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Becker’s Healthcare Podcast
Dr. Vladimir Manuel, Vice Chair of Clinical Affairs for the Department of Family Medicine & Scott Jahnke, Senior Director of Operations at UCLA Health
00:16:26
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- [00:00]
A
This is Laura Deardel with the Beckers Healthcare Podcast. I'm thrilled today to be joined by Dr. Vladimir Emanuel, who is the Vice Chair of Clinical affairs for the Department of Family Medicine, and Scott Yankee, who's the Senior Director of operations at UCLA Health. Dr. Emanuel Scott, thank you so much for being here today.
- [00:17]
B
Thank you so much for having us.
- [00:21]
A
Absolutely. Now, I'm excited for our conversation because I know we're going to be talking through a good number of things, but in particular focusing on some of the things you've been doing in improvement science, applying from the into the hospital operations and some of the real results that you've been getting at during that process. So I'm looking forward to that conversation. But before we begin, can you tell us a little bit more about yourselves and your background?
- [00:46]
B
Yeah, for sure. So again, I'm Scott Yankee, senior Director of Operations at UCLA Health. Started my healthcare journey back at University of Michigan, where I later went to Tampa General Hospital, created command center at Tampa General Hospital, was the first in the state of Florida, and then from there moved to UCLA back in 2020 and operationalized the command center here at UCLA Health.
- [01:17]
C
Vladimir Manuel I have been fortunate enough to work on both operations and quality work, and sometimes they're thought of separately. But I helped to develop the urgent care system at UCLA and drive access, improved access and reduced ER visits through there, and then have been working with different senior quality officer projects throughout the system and over the past three, four years have really delved into hospital operations around the command center with Scott. And that's been a wonderful journey.
- [01:55]
A
Absolutely. Well, that's fantastic. And we'll dive right in here. Looking at that hospital command center, can you tell us a little bit more about how it was developed and where it's at today and in particular how you've taken that improvement science into that, those operations to really make it shine.
- [02:12]
B
Yeah, of course. So hospital command centers have become more and more popular over the last few years, and I was fortunate enough to be on the front edge building the one in Tampa back in 2017. At the time, we were really focused on the current state and the future projection of everything within operations. And we were focusing on escalation of care. We were the easy button. And that model continues throughout today. However, over the years, I've realized that we really created a firefighting mentality within our organization by doing that, by escalating each individual case through the command center. We're always just chasing down and putting out fires. I had the privilege to meet a couple amazing people Dr. Moira Inglis and Dr. Peter Margolis, who are really leaders in the improvement science industry, as well as Dr. Manuel here that's on the call with us and began to understand how we could use all of this real time information and understand where the variation was and where we were seeing special cause variation from common cause variation to really fix the problem at its root cause and focus on the de escalation of care. So instead of just keep building models that are saying what's happening in three days from now, we're able to get to the root of the problem and avoid those problems from even happening. Reducing the amount of escalation significantly into the command center.
- [03:55]
C
Yeah, and I, I think one of the areas that our work has focused on, which tends to not be the focus of a lot of work that we see in the industry, is that resource utilization throughout the system is really driven by certain key decision moments. And a lot of times those decision moments are MD involved, but they can also be staff involved and improving how those decisions are made. So one of the examples that we give is there's a lot of platforms at work that try and reduce length of stay by 20% or 30%. And we say, well, we can reduce length of stay by 100% by not admitting the patient that doesn't need to be admitted into that hospital or admitted at all. And those are the kinds of gains that we drive.
- [04:47]
B
And Dr. Manuel brings up a great point about effectiveness of decision making versus efficiency. So one of the things that the command centers focus on historically is improving operational efficiency and sometimes improving the effectiveness or oftentimes improving the effectiveness of the key decision moments, you can eliminate that entire process entirely. So taking a real world example of transfer center cases, for example, if you have 80% of your physician involvement in cases that you know are not coming into the hospital, and you improve the decision making from the transfer center nurse at the time of that original call, you can save hours, sometimes days, on the entire transfer process and also eliminate unnecessary utilization of physician time. And we all know that the most precious resource from a physician perspective is their time with the patient. So giving that back, it really drives outcomes and quality improvement.
- [05:54]
A
That's amazing to hear and, you know, really cool to have that understanding of how the command center came together and then the ways that you're thinking about avoiding issues, problem management and solving, and streamlining things upstream really, so that you know you have efficient and effective processes on the floor. Now, I know you've seen about a 48% improvement in net margin as well through the transfer center in the first six months, and it's projected to see another 30% in the 2026 fiscal year. So could you tell me a little bit more about that and especially, like, how you were able to achieve these results? What has been really the ways you've been measuring and galvanized the team around making these changes so you can actually have those improvements across the board?
- [06:40]
B
Board, yeah, of course. Thank you, Laura. That. That ties back into that effectiveness of decision making. So by saving the time, not only from the physician teams, we're able to save the time on the command center teams and the transfer center teams, and they're able to focus on the right patients. So we were able to reduce our loss referrals into the system by focusing on the correct patients. So instead of patients waiting on our board that we knew weren't going to come or did not need UCLA care, we were able to make a decision right up front that was what allowed us to increase our completion rate for transfers and get the patients that need CUCLA Health into UCLA Health. And this is both from a mission vision perspective, so taking care of the patients in Los Angeles that need UCLA care, as well as patients that help us sustain our institution. Moving into the future.
- [07:42]
C
And Laura used a really critical word, which is that notion of upstream. And so one of the methods that we approach that with is a lot of systems will look at their data and kind of say, oh, you know, this is the number of patients coming in, this is the number of beds we have. Let's try and move people around. And it's all. It's all very reactive. And by moving upstream, you can turn that into proactive work. And one of the ways we can talk about specific examples, but one of the methods that, by which we do that is we look at cases and review and activate staff to be thoughtful about where the cases could have gone better. And that constant interrogation of the workflows, the decisions that were made, changes how people respond to future cases. And so it's not in the moment that the changes necessarily always have their methodological approach, but sometimes it's in the review and the thoughtfulness and the application of those learnings to future decisions. And so it's really driven by creating a learning culture that's activated by having the right data, the right way to display data in the right way to look at it correct.
- [08:59]
B
And that's where bringing the improvement science into the command center is critical, because we can annotate when those small tests of change occur, and we can See if we're actually changing the system based on the shift in the stability of the system. So thank you Dr. Mano.
- [09:19]
A
That's impressive to hear and especially thinking through, as you just mentioned, Scott, the data and everything that goes into collecting data, analyzing it and getting into the right space. I know there's a big undertaking to actually transform and have that information as quickly as possible and then people using it in the right way. I'm curious how also you applying this methodology to the health system in general to hopefully get some similar results.
- [09:48]
B
Yeah, it's a great question. It's very exciting. Moving on. We are currently moving into ED admission avoidance. This is something that most of the country, if not all of the country, struggles with currently. And we know by looking at the correct charts, and for us it's a funnel chart of physician admission rates, that there is significant variation between our position teams on that decision to admit. And it's the same in a few different organizations that we've looked at and talked to. It shows that there's significant opportunity. So you look at a period of time, in our case it was over three years to create the law of large numbers and to standardize the data set and eliminate some of that noise. And we see that there is still big opportunity on reduction of our admissions to our quaternary campus. And through the math we know that a 4 to 5% reduction in our admission rate would effectively eliminate ED boarding at our quaternary campus. So that's, that's the next exciting journey that we're moving on. And Dr. Manuel, you may have something to add to there, but you've also done some incredible work around this on the ambulatory side.
- [11:06]
C
Yeah, I mean, I think that the, this approach works on lots of different verticals that are important to systems and it depends on where their incentive structures are and where their pain points are. So like Scott was saying, if the biggest challenge is the over admission of patients into the hospital, which we see opportunity everywhere for that, or if there is more incentive in the ambulatory side to reduce patients going to ED to begin with versus readmissions or back transfers, there's lots of different verticals that we've worked in. This one that Scott's talking about is the current work. That's very exciting. I also, you know, this wanted to pick up on some aspect around this seeing your organization through data. And one of the things we talk about in conferences that's slightly related to that is that a lot of people are discussing AI applications and what we try and emphasize in those conversations is that if you haven't set up this structure where you know how to respond to data and learn from your responses, and then adding new ways to see data doesn't help drive improvement. And that's why we're finding with a lot of our colleagues that AI implementation isn't driving results because this pre work hasn't been done. So we are agnostic into like which data streams come in. So some of it can be AI driven versus just being thoughtful about how to visualize your system with the data that already exists in it. But the response to that data and how you operationalize that response, create that learning culture and that improvement cycle is critical for that to be in place, no matter which data streams you leverage.
- [12:56]
A
That's fascinating to hear and a really great reminder of how technology in and of itself isn't the solution, but being able to think critically about it and apply it with the overall process. Improvements to redesign for more efficient and effective work seems to make a lot of sense and it's very critical now, you know, as, as you're looking into the future as well. I wanted to get a sense of, you know, what advice would you give leaders if they're trying to figure out how to do similar things within their own organizations? How can they take what you all have done, those principles and smartly apply it within their teams?
- [13:38]
B
I think for me, piggybacking on what Dr. Manuel had said is you need to be able to see the system clearly. So even before you try to automate any type of workflow or jump to an AI solution, you need to understand where your system is at and where you want to be. And so utilizing a systems thinking lens and the, the data to be able to see the stability of how you're functioning is, is the, the foundation of the work. That way as you implement different changes, you can see the impact overall. Using the ED admission example, we can look at three years of data to see the admission rate and to see that it's unchanged. We've done many projects over the years. We've engaged with different consulting groups, we've done, you know, you name it, we've put in AI, AI solutions, but we haven't seen any change. And there, there is no change in the center line, There is no change in the, the stability of the system. It's very, very stagnant. So understanding where you're at and if you're actually improving is pretty critical as you move forward with any of these technological solutions.
- [15:07]
C
Yeah, and I, I think to that question I would add, agree with everything that Scott has said. And then I would add that in, in medicine we have this, I think, well known saying at this point, C1, do one, teach one. I think it's very hard to implement this work without having seen it in action. And the network of improvements is based upon that, where people are very open and bring you in and show you. Because if you haven't seen that switch from reacting to data and you think you've put, there's a lot of words that people will use and say, yes, we've done this, we've done the learning and have the learning culture in place. But when you look at it, it really isn't operationalized that. So actually experiencing and seeing when it's done well how it works, I think is fundamental to trying to implement it in your own organization.
- [16:04]
A
That's great to hear. Dr. Manuel Scott, thank you so much for joining us on the podcast today. This has been a really informative and inspiring conversation and I look forward to connecting with you both again soon.
- [16:15]
B
Thank you so much, Laura.