familiar with your culture, but assume good intent. The typical things direct your questions to the right person, but also prioritize where you're going to focus. Everything doesn't have to come together boom the first year. What are the most important things that are going to make a difference? And it it's not about saying, which way are we going to do things your way or my way. It's about sitting down and saying, what's the best way to do this and learning from each other. Yeah, long answer to your question. So let me jump into practice so real quick with practice, I think we all have to think this will be less challenging because of evidence-based practice. And what I have found is that nurses are really invested in what they built and what they—been involved in creating and evidence-based practices. There's evidence, but there's also regional differences and cultural taking into account cultural differences. I think there are even things like we might approach practice decisions differently. How is your shared governance structure? Do you have a practice permit? Documentation is something the nurses are often invested in and not necessarily practice, but practice drives that. And I found when we got to when in the initial merger where we got to documentation, we really did have some very robust discussions and you get through it. But again, you've got to go back to those basic principles and really just prioritizing, where do we have common ground and where, again, where it's going to make the most difference. So for example, we had similar competency programs. So we zeroed in on that. We looked at what are the basic values of specific programs and made sure that they were embedded, and maybe the execution is a little bit different. So it's really keeping an open mind, respecting each other, and trying to do the best thing for patients and for nurse.

Molly McCarthy:
Now those are all great points. And just to summarize for our listeners, I heard scale and I didn't realize that you're the third largest not-for-profit. Now that's wonderful synergy obviously to improve care. You mentioned health equity. I know that's a huge priority really across the country, cost reduction. And the other piece is just integration. And I really like how you when you talked about culture changes, assuming good intent, obviously looking for the best outcomes for the patient and keeping an open mind; I think is really important as cultures come together. And at the end of the day with our nurses, obviously, they're there for the patients and want to ensure best patient care. I appreciate that very thoughtful answer to your question. The second question is really around thinking about care models and transformation. And obviously with our current care models they're becoming somewhat unsustainable, both economically, physically, emotionally, and to some extent clinically. We're asking our clinicians to do so much. And I have another two-part question for you.

Mary Beth Kingston:
Well, these two part questions.

Molly McCarthy:
I can read. The first I have to remember. Okay, I'll read the first question.

Mary Beth Kingston:
I'm only kidding. Okay.

Molly McCarthy:
So as you think about the clinical transformation that's happening throughout your system and throughout the country, what role do you think nursing must have to ensure new care models best serve their patients and, quite frankly, themselves as caregivers? And then the second part of my question is, how do you think about technology as an enabler to make new care delivery models possible that help us improve quality, safety, equity, clinical outcomes, obviously, while lowering costs at the same time? That pie-in-the-sky quintuple aim. So two parts there, and feel free to attack any part.

Mary Beth Kingston:
I will, I'll mix them up, maybe. First of all, let me state the obvious. Nurses have to be at the table. They have to be involved in the discussions. I'm always amazed if I see someone discussing care transformation and there's no nurse at the table. I think when nurses are pulled in many times, we tend to be focused only on the inpatient model. And I that's I do think that's a myth too. While that's an area where we see a lot of costs now, which might be driving that, there's care models that we can be looking at across the whole continuum. So I just think as nurse leaders, we just have to make sure that we are in there, and we've got to raise our hand and say, I'm sorry, you don't have a nurse on there because you'll develop something that doesn't work because nurses are the ones that are there that know the operational model. And frankly, you're going to be the ones that are the most embedded in these different care models. I think back to the creation of or the program of T-CAB. I don't know if you remember that 'Transforming Care at the Bedside', where they actually went in and listened to the nurses that were delivering care and really made some great strides. The only issue there is, I don't think we really embedded technology in that discussion. And that's the other part of your question for me. I think we need to start looking at what is the work that needs to be done, what are we, what needs to be accomplished, who is doing it, and then determine how technology enables what we're trying to accomplish? We've got a lot coming at us today. We've got all types of apps and artificial intelligence, and if we focus on the technology first and try to fit it into something, we're going to make error. So I do think we have to do that piece. Also important that we know what we're solving for. Are we solving for quality of care? Are we solving for safety and or all of the above? We both know examples where there's plenty of technologies out there that can give alerts and can algorithms and all types of things. And then, if you have a staff that is stretched, that simply just overwhelms them and doesn't really help in any way. What's the work that needs to be done? Who's doing it, and what exactly are we solving for? If we simply believe we won't have enough nurses, then we're going to go a different route, which may indeed be true. Though to digress, I've seen some data lately that looks like we're seeing some improvements, but not really in the inpatient setting. So I think the technology can can potentially help us there in creating efficiencies. So if we don't have enough nurses, virtual nursing I know you've discussed that's really taking off. And we're seeing some promise there, which I think is great. We need to focus on reducing the burden for nurses. So I like to start at the beginning after we look at the work that needs to be done, etc., going in and saying what can be automated. What's what is creating burden for nurse managers, for example, or nurses right at the point of care? And what can we move off? What work does it need to be done by that particular person, or what can technology contribute to that? So I think that's a big piece of it.

Mary Beth Kingston:
There are some case studies, I think, where we've seen reduced costs from some of the technologies, but cost is complex. And I think we and this is just my opinion, but I think we have zeroed in so much on the labor cost that sometimes we forget about the value that nursing brings. And there's other ways of reducing. Don't get me wrong, we need to decrease the high travel rate and all of that. And there's always a place for, I believe, for additional staff coming in. But the amounts that we had during Covid it really did just knock us out a little bit. But I do think that there's other things we can be looking at with technology and how can we reduce the length of stay, for example, which is going to dramatically reduce cost. So if we can use technologies that promote efficiency, that utilize nurses to their full capability, we've been talking about that for years, then I think we could impact things like length of stay outcomes with screening for social drivers of health, for example. These things all play a role. And I think there's lots of technology that can be helpful in that regard.

Molly McCarthy:
That's great. And one thing I just wanted to jump up and give you a high five at the beginning when you answered and said just to have nurses at the table; I couldn't agree with you more. And I'm always like, and if no one's asking, you just show up at the table.

Mary Beth Kingston:
And you know what? Most of the time, people will say, oh, like it's basically, oh, I forgot what I. But you have to you if you're not included, you've got to step up. And I very rarely when I've seen nurses do that across the country, there usually are incorporated then into the conversation. So we do have to make it.

Molly McCarthy:
The other point that I want to stress is sometimes overlooked as well, and that we need to look beyond just the inpatient model and really look across the care continuum, whether that's outpatient, whether that's at home, etc. I think that's a really important piece. As we continue to think about nursing, as well as the promise and opportunities for our nurses.

Mary Beth Kingston:
I think hospital at home has that has real potential. The pandemic kind of spurred it and were different legislations and payment models still need to be worked out. But that's where technology could play a really significant role and is in terms of the monitoring and what we can manage at home, and that's going to reduce the cost of care.

Molly McCarthy:
Yeah, I Know, I think going back to what I heard from you were just three points. When we think about the technology, whether it's in the hospital or at home or remotely within the hospital, for example, but really thinking about what work needs to be done, who is doing that work, and then what are we solving for? I think that's so key. And thinking about those workflows and where technology can be helpful or automate some of the tasks that we do. And I think such great points in, especially as we try and push our clinicians to work to the top of their license. My next question is really...

Mary Beth Kingston:
Is it another two-parter, Molly?

Molly McCarthy:
It is. But I it's I'm going to ask each question separately. I mentioned in my opening statement that historically, healthcare technology has added a burden to bedside caregivers, and I think we discussed some of that. Another contributor to burnout for our caregivers is workplace violence. And prepping for this, I went and read your op-ed from November of 2020, stating that a survey of registered nurses working in hospitals showed that during the pandemic, 44% reported experiencing physical violence and 68 reported experiencing verbal abuse. And I know we've all seen in the news, etc., just this growing trend of misbehavior, so to speak, within the hospital workplace, from patients, from families, etc. and I know that, you I mentioned earlier, you serve on the AHA on an advisory board. So, with your knowledge, what are your thoughts around this increase workplace violence, and how can we protect our employees, including our bedside nurses?

Mary Beth Kingston:
We're going to need another hour for this one. But, um, even the survey that you quoted, I think this issue is vastly underreported, and it's a combination of a number of things. It's the of course, the instability in our society and all of that. It's that vulnerability of people coming into our hospitals, and whether or not they can get access to care or like, I spoke with someone yesterday that helped me look at this even a little bit differently, and talked about how the social drivers of health can actually impact workplace violence, that when you have someone that comes into the hospital and then this aligns with trauma-informed care as well, what's happening with that person? And then you get a stress and then you begin to see some escalating behavior. So I think we need to as care providers we need to have all of that. But on the other hand, if you've been, which most nurses have been experienced workplace violence and again, it has many forms, but physical and verbal and intimidation and harassment, if you're if you are not feeling safe at work, it's really hard to do your best at work as well. So it could just be it can just be this vicious cycle. I think there's a couple of things that I would comment on. Number one, I think it has to be an organizational priority. And yes, it's about keeping our care providers safe, but it's also about creating a safe environment for everyone. And we've really embraced patient safety and I'm beginning to see workplace safety have that same high profile. But the two are linked the same high-reliability principles. We you're going to have different strategies to address it, but it's part of your overall safety. And the board and senior leadership have to have that commitment. And identifying this as a top-priority, date is important. You got to make it easy for people to report if you've been hit or punched or even screamed at, and you have to fill out an incident report, you might have to go to the ER to be treated. Someone else might want to report. And I'm just it's different everywhere, so I'm just giving that as an example. You just don't feel like doing that. But that's on and I've had nurses I'll say you need to fill out one incident report whenever you have verbal abuse. And they said I think I'd be doing that most of the day. And that's a sad commentary. But I think what we need to do is make it easy to be able to report, because that data, you don't have to have the data. We know it's happening, but it helps you prioritize. It helps you develop your strategies based on what's happening in your organization. And there can be differences, though workplace violence occurs every day, I think a good threat assessment and risk assessment program, so the risk can be things like your buildings. We know parking lots are notoriously can be unsafe places, and even things like hardware is like low technology, things can be helpful there. But having a good strong threat assessment and management program is key. Like I said, I could go on. Part of that is training, and it's not just training for nurses; training with customer service and patient advocates to when someone is upset about something, to be able to diffuse that in a very respectful way so that it doesn't escalate. I think that is not some people can do it naturally, most people need training on that. And so it's not just how to get out of a chokehold or something like that. It's real. Looking for signs, symptoms and being able to de-escalate in a way that doesn't contribute to that cycle that I talked about earlier. There's different types. There's planned trauma. There's planned violence. I don't think we're really, um, really focusing on that right now, but that could be someone planning to come in with a mass shooting, for example. And then I think what we experience more often is violence that happens in the moment with nursing. So I think that's one piece setting behavioral guidelines. I was asking someone the other day who's I think an expert in this field as well. I said, what about when someone starts to yell at you? She said, you have to, in a respectful way, set those guidelines because if someone's yelling at you one day, that can easily escalate and don't be surprised.

Mary Beth Kingston:
So I'll give you an example. Um, I can remember the organization on will remain unnamed, but having Iris to manage an E.R. in my past as well. So patient came in, had some behavioral health issues, which we know violence is not limited to people with behavioral health issues. I had some substance abuse history, fell off a roof, and was, um, having surgery. And when he came out of anesthesia and he was very agitated, was yelling, and all all this whole event occurred. And when we looked at that, we were not blaming the individuals that were involved in that. But why were we surprised that, like, we should have been able to say, let's prepare for this. So, I think anticipating and developing an individual plan of care is really important too. And there's a number of assessment tools out there that you really have to watch for bias, but that focus more on behaviors to alert folks so that the bias piece can be very real. And then I think you really have to have a multidisciplinary team and it's a partnership. It can't just be safety and security leading the charge. It can't just be the clinical folks. It's got to be a whole group of people coming together to identify the issues, develop the plan, and make sure that you have a plan in place. And then, of course, you got to have support for people when they do go through something. So that's again a long-winded answer. And I don't know if I answered both your questions.

Molly McCarthy:
No. That's great. I think you mentioned organizational priority. And just like patient safety, workplace safety has to be something that the board and senior leadership is invested in. But you mentioned reporting the incident report. And I can remember back in the day I was punched one time as a nurse. This is a long time ago. And the incident report at the time was a three-sheet-thick piece of paper that you had to fill out.

Mary Beth Kingston:
And his paper?

Molly McCarthy:
Yeah, paper.

Mary Beth Kingston:
We're dating ourselves.

Molly McCarthy:
Oh, that's okay, that's okay. But and just over time, even just reporting has it become easier. I know that's critical as we think about the data, but you mentioned so many great tools to help mitigate the workplace violence. Thank you.

Mary Beth Kingston:
Yeah. The key is prevention. Anything we can do to prevent it's just yeah...

Molly McCarthy:
An awareness.

Mary Beth Kingston:
Yes.

Molly McCarthy:
And then that the last part of my question is, and you mentioned cameras for example in parking lot, but. Have you seen any advances in technology, just in terms of safeguarding our health professionals without compromising patient care? And I'll just give you an example. One thing we've done over time for patient safety is a sitter in the patient's room, whether that's a virtual sitter or even just a camera that detects movement. I'm just wondering if you've seen technology out there that can assist with protecting our health professionals at the bedside.

Mary Beth Kingston:
Yeah. So, there are a few things that are out there. And I think this is an area that's really being built up. So one of them are you've heard obviously of metal detectors, but now there's some new technology which is weapons detection. So people walk through, and you're able to see if anyone is carrying a weapon. Obviously you have to have someone that feels comfortable going up and saying, oh, by the way, but it doesn't slow things down as much as a metal detector at the renovated point of access. Interestingly enough, I talked to one organization, and when they put this in, 60% of the weapons they found were from employees who brought weapons to work there. There's again, you got to look at safety in the broad perspective. So I think these weapon detection systems are really interesting. And I know there's a lot of work going on there. The other area that is just booming right now are the mobile. They have different names, but I usually refer to them as mobile duress alerts. And there's a number of companies out there that have them. Some are LT-TLS technology. The main thing is to be able to pinpoint someone if they need help. Some of them are that you wear right on your badge. And so it's not like a panic button that you have to reach over the patient and jump behind the bed to get to. It's right there. And then I think to me, the ones that really work very well are those that not only alert the security team right away but also alert your co-workers. And that's especially important when you think about it in the ambulatory care setting. We're still, I think, trying to determine home care, because that's an area that right now, if we believe there's some type of danger.

Mary Beth Kingston:
Number one, you have to communicate it. I've had nurses who will say, no one told me that there might have been a gun in the house, for example, so that for us, what we do is we end up having someone if we think there's a problem, we have someone that comes into the ghost with the individual to the home and helps them assess that. So I think that's another good piece. But yeah, it's the technology is developing. And then there are things like motion detectors and cameras and all. And I think that technology has improved dramatically over the years as well. I can remember reviewing tape when I managed an E.R. with just these shadowy figures, and now it's not taped, but something else. The other thing I would say is there might be some AI applicability in the future. Again, as you well know, in the AI field, bias is the thing that we worry about and what's built in there, and that would be the only thing you'd want to be sure of. So are there things are there predictors that can raise pull from different information that could raise alerts? On the other hand, we want to prepare people so that they are there's a plan of care if we believe someone is going to escalate. On the other hand, if you believe someone's going to escalate, you may approach them differently. So I think it's just it's really a difficult thing to think about. But that could be a potential down the road. I in terms of assessment, I like focusing on behaviors that you're looking at that are triggers, rather than picking and choosing from a person's background to determine what might contribute.

Molly McCarthy:
Now, those are all salient points. And I think, as you mentioned, it's really a delicate balance when you consider obviously bias potential as well. So many great discussion points today. I want to wrap up and our listeners are CNOs, CNIOs, healthcare teams really throughout the country. And obviously you have an amazing lens walking through each of the different roles throughout your career. And as a national thought leader, I'm just wondering, just reflecting on our discussion and some of the challenges that you're up against today. If you could take one piece of advice, practical advice for our listeners, what would it be?

Mary Beth Kingston:
That's a hard one, but I think I've said it a few times throughout our time together, and that is really to seek out and empower and listen to nurses that are practicing at the point of care. To me, it's just the biggest untapped resource. I if I don't, I have to meet with nurses, I have to round, I just feel that if I don't do that, I can. If you're so far removed, then you lose that contact with what's happening now. You as you move along in your career, it's going to be a little bit less. But I think you have to seek out those opportunities in a way that works for you, whether it's a shared governance group that you meet with monthly or something along those lines. But there's also some actually there's some technology out there now that helps nurses get their input to a number of leaders, which is also helpful on a regular basis. But even if you do routine surveys, looking at those comments of workplace violence always comes up. I will say that across the country. So I think that there's so many different things I could point to. But as a nurse leader, I think that's one of the most important.

Molly McCarthy:
Thank you. Just to reiterate, really seeking out from our nurses and empowering them at the point of care. I couldn't agree with you more. I think it's so critical to have their voice in really everything, all the decisions that we're making for our system so very well.

Mary Beth Kingston:
We'll make better decisions because of it. Right? I think that's it's the right thing to do, but it's also the smart.

Molly McCarthy:
Thank you, Mary Beth. Certainly appreciate you taking time out of your incredibly busy schedule. And I really look forward to hopefully seeing you in person really soon. Thank you.

Mary Beth Kingston:
Me too. Take care Molly. Thank you.

Intro/Outro:
Thanks for listening to the Smart Care Team Spotlight for best practices in AI and Ambient Intelligence, and ways your organization can help lead the era of smart care teams. Visit us at virtualnursing.com. And for information on the leading smart care facility platform, visit care.ai.

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