The Exec: Dartmouth Health Chief Clinical Officer addresses the goals of the Rural Academic Medical Center

Dartmouth Health has provided leadership 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 six affiliated members, says Chief Clinical Officer Edward Merrensmd

HealthLeaders spoke to Merrens on a range of topics including the healthcare system’s mission, burnout, current clinical challenges and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.

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

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

So we have a responsibility towards the region. When we think about it, our responsibility is to meet complex needs, but also to ensure that the smaller hospitals have a role to play in their communities. You have many options and not only have we served as a place where complex care takes place, but we have worked to ensure that we can serve smaller hospitals as well. We have committed to providing complex orthopedic care in smaller hospitals, developing hospital programs in our critical access hospitals, connecting with smaller hospitals through telemedicine, and unifying our emergency medical professionals across the system.

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

HL: In addition to telemedicine, how are you directly connected to your affiliated hospitals?

Merrens: They are part of our electronic health record. I work with their Chief Medical Officers and their CEOs. We want to develop joint programs. We strive to develop public relations. We have membership on their boards. So we are a closely coordinated system – we have developed several system programs. It’s not just about sticking a Dartmouth sticker on their doors. We have set up a system pharmacy and therapeutics committee. We have ways of trying to align our clinical practices so that they are consistent across the system. We tried to align the care.

It was worth figuring out how we can develop algorithms, policies, and procedures that work across the system. We’ve done this in several areas, making it easier for patients to navigate the system and doctors to work in it. Once you share an electronic health record and there’s a way to do things, it brings you together.

Edward Merrens, MD, is Dartmouth Health’s Chief Clinical Officer. Photo courtesy of Dartmouth Health.

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

Merrens: We’re similar to other healthcare systems across the country – we’re not just dealing with burnout among physicians, but more broadly among healthcare workers. It is concerning everybody.

We have done a lot to fight burnout. We have developed a wellbeing council and dedicated resources and staff for a caregiver wellbeing department that includes physicians, advanced practice providers and nurses. We have developed a robust employee support program that is available 24/7. We turned on pastoral care. We have developed lifestyle programs including diet and exercise.

We also know that burnout is about more than having enough healthy vegetables and enough yoga. We have developed support systems for people. We are working on adding more resources. We streamline the electronic patient file. We’re trying to figure out if we need new roles in the organization, like scribes and other people, to make things easier for clinicians.

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

HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic is over?

Merrens: The clinical challenges match the needs of the region, including an increasing number of patients seeking our care. We are building a new stationary tower with 64 new beds and we can ramp up to 100 beds. Remarkably, we are building more inpatient beds at a time when other hospitals are shrinking.

We have a critical staffing shortage – mainly at the nursing level, but also radiology technicians and all aspects of staffing. 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 employees. The critical staff shortage is a clinical challenge. It affects meeting patients’ expectations for the way they want to receive care.

The personnel crisis does not only affect us. One of the big problems for our 400 bed hospital is that we are struggling to find places to discharge patients due to the lack of staff at the skilled nursing and rehab facilities and the number of patients they can accommodate, is limited. So we have several bottlenecks in the system that make our work challenging. These bottlenecks have meant that we have long-term patients in the hospital.

HL: How does the organization deal with the labor shortage?

Merrens: We have several programs including programs aimed at secondary schools – apprenticeship programs and training programs. We focus on the core members of the care team who make things happen. We have had a physician assistant program for many years.

We train people to be phlebotomists because one day they will be licensed nursing assistants, then registered nurses, and then nursing practitioners. We want people to focus on the incremental growth in healthcare and what might be the starting point.

We have a health worker readiness institute that deals with people and offers opportunities to be hired as a worker during their training. We have a committed relationship with the Colby-Sawyer College School of Nursing – it is our nursing school and we hire as many graduates from there as we can.

Our focus was on promoting our own employees. We have increased our minimum wage to $17 an hour in 2021. We may need to adjust this wage further. We’ve increased pay for several positions, including Nurses, Medical Assistants, LNAs, and Technicians.

We were also innovative from a state perspective. We were part of 17 organizations across the country that received a grant for rural health workforce development. It was a $40 million grant and we were awarded $2.5 million.

HL: What patient safety initiatives have Dartmouth Health taken on?

Merrens: We have focused on the hospital and clinic-related measures that are important. We’ve looked at the infections you need to watch out for. We have reduced catheter-related infections, central catheter-related infections and communicable infections such as Clostridium difficile by 45% to 70% by being careful about tracking infections and using a quality team.

For example, we focused on this area for Central Infections in 2019 and continued to work during the pandemic. When we measured where we were in 2021, we had a 66% drop in our center line infections.

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

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

We also have an in-house team that investigates adverse events and performs root cause analysis. You look at unwanted events and do the tracing to understand how those events occur.

We have an inpatient team that focuses on patients with high glucose levels and ensures our best practice warnings for treating sepsis are followed.

We have also considered the impact on the safety of our caregivers. From 2021 to 2022, we saw a 37 percent reduction in blood-borne pathogens such as needle sticks and exposure to blood products in the emergency and operating rooms.

See also: The Exec: 7 Questions with Yale New Haven Health Chief Clinical Officer Thomas Balcezak

Christopher Cheney is Senior Clinical Care Editor at HealthLeaders.

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