Designing a Successful Health System Command Center

Interviewer: Thank you. Welcome, Melanie.

Melanie: Thank you. My name is Melanie Morris. I am the senior director of Carilion Clinics Transfer and Communication Center. We are actually a health system. We've got six additional campuses besides our main campus in Roanoke. We currently do bed placement and transfer functionality for two of our campuses. And we are soon to be expanding to all of our campuses for bed placement here in a few weeks. We are following the hospital command center model, in that we have multiple departments within our command center right now that includes a transfer center bed placement. And we also have a communications center, which they are the dispatchers for our ambulance fleet, as well as three helicopters. We have EVs, a dispatch station in the room for them. We also do oversight for clinical transport operations. And we do have tight integration with UM nurses, as well. They did sit in our center at one time, but now they're located outside the room. But we still communicate with them very closely. And soon to expand our operations into a satellite room for remote telemetry as well as remote TeleSitters.

Interviewer: Wonderful. Yes, I had the opportunity to see your center last year and it is an amazing thing to be able to witness firsthand. Melanie, Carilion has been an early adopter of a centralized approach to care and you've actually set up four or five centers over the past 10 years. How has each center evolved and what lessons have you learned along the way as you move through this process?

Melanie: Yeah, so it's definitely a learning process. Each time you move or grow and I'll underline the word growth. So when folks are looking to set up some form of logistics or hospital command center, I encourage them to think big, bigger than you think you need. Each time we've moved we found we needed a bigger footprint to operate from. Just because once you realize the advantages of co-locating different areas who so importantly impact your hospital throughput, that lots of benefits added to put them in the same workspace area. So you're going to quickly realize, oh, I should've thought to add that department or this department. So I encourage folks when they're thinking about doing something like this to think big. Get as much of a footprint or floor plan as you can upfront because you certainly will, it should not take long at all, you'll be filling your space.

And so we've also learned what players to put in the room. We started with just two groups. We started with the transfer center and the communications center for our transport. And transport, by transport, I mean ambulance and helicopter transport. And again, we quickly realized the synergies that could be formed by moving more folks in the room. And it doesn't even mean you need to manage the operations necessarily if you put players in the room. But have a key point person in the room who's communicating those departments. So for instance, I don't have oversight or operational management over the environmental services department.

But I do have one of my employees sit and they're kind of the traffic cop, so to speak. So they're watching the dashboard, watching EVs turn times and communicating with EVs leadership. And the reason that's important for me, that key person who is the liaison with EVs is sitting in the room and has situational awareness of where our pinch points are and what we need to prioritize in real time or that day. So they're sitting right behind the transfer center nurses. They're sitting right behind the transportation folks. So it's important for them to be able to real time communicate to environmental services. "Hey, I've got a helicopter landing in 10 minutes, so I need this bed before I need that bed." Same with transfer center folks maybe may have to make several moves to make an ICU bed open for that helicopter that's getting ready to land. They need to help guide EVs, to let them know which bed cleans need to be done first to make several moves to open up that ICU bed.

So again, think bigger than you think you need. Don't just think in a silo of the one or two departments that you're initially going to place in the center. We've learned about who to staff in the center. We get a lot of questions about that. And it's okay to have a mix of people in there. You don't have to have just one type of skill set to do all jobs. We've got nurses working in our transfer center. We've got EMTs and paramedics working in our communications center. Initially that was a little threatening to both of them. They thought the other person was going to take over their job but we made them quickly realize they each brought different skillsets to the table that had a lot of value and we wanted them to maintain those skillsets. And work, just collaborate with each other, not have to do each other's jobs, but wanted them to just appreciate the synergy of sitting right next to each other.

Interviewer: Melanie, some command centers are a part of the hospital. Others are located off-site. I know yours is off-site. Could you share what the benefit of that type of location are?

Melanie: Another great question. I get that question a lot, so we did start inside the hospital just because that's a space that was available and given to us. Obviously, the biggest advantage I can think of about being in the hospital, really, it's more for convenience for the management individuals, I think. I mean, I'm still in meetings in the hospital, so I'm having to be on-site a lot. Your staff and the actual operations going on inside your command center, they can operate from anywhere. So anybody who has a multi-campus system can appreciate that you can't be inside all campuses but you can do the bed placement, the transfers, even manage the environmental services and internal clinical transporters from any site.

And that's how I helped my staff who had always been in the hospital. They panicked a little and we told them we were going to move off-site, which we eventually did. And I reminded them they were already doing bed placement for our second campus, which was 45 minutes south of us and no problems there. Really, you get a lot of added benefits moving off-campus. If you're like most health systems, you're going to end up having much better parking. Probably a nicer space. You're going to have more choices for floor plans and spaces because I feel like the logistic centers or command centers kind of get just sloppy seconds of what's leftover in a hospital because space is such a premium for clinical areas, as it should be in the hospital.

So if you look to move off-site, I think your options will open up a lot about what kind of floor plan you can have. And you also are not distracted by if you've, some health systems, as did we, find you've got players in the hospital wanting to come and try to intervene in what you're doing or if you've got people not happy with decisions being made. And that's just a distraction from my staff doing the front line work. So move off-site, protect them from that kind of distraction. And I think that just helps them keep their mind in the game, what they're doing better. And then as far as for management, like myself, I told you I still go back and forth to hospital meetings. I mean, that's just a few of us that have to do that. So that's, I think the trade-off is better for the staff to be in a better place.

Interviewer: Melanie, you're talking about design and floor plans. What are some of the things, if somebody's starting from scratch, that they you should keep in mind, like what kind of desks or what kind of chairs, what are some of the details?

Melanie: So details inside the center, first and foremost, I encourage everyone to get staff participation in making those decisions. Because that's a really big deal to staff. What kind of chair you're in, as you said. What kind of desk you're sitting at. They're the ones that are going to be 24/7 using that type of equipment. So we put together committees where we had a representative from every department that was going to be in the center and let them have a voice. So for things like chairs, we brought in three to four different chairs and let them trial them all. Desks, sit/stand desks were a huge win for my staff. Some folks like sitting, some people like standing or they at least like the ability to change it up during the shift.

We've successfully used some of the ergonomic type chairs or with the exercise balls you can sit on or some of the different ergonomic chairs. Lighting, all those things that are just... Think about it at your house, things that individually you pick out that you like it. Whether it's a warm light, bright light. Really with lighting, the ability to adjust the light is the biggest key. So the HVAC system, you've got to think about, again, 24/7 operations. You've got a lot of equipment in the room. It can get hot in there, so make sure you've got good air flow. Ability to customize the temperature. Things like headsets, that's another thing we use. We let them trial different headsets to see what was more comfortable, one vendor versus another. But again, the most important thing is don't let management solely make that decision. Let staff have input as far as what you're putting in there that they're going to be using.

Interviewer: That's great advice. Thank you. Taking something like this on, this is obviously a very large investment for a hospital or a health system. Who should be involved in the discussions when you're seeking support for an initiative like that? And then part two would be how do you get the physicians to buy into this?

Melanie: So initial support, you definitely want to stop with your, or excuse me, start with your executive level. Not just from a buy-in for the other players in the hospital, but for just asking. It's a big money ask upfront for most people, especially if you are starting from ground zero and you need 100% of your equipment. You need a room or a space, construction to be involved. So definitely get your C-suite players involved and include physician leadership in that. And then you're quickly going to have to use your physician leaders to be at the table initially when you're writing policies, procedures of how you're going to set up everything related to throughput, especially with your transfers.

So if you're going to have cardiology transfers look like this and you have associated templated procedures, have your cardiology chair sign off on that. And it's up to the cardiology chair to set the expectations for his or her staff. Before we put a lot of procedures in place, we found that a lot of physician services just had a ton of variability in how they allow transfers or flow to happen in their areas. Dr. A wants it this way. Dr. B wants it that way. And that kind of variability is just... It's inefficient and it's also frustrating to your customers, who are the referring facilities wanting to interface with them. So start with your physician leads, chairs. Have them sign off on what what's your putting into place and then let them drive the accountability to their direct reports.

And then the finance side, of course, I go back to the C-suite. When you build a good ROI and you're at the table with those folks, I think they will quickly... You'll get their buy-in if you're showing them expected outcomes, efficiencies you're going to gain. Especially when it comes down to things like loss transfers that you've been encountering as a system, reducing length of stay, those types of things, you're going to put in an ROI in front of them. That's where, again, you need the C-suite level folks, your CFO, your CIO, your CEO, all the C-suite players. Because the accountability is going to end up being a nightmare if you don't have their support at the top because then you're going to have other folks running to them saying, "This isn't working. We don't want to play that way." So if you've given them the why behind what you're doing before you roll it out to the other players in the hospital, they'll quickly support you.

Interviewer: Great. Like I said, you've had a tremendous amount of success over these past 10 years. What would you say are your top three keys?

Melanie: So when I think of top three keys on building a command center, I think putting the right people in the room and recognizing the synergies that will get you the biggest bang for your buck. Obtaining that correct executive support, like we just talked about, so you're not fighting an uphill battle. You can build the best method or best procedures in the world, but if you don't have the system buying into it when you try to roll them out, you'll quickly fail. So getting the executive buy-in. And then third, I'd say setting the right culture, and that's including getting the right leaders and the right employees in the room.

So it's really important work they're doing. And my staff in the center is really proud of the work they do. They get a lot of attention, both internally and externally, as people come to look at what we've built. So put the right people in there and make them proud of their jobs and set the right culture from the beginning. Make them understand how critical they are to the patient's journey through the health system. Because these are mostly clinicians who used to work at the bedside. So and if they're first coming in there, it's a different world, they don't feel like they're hands-on. They're not at the bedside anymore.

But making them a part of that vision of how important what we do in the center and how many people we touch. On a prior shift as a nurse we maybe have just seen, I don't know 10 patients a shift, depending on where you're working, or 20 patients a shift. And when you're working in a center like this, you're touching hundreds of patients a shift. And that's really a different way to look at being a provider. Touching a patient in a different way when you're not physically touching the patient, but you are helping them get through the system, many times from miles away. Just getting them into the health system where they need to get to and then seeing them all the way through, getting back to their home, to their loved ones. So I think that be the three key takeaways I would talk about.

Interviewer: Great. Great. Thank you. This also ties to all the success that you've had. What would you consider your top three outcomes?

Melanie: So top outcomes that come to mind right away are, we definitely have done a lot of work with ER and PACU throughput. And ER specifically, we looked at occupied timer, which I'm throwing out a TeleTracking phrase that we're all familiar with. But so basically when we assign a patient to a clean, ready bed, how quickly are we moving the patient to that bed? And when we first started a deep dive on that metric alone, our ER, which is a very busy, very overcrowded ER, who many days is boarding way too many patients. It was taking them 60 plus minutes to move a patient to a clean, ready bed. Which quite frankly, when all the leadership, we pointed that out, they said that's unacceptable. So we let them self set a goal. ER leadership said, "You know what? We should be having that patient out to clean, ready bed in no greater than 30 minutes."

And we set that as a goal. And we immediately realized that we were able to achieve that goal for the most part. And so we immediately, within just the first couple months of really concentrating on that metric and setting escalations in place, we're able to shave 30 minutes off of each ER admission up to a clean bed. Excuse me. Which when you look at just saving 30 minutes off every ER admission, we have a busy ER. We admit at least 60 admissions a day, 60 patients times 30 minutes per patient. You can count up how that quickly adds to time saved for all things throughput within the system. Excuse me, I should brought water in. Sorry.

Interviewer: So again, you've had a tremendous amount of success. What's the next step in your journey?

Melanie: Next step? I would love to get, in fact, I've talked to a lot of my administrators about this. I would love to build an ambulatory world CTaC. So same thing we're doing now looking at the other products available through TeleTracking, things like the community portal. Would love to just do a mirror image of our current CTaC and make it concentrate on the ambulatory world.

Interviewer: That's exciting.

Melanie: Yes. Would love to do that.

Interviewer: Well, Melanie, thank you so much for joining us and sharing your thoughts. We really appreciate it.

Melanie: You're welcome. Thank you for having me.