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Joanne's Journal - Thursday, March 1, 2018

Joanne's Journal - Thursday, March 1, 2018

Senior Leader Rounding

I got into my car this morning listening to the birds chirping and seeing dirt instead of snow on my lawn. I turned onto Route 120 and thought “spring is here”...and then I looked at the outside temperature on my dashboard and it said 23 degrees! I laughed….it is all relative…it is so New England!

As I walked through the Borwell entrance, I was reflecting on rounding in “my units” as part of our newly launched Executive Leader Rounding Program. My units are: 1 East, 1 West, and Concord Outpatient Primary Care, Pediatrics, Information Management, Cardiology and Orthopedics. We also just held our first meeting as a senior leader rounding team and have also heard the reports from the rest of the team.

Let’s be clear, having our senior leaders rounding in departments and units across the system is an activity not a strategy. To engender real engagement we need to increase levels of trust, transparency and autonomy, make sure colleagues feel cared for, valued, and understand the connection of their work to our purpose. Rounding, however, is a great way to hear what is happening in the organization, to be present, develop relationships and address some “low-hanging fruit.”

I am going to review some of our initial findings, but I am interested in your feedback as well.

We have identified issues that fall into several categories.

Things that are easy to fix:

  • Communication around evening and weekend acute care food service options
  • Understanding where the organization is going strategically
  • Areas where we need more housekeeping horsepower
  • Bubbling up ideas for expense savings that come from the front lines
  • Integrating community insights from our ambulatory practices in our strategic and operational planning
  • Improving our internal customer service…i.e. responsiveness
  • Long waits to fill jobs in high-demand areas like Food and Nutrition Services on the Lebanon campus

Things that are hard to fix and require some more analysis:

  • Can we address the LNA (Licensed Nursing Assistant) shortage by identifying non-licensed staff to assist with appropriate patient care tasks (i.e. mobility techs) and utilize a separate cohort of clinical staff to work as “sitters” for patients that need this attention in order to free our LNAs to work at the top of their license?
  • Are the nursing documentation requirements in eD-H customized and require too much nursing time (i.e. the volume and frequency required makes it difficult to do in the normal flow of work)?
  • Is our health benefit structure getting in the way of keeping employees healthy?
  • How do we address the post-acute placement challenges that confront our case managers daily?
  • Prior-authorizations are taking up more and more time as insurance plans change their formularies and what they will and won’t cover (i.e. imaging and procedures).

Things that surprised us:

  • The Clinical Decision Unit (for observation patients) cannot be maximally utilized on weekends unless we have other support services available.
  • We may not always be using our internal job transfer process when hiring experienced staff from within our system.

Things that are working well:

  • Our Workforce Readiness Institute apprenticeship programs for Medical Assistants, Surgical Techs and LNAs (to name a few positions) are helping address some of our staff shortages and retention of staff.
  • Our recent change in interview process for LNAs has decreased our time to fill positions and we plan to use this process to more efficiently hire new-grad nurse residents this spring.
  • The centralization of some of our services has expanded coverage and created opportunities for us to help each other manage the work load across sites…i.e. in information management and the call center. 
  • People say the #1 reason that they love working here is their team.

We are continuing to look for emerging themes and will triage them to appropriate work groups for solutions and will communicate back to the organization. The staff throughout this process has been authentically enthusiastic about having senior leaders round frequently in their areas and so have the senior leaders!

If you have any comments or suggestions about the Executive Leadership Rounding program, please reply to this email or send a note to and I’ll share with our senior leadership team.

D-H’s Center for Addiction Recovery in Pregnancy and Parenting Receives $2.7 Million Grant

From left: Dr. Steven Paris, regional medical director for D-H; Stephanie Allain Savard, CEO of Families in Transition; Dr. Julia R. Frew, director of D-H’s Center for Addiction Recovery in Pregnancy and Parenting program; U.S. Rep. Ann McLane Kuster (D-NH2); Daisy Goodman, a certified nurse midwife and member of the CARP team; Manchester Mayor Joyce Craig; and D-H CEO and President Dr. Joanne Conroy

From left: Dr. Steven Paris, regional medical director for D-H; Stephanie Allain Savard, CEO of Families in Transition; Dr. Julia R. Frew, director of D-H’s Center for Addiction Recovery in Pregnancy and Parenting program; U.S. Rep. Ann McLane Kuster (D-NH2); Daisy Goodman, a certified nurse midwife and member of the CARP team; Manchester Mayor Joyce Craig; and D-H CEO and President Dr. Joanne Conroy.

At a February 21 press conference in Manchester, New Hampshire, Dartmouth-Hitchcock (D-H) CEO and President Joanne Conroy gathered with legislators, maternal health clinicians and community health care providers to announce that D-H had received a $2.7 million federal grant to help combat the opioid crisis.

“We’re here to celebrate this incredible opportunity to make a difference in the state of New Hampshire,” said Conroy of the grant, which was awarded to D-H’s Center for Addiction Recovery in Pregnancy and Parenting (CARPP) through the 21st Century Cures Act. The grant will enable CARPP to support and bolster obstetrical practices across New Hampshire by helping to implement effective screening and treatment for pregnant women with opioid use disorders.

“When you start talking about the challenge of substance abuse, not only in families, but in child-bearing women, you realize that this busts all economic, social and geographic barriers,” said Conroy. “Every single family has a story if you just begin to talk about it. But we have to move from talking about it to actually doing something about it.”

The announcement was made at Families in Transition, and was attended by Conroy; Julia R. Frew, MD, director of CARPP; certified nurse midwife and women’s health nurse practitioner Daisy Goodman, DNP, MPH, CNM, WHNP-BC, a member of the CARPP team; and Steven Paris, MD, regional medical director for D-H. Also in attendance were U.S. Rep. Ann McLane Kuster (D-NH2) and Manchester Mayor Joyce Craig.

The two-year grant—awarded by the NH Executive Council and the NH Department of Human Services (DHHS) in late January—is funded through June 2019. It will help D-H assist seven maternity care practices around the state to develop integrated medication assisted treatment programs within the maternity care setting, serving pregnant and newly postpartum women. The seven sites include Cheshire Medical Center and D-H clinics in Nashua and Bedford, as well practices in Berlin, Dover, Laconia and Littleton that are not affiliated with D-H. Frew noted that D-H Keene has already established a medication-assisted treatment program, “so we will be providing them with additional resources and support.”

Frew said that she and her colleagues “are delighted to share what we’ve learned over the past four-and-a-half years at the D-H Moms in Recovery program to support other maternity practices around New Hampshire in caring for this population.” In addition to offering buprenorphine, in this medication assisted treatment program, Frew said they will also help participating practices to “build the ancillary services that are so desperately needed by this population, including peer recovery coaching, links to other community resources and to the recovery community, counseling, psychiatric consultation and provide help overcoming barriers to treatment such as transportation and child care.”

Additionally, Frew said the program will focus on ensuring that participants have continued access to health care and support resources following the birth of their children. “Their needs do not stop when they have their babies,” she said, noting that having community-based, integrated medical care and behavioral health care is crucial for the continued well-being of this patient population and their babies. “Our ultimate goal is to build a network of what we term recovery-friendly obstetric practices around New Hampshire with very close connections and ties to all of the community resources that already exist or are in the process of being built.”

Kuster said she was proud of the work being done by D-H and Families in Transition, and believed that the grant announcement was a “historic moment. I feel that New Hampshire is not only going to address the opioid epidemic that we face, but we are going to lead the rest of the country out of it.”

125th Anniversary of Mary Hitchcock Memorial Hospital: Who’s Mary?

Mary Hitchcock

When Mary Hitchcock Memorial Hospital in Hanover, NH, was demolished in 1995, three years after the new Dartmouth-Hitchcock Medical Center opened in Lebanon, a century-old time capsule was discovered among the debris. Inside was a love letter to Mary Maynard Hitchcock, written by her husband Hiram Hitchcock, the wealthy hotelier who had built the hospital in 1893 as a memorial to his late wife. Hiram wrote of his childhood sweetheart, “It is a memorial of one of the noblest and best of God’s gifts to the human race. God grant that this hospital may be all, and more than all that she would have it to be. She was my life here. May God in His infinite mercy unite us again.”

Hiram’s grief was understandable. The couple had known each other since Mary was 8 and Hiram was 10, having both grown up in the small town of Drewsville, NH. Mary was born there in 1834 to Roxy Davis Maynard and John P. Maynard, and Hiram’s family moved from Claremont, NH, to Drewsville in 1842. After what was termed “a long courtship,” they were married in 1858, when Mary was 24. Hiram had already embarked on a successful career in the hotel business, having moved to New Orleans at age 20 to work at the renowned St. Charles Hotel and later at the Nahant House, a seaside resort hotel just outside of Boston.

After their wedding, Hiram and Mary moved to New York City, and a year later Hiram and two colleagues—Alfred B. Darling and Paran Stevens—built the Fifth Avenue Hotel, which was the largest and one of the most popular hotels in Manhattan. Mary became a prominent hostess, entertaining such luminaries as President Grover Cleveland and Theodore Roosevelt prior to his presidency. But, while their business and social lives were thriving, the couple’s personal life was consumed with loss. Their daughter Mary, born in 1863, lived only a month. A year later, when Mary was 31, their son Maynard was born, but he died just 14 months later.

Three years later, Hiram retired at the age of 34, reportedly due to ill health. During the years from 1866 through 1879, he and Mary traveled the world as Hiram pursued his interest in archaeology. While traveling in Europe, Hiram gave Mary a bracelet, earrings and a brooch that were copies of the crown jewels of Russia. During this time, they also bought a house in Hanover, NH, that had belonged to Dartmouth College Professor Henry Fairbanks. Dubbed “Hitchcock Mansion,” the large, French-style house stood where Russell Sage dormitory is now located, and their property stretched down to the Connecticut River.

The couple returned to New York City in 1879, as Hiram resumed his role of running the Fifth Avenue Hotel, and also helped found Madison Square Garden, serving as its president. They divided their time between Hanover and New York, but Mary died in New York of unknown causes in 1887 at the age of 53. Hiram initially commemorated her life by redecorating the Church of Christ at Dartmouth College in Hanover, which overlooked the northeast corner of the Dartmouth Green, and also buying the church a new organ. In 1889, he decided to further honor her memory by paying for the construction of a new hospital. Mary Hitchcock Memorial Hospital, which opened on May 3, 1893, would serve the Upper Valley’s residents, be a teaching hospital for Dartmouth (now Geisel) Medical School students and also train nurses. The Mary Hitchcock Memorial Hospital Training School for Nurses, which also opened in 1893, educated nurses for 87 years until its closing in 1980.

Built at an estimated cost of about $220,000, the state-of-the-art hospital was bright and airy and graced by impressive pillars, a fireplace carved from Siena marble and a beautiful mosaic tile floor. After Hiram officially donated the hospital to the corporation that would oversee it, he then addressed Dr. Carleton Frost, a close friend and dean of Dartmouth Medical School. He said, “This hospital is a lasting memorial of the great moral and sympathetic power of a noble Christian woman’s life in its devotion to the relief of human suffering and misery; and it is a precious privilege to have been permitted to establish a memorial that, under Providence, will realize the fond aspirations of that life.”

Save the Date: To commemorate the 125th anniversary of Mary Hitchcock Memorial Hospital, a special celebration will be held on Thursday, May 3, from 12 noon to 1 pm, at the Main Rotunda on Level 3, at DHMC, featuring a brief presentation by Jim Varnum, former president of Mary Hitchcock Memorial Hospital, light refreshments and entertainment.

Provider Ambassadors for Patient Experience: Jonathan Ross, MD

Dr. Jonathan Ross

Dr. Jonathan Ross

Provider Ambassadors for Patient Experience—all Dartmouth-Hitchcock (D-H) providers themselves—provide coaching and peer-to-peer support in a collaborative nature. Through peer-to-peer observations and mentoring, the ambassador team partners with a provider in a reflective, thought-provoking and creative way to observe, talk through, inspire, or simply make small changes in style or behavior that can have a significant and lasting impact on the relationship with his or her patients and colleagues. (More information about the program is below.)

Jonathan Ross, MD, says as a general internist, a focus at the core of his practice has been the relationship and communication between the clinician and patient. When Larry Dacey, MD, medical director, Patient Experience, approached him about the Provider Ambassador program, he says he was delighted to participate.

“The importance of the clinician-patient relationship is central to our effectiveness as physicians,” he says. “Once you leave a residency program, you’re almost never observed or receive feedback, and I thought we should be able to do something about this. So when Larry approached me, I anticipated this program would be one in which I would have an opportunity to work with colleagues in a variety of settings. And that’s been the way it’s turned out.”

Ross says part of his work has always been relating to his patients, and building a trusting relationship.

“Part of this is the knowledge base that physicians amass over their training years, and part of it is facilitating the transfer of this knowledge to the patient. When I am with a patient, there’s nothing else that’s important other than what’s going on between us,” he says. “I think for patients, knowing that your physician is fully present, mindful, respectful, gives you space to breathe, and hears your questions, is really critical.”

“When I hear about clinicians with low patient satisfactions ratings or multiple complaints about them, then I know there may be fundamental communication and relational issues that need to be addressed. No patient should be in a doctor’s office and feel that they aren’t the most important person on the doctor’s agenda for that day,” he says. “That’s something we [physicians] should aspire to. Sometimes we need a little help from colleagues to say, ‘Hey, you could have done something a little different here,’ or, ‘Try doing it this way next time,’ or ‘Do you realize you are doing (such and such)?’ Everyone I’ve worked with is committed to doing their work well. I just think there’s an opportunity to enhance the patient experience by helping clinicians be centered in their work.”

During his time as a provider ambassador, Ross says he has faced some challenges, but they have resulted in teachable moments that have made the clinician more effective, while hopefully improving the patient experience.

In one situation, Ross worked with a clinician who did not have multiple complaints from patients, but rather said that they felt inefficient, and that they were not doing the best job they could.

“From what I observed, the doctor was actually quite comprehensive, thoughtful, and good in their interactions with the patient. We decided that this doctor might work with other clinicians to identify obstacles that were in this doctor’s way and improve the system—do a quality improvement exercise. In the end, the doctor felt relief that it wasn’t their behavior, and they were appreciative of being observed and having a colleague provide this feedback.”

Ross says all providers can benefit from this program.

“It’s private, personal, collegial, supportive, and it’s not punitive or judgmental. I think it’s an effort by the organization to send the message that we’re all in this together, and we want not only our patients to be happy and satisfied, but our clinicians too,” he says.

Ambassadors for Patient Experience: A Peer-to-Peer Provider Coaching Program

Provider coaching offers peer-to-peer support in a collaborative nature with a member of our Patient Experience Ambassador team who are all D-H providers themselves. Through peer-to-peer observations and mentoring, our Ambassador team will partner with a provider in a reflective, thought-provoking and creative way to observe, talk through, inspire, or simply make small changes in style or behavior that can have a significant and lasting impact on the relationship with their patients and colleagues.

Ambassadors help to improve:

  • Provider-patient communication/interpersonal skills
  • Patient satisfaction and resulting scores
  • Patient loyalty, adherence, and outcomes
  • Time management and efficiency of practice
  • Co-worker interactions and communications that improve patient experience (i.e., hand-offs, and interactions in front of patients/families)
  • Provider satisfaction and engagement

Many of the ambassadors are specially trained or have worked through solutions themselves or with other providers, on topics ranging from improving patient communication, use of the electronic health record, time management, and improving interactions with co-workers.

Opportunities for coaching are available in person, through observation, following review of patient satisfaction scores, over the phone, or may be as simple as a question sent via email. Individual providers may self-refer on their own, or a department chair or practice manager can make a referral based on needs foreseen by the department’s leader.

D-H Operating Room Initiates “Tyvek Tuesday”

Dr. Joanne Conroy congratulates Jan Hill, RN

Dr. Joanne Conroy congratulates Jan Hill, RN.

The Olympic theme song played outside Dartmouth-Hitchcock Medical Center’s operating room (OR) lounge on 4 West as medals were handed out to employees who participated in the inaugural “Tyvek Tuesday” recycling event on February 20. Organized by General Surgery OR nurse Patricia Stockwell, who chairs the OR’s Green Team, employees collected roughly 30 pounds of Tyvek—Stockwell notes like milk jugs, which is made of #2 plastic (HDPE) and doesn’t break down or degrade in landfills—from medical packaging that’s used every day in the hospital.

D-H CEO and President Dr. Joanne Conroy, accompanied by D-H Board of Trustees Chair Anne-Lee Verville, presented medals to the winning employees, who were drawn at random from the more than 70 participants. The awardees were as follows:

  • Perioperative Services technician Shawnette Fowler, gold medalist,
  • Perioperative Services surgical technologist Moses Mucheke, silver medalist; and
  • Perioperative Services clinical nurse Jan Hill, RN, bronze medalist.

Stockwell has been eager to start a Tyvek recycling initiative since learning that D-H’s Blood Bank recycles the small amount of Tyvek they generate by mailing it directly to DuPont, the manufacturer. “We generate a significant amount in the OR because Tyvek is on packaging in the operating room, and we do 20,800 surgeries a year,” says Stockwell. “People don’t realize how it adds up. There’s one particular vascular surgery where we accumulate a pound of Tyvek for each of those surgeries.”

Zac Conaway, manager of waste recycling and training in D-H’s Environmental Services and Waste Management department, says that by collecting Tyvek for a day, his department hopes to demonstrate to Cassella Waste Management Services “that we have enough Tyvek to recycle and then work out the logistics of collection moving forward.” Following further discussions with Cassella, Conaway says he and Stockwell will organize a second Tyvek Tuesday in the coming months.

“That would kick off regular collection of Tyvek, and we’d have it go into the OR zero sort and then it would be sorted in the waste room on a regular basis,” Conaway says. “I’m hoping that with Tyvek recycling in 2018, we will be able to get close to the amount of blue wrap we collected and recycled in 2016, which was about four-and-a-half tons. But Tyvek Tuesday was Pat’s brain child and I’m glad we were able to pull this off. Hopefully it will lead to a new recycling stream!”