The Exec: Dartmouth Health Chief Clinical Officer addresses goals of rural academic medical center

Dartmouth Health has taken a leadership role for several small hospitals in New Hampshire and Vermont.

Dartmouth Health is a unique healthcare organization, with an academic medical center in a rural area and eight affiliated hospitals, says clinical director Edouard MerrensMD.

HealthLeaders spoke with Merrens about a range of issues, including the mission of the healthcare system, burnout, current clinical challenges and workforce shortages. The following transcript of this conversation has been edited for clarity and brevity.

HealthLeaders: What is Dartmouth Health’s vision for clinical care?

Edward Merrens: We are unique in having a tertiary-quaternary medical center in a rural state. We have a cancer center designated by the National Cancer Institute. We have the only children’s hospital in the state. We are increasingly one of the only facilities able to deliver as smaller hospitals withdraw from providing obstetrics services. We are a level 1 trauma center.

We therefore have a responsibility towards the region. When you think about it, our responsibility is to be able to meet complex needs, but also to ensure that small hospitals have a role to play in their communities. They have a lot of opportunity, and we have not only served as a place where complex care is delivered, but we have also reached out to ensure that we can provide care in smaller hospitals as well. We are committed to providing complex orthopedic care in small hospitals, developing hospital programs in our critical access hospitals, connecting with small hospitals through telehealth, and unifying our emergency physicians across the system. .

The other things we are doing are improving our center of care coordination capacity to coordinate patients moving through the system in the most appropriate way. Being responsible for the region, we have dedicated ourselves to the coordination between all the hospitals in our system, mainly the critical access hospitals. We have fundamentally changed the nature of their work by offering them the opportunity to fill their operating rooms. It’s a great experience for our clinicians and an opportunity for patients to get care close to home.

HL: In addition to telehealth, how are you directly involved with your affiliated hospitals?

Merrens: They are part of our electronic health record. I work with their chief medical officers and their CEOs. We seek to develop joint programs. We seek to develop outreach. We have members on their boards. So we are a tightly aligned system – we have developed several system programs. It’s not just about putting a Dartmouth sticker on their doors. We have developed a Systemic and Therapeutic Pharmacy Committee. We have ways of trying to align our clinical practices so that they are the same across the system. We tried to align care.

It has been rewarding to understand how we can develop algorithms, policies and procedures that work across the whole system. We’ve done this in several areas, making it easier for patients to navigate the system and for physicians to work within it. Once you share an electronic health record, and there’s a way to do things, it brings you closer.

Edward Merrens, MD, is the chief clinical officer for Dartmouth Health. Photo courtesy of Dartmouth Health.

HL: What is the status of physician burnout at Dartmouth Health?

Merrens: We are similar to other healthcare systems across the country – we not only address physician burnout, but also healthcare worker burnout more generally. It affects everyone.

We have done a lot of things to fight against burnout. We have developed a Wellness Council as well as dedicated staff and resources for a Caregiver Wellness Department that includes physicians, advanced practice providers and nurses. We have developed a strong employee assistance program that is available 24/7. We involved the chaplaincy. We have developed lifestyle programs including nutrition and exercise.

We also recognize that burnout isn’t just about having enough healthy vegetables and enough yoga. We have developed support systems for people. We are working to add more resources. We are streamlining the electronic health record. We are trying to determine if we need new roles in the organization such as scribes and others to facilitate the work of clinicians.

We try to raise awareness of burnout. We educate people, respond to needs, tackle stressors and try to tackle the problem on all fronts.

HL: What are your main clinical challenges now that the crisis phase of the coronavirus pandemic has passed?

Merrens: Clinical challenges meet the needs of the region, including an increasing number of patients seeking our care. We are building a new hospitalization tower which will have 64 new beds and we can increase up to 100 beds. Remarkably, at a time when other hospitals are contracting, we are building more inpatient beds.

We have a severe shortage of staff, primarily at the nursing level, but that includes X-ray technicians and all staffing areas. It’s partly a function of the job market – New Hampshire has one of the lowest unemployment rates in the United States. We have a unique environment to recruit people. The critical shortage of staff is a clinical challenge. This has an impact on meeting patients’ expectations of how they want to receive care.

The personnel crisis is not just us. One of the big problems in our 400 bed hospital is that we have trouble finding places to discharge patients because the skilled nursing facilities and rehabilitation centers are unstaffed and they have limited the number of patients they can take. So we have several bottlenecks in the system that make our job difficult. These bottlenecks have led us to have patients in long hospital stays.

HL: How does the organization deal with labor shortages?

Merrens: We have several programs, including programs for high schools—apprenticeship programs and training programs. We focus on the key members of care teams who make things happen. We have had a medical assistance program for many years.

We train people to be phlebotomists because one day they will be licensed practical nurses, then registered nurses, then nurse practitioners. We want people to focus on the incremental growth of health care and what the starting point might be.

We have a Health Workforce Readiness Institute that reaches out and offers people the opportunity to be hired as employees during their training. We have a special relationship with the Colby-Sawyer College School of Nursing, it is our school of nursing and we hire as many graduates as possible.

Our goal has been to develop our own employees. We have increased our minimum wage to $17 per hour in 2021. We may need to continue to adjust this wage. We’ve increased pay for several roles, including Nursing, Physician Assistants, LNAs, and Technicians.

We have also been innovative from a government perspective. We were one of 17 organizations nationwide to receive a rural health workforce development grant. It was a $40 million grant, and we received $2.5 million.

HL: What patient safety initiatives have been launched at Dartmouth Health?

Merrens: We have focused on hospital and clinical measures that are important. We’ve looked at the infections you need to be aware of. We have reduced catheter-associated infections, central line-associated infections, and transmittable infections such as Clostridium difficile by 45% to 70% by paying attention to infection tracking and dedicating a quality team.

For example, with central line infections, we started focusing on this area in 2019 and continued the work during the pandemic. When we measured where we were in 2021, we saw a 66% reduction in our central line infections.

From 2018 to 2022, our reduction in urinary catheter infections was 60%.

From 2017 to 2022, we had a 45% reduction in Clostridium difficile.

We also have an in-house team that reviews adverse events and performs root cause analysis. They review adverse events and follow up to understand how these events occur.

We have an inpatient team that focuses on patients who have high glucose levels and ensures that our best practice alerts for sepsis management are followed.

We have also thought about the impact on the safety of our caregivers. From 2021 to 2022, we have recorded a 37% reduction in exposure to blood-borne pathogens such as needle sticks and exposure to blood products that occur in emergency rooms and operating rooms.

Related: The Exec: 7 Questions with Yale New Haven Health Clinical Director Thomas Balcezak

Christopher Cheney is the Clinical Care Editor at HealthLeaders.


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