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Welcome to Quality Time, a Houston Methodist leading medicine podcast.
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I'm your host, Dr. Shlomit Schaal, a clinician scientist and a retina specialist, and I serve as the Chief Physician Executive of Houston Methodist.
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Join us each month as my guests and I discuss the many ways that quality impacts care delivery.
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I am pleased to welcome two leaders at the Houston Methodist Physician Organization.
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Margaret Head is our Chief Nursing Officer.
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She has extensive senior executive and nursing experience in ambulatory care.
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Her focus is on patient safety, quality improvement, and optimization of care team models in more than 260 of our outpatient clinics here in Houston.
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Kayla Gutierrez is our Director of Advanced Practice.
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She is a board-certified adult gerontology primary care nurse practitioner and a board-certified nurse executive with nearly 20 years of healthcare experience.
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In her current role, she leads enterprise-wide strategy for the growth and professional development of more than 600 APPs.
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Welcome both.
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Margaret, let's start with you.
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Tell us a little bit about yourself and how you became to be the famous Margaret Head.
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Well, I've had a very interesting career journey.
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I started my career as a staff nurse in the ICUs.
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Never imagined that there was an ambulatory care environment.
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Didn't understand all the many leadership opportunities that were available to me as a nurse.
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So I have had a very long career in non-traditional nursing roles that you would expect to see in a hospital.
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So I've spent the last 35 years in ambulatory care.
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And it really, it's a great opportunity to take care of a large number of patients and to really impact patient outcomes and patient safety in a totally different way.
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DR. SCHAAL: Wonderful.
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Welcome to this show.
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MARGARET: Thank you.
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And Kayla, tell us a little bit about yourself.
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Sure.
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I actually started my nursing career here at Houston Methodist many, many years ago.
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And like many of our nurses, decided to go back to grad school, became a nurse practitioner, did practice for a few years in primary care and orthopedic surgery.
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And then this role came about a few years ago.
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It was new to the organization, to the physician organization specifically.
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And kind of like you were mentioning, Margaret, you know, wasn't fully aware of all of the various different leadership roles that one could have as a nurse practitioner.
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And so when this role became available, put my name in the hat, as they say, and the rest is history and have really enjoyed growing in this role, developing the role and working together with folks like Margaret and like yourself, Dr. Schaal, with our advanced practice provider population.
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DR. SCHAAL: Fantastic.
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So Margaret, you said something that caught my ear.
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You said, you know, you were focused on acute care.
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Mm-hmm.
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And then you made the transition to ambulatory care.
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And I want to ask you specifically, this is a Quality Time show.
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We're talking about quality.
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We spend so much time talking about hospital quality, acute care quality.
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Tell us a little bit about the difference, you know, from your perspective and also from the executive perspective.
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What's the difference between ambulatory care and acute care in the hospital?
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So I really think the main difference is we take care of thousands, hundreds of thousands of patients who may never, ever set foot in a hospital.
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In fact, that's our goal.
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We want to keep people out of the hospital and healthy, functioning in their own environment.
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So we focus on different things than a hospital does.
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So for example, to quote you,"access is quality," and so our number one goal is we want to provide timely access to our patients because the longer they delay their care, waiting on an appointment, you know, there are many things that can happen.
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They can get sicker or they may have an emergency room or hospital visit or they may choose to go elsewhere.
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So it is important that we provide timely access to care.
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We also focus on some of the same things that the hospital does.
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For example, medication safety and some of our big projects around rolling out barcode scanning for medication administration.
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And also--
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These are medications that are given in the clinic?
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In the clinic, yes.
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So make sure that you get the right medication to the right person every time.
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That's correct.
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And that we're safely handling medications in our outpatient environment.
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So another area that's harder on the outpatient side is when you have over 260 distributed locations, how you make sure that you have the same standards of care, the same quality of care and service, and that we're providing that same Methodist care to all of our patients no matter what location they're in is a challenge because we're so geographically spread.
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Yes, absolutely.
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So different clinics, different environments all over Greater Houston.
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Yes, and well outside and actually into some of our rural communities.
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DR. SCHAAL: Fantastic.
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So Kayla, what is an APP?
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KAYLA: Sure.
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So an Advanced Practice Provider includes a group of different individuals, including nurse practitioners, physician assistants, nurse midwives, and nurse anesthetists.
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And it's a large population, as you mentioned in the introduction.
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We have almost 600 APPs.
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And these are individuals that have been trained in various different areas of medicine.
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For example, our nurse midwives, right?
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They're focused on that obstetrics and, you know, women's healthcare along with some other areas.
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And so this group, it's, yeah, they have various advanced trainings and they are ready to provide care to the highest quality.
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So is it true that the population that is growing most in terms of clinicians in the physician organization, it's our APP population?
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So, yes.
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So we've been growing rapidly over the last few years.
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For example, when I got into my role about four years ago, we had about 350 APPs.
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And now we're, you know, up getting close to 600.
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So we are rapidly expanding.
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DR. SCHAAL: And why is that?
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How does it relate to quality?
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Maybe Margaret can answer that.
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Why are we hiring so many APPs?
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Well, I think we already have barriers to access in our physician population.
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And we know that the growth in physicians over the next 10 years is going to be much lower, about 3% versus nurse practitioners who are projected to be about 40%.
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Growth.
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KAYLA: Growth.
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Growth nationwide.
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MARGARET: Nationwide.
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So we're training more?
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We're training more.
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And that's the way that we're going to be able to provide access to care as a team, not as an individual, but as a multidisciplinary team so that we can better manage those patients and achieve better outcomes.
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So the role of an APP and the reason that we're training so many APPs across the nation is to really help clinicians provide better care.
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How is that translated into practice?
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How are we doing this?
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KAYLA: Yeah.
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So team-based, right?
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Really focusing in on everybody's individual role and not just the APPs and the physicians.
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I mean, the team starts at the front desk.
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That's the person that the patient's going to interact with first through their visit.
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But specifically when it comes to APPs and physicians and clinicians, everybody practicing to the top of their license is how we're going to increase access.
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And so what does that look like?
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I'll give you an example in surgery, right?
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Our physician assistants, excellent clinicians, let them handle the non-surgical cases and patients and care --
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Like before surgery or after?
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Before, after, or even perhaps, I'll give you an orthopedic example from my previous roles here at Methodist.
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A lot of times patients would come in with knee pain that was going on for many years.
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We would do the workup as the NPs, PAs.
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We would determine if they needed to go through physical therapy or perhaps some non-invasive modalities of therapy such as, you know, viscosupplementation injections, things such as that.
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And so there were sometimes we could handle those.
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They don't need to see the surgeons for that.
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Or we would see them and we'd go, "Wow, this is beyond what physical therapy is going to help you achieve," right?
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"We know you need to see our surgeon and so let's get you set up with him or her." And so we can handle those non-surgical cases.
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So then it allows our physicians to practice to the top of their license and training and expertise.
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And so now that surgeon is in surgery more.
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I've never met a surgeon who doesn't want to do more surgery.
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And so it allows them to do what they were trained to do.
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And it's allowing us to do what we were trained to do and handle those patients in a high quality manner.
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Now fantastic.
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I love the surgical example.
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That's very clear.
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However, what I wanted to ask you about the non-surgical practice, let's say primary care.
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I know we have a lot of APPs in primary care and that's growing as well.
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How are APPs really achieving what they're supposed to achieve within those care models?
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Yeah. So, you know, in primary care, it's going to look a little different, obviously.
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So in primary care, many of our APPs carry their own panel of patients.
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They are the primary care provider.
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I hesitate to use that word, but they are the PCP for a specific panel of patients.
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They have some very complex patients.
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However, they are trained to take care of these patients.
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They work very collaboratively with the physicians.
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Even though these patients are being managed by our APPs, they are still very closely collaborating with physicians, having those conversations, discussing the care, therapies, et cetera, of these patients with their collaborating physicians.
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There's also some models in primary care where they work very closely as a team to take care of kind of a group or a panel of patients.
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So I'll give you an example.
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As a new patient, they come into the clinic.
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They establish care with the physician.
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For their follow-up subsequent care, they may come and see the APP for subsequent care.
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Let's say start on a blood pressure medication in three months or however long.
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They'll come back and they'll see the APP.
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And so we're working together collaboratively to manage that patient within the primary care setting.
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So that really results in better quality of care for our patients.
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Margaret, I know you're a really strong proponent of teams and team building and roles.
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How are we doing this at Houston Methodist?
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How we make clear what the roles are?
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And to your point, you said we have more than 260 clinics.
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How do we standardize the excellent care all over Houston?
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Well, first we start with daily safety huddles at the clinic level.
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And so we use the daily management system or DMS.
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And we-- DR. SCHAAL: What is DMS?
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It's daily management system.
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So it's a LEAN tool.
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DR. SCHAAL: Mm-hmm.
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And it's a methodology where the local whole patient care team makes decisions about problems or issues at the clinic level.
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It really promotes that unit level continuous process improvement.
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So we build on that.
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We have additional huddles that we call tiered huddles.
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So the next level of management and then the next level of management.
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So that ultimately every morning we have a tier five huddle, which is the executive team.
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So we can hear from the front lines problems that are rising up where they need our help to solve or for our awareness or for our tracking.
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And then we also use those same tiers to communicate down announcements, new programs, policy changes, things that we need to get to every clinic.
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We can use those same huddles and send communication down the organization.
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Yeah, I was really impressed.
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You know, we didn't have huddle boards in our clinic before you joined Houston Methodist.
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And now every clinic has it.
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And I ask to see these boards every time I visit and they look the same.
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They have different metrics, but they look the same.
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And the teams are huddling every day to solve problems.
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So that's -- I think that's a super impressive something that we started recently.
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How is it contributing to the quality of care for our patients?
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So we've been able to see changes in our metrics.
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For example, how soon we refill prescriptions.
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So we want to be able to respond to that quickly so that a patient doesn't run out of their medication as one example.
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We also look at our turnaround time on our test results, lab results, our communication with patients and response to their request for medical advice via the MyChart in baskets.
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So we want to make sure that we're promptly responding to patient needs.
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And those we've seen great improvements, particularly in primary care in those areas.
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Yeah, and I see, you know, access is a metric there.
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MARGARET: Yes.
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And, you know, other metrics that the clinic tracks is usually related directly to the quality of care that we provide to our patients.
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I want to get back to APPs, you know, when we talk about clinicians, other clinicians, physicians, surgeons, let's say if I say an orthopedic surgeon, kind of know what that means and how the career develops.
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From your experience and what you're trying to do together, actually, here at Houston Methodist, how are we envisioning development of APP throughout the career?
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Because I understand, you know, you're trained, then you join a clinic, but then what happens in five years, in ten years?
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How do you become a Kayla?
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How do you become Margaret?
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Yeah, and that's an excellent, excellent question.
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So at Houston Methodist, we've started looking at this very closely and working through various different initiatives.
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And so one of them is our transition to practice program that we have for our new graduate APPs.
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Like many of us, as we first start our careers, the first year or so can be a bit rocky at times.
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And so this program really is to set folks up from the start for success.
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And so we focus on areas such as coding and documentation.
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So hold on.
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These are graduates?
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These are new APPs.
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They just graduated from, let's say, NP school.
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So we hire them, but then they go through that program?
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They go through the program.
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As they're learning the clinical practice side within their clinics, they're also joining us on my team to learn about the non-clinical side of being a clinician, right?
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The coding documentation, the, "How do we have tough conversations with our patients and one another?
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How do we communicate effectively with our collaborating physicians?" Things such as that that we don't learn in nursing school or PA school or sometimes even medical school from having conversations with some of our physicians about these things.
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We also want to make sure that we're setting our APPs up for success, those with more experience, say, than the new graduates, right?
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So we're launching, we're piloting, I should say, right now and looking to launch in '27 our APP leadership program.
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So for those who do want to develop into formal leaders, if they want my job one day, come on, let's get you prepared and set up to take it over.
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So we are working to have these programs within our physician organization?
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Anticipating that, you know, we want this to, this population to grow and be happy and stay with us.
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KAYLA: Correct. Correct.
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And also to, you know, leadership isn't for everyone, but there -- we have some APPs that are very interested in research.
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Well, let's get connected with the RI, right?
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Let's build different connections there.
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There are some that want to teach.
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We have some excellent APPs who precept and teach the next generation of APPs.
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Well, let's get some faculty appointments at some of our local universities, right, for different, you know, nursing and PA programs.
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And so there's a lot of opportunity and that's what we're working to develop towards.
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Yes. And I can't help but put a plug into our new safety, quality, and well-being institute where, you know, APPs and physicians, every clinician that is interested in either safety, quality, or well-being can have an academic appointment because we have a safety, quality, and well-being track, academic track.
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And also we have grants and, you know, opportunities for people to develop an academic career in that track.
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So, you know, thank you.
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Thank you for that.
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And thank you for leading that.
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Margaret, you are our first ever Chief Nursing Officer in the physician organization?
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MARGARET: That is correct.
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So how are you connected to the other CNOs in the hospitals?
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And, you know, what are you providing them?
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What do they provide you?
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And how do we actually keep all our nurses in one community?
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So I participate every month with the CNO council that's led by our CNE, Gail Vozzella.
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And we have tackled some very challenging issues.
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You know, there's a lot of challenges now in the nursing profession, whether you're inpatient or outpatient.
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And so we've been able to learn from each other.
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We stay connected on key policy decisions as well as we want to have the one Houston Methodist nurse.
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So we really want not to think of ourselves as, "Oh, I only work," you know,"in the PO," or "I only work in this hospital." But there is a brand and a standard of care, and compassion --
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So what is the Houston Methodist nurse?
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What is that brand?
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I think it's compassionate care, partnered with technology, innovation, learning, and making sure that our nurses, wherever you practice, have all the right tools to be successful and take the best care of our patients.
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So we hear a lot of innovation in the acute care setting in the hospitals.
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Are there innovations in the ambulatory settings that specifically affect, you know, nurses, APPs, and our patients?
00:20:06.872 --> 00:20:08.740
MARGARET: Yes.
00:20:08.807 --> 00:20:18.884
So we're looking at some different technologies within our clinics that help us focus on patient flow through the clinics, bottlenecks.
00:20:18.951 --> 00:20:21.686
We want to eliminate long wait times.
00:20:21.752 --> 00:20:27.759
And how do we appropriately use our resources that we have, our space?
00:20:27.826 --> 00:20:34.599
How do we make sure that our staff and our teams are well equipped and optimized?
00:20:34.665 --> 00:20:47.011
And so we have different tools that track throughput, that also even track how long our patients have been alone in an exam room.
00:20:47.078 --> 00:20:50.248
That's one of the worst feelings in the world.
00:20:50.315 --> 00:20:54.118
They put you in a little room, close the door, and you wonder if they're ever coming back, you know?
00:20:54.185 --> 00:20:57.788
So really, we need to minimize that time.
00:20:57.855 --> 00:20:58.990
Yes.
00:20:57.855 --> 00:20:58.990
And we do.
00:20:59.057 --> 00:21:00.025
We do.
00:20:59.057 --> 00:21:00.025
We do.
00:21:00.092 --> 00:21:01.460
We've implemented different strategies.
00:21:01.526 --> 00:21:05.063
So these tools really help our people understand where the patients are.
00:21:05.130 --> 00:21:06.097
Yes.
00:21:06.163 --> 00:21:08.599
And really make sure that the flow continues.
00:21:08.666 --> 00:21:11.336
So we talked about access, you know, reaching us.
00:21:11.403 --> 00:21:18.210
But then once you reach us, you do not want the visit to be like 45 minutes wait.
00:21:18.276 --> 00:21:21.078
You want to get right in and then do what you need to do.
00:21:21.145 --> 00:21:24.982
And in our clinics, just talk about, you know, different modalities that we have.
00:21:25.049 --> 00:21:28.753
It's not only a doctor's visit or an APP visit.
00:21:28.819 --> 00:21:30.821
What do we have in our clinics?
00:21:30.888 --> 00:21:34.759
So we have full diagnostic testing, radiology testing.
00:21:34.826 --> 00:21:37.796
We have cardiology diagnostic testing.
00:21:37.863 --> 00:21:41.465
We have vein centers.
00:21:37.863 --> 00:21:41.465
We have pain clinics.
00:21:41.532 --> 00:21:43.167
We have infusion centers.
00:21:43.234 --> 00:21:52.210
And we also have other ancillary testing that used to be done in the hospital, but now is done in the outpatient setting.
00:21:52.277 --> 00:21:59.384
And I think over the next several years, we're going to see more and more services move into the ambulatory environment.
00:21:59.451 --> 00:22:06.391
And that's why we have to make sure that our care teams are well prepared to take care of those patients as we make that transition.
00:22:06.458 --> 00:22:09.827
And we have an ambulatory surgical center.
00:22:09.894 --> 00:22:10.429
Oh, yeah.
00:22:10.494 --> 00:22:12.596
[Laughing] How could I forget?
00:22:11.195 --> 00:22:12.596
DR. SCHAAL: Right.
00:22:12.663 --> 00:22:14.298
So tell us a little bit about that.
00:22:14.365 --> 00:22:16.067
And, you know, how is it different?
00:22:16.134 --> 00:22:22.641
Because in Houston Methodist, we used to have all our surgery care attached to the hospitals.
00:22:22.708 --> 00:22:26.444
How is this now different?
00:22:22.708 --> 00:22:26.444
And what have we learned?
00:22:26.510 --> 00:22:33.652
So this is the first freestanding ASC, not a hospital-based ASC in the Methodist system.
00:22:33.719 --> 00:22:48.365
And so our goal is we wanted to go ahead and let's start working in this space because we know that the pressures from CMS and our other payers on price neutrality are going to hit us.
00:22:48.432 --> 00:22:56.307
And we also need our acute care patients being seen in the hospital or the more acute ambulatory cases.
00:22:56.374 --> 00:23:03.981
So let's make room for those cases and move the more community-based procedures to a freestanding ASC.
00:23:04.048 --> 00:23:08.286
So we've been open for a year and a half.
00:23:08.353 --> 00:23:09.855
We have four ORs.
00:23:09.921 --> 00:23:15.693
And we provide ophthalmology services, ENT, and orthopedic hand.
00:23:15.760 --> 00:23:17.194
And we're looking to expand more.
00:23:17.261 --> 00:23:27.305
But I think what we've learned is we're in this hybrid space where we're not a for-profit community-based hospital.
00:23:27.372 --> 00:23:34.211
We still retain the Methodist standards of care and that service level that our patients expect.
00:23:34.278 --> 00:23:41.519
But we're not as complicated either as the hospital-based outpatient surgery centers.
00:23:41.586 --> 00:23:45.624
So we're really able to offer something unique in the market.
00:23:45.690 --> 00:23:48.727
And we've just seen tremendous growth.
00:23:48.794 --> 00:23:51.262
And so very proud of our unit.
00:23:48.794 --> 00:23:51.262
DR. SCHAAL: Yeah.
00:23:51.328 --> 00:24:07.578
And I think the entire idea of moving things to the ambulatory environment is to provide easier access, free parking in and out, no matter where you go to a clinic visit or surgery or -- in and out.
00:24:07.645 --> 00:24:10.714
And it's much less hassle than a hospital.
00:24:10.781 --> 00:24:11.549
Any hospital.
00:24:11.615 --> 00:24:14.618
Hospitals are great if you need them.
00:24:14.685 --> 00:24:21.726
But if you don't, we try to keep our patients outside the hospital.
00:24:21.792 --> 00:24:24.461
So Kayla, what are you hearing nationally?
00:24:24.528 --> 00:24:27.265
I asked you before, what is an APP?
00:24:27.332 --> 00:24:32.503
And I'm guessing other systems really trying to grapple with that same question.
00:24:32.570 --> 00:24:33.672
What is the role of APP?
00:24:33.738 --> 00:24:38.175
And as APPs, we have more and more of them in the market.
00:24:38.242 --> 00:24:40.478
What role they're going to serve?
00:24:40.545 --> 00:24:45.049
So what are you focused on nationally as APPs nationally?
00:24:45.115 --> 00:24:48.153
Yeah. So nationally, I think it's role delineation.
00:24:48.220 --> 00:24:52.223
It's determining what is the role of an APP.
00:24:52.289 --> 00:25:03.535
How do we provide high quality care in collaboration with physicians, other clinicians, others in the clinical settings, such as our nurses and others.
00:25:03.602 --> 00:25:06.471
Also to the professional development.
00:25:06.538 --> 00:25:21.553
I think when I think of nursing, there's many clear pathways, if you will, to become whatever type of nurse one wants to become, whether it's a nursing leader, a nurse researcher, things like that.
00:25:21.619 --> 00:25:26.590
And in the APP space, there's not as clear of pathways yet.
00:25:26.657 --> 00:25:30.028
And so here at Houston Methodist, we want to lead that effort.
00:25:30.095 --> 00:25:34.499
And so that's where we're focusing in on creating these various different opportunities.
00:25:34.566 --> 00:25:49.114
As I mentioned earlier, if we have an APP that wants to be the best darn researcher they can be, and that's what they want to do with their career, well, then let's work together to get that set up so that they can get on that pathway and focus their efforts on that.
00:25:49.180 --> 00:25:59.089
Yeah. And I know we have an APP council where we are listening to the voices of APPs to really develop that and make it better as we go forward.
00:25:59.156 --> 00:26:08.133
And now I have to ask you both the question that I ask every single guest that sits here with me in this podcast.
00:26:08.199 --> 00:26:13.371
And the question is, what does quality mean to you?
00:26:13.438 --> 00:26:18.143
So start with Margaret, what does quality mean to you?
00:26:18.209 --> 00:26:31.588
Quality to me means that we are providing evidence-based care in efficient models, but it has to be done with compassion.
00:26:31.655 --> 00:26:36.528
Because if you don't have compassion, they're just empty metrics.
00:26:36.594 --> 00:26:45.202
And so I think it's that right balance between the science of nursing and the art of nursing.
00:26:45.269 --> 00:26:46.671
Fantastic.
00:26:45.269 --> 00:26:46.671
How about you?
00:26:46.738 --> 00:26:48.506
What does quality mean to you, Kayla?
00:26:48.573 --> 00:26:51.076
Well, I would say ditto to what Margaret said.
00:26:51.142 --> 00:26:52.743
That was a great answer.
00:26:52.810 --> 00:27:12.297
I think to expound upon that, as an APP specifically, when we focus in on quality, it's making sure that our patient receives the best care that's evidence-based in its foundation and that they receive it every time.
00:27:12.364 --> 00:27:16.601
It's the consistency aspect, right, of medicine.
00:27:16.667 --> 00:27:23.375
As you mentioned earlier, Margaret, about the 260 plus clinics, how do we keep things organized and standardized?
00:27:23.441 --> 00:27:25.442
Well, the same as an APP.
00:27:25.509 --> 00:27:35.487
How does a cardiology patient at the Woodlands receive high-quality care in a similar fashion that they do here at, say, the Med Center, right?
00:27:35.553 --> 00:27:40.424
How do we as APPs make sure that we can maintain those standards and evidence-based practice?
00:27:40.491 --> 00:27:51.769
Yeah, I love these answers because it is really you wanna standardize, we wanna replicate and make it reliable.
00:27:49.500 --> 00:27:51.769
KAYLA: Yes.
00:27:51.836 --> 00:27:53.704
However, we wanna make it human.
00:27:53.771 --> 00:27:54.638
Yes.
00:27:54.705 --> 00:28:00.444
And we want every patient to think that we're here for you, only for you.
00:28:00.511 --> 00:28:05.115
Even though we do it so many times, we're here for you.
00:28:03.448 --> 00:28:05.115
KAYLA: Correct.
00:28:05.182 --> 00:28:05.884
Thank you both.
00:28:05.950 --> 00:28:07.684
I really enjoyed the conversation.
00:28:07.751 --> 00:28:08.853
Thank you for coming.
00:28:08.920 --> 00:28:09.887
Thank you for having us.
00:28:09.953 --> 00:28:12.390
Thank you so much.
00:28:12.457 --> 00:28:14.826
And thank you for listening.
00:28:14.893 --> 00:28:19.396
So that you never miss an episode, subscribe to Quality Time.
00:28:19.463 --> 00:28:23.434
New episodes will download to your podcast device.
00:28:23.500 --> 00:28:26.003
I appreciate your support.
00:28:23.500 --> 00:28:26.003
Thank you.
00:28:26.070 --> 00:28:29.039
And until next time, I am always listening.
00:00:01.735 --> 00:00:07.206
Welcome to Quality Time, a Houston Methodist leading medicine podcast.
00:00:07.272 --> 00:00:18.350
I'm your host, Dr. Shlomit Schaal, a clinician scientist and a retina specialist, and I serve as the Chief Physician Executive of Houston Methodist.
00:00:18.417 --> 00:00:28.495
Join us each month as my guests and I discuss the many ways that quality impacts care delivery.
00:00:28.560 --> 00:00:34.167
I am pleased to welcome two leaders at the Houston Methodist Physician Organization.
00:00:34.234 --> 00:00:38.170
Margaret Head is our Chief Nursing Officer.
00:00:38.237 --> 00:00:44.411
She has extensive senior executive and nursing experience in ambulatory care.
00:00:44.476 --> 00:00:57.890
Her focus is on patient safety, quality improvement, and optimization of care team models in more than 260 of our outpatient clinics here in Houston.
00:00:57.957 --> 00:01:02.295
Kayla Gutierrez is our Director of Advanced Practice.
00:01:02.362 --> 00:01:15.441
She is a board-certified adult gerontology primary care nurse practitioner and a board-certified nurse executive with nearly 20 years of healthcare experience.
00:01:15.507 --> 00:01:27.253
In her current role, she leads enterprise-wide strategy for the growth and professional development of more than 600 APPs.
00:01:23.316 --> 00:01:27.253
Welcome both.
00:01:27.319 --> 00:01:28.388
Margaret, let's start with you.
00:01:28.454 --> 00:01:34.126
Tell us a little bit about yourself and how you became to be the famous Margaret Head.
00:01:34.194 --> 00:01:37.397
Well, I've had a very interesting career journey.
00:01:37.463 --> 00:01:41.099
I started my career as a staff nurse in the ICUs.
00:01:41.167 --> 00:01:46.406
Never imagined that there was an ambulatory care environment.
00:01:46.472 --> 00:01:53.313
Didn't understand all the many leadership opportunities that were available to me as a nurse.
00:01:53.379 --> 00:02:01.221
So I have had a very long career in non-traditional nursing roles that you would expect to see in a hospital.
00:02:01.287 --> 00:02:04.858
So I've spent the last 35 years in ambulatory care.
00:02:04.924 --> 00:02:19.405
And it really, it's a great opportunity to take care of a large number of patients and to really impact patient outcomes and patient safety in a totally different way.
00:02:17.135 --> 00:02:19.405
DR. SCHAAL: Wonderful.
00:02:19.472 --> 00:02:21.139
Welcome to this show.
00:02:19.472 --> 00:02:21.139
MARGARET: Thank you.
00:02:21.206 --> 00:02:23.675
And Kayla, tell us a little bit about yourself.
00:02:23.742 --> 00:02:24.510
Sure.
00:02:24.576 --> 00:02:30.116
I actually started my nursing career here at Houston Methodist many, many years ago.
00:02:30.182 --> 00:02:40.360
And like many of our nurses, decided to go back to grad school, became a nurse practitioner, did practice for a few years in primary care and orthopedic surgery.
00:02:40.425 --> 00:02:43.263
And then this role came about a few years ago.
00:02:43.329 --> 00:02:48.100
It was new to the organization, to the physician organization specifically.
00:02:48.167 --> 00:02:58.110
And kind of like you were mentioning, Margaret, you know, wasn't fully aware of all of the various different leadership roles that one could have as a nurse practitioner.
00:02:58.176 --> 00:03:17.396
And so when this role became available, put my name in the hat, as they say, and the rest is history and have really enjoyed growing in this role, developing the role and working together with folks like Margaret and like yourself, Dr. Schaal, with our advanced practice provider population.
00:03:15.662 --> 00:03:17.396
DR. SCHAAL: Fantastic.
00:03:17.462 --> 00:03:19.731
So Margaret, you said something that caught my ear.
00:03:19.799 --> 00:03:22.835
You said, you know, you were focused on acute care.
00:03:22.901 --> 00:03:23.635
Mm-hmm.
00:03:23.703 --> 00:03:26.673
And then you made the transition to ambulatory care.
00:03:26.739 --> 00:03:32.245
And I want to ask you specifically, this is a Quality Time show.
00:03:27.973 --> 00:03:32.245
We're talking about quality.
00:03:32.312 --> 00:03:38.484
We spend so much time talking about hospital quality, acute care quality.
00:03:38.550 --> 00:03:44.157
Tell us a little bit about the difference, you know, from your perspective and also from the executive perspective.
00:03:44.223 --> 00:03:49.461
What's the difference between ambulatory care and acute care in the hospital?
00:03:49.528 --> 00:04:03.308
So I really think the main difference is we take care of thousands, hundreds of thousands of patients who may never, ever set foot in a hospital.
00:04:00.907 --> 00:04:03.308
In fact, that's our goal.
00:04:03.376 --> 00:04:09.414
We want to keep people out of the hospital and healthy, functioning in their own environment.
00:04:09.481 --> 00:04:13.419
So we focus on different things than a hospital does.
00:04:13.485 --> 00:04:30.970
So for example, to quote you,"access is quality," and so our number one goal is we want to provide timely access to our patients because the longer they delay their care, waiting on an appointment, you know, there are many things that can happen.
00:04:31.036 --> 00:04:36.875
They can get sicker or they may have an emergency room or hospital visit or they may choose to go elsewhere.
00:04:36.942 --> 00:04:42.148
So it is important that we provide timely access to care.
00:04:42.214 --> 00:04:45.485
We also focus on some of the same things that the hospital does.
00:04:45.550 --> 00:04:54.360
For example, medication safety and some of our big projects around rolling out barcode scanning for medication administration.
00:04:51.223 --> 00:04:54.360
And also--
00:04:54.427 --> 00:04:56.262
These are medications that are given in the clinic?
00:04:56.329 --> 00:04:57.797
In the clinic, yes.
00:04:57.863 --> 00:05:01.767
So make sure that you get the right medication to the right person every time.
00:05:01.834 --> 00:05:02.601
That's correct.
00:05:02.668 --> 00:05:08.173
And that we're safely handling medications in our outpatient environment.
00:05:08.240 --> 00:05:36.636
So another area that's harder on the outpatient side is when you have over 260 distributed locations, how you make sure that you have the same standards of care, the same quality of care and service, and that we're providing that same Methodist care to all of our patients no matter what location they're in is a challenge because we're so geographically spread.
00:05:36.702 --> 00:05:37.903
Yes, absolutely.
00:05:37.970 --> 00:05:42.040
So different clinics, different environments all over Greater Houston.
00:05:42.108 --> 00:05:47.180
Yes, and well outside and actually into some of our rural communities.
00:05:44.509 --> 00:05:47.180
DR. SCHAAL: Fantastic.
00:05:47.245 --> 00:05:49.716
So Kayla, what is an APP?
00:05:47.245 --> 00:05:49.716
KAYLA: Sure.
00:05:49.781 --> 00:05:58.990
So an Advanced Practice Provider includes a group of different individuals, including nurse practitioners, physician assistants, nurse midwives, and nurse anesthetists.
00:05:59.057 --> 00:06:06.899
And it's a large population, as you mentioned in the introduction.
00:06:03.262 --> 00:06:06.899
We have almost 600 APPs.
00:06:06.966 --> 00:06:13.172
And these are individuals that have been trained in various different areas of medicine.
00:06:13.238 --> 00:06:15.208
For example, our nurse midwives, right?
00:06:15.274 --> 00:06:22.348
They're focused on that obstetrics and, you know, women's healthcare along with some other areas.
00:06:22.415 --> 00:06:33.860
And so this group, it's, yeah, they have various advanced trainings and they are ready to provide care to the highest quality.
00:06:33.925 --> 00:06:42.367
So is it true that the population that is growing most in terms of clinicians in the physician organization, it's our APP population?
00:06:42.435 --> 00:06:43.401
So, yes.
00:06:43.468 --> 00:06:47.105
So we've been growing rapidly over the last few years.
00:06:47.173 --> 00:06:53.178
For example, when I got into my role about four years ago, we had about 350 APPs.
00:06:53.245 --> 00:06:56.516
And now we're, you know, up getting close to 600.
00:06:56.581 --> 00:06:59.651
So we are rapidly expanding.
00:06:56.581 --> 00:06:59.651
DR. SCHAAL: And why is that?
00:06:59.718 --> 00:07:01.620
How does it relate to quality?
00:07:01.687 --> 00:07:03.755
Maybe Margaret can answer that.
00:07:03.822 --> 00:07:06.158
Why are we hiring so many APPs?
00:07:06.225 --> 00:07:13.266
Well, I think we already have barriers to access in our physician population.
00:07:13.331 --> 00:07:26.778
And we know that the growth in physicians over the next 10 years is going to be much lower, about 3% versus nurse practitioners who are projected to be about 40%.
00:07:26.846 --> 00:07:28.314
Growth.
00:07:26.846 --> 00:07:28.314
KAYLA: Growth.
00:07:28.380 --> 00:07:29.382
Growth nationwide.
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MARGARET: Nationwide.
00:07:29.447 --> 00:07:30.983
So we're training more?
00:07:31.050 --> 00:07:32.451
We're training more.
00:07:32.517 --> 00:07:46.665
And that's the way that we're going to be able to provide access to care as a team, not as an individual, but as a multidisciplinary team so that we can better manage those patients and achieve better outcomes.
00:07:46.732 --> 00:07:58.944
So the role of an APP and the reason that we're training so many APPs across the nation is to really help clinicians provide better care.
00:07:59.011 --> 00:08:02.615
How is that translated into practice?
00:08:02.682 --> 00:08:04.317
How are we doing this?
00:08:02.682 --> 00:08:04.317
KAYLA: Yeah.
00:08:04.382 --> 00:08:06.619
So team-based, right?
00:08:06.685 --> 00:08:12.692
Really focusing in on everybody's individual role and not just the APPs and the physicians.
00:08:12.757 --> 00:08:14.627
I mean, the team starts at the front desk.
00:08:14.694 --> 00:08:19.264
That's the person that the patient's going to interact with first through their visit.
00:08:19.331 --> 00:08:29.242
But specifically when it comes to APPs and physicians and clinicians, everybody practicing to the top of their license is how we're going to increase access.
00:08:29.307 --> 00:08:31.810
And so what does that look like?
00:08:31.877 --> 00:08:34.312
I'll give you an example in surgery, right?
00:08:34.379 --> 00:08:42.455
Our physician assistants, excellent clinicians, let them handle the non-surgical cases and patients and care --
00:08:42.520 --> 00:08:43.923
Like before surgery or after?
00:08:43.990 --> 00:08:54.100
Before, after, or even perhaps, I'll give you an orthopedic example from my previous roles here at Methodist.
00:08:54.166 --> 00:08:58.803
A lot of times patients would come in with knee pain that was going on for many years.
00:08:58.870 --> 00:09:01.974
We would do the workup as the NPs, PAs.
00:09:02.041 --> 00:09:16.322
We would determine if they needed to go through physical therapy or perhaps some non-invasive modalities of therapy such as, you know, viscosupplementation injections, things such as that.
00:09:16.389 --> 00:09:18.423
And so there were sometimes we could handle those.
00:09:18.490 --> 00:09:21.192
They don't need to see the surgeons for that.
00:09:21.259 --> 00:09:26.731
Or we would see them and we'd go, "Wow, this is beyond what physical therapy is going to help you achieve," right?
00:09:26.798 --> 00:09:33.371
"We know you need to see our surgeon and so let's get you set up with him or her." And so we can handle those non-surgical cases.
00:09:33.438 --> 00:09:39.245
So then it allows our physicians to practice to the top of their license and training and expertise.
00:09:39.312 --> 00:09:41.547
And so now that surgeon is in surgery more.
00:09:41.614 --> 00:09:44.450
I've never met a surgeon who doesn't want to do more surgery.
00:09:44.517 --> 00:09:48.955
And so it allows them to do what they were trained to do.
00:09:49.020 --> 00:09:56.729
And it's allowing us to do what we were trained to do and handle those patients in a high quality manner.
00:09:56.796 --> 00:09:58.965
Now fantastic.
00:09:56.796 --> 00:09:58.965
I love the surgical example.
00:09:59.030 --> 00:10:01.033
That's very clear.
00:10:01.100 --> 00:10:06.438
However, what I wanted to ask you about the non-surgical practice, let's say primary care.
00:10:06.504 --> 00:10:11.744
I know we have a lot of APPs in primary care and that's growing as well.
00:10:11.811 --> 00:10:19.684
How are APPs really achieving what they're supposed to achieve within those care models?
00:10:19.751 --> 00:10:24.090
Yeah. So, you know, in primary care, it's going to look a little different, obviously.
00:10:24.155 --> 00:10:28.159
So in primary care, many of our APPs carry their own panel of patients.
00:10:28.226 --> 00:10:30.261
They are the primary care provider.
00:10:30.328 --> 00:10:35.567
I hesitate to use that word, but they are the PCP for a specific panel of patients.
00:10:35.634 --> 00:10:37.870
They have some very complex patients.
00:10:37.937 --> 00:10:41.307
However, they are trained to take care of these patients.
00:10:41.374 --> 00:10:43.808
They work very collaboratively with the physicians.
00:10:43.875 --> 00:11:00.625
Even though these patients are being managed by our APPs, they are still very closely collaborating with physicians, having those conversations, discussing the care, therapies, et cetera, of these patients with their collaborating physicians.
00:11:00.692 --> 00:11:08.967
There's also some models in primary care where they work very closely as a team to take care of kind of a group or a panel of patients.
00:11:09.034 --> 00:11:10.870
So I'll give you an example.
00:11:10.936 --> 00:11:13.004
As a new patient, they come into the clinic.
00:11:13.072 --> 00:11:15.374
They establish care with the physician.
00:11:15.441 --> 00:11:21.013
For their follow-up subsequent care, they may come and see the APP for subsequent care.
00:11:21.080 --> 00:11:25.650
Let's say start on a blood pressure medication in three months or however long.
00:11:25.717 --> 00:11:27.586
They'll come back and they'll see the APP.
00:11:27.653 --> 00:11:32.524
And so we're working together collaboratively to manage that patient within the primary care setting.
00:11:32.591 --> 00:11:37.229
So that really results in better quality of care for our patients.
00:11:37.296 --> 00:11:45.171
Margaret, I know you're a really strong proponent of teams and team building and roles.
00:11:45.236 --> 00:11:47.505
How are we doing this at Houston Methodist?
00:11:47.572 --> 00:11:51.943
How we make clear what the roles are?
00:11:52.010 --> 00:11:55.413
And to your point, you said we have more than 260 clinics.
00:11:55.480 --> 00:12:00.119
How do we standardize the excellent care all over Houston?
00:12:00.186 --> 00:12:05.658
Well, first we start with daily safety huddles at the clinic level.
00:12:05.724 --> 00:12:09.195
And so we use the daily management system or DMS.
00:12:09.260 --> 00:12:11.697
And we-- DR. SCHAAL: What is DMS?
00:12:11.764 --> 00:12:12.898
It's daily management system.
00:12:12.965 --> 00:12:14.667
So it's a LEAN tool.
00:12:12.965 --> 00:12:14.667
DR. SCHAAL: Mm-hmm.
00:12:14.732 --> 00:12:28.013
And it's a methodology where the local whole patient care team makes decisions about problems or issues at the clinic level.
00:12:28.080 --> 00:12:35.653
It really promotes that unit level continuous process improvement.
00:12:31.850 --> 00:12:35.653
So we build on that.
00:12:35.721 --> 00:12:40.893
We have additional huddles that we call tiered huddles.
00:12:40.960 --> 00:12:45.965
So the next level of management and then the next level of management.
00:12:46.030 --> 00:12:51.470
So that ultimately every morning we have a tier five huddle, which is the executive team.
00:12:51.537 --> 00:13:01.614
So we can hear from the front lines problems that are rising up where they need our help to solve or for our awareness or for our tracking.
00:13:01.679 --> 00:13:14.659
And then we also use those same tiers to communicate down announcements, new programs, policy changes, things that we need to get to every clinic.
00:13:14.726 --> 00:13:20.666
We can use those same huddles and send communication down the organization.
00:13:20.732 --> 00:13:21.767
Yeah, I was really impressed.
00:13:21.833 --> 00:13:27.339
You know, we didn't have huddle boards in our clinic before you joined Houston Methodist.
00:13:27.405 --> 00:13:30.875
And now every clinic has it.
00:13:30.942 --> 00:13:38.216
And I ask to see these boards every time I visit and they look the same.
00:13:38.283 --> 00:13:40.852
They have different metrics, but they look the same.
00:13:40.919 --> 00:13:44.956
And the teams are huddling every day to solve problems.
00:13:45.024 --> 00:13:51.563
So that's -- I think that's a super impressive something that we started recently.
00:13:51.629 --> 00:13:57.202
How is it contributing to the quality of care for our patients?
00:13:57.269 --> 00:14:02.173
So we've been able to see changes in our metrics.
00:14:02.240 --> 00:14:06.044
For example, how soon we refill prescriptions.
00:14:06.110 --> 00:14:13.686
So we want to be able to respond to that quickly so that a patient doesn't run out of their medication as one example.
00:14:13.751 --> 00:14:25.630
We also look at our turnaround time on our test results, lab results, our communication with patients and response to their request for medical advice via the MyChart in baskets.
00:14:25.697 --> 00:14:30.469
So we want to make sure that we're promptly responding to patient needs.
00:14:30.535 --> 00:14:36.442
And those we've seen great improvements, particularly in primary care in those areas.
00:14:36.508 --> 00:14:40.178
Yeah, and I see, you know, access is a metric there.
00:14:38.977 --> 00:14:40.178
MARGARET: Yes.
00:14:40.245 --> 00:14:48.821
And, you know, other metrics that the clinic tracks is usually related directly to the quality of care that we provide to our patients.
00:14:48.886 --> 00:15:03.635
I want to get back to APPs, you know, when we talk about clinicians, other clinicians, physicians, surgeons, let's say if I say an orthopedic surgeon, kind of know what that means and how the career develops.
00:15:03.701 --> 00:15:14.779
From your experience and what you're trying to do together, actually, here at Houston Methodist, how are we envisioning development of APP throughout the career?
00:15:14.846 --> 00:15:22.288
Because I understand, you know, you're trained, then you join a clinic, but then what happens in five years, in ten years?
00:15:18.951 --> 00:15:22.288
How do you become a Kayla?
00:15:22.354 --> 00:15:23.721
How do you become Margaret?
00:15:23.788 --> 00:15:26.024
Yeah, and that's an excellent, excellent question.
00:15:26.091 --> 00:15:35.100
So at Houston Methodist, we've started looking at this very closely and working through various different initiatives.
00:15:35.167 --> 00:15:42.006
And so one of them is our transition to practice program that we have for our new graduate APPs.
00:15:42.073 --> 00:15:48.813
Like many of us, as we first start our careers, the first year or so can be a bit rocky at times.
00:15:48.880 --> 00:15:53.851
And so this program really is to set folks up from the start for success.
00:15:53.918 --> 00:15:58.289
And so we focus on areas such as coding and documentation.
00:15:58.356 --> 00:16:00.158
So hold on.
00:15:58.356 --> 00:16:00.158
These are graduates?
00:16:00.225 --> 00:16:02.528
These are new APPs.
00:16:02.594 --> 00:16:04.562
They just graduated from, let's say, NP school.
00:16:04.629 --> 00:16:06.999
So we hire them, but then they go through that program?
00:16:07.066 --> 00:16:08.399
They go through the program.
00:16:08.466 --> 00:16:20.312
As they're learning the clinical practice side within their clinics, they're also joining us on my team to learn about the non-clinical side of being a clinician, right?
00:16:20.379 --> 00:16:26.719
The coding documentation, the, "How do we have tough conversations with our patients and one another?
00:16:26.784 --> 00:16:40.631
How do we communicate effectively with our collaborating physicians?" Things such as that that we don't learn in nursing school or PA school or sometimes even medical school from having conversations with some of our physicians about these things.
00:16:40.698 --> 00:16:48.941
We also want to make sure that we're setting our APPs up for success, those with more experience, say, than the new graduates, right?
00:16:49.006 --> 00:16:56.248
So we're launching, we're piloting, I should say, right now and looking to launch in '27 our APP leadership program.
00:16:56.315 --> 00:17:05.490
So for those who do want to develop into formal leaders, if they want my job one day, come on, let's get you prepared and set up to take it over.
00:17:05.557 --> 00:17:09.327
So we are working to have these programs within our physician organization?
00:17:09.394 --> 00:17:15.500
Anticipating that, you know, we want this to, this population to grow and be happy and stay with us.
00:17:13.432 --> 00:17:15.500
KAYLA: Correct. Correct.
00:17:15.567 --> 00:17:22.374
And also to, you know, leadership isn't for everyone, but there -- we have some APPs that are very interested in research.
00:17:22.441 --> 00:17:25.076
Well, let's get connected with the RI, right?
00:17:25.144 --> 00:17:29.314
Let's build different connections there.
00:17:29.381 --> 00:17:31.150
There are some that want to teach.
00:17:31.215 --> 00:17:36.521
We have some excellent APPs who precept and teach the next generation of APPs.
00:17:36.587 --> 00:17:43.327
Well, let's get some faculty appointments at some of our local universities, right, for different, you know, nursing and PA programs.
00:17:43.394 --> 00:17:48.066
And so there's a lot of opportunity and that's what we're working to develop towards.
00:17:48.133 --> 00:18:09.922
Yes. And I can't help but put a plug into our new safety, quality, and well-being institute where, you know, APPs and physicians, every clinician that is interested in either safety, quality, or well-being can have an academic appointment because we have a safety, quality, and well-being track, academic track.
00:18:09.988 --> 00:18:18.297
And also we have grants and, you know, opportunities for people to develop an academic career in that track.
00:18:15.394 --> 00:18:18.297
So, you know, thank you.
00:18:18.363 --> 00:18:20.665
Thank you for that.
00:18:20.731 --> 00:18:22.201
And thank you for leading that.
00:18:22.267 --> 00:18:29.106
Margaret, you are our first ever Chief Nursing Officer in the physician organization?
00:18:26.805 --> 00:18:29.106
MARGARET: That is correct.
00:18:29.173 --> 00:18:35.681
So how are you connected to the other CNOs in the hospitals?
00:18:35.747 --> 00:18:39.250
And, you know, what are you providing them?
00:18:39.317 --> 00:18:40.551
What do they provide you?
00:18:40.618 --> 00:18:44.823
And how do we actually keep all our nurses in one community?
00:18:44.890 --> 00:18:53.598
So I participate every month with the CNO council that's led by our CNE, Gail Vozzella.
00:18:53.664 --> 00:18:59.971
And we have tackled some very challenging issues.
00:19:00.038 --> 00:19:05.109
You know, there's a lot of challenges now in the nursing profession, whether you're inpatient or outpatient.
00:19:05.176 --> 00:19:07.778
And so we've been able to learn from each other.
00:19:07.846 --> 00:19:17.756
We stay connected on key policy decisions as well as we want to have the one Houston Methodist nurse.
00:19:17.823 --> 00:19:34.239
So we really want not to think of ourselves as, "Oh, I only work," you know,"in the PO," or "I only work in this hospital." But there is a brand and a standard of care, and compassion --
00:19:34.306 --> 00:19:35.740
So what is the Houston Methodist nurse?
00:19:35.807 --> 00:19:37.843
What is that brand?
00:19:37.910 --> 00:19:56.028
I think it's compassionate care, partnered with technology, innovation, learning, and making sure that our nurses, wherever you practice, have all the right tools to be successful and take the best care of our patients.
00:19:56.094 --> 00:20:00.464
So we hear a lot of innovation in the acute care setting in the hospitals.
00:20:00.531 --> 00:20:08.740
Are there innovations in the ambulatory settings that specifically affect, you know, nurses, APPs, and our patients?
00:20:06.872 --> 00:20:08.740
MARGARET: Yes.
00:20:08.807 --> 00:20:18.884
So we're looking at some different technologies within our clinics that help us focus on patient flow through the clinics, bottlenecks.
00:20:18.951 --> 00:20:21.686
We want to eliminate long wait times.
00:20:21.752 --> 00:20:27.759
And how do we appropriately use our resources that we have, our space?
00:20:27.826 --> 00:20:34.599
How do we make sure that our staff and our teams are well equipped and optimized?
00:20:34.665 --> 00:20:47.011
And so we have different tools that track throughput, that also even track how long our patients have been alone in an exam room.
00:20:47.078 --> 00:20:50.248
That's one of the worst feelings in the world.
00:20:50.315 --> 00:20:54.118
They put you in a little room, close the door, and you wonder if they're ever coming back, you know?
00:20:54.185 --> 00:20:57.788
So really, we need to minimize that time.
00:20:57.855 --> 00:20:58.990
Yes.
00:20:57.855 --> 00:20:58.990
And we do.
00:20:59.057 --> 00:21:00.025
We do.
00:20:59.057 --> 00:21:00.025
We do.
00:21:00.092 --> 00:21:01.460
We've implemented different strategies.
00:21:01.526 --> 00:21:05.063
So these tools really help our people understand where the patients are.
00:21:05.130 --> 00:21:06.097
Yes.
00:21:06.163 --> 00:21:08.599
And really make sure that the flow continues.
00:21:08.666 --> 00:21:11.336
So we talked about access, you know, reaching us.
00:21:11.403 --> 00:21:18.210
But then once you reach us, you do not want the visit to be like 45 minutes wait.
00:21:18.276 --> 00:21:21.078
You want to get right in and then do what you need to do.
00:21:21.145 --> 00:21:24.982
And in our clinics, just talk about, you know, different modalities that we have.
00:21:25.049 --> 00:21:28.753
It's not only a doctor's visit or an APP visit.
00:21:28.819 --> 00:21:30.821
What do we have in our clinics?
00:21:30.888 --> 00:21:34.759
So we have full diagnostic testing, radiology testing.
00:21:34.826 --> 00:21:37.796
We have cardiology diagnostic testing.
00:21:37.863 --> 00:21:41.465
We have vein centers.
00:21:37.863 --> 00:21:41.465
We have pain clinics.
00:21:41.532 --> 00:21:43.167
We have infusion centers.
00:21:43.234 --> 00:21:52.210
And we also have other ancillary testing that used to be done in the hospital, but now is done in the outpatient setting.
00:21:52.277 --> 00:21:59.384
And I think over the next several years, we're going to see more and more services move into the ambulatory environment.
00:21:59.451 --> 00:22:06.391
And that's why we have to make sure that our care teams are well prepared to take care of those patients as we make that transition.
00:22:06.458 --> 00:22:09.827
And we have an ambulatory surgical center.
00:22:09.894 --> 00:22:10.429
Oh, yeah.
00:22:10.494 --> 00:22:12.596
[Laughing] How could I forget?
00:22:11.195 --> 00:22:12.596
DR. SCHAAL: Right.
00:22:12.663 --> 00:22:14.298
So tell us a little bit about that.
00:22:14.365 --> 00:22:16.067
And, you know, how is it different?
00:22:16.134 --> 00:22:22.641
Because in Houston Methodist, we used to have all our surgery care attached to the hospitals.
00:22:22.708 --> 00:22:26.444
How is this now different?
00:22:22.708 --> 00:22:26.444
And what have we learned?
00:22:26.510 --> 00:22:33.652
So this is the first freestanding ASC, not a hospital-based ASC in the Methodist system.
00:22:33.719 --> 00:22:48.365
And so our goal is we wanted to go ahead and let's start working in this space because we know that the pressures from CMS and our other payers on price neutrality are going to hit us.
00:22:48.432 --> 00:22:56.307
And we also need our acute care patients being seen in the hospital or the more acute ambulatory cases.
00:22:56.374 --> 00:23:03.981
So let's make room for those cases and move the more community-based procedures to a freestanding ASC.
00:23:04.048 --> 00:23:08.286
So we've been open for a year and a half.
00:23:08.353 --> 00:23:09.855
We have four ORs.
00:23:09.921 --> 00:23:15.693
And we provide ophthalmology services, ENT, and orthopedic hand.
00:23:15.760 --> 00:23:17.194
And we're looking to expand more.
00:23:17.261 --> 00:23:27.305
But I think what we've learned is we're in this hybrid space where we're not a for-profit community-based hospital.
00:23:27.372 --> 00:23:34.211
We still retain the Methodist standards of care and that service level that our patients expect.
00:23:34.278 --> 00:23:41.519
But we're not as complicated either as the hospital-based outpatient surgery centers.
00:23:41.586 --> 00:23:45.624
So we're really able to offer something unique in the market.
00:23:45.690 --> 00:23:48.727
And we've just seen tremendous growth.
00:23:48.794 --> 00:23:51.262
And so very proud of our unit.
00:23:48.794 --> 00:23:51.262
DR. SCHAAL: Yeah.
00:23:51.328 --> 00:24:07.578
And I think the entire idea of moving things to the ambulatory environment is to provide easier access, free parking in and out, no matter where you go to a clinic visit or surgery or -- in and out.
00:24:07.645 --> 00:24:10.714
And it's much less hassle than a hospital.
00:24:10.781 --> 00:24:11.549
Any hospital.
00:24:11.615 --> 00:24:14.618
Hospitals are great if you need them.
00:24:14.685 --> 00:24:21.726
But if you don't, we try to keep our patients outside the hospital.
00:24:21.792 --> 00:24:24.461
So Kayla, what are you hearing nationally?
00:24:24.528 --> 00:24:27.265
I asked you before, what is an APP?
00:24:27.332 --> 00:24:32.503
And I'm guessing other systems really trying to grapple with that same question.
00:24:32.570 --> 00:24:33.672
What is the role of APP?
00:24:33.738 --> 00:24:38.175
And as APPs, we have more and more of them in the market.
00:24:38.242 --> 00:24:40.478
What role they're going to serve?
00:24:40.545 --> 00:24:45.049
So what are you focused on nationally as APPs nationally?
00:24:45.115 --> 00:24:48.153
Yeah. So nationally, I think it's role delineation.
00:24:48.220 --> 00:24:52.223
It's determining what is the role of an APP.
00:24:52.289 --> 00:25:03.535
How do we provide high quality care in collaboration with physicians, other clinicians, others in the clinical settings, such as our nurses and others.
00:25:03.602 --> 00:25:06.471
Also to the professional development.
00:25:06.538 --> 00:25:21.553
I think when I think of nursing, there's many clear pathways, if you will, to become whatever type of nurse one wants to become, whether it's a nursing leader, a nurse researcher, things like that.
00:25:21.619 --> 00:25:26.590
And in the APP space, there's not as clear of pathways yet.
00:25:26.657 --> 00:25:30.028
And so here at Houston Methodist, we want to lead that effort.
00:25:30.095 --> 00:25:34.499
And so that's where we're focusing in on creating these various different opportunities.
00:25:34.566 --> 00:25:49.114
As I mentioned earlier, if we have an APP that wants to be the best darn researcher they can be, and that's what they want to do with their career, well, then let's work together to get that set up so that they can get on that pathway and focus their efforts on that.
00:25:49.180 --> 00:25:59.089
Yeah. And I know we have an APP council where we are listening to the voices of APPs to really develop that and make it better as we go forward.
00:25:59.156 --> 00:26:08.133
And now I have to ask you both the question that I ask every single guest that sits here with me in this podcast.
00:26:08.199 --> 00:26:13.371
And the question is, what does quality mean to you?
00:26:13.438 --> 00:26:18.143
So start with Margaret, what does quality mean to you?
00:26:18.209 --> 00:26:31.588
Quality to me means that we are providing evidence-based care in efficient models, but it has to be done with compassion.
00:26:31.655 --> 00:26:36.528
Because if you don't have compassion, they're just empty metrics.
00:26:36.594 --> 00:26:45.202
And so I think it's that right balance between the science of nursing and the art of nursing.
00:26:45.269 --> 00:26:46.671
Fantastic.
00:26:45.269 --> 00:26:46.671
How about you?
00:26:46.738 --> 00:26:48.506
What does quality mean to you, Kayla?
00:26:48.573 --> 00:26:51.076
Well, I would say ditto to what Margaret said.
00:26:51.142 --> 00:26:52.743
That was a great answer.
00:26:52.810 --> 00:27:12.297
I think to expound upon that, as an APP specifically, when we focus in on quality, it's making sure that our patient receives the best care that's evidence-based in its foundation and that they receive it every time.
00:27:12.364 --> 00:27:16.601
It's the consistency aspect, right, of medicine.
00:27:16.667 --> 00:27:23.375
As you mentioned earlier, Margaret, about the 260 plus clinics, how do we keep things organized and standardized?
00:27:23.441 --> 00:27:25.442
Well, the same as an APP.
00:27:25.509 --> 00:27:35.487
How does a cardiology patient at the Woodlands receive high-quality care in a similar fashion that they do here at, say, the Med Center, right?
00:27:35.553 --> 00:27:40.424
How do we as APPs make sure that we can maintain those standards and evidence-based practice?
00:27:40.491 --> 00:27:51.769
Yeah, I love these answers because it is really you wanna standardize, we wanna replicate and make it reliable.
00:27:49.500 --> 00:27:51.769
KAYLA: Yes.
00:27:51.836 --> 00:27:53.704
However, we wanna make it human.
00:27:53.771 --> 00:27:54.638
Yes.
00:27:54.705 --> 00:28:00.444
And we want every patient to think that we're here for you, only for you.
00:28:00.511 --> 00:28:05.115
Even though we do it so many times, we're here for you.
00:28:03.448 --> 00:28:05.115
KAYLA: Correct.
00:28:05.182 --> 00:28:05.884
Thank you both.
00:28:05.950 --> 00:28:07.684
I really enjoyed the conversation.
00:28:07.751 --> 00:28:08.853
Thank you for coming.
00:28:08.920 --> 00:28:09.887
Thank you for having us.
00:28:09.953 --> 00:28:12.390
Thank you so much.
00:28:12.457 --> 00:28:14.826
And thank you for listening.
00:28:14.893 --> 00:28:19.396
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00:28:19.463 --> 00:28:23.434
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00:28:26.070 --> 00:28:29.039
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