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Becker’s Healthcare Podcast
Transforming Serious Illness Care and High Reliability at Geisinger with Dr. Narayana Murali
00:20:39
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- [00:02]
A
Every year, Becker's annual meeting brings healthcare leaders together to unpack the most pressing issues facing the industry. And every year, those conversations shift in profound and unexpected ways. This April, more than 3,500 healthcare executives will return to Chicago for Becker's 16th annual meeting. 795 elite speakers will offer new lessons, new case studies, and predictions about what comes next. Join us April 13th through the 16th. For the agenda and event details, visit BeckersHospitalReview.com and click on the events tab in the upper right.
- [00:38]
B
This is Laura Dearda with the Beckers Healthcare Podcast. I'm thrilled today to be joined by Dr. Murreli, Chief Medical Officer at Geisinger Clinic. Dr. Murley, it's a pleasure to have you on the podcast today.
- [00:48]
C
Such a pleasure to be here, Laura.
- [00:50]
B
Absolutely. Now, I'm excited for our conversation because I know Geisinger is such an innovative organization and truly an area where in healthcare, you know, there's so many opportunities to do things differently and use technology as well as transformational efforts. And so I'm excited to learn more about what you're doing at Geisinger. But before we do, can you introduce yourself and just tell us a little bit about the health system?
- [01:12]
C
Sure. So I am a nephrologist by trade and serve as the Chief Medical Officer at Geisinger Clinic. And Geisinger as an organization is an integrated health system that has a very broad footprint across Pennsylvania. We serve some urban areas, but largely rural communities across central Pennsylvania. Today, we care for approximately 1.2 million unique lives across the clinical enterprise. And this would be the hospitals, it would be the ambulatory care, the post acute care, the home based services that we provide, including our health plan. While that skill gives us opportunity and responsibility, it lays out the need for us to design care models that are clinically excellent, but also deeply patient centered, with a great focus on zero harm and high reliability, where safety is our core value. I hope that that provides you some sense of who we are as an organization.
- [02:14]
B
Absolutely. And I think having that ability to design those care models, think about clinical excellence, and then really define it as zero harm and high reliability is truly a huge goal and a huge undertaking. And so to see how successful that you've been at Geisinger and achieving those things is really inspiring. Now, I was wondering if we could zero in on the last year or so, could you tell us about the most important initiative that you led? What did you do and what were the results?
- [02:43]
C
Yeah, so my role is actually bringing physicians, clinicians, nursing as well as operational teams all together and greasing the skits. Right. There are several projects that we've been involved in, whether it is related to access, new patient access, whether it's care redesign, whether it's innovative care models, so on and so forth. But I think the most meaningful initiative for me this past year has been a system wide redesign of our approach to serious and advancing illness. The work is rooted on a very simple but uncomfortable truth. While everyone agrees that advance care plan conversations are important, they often happen late, are inconsistent, or do not happen at all. Most people want to die at home, surrounded by the comfort of their family as well as the familiarity of the home. And yet only a very small fraction of people actually do. This means more to me because I lost my mother this past year and my mother in law the year before, both of whom died at home. For our seniors, that cost of that disconnect between their desires to what really happens is enormous. Too often we as clinicians fail to involve patients and families early in a shared decision making. And these conversations are hard. They're not easy. They compete with many other clinical priorities in practice. When they happen too late, patients are deprived of a chance to develop prognostic awareness, to reflect on what truly matters to them and shape the care of the process as well as the support to preserve quality of life. But when it is done well and when it is done early, those conversations change everything. They improve outcomes related to disability, related to pain, treatment, invasiveness, they address mood and psychological distress. And they also actually help families to see death as a non traumatic event, not as a failure and as a natural outcome of serious illness. And so importantly, it reduces unwanted in hospital deaths and very late referrals to hospice where patients can find comfort and improved quality of life. Yet there is a paradox. In our entire country, this paradox exists. Everyone knows that these conversations are important. When everyone knows these conversations are important and it becomes everyone's job to address it, it becomes no one's job to do it. They go far beyond delivering bad news. They translate directly into medical decisions. They require coordination across settings. In the absence of clear medical guidelines, clinicians are left to balance between patient autonomy and non maleficients. Something we do imperfectly and for that matter, the whole country does imperfectly. So we started to establish a very clear baseline and I think it was important for us to know how effective we were in terms of our advanced care planning with our senior bundles. What our dashboard showed is that we hadn't budged our numbers beyond 5% until a year ago. Those numbers made that very, very real. What we did is we looked at it clinically and operationally. We focused on care fragmentation, we focused on patient experience, we focused on end of life outcomes and we completely redesigned the model end to end. At the core of this model, we have a very high touch, tightly integrated clinical model designed specifically to care for the sickest of our sick. We embedded a very focused team with very deep palliative expertise and clear clinical oversight to partner with patients who have a predicted life expectancy of 12 months or less. Using a validated predictive tool, the team works alongside with the patient and basically goes throughout the entire last mile of their journey. The role is not scripted at all. It is a series of conversations that happen longitudinally and help patients cope with their serious illness and the enormity of their illness through a continuum of conversations. These conversations are delivered reliably and consistently, whether the patient's at home or in a post acute setting. It does not matter. This team actually focuses on that. The intent is very simple. Give patients and families time. Time to cognitively and emotionally understand and process the prognostic information, time to oscillate naturally between hope and realism, and time to adapt. The work did not happen just like that. It took a village. In fact, it required our ethics teams to come together to review our tools. The College of Health Sciences from the standpoint of cascading education, multidisciplinary clinical teams, specialists in palliative care, the hospital partners, the nurses and the nursing leaders, all stacked hands, recognizing both the urgency as well as the complexity of the work. Along the way, we confronted real challenges. It was difficult to actually cascade that education on dying with dignity because we had imperfect triggers and the care was very, very fragmented between the inpatient, the outpatient, the post acute as well as the home settings. We also had to acknowledge that there was a hard truth. The truth was that we commonly used a surprise question. And the surprise question was asking our physicians and clinicians whether they would be surprised if this patient died in one year and realized that that was a very imperfect signal when patients and family needed deeper support. What we did is we pulled in our MyCare Choices team. We helped explore the elements that really matter. We went through that process intentionally and then wanted to get to real change. This far, We've enrolled about 1800 patients or so of the highest risk sickest of the six seniors. The work focused on exploring their hopes, their worries, their grievances, their clarity on priorities, as well as building coping skills to live with the serious illness. At home. As I said, this is not a single conversation. This is a very iterative process that unfolded over months. As patients integrated that information, they understood the trajectory of their illness and started to focus on what matters most to them. Those things translated to clear goals and values of shared decision making for them as well as our teams. This was a huge cultural shift. We started with about a 5% bundle rate, and now we are hovering at about 45 to 50% of our identified patients completely engaged in the process. In the recent snapshot of the thousand or so patients who had been completely engaged, we recognized that close to about a third of them had celestial ascent. And of the third, 50% of them spend their time in hospice, with an average hospice time of approximately 30 days. So a significant shift from where we were. And this, to me, was the most meaningful initiative that we've had, from my perspective. I know this was a very long response, Laura, but I thought it's important to lay out the elements.
- [10:38]
B
Yeah, absolutely. Now, that was fantastic. And I really appreciate you going into detail about how you put this together and why it was so important and critical, because I think it's something that many hospitals and systems overlook or just continue to handle this patient population in the way they always did, which is high cost and not exactly, as you mentioned, what the patients or families want in the experience for the end of their life. I know it's so critical having these conversations and putting these systems together. I appreciate you also mentioning all the number of folks that are involved in putting this together, whether it's the clinical leaders as well as the ethics teams and everybody else, just to make sure it's done in the right way, in a meaningful and compassionate way, too, because it's a very challenging time, I know, in the patients and lives of their family members, too. And so it makes a big difference. Now, when you think about the future, where do you see the system heading? What are some of the big priorities and headwinds that you have your eye on for 2026?
- [11:42]
C
Oh, there are several, but I think when I think about it, perhaps the most important piece for us to scale what we need to do as an organization is the physician app alignment. I think the care team realignment and having the teams practice at the top of our license is a refrain that we've heard for a long time. But in reality, that alignment and engagement is probably one of our biggest opportunities. The other pieces that come along with that is workforce sustainability, trying to use data, or what is right now the buzzword AI in terms of Services access redesign, which is again a bread and butter element, but looking to figure out how we can actually improve access for our new patients. And more importantly, continuity of care that is not episodic or fractured is another element. We have other areas that we are working on as big ticket issues related to clinical pathways, having a pharmacy led management and then focusing on patient experience, particularly as it relates to their likelihood to recommend as the primary signal that we follow from the standpoint of care. Now, none of these topics that I'm sharing with you are new topics. These are topics that have been things that we are working, but we are re engineering these over and again to address what needs to be done. Now in terms of your question related to headwinds, I think the biggest headwinds are workforce constraints, right? The changing mix in terms of physicians versus apps or clinicians and then collision fatigue because now you have sicker older patients in the hospital setting, particularly in a rural environment where there are also financial challenges and challenges of social determinants of health that is substantial. That is in further, it is kind of tied in with the financial pressures of the decisions that are coming down the federal as well as the state related regulations and support from the standpoint of healthcare and then aligning what is required from the standpoint of clinical care with the patient and what the patients actually want. Those I think are the big headwinds that one needs to think through from the healthcare landscape.
- [14:21]
B
I think all those things you mentioned are so critical, especially the workforce piece, something I hear time and time again from leaders across the board who are trying to design a system of more collaboration, more alignment, more connecting points between physicians, apps and clinicians across the board and their non clinical counterparts as well to make this whole system work. I'm curious, what do you think the hardest thing you'll have to do in the coming year will be?
- [14:49]
C
That's a tough question because there are so many things that are coming down the pike. But I think the most important thing will be driving behavior change at scale. At the heart of our mission, we have an unwavering commitment to bring high reliability, which really means we are pursuing zero harm and embedding safety in every aspect of our care because we believe that that is the driver of trust. Achieving excellence without exception every time is not just an aspiration, but it is a core expectation of our leadership. Our CEO has set the stage in terms of what is important and the entire executive leadership team is working on excellence without exception. And when I mention zero harm, I'm not talking about zero events, but really talking about zero errors from the standpoint of zero harm. And we wish to ensure that every patient, every family, every team member can trust that their well being is our highest priority. That our systems, our process and the culture are aligned to support safe, reliable and exceptional care at every encounter. So that probably is the biggest piece. All of those are behavioral change elements because it needs both our clinicians, our nursing teams, as well as our entire staff to rethink long standing habits. When do we intervene? How do we talk about prognosis? How do we define success? What really matters? How do you understand this from an empathetic angle and then stop being heroic or reactive, but really focusing on being intentional and anticipating care and providing that career with hope and compassion. So that's really the fundamental change. So changing culture is probably the most important thing in my mind.
- [16:58]
B
I love that and I know much easier said than done. And when you look at that culture change, needing to make the shift and wanting to zero in on that high reliability, zero harm culture and mission, how do you do that? Have that mission out in front of folks, communicate that, and then really hold that bond bar high as you're going through these changes in different team members might be in different places in terms of how easily and quickly they can adapt and others who maybe are holding on to the way they always had done things differently. So I'm curious, how do you manage all of that, especially in an environment, as we talked about that finances are tight, a lot of changes in all the other dynamics that are happening in the healthcare space today.
- [17:45]
C
Yeah, as I shared before, our CEO as well as the executive leadership team has made complete commitment to that. So basically we are bringing all our leaders for training on HRO and zero harm. Every staff member with about 1100 sessions are going to go through this program on the education as well as understanding what this really means and what should be the change in the strategic mindset to deliver on that. But rooted in all this is the process of just culture and all the safe tenets of what a high reliability organization is. And so that's really how we're going about the process. It's going to be a journey. It's going to be a journey of this next year. But that's really the biggest area of focus for us as an organization for this year. Towards the end of this year.
- [18:38]
B
Absolutely makes a ton of sense. Thank you for sharing with us. Now, before we wrap up, I have one more question. Where do you see some of the best opportunities for growth in the coming year? Or two,
- [18:49]
C
I think I can give a standard response of saying that, well, growth can be on clinical excellence, it can be on patient experience, it can be on value based care. But I really think it is at the intersection of all these three elements. Specifically, when I think about it, I think that much of the growth has to be in home based care models where we can deliver better care and better outcomes and also honor patient preferences. We think that there's opportunity for integration across the continuum. I shared with you how fractured healthcare is across the country. There is opportunity in terms of partnerships, both external and internal. We don't need to build every wheel. We can buy the wheel off the shelf and actually move things faster. Then more importantly, developing our leaders as well as our teams so that they are comfortable operating in a space of ambiguity and complexity and also recognize our unwavering commitment to high reliability organization with safety as its core value. Ultimately, the growth for us isn't about size, it's really about impact. And if we can consistently deliver that care to our patients that we would choose for ourselves and our families and deliver that excellence, without exception, we will have succeeded.
- [20:12]
B
I love that. Thank you so much, Dr. Morale, for joining us on the podcast today. This has been such a fascinating discussion. I really learned a lot and I can tell you're so passionate about what you do. So thank you for the time and I look forward to seeing you as well in April. I know you'll be speaking on one of our panels at the annual meeting and so it'll be great to catch up and dig a little bit deeper into all of the things we talked about about today.
- [20:33]
C
Thank you, Laura. You've been exceptional and kind and thanks a million.