Episode 17 : Preserving the Human Connection in an AI Era

SCTS - David Marshall.mp3: Audio automatically transcribed by Sonix

SCTS - David Marshall.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

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. It's time for smart technology to empower care with a more human touch. We have a treat in store for you today: one of the luminary nursing executives in our industry, who currently helps lead one of the finest and most respected health systems in the country and perhaps the world by almost any measure. Doctor David Marshall is Senior Vice President and Chief Nursing Executive at Cedars-Sinai, a leading medical center and growing health system in Los Angeles, California. Doctor Marshall has more than 30 years of professional nursing experience and 20 years of experience as an executive nurse leader and an academic medical center prior to joining Cedars-Sinai. Doctor Marshall was system chief nursing and patient care services executive at the University of Texas Medical Branch in Galveston, Texas, where he began his nursing career. He has served on the boards of professional organizations at the local, state, and national level, including service with the American Organization for Nurse Leadership and as commissioner of the ANCC Magnet Commission. Doctor Marshall's area of expertise includes clinical operations, innovation, leadership development, and performance improvement. Welcome, David, and thank you so much for joining the Smart Care Team Spotlight today.

Dr. David Marshall:
Thank you for that introduction, Molly, and it's a pleasure to be with you today.

Molly McCarthy:
Well, great. I know we just missed each other at Magnet, but I appreciate historically your participation in the Nurse Hack for Health. And you've really been at the forefront of leading nurses in the innovation process. So it's so great to have you here. So in preparation for this conversation today, I came across a four-and-a-half-year-old podcast with Cedars-Sinai CEO Tom Priselac, where he discusses AI, ambient listening, and the organizational commitment to innovation and technology with a voice and vision that most health system leaders are just catching up to understand today. Moreover, in an era where the average tenure for a health system CEO is less than five years, Mr. Priselac has been with Cedars-Sinai for almost 45 years and served as CEO for almost 30 years. So as you join Cedars in 2019, I would love for you to share with our listeners the gift of this astounding stability, visionary thought leadership, and commitment to innovation within your organization. How has it been for you, your leadership, and then the bedside nursing staff?

Dr. David Marshall:
It's really one of the things that attracted me to Cedars-Sinai, the spirit of innovation that I could feel living within the organization and to walk in the doors and to see on the wall when you walk in the names of Jeremy Swan and Gantz, the Swan-Gantz catheter was developed at Cedars-Sinai. And that the legacy or the story is that they sold that for $10,000. And then, after that, Cedars-Sinai said they weren't going to allow any more of their inventions to go for that bargain basement price. And, you know, you could feel the organization's commitment to looking for technological solutions to dilemmas in healthcare. And that was born out to me through the accelerator program that exists at Cedars-Sinai, where they bring up to ten companies a year in for three months, really start-up companies that have developed unique solutions, they invest in them, and then they give them access to every nurse, physician, logistics person at Cedars-Sinai so that they can learn how to make their products better, how to market them to healthcare professionals, and maybe tips from healthcare professionals about how they can improve upon the products that they developed. So that spirit really captured my attention, as well as Cedars-sinai's long history of innovating in many spaces and starting as a nurse, and in the 80s, when the Swan-ganz catheter was just coming out and being a critical care nurse by background, that was really inspirational for me to think about the developments that have occurred here and what that might do for me as a senior nurse executive. And it, I think that there really does exist at Cedars-Sinai a culture of inquiry. And I've tried to bolster that, and they have an almost 30-year history of having a nursing research conference every year. I think this year was the 29th annual Nursing Research Conference, and we had more than 90 abstracts submitted from nurses at Cedars-Sinai. It's just a unique environment to practice as a nurse executive. More than 93% of our nurses are prepared at the baccalaureate level or higher, and 17% of our direct care nurses have a master's degree. So it's an environment where people do question. They have the psychological safety, I think, to ask questions and to speak up. And maybe I'm not sure I brought anything that didn't already exist here, but just the desire to perpetuate that culture of inquiry was really what I came in with and what I try to sustain today.

Molly McCarthy:
I love that culture of inquiry. Also, the added piece of with the psychological safety, it's important to know that they can ask those questions and not be penalized for that. And you mentioned that 93% of your nurses are baccalaureate-prepared, which really kind of leads me into my next question for you, and Cedars has recently achieved its sixth magnet designation, so congratulations. And has earned a significantly lower nursing turnover rate than almost any other health system in the country, which obviously speaks, I think, to the culture that you were just describing, as well as your leadership, and no other health system is in today is really operating in a utopia by any stretch of the imagination, but it appears from the outside that you definitely have the luxury of being less distracted with the existential challenge of workforce sufficiency, perhaps allowing you more time and resources to focus on other projects.

Dr. David Marshall:
As you stated, it's not a utopia, and we work on many of the same issues that others work on. What I tell people is that we seem to be on the other side of some of the issues that continue to plague my colleagues across the nation post-COVID-19 pandemic. And, you know, I think going into the pandemic from a place of strength where there had been decades of investment in professional development of nurses at Cedar-Sinai, that resulted in a unique environment that really kept nurses engaged even through the pandemic. Of course, we had our losses like everyone else did. People decided it was time to retire. People tried to go after the lucrative travel dollars and sought those opportunities, but we shifted our focus and continued to do nurse residency programs throughout the pandemic. And I think that has resulted in us having a more stable workforce. We've weaned ourselves off of most of the expensive travel nurses that we were using. We needed them, and we appreciated them and encouraged as many of them who wanted to stay with us after they found out what it was like working here. And many of them have really, I think, focusing on our nurse residency program, continue it through the pandemic, continuing to allow nursing students to come into our environment during the pandemic so that they could get clinical exposure, and really embracing those travelers who came to us, telling those who left to travel that will welcome you back when you're ready to come back. All those things really, I think, helped us, put us in the position that we're in today. And then also we really focused on re-energizing professional governance in the middle of the pandemic. We had a strategic retreat on in November of 2020 and really took a model from Stanford that one of our new vice presidents of nursing brought with her and focused on really sharing the leadership for nursing, focusing on management accountabilities and then professional governance accountabilities of nurses. And that has really paid dividends for us. I think over the past two and a half years since we did that reset of professional governance here.

Molly McCarthy:
Yeah, I'd love to hear a little bit more about that. I know that we started here talking about your amazing nurse retention rates as well as Magnet, but I think you mentioned one thing. The decades of investment that you've placed in the nurses obviously has is paying off. But one thing that really stuck out to me is how you mentioned you keep your nurses engaged and interested, and I think that's so critical. I was chatting with someone earlier today, and it's like, where are the high-value tasks or roles that nurses play that yield the biggest outcomes instead of the high-burden, low-value tasks? So I would love to hear from your perspective as the Chief Nurse Exec. Aside from retention and turnover and staffing and workforce, what are some of your other system-wide priorities?

Dr. David Marshall:
We have the same priorities as everyone else, I'm sure, on quality, safety, financial performance, and maintaining things like Magnet. But I think our professional governance has been one thing that we focused on and feel like is an investment that will sustain engagement for the future. It's definitely paid off now. In our engagement scores were well above industry average in our last pulse survey. We're going through a pulse survey right now, and I expect it to be sort of the same. We're challenged with more volume than we have capacity for, and that's really creating production pressure on nurses to do things. Most things patients through the system faster. It's resulting in patients backing up in the emergency department waiting for beds. It's pressing us into the use of alternate bases for care like units that used to be post-anesthesia care units, and placing patients there where there's not an adequate bathroom facilities for the 15 patients that we have there. But we're still giving them the standard of care that Cedars-Sinai holds itself to and are serving as many people from our community as we can. And we have, I think, 915 licensed beds. And we had a sense of 980 to start the week, and we were over 1000 at the end of last week. So dealing with that challenge is, is really something that the entire system is focused on, trying to reduce the length of stay. Of course, our complexity is very high with, you know, being one of the top transplant centers in the world and doing those tertiary quaternary things that just other organizations don't do, and our desire to continue to offer those to the community, I think, really motivates us to do better in the patient flow and capacity management.

Dr. David Marshall:
I was recently looking at the patient experience scores from one of those alternate care units, and of course, some of the amenities were lacking and those were reflected. But we've adopted Jean Watson's caring science model as our nursing theory that we go by, and our vision is excellence in human caring. And we added a couple of questions that Jean has developed with press Ganey. One of them is, were you treated with loving kindness and that alternate care unit where conditions aren't ideal? We had the same results for where you treated with loving kindness. As someone who had a room with four walls, and they were both at the 90th percentile for that question, it just spoke to me about how the nurses surround those patients with that kindness and that love, and that the patients feel it. So that's the kind of environment that we've strived to create and want to maintain. But it's about the human connection. That's my job, too, with the nurses, is to maintain that human connection. And I think that's how we get the engagement that we want.

Molly McCarthy:
I love that the human connection is so critical. I think I've been in the world of tech for quite some time, and I always say that tech is tech, but you can't replace the human touch and connection with the patients. And just moving on to our next question. I love your description of your culture and your priorities. Obviously, clinical and operational innovation happening at the bedside to the boardroom. It's just baked into your DNA. I would love to hear and share with our listeners your thoughts around future investments you anticipate making regarding clinical transformation and obviously, technology in the coming months and why? I know you talked about the supply and demand issue with beds, etc., but as you look to the future, where do you see yourself and your team's focus?

Dr. David Marshall:
Well, before I get to that question, I want to make one statement and that is that Sir Isaac Newton said when he was talking about his scientific achievements, if he had seen further, it was because he was standing on the shoulders of giants. And certainly at Cedars-Sinai, I stand on the shoulders of Linda Burns Bolton, who was an iconic nurse leader who was at Cedars for, I think, almost 40 years herself and left the place in really good condition for me to pick it up. So it's been four years of transition from Linda's leadership to mine, but trying to sustain the best of what she left and then to augment it with my ideas has really it's been a blessing for me. And one of the things that attracted me to Cedars-Sinai is that has been their mantra since they were founded in 1902, is that they want to be a blessing to the community. So being part of that is something that's special to me. So I just wanted to mention that before I went to answer that next question.

Molly McCarthy:
Well, thank you.

Dr. David Marshall:
And you know we've done some great things since I've been here. I was a champion of bringing diligent robotics and moxie into Cedars-Sinai accelerator in the middle of the pandemic. They were in the pandemic cohort and the summer of 2020, and we now have four moxie robots roaming the facility, really to do point-to-point deliveries. But, you know, I think the biggest surprise for me about implementing the robot has been the enthusiasm that you see in people's faces when they interact with the robot, when they retrieve something from the robot's supply cabinet or supply compartment. And just when the robot flashes its hard eyes at someone, even a patient, a family member, or a nursing staff member, it gives them a little bit of enthusiasm and puts a little extra pep in their step, I think. And I heard many comments like that before I got here. They had implemented ambient listening in the rooms through a product, Alexa, like product through another company, but that provides an opportunity for the patient or family member to make entertainment choices...And what it's done for nursing is sort of make sure the right person goes to the room. So when the patient presses their nurse call bell, they're able to either say, Alexa, let my nurse know I need pain medicine or let the staff know I need the TV channel change so you can send a different person to the room to do those two things one, a nurse to assess the pain and address it, and someone else to change the channel on the television. So it's allowed us to reduce or get the right person to the room. And I think to save some nursing time that way. Last two weeks ago, we held an Idea-thon, that's what we called it, but it was an AI idea thon for clinical staff. So it was frontline nurses, therapists, pharmacists to think about how are we going to leverage these big language models to really, you know, I'll say, augment our human expertise to not take over our jobs, but to make us better where it can. I don't have the proceedings from that meeting. But, you know, some of the ideas were around making the patients flow through the whole operative experience better. And so ideas like that came out of that meeting. But it was a four-hour session, and we had it. We did it sort of like a shark tank and a few of the executives, the chief medical officer, myself, the facility chief nursing officer and one of our information services vice presidents and our chief medical informatics officer and our chief nursing informatics officer all served as judges.

Dr. David Marshall:
So I think as we sort of explore those things and how we might use them in the future, we'll make investments there. For a long time, we've used AI to do census and staffing predictions based on historical trends. That was in place when I came four years ago. So every morning, when we have our huddle and look at what the next day is going to hold, we use what we call our Alex prediction. I think that stands for Automated Learning Exchange. But Alex sort of predicts our census. And where will we need staff the next day? So there's also already been an embrace of some forms of AI in the organization. And there's definitely more investment, they just recruited a new surgeon who's looking at how AI can make the perioperative experience for the provider better. So those investments are going on in the organization, and I know that nursing will be asked to be a part of that, as they are and everything else.

Molly McCarthy:
That's amazing. I love your examples of moxie, the robot bringing that in. Did you mention, I think you said during Covid, did you bring. Yeah, yeah that's great. And then what I really love is the inclusion that you've done with the clinical staff, the idea-thon, I can't stress that enough to our listeners. I think in one of my podcasts more recently, we were talking about the design, development, and deployment process of technology, and we added another D to that. And that's the first step is discovery. And for what you're doing, that discovery with the ideathon and bringing the people who care for the patients every day together is fabulous. And also, I love the fact that you're already talking to them about LLM and how can we augment our expertise. So really demonstrating how it's a tool rather than something taboo or something that's going to replace them but really enhance their practice. So that's great. I love that idea.

Dr. David Marshall:
As I said earlier, you know, that was one of the things that attracted me here is that belief that some of the dilemmas that we face in healthcare can be supported with technology, not to say solved, but supported with technology and innovation. And I think everybody has that desire to make that come alive.

Molly McCarthy:
I couldn't agree more. My second to last question, a key aim for our podcast is to really help define for the industry how advanced technologies, which obviously, as you know, have been so transformational in other industries, and how can they be applied to healthcare, really to create smart care teams. And it sounds like you're doing some of that, for example, with the ambient listening, etc., with inclusion of the robots who can perhaps do the tasks which really don't belong in the hands or minds of a bedside nurse. But I'm just wondering from your perspective, as you think about a smart care team, how do you envision that? And like, what would be the ingredients to make a smart care team with nursing really pushing for that and leading that?

Dr. David Marshall:
I think it begins with the care team, and we talked about the importance of human connections earlier. You have to have a strong care team to be able to use the smart stuff. And when I think of smart stuff, it's the digital innovations being applied to and the AI-driven insights, and really using real-time data and interconnected tools to augment the healing touch that the care team can make. And so I think that's where it's headed. And then I forgot the rest of your question. Sorry.

Molly McCarthy:
No, that's fine, I think. No, I think that you really answered it. And I just listening to you, hearing you say augment the healing touch of the care team utilizing technology. It's spot on. It's really what we've been discussing for the past few minutes. And I think with nurses at the helm. The other piece that I've heard more recently is how can we include patients in that process.

Dr. David Marshall:
And I think the care team includes the patient and the family. So I should have said that in the beginning. You have to include the patient in the family. And we have patient and family advisers by the boatload at Cedars-Sinai. They come to our patient experience meetings, they you know, I heard from a board member recently about her experience with seeing Moxie in the hospital and how uplifting it was to her, but involving them in what we do. And it's such a part of the fabric of what Cedar-Sinai is. I probably skipped over it, and when I was saying it starts with the care team. The care team absolutely involves the patient in the family.

Molly McCarthy:
Yeah, I couldn't agree with you more. I think also we have smarter patients nowadays just with their access to information in their own patient information and history, so critical to continue to include them in the process, really across the care continuum. My final question for you today is just to share with our listeners any closing words of wisdom. As you know, our listeners are CNOs CNIOs, their teams, and healthcare leaders, and you obviously have a very unique lens as a national leader within healthcare as well as an innovator. And so if you could give one piece of advice out to our listeners today, what would it be?

Dr. David Marshall:
One. Just one, huh?

Molly McCarthy:
Well, you know, I have to tell you, I've been allowing two. So if you need to go two we'll take two.

Dr. David Marshall:
You know, when I reflect on that, things that have made Cedars-Sinai so successful and we talked about one earlier and that's that investment in professional development, I think that for nurses, that investment in professional development is going to be what prepares them to be the best they can be, and probably what is the next revolution, the digital and robotic revolution. You know, our ancestors went through, they were foraging, really went through the agricultural revolution and became farmers. And then hundreds of years later, they went through the Industrial Revolution and moved out of the farms to the factories. And then, you know, a few decades ago, we probably went into the technology revolution, but now we're going into this digital and robotic revolution, and I think investment in professional development of nurses and preparing them to be in that world is something that probably we all need to focus on. And then if you're going to allow me a second one, I think embracing that culture of inquiry is something that is important for people in my position, other nurses who lead teams to develop that psychological safety and give people a place to bring their ideas about how things could be better and pay attention to them and act on them and let them see how you act on them. So those would be my two.

Molly McCarthy:
Right, I love both of those. You know, going back to what you said, and I wrote it down here to keep the nurses engaged and interested. Obviously, we're humans as well, and the investment and their professional development is just obviously paid off dividends for Cedars-Sinai. But to your point about preparing them to live and breathe and practice in the digital world, it sounds like you're actively doing that through the ideathon and some of your other activities. And then I'm just going to leave our listeners with that culture of inquiry. I think that's so critical in today's world to ask questions, to be curious in a safe and really psychologically safe environment. So thank you so much, Doctor Marshall, it's been a pleasure having you here today.

Dr. David Marshall:
Thanks, Molly. I appreciate the opportunity to talk to 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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