Dan:
Mollie and Kelly, welcome to the show.

Mollie:
Thanks for having us. We're really excited to be here.

Dan:
Awesome. So tell me what you guys are up to. The crisis has been going on for 10 months. You were quick to respond and make some rapid changes with the front lines very quickly. Can you talk and give us an overview of what you did and how is it going now?

Mollie:
Absolutely. So it started as a personal experience. My family is from New York. That's where I was born and raised. My brother is a nurse as well, and my other brother was in the Police Academy at the time. So we were all very strict about quarantining and not seeing each other. Family FaceTime became very frequent and well-loved. So when we heard that Duke was going into the strict no visitation, Kelly and I initially joked about the idea of FaceTiming with families and the patients, and then realized that we had a good idea that we could move forward with.

Mollie:
So that same day we requested iPads. The rest is history. We quickly developed Workflow with help of faculty at Duke School of Nursing, amongst the Heart Center Leadership Team, both clinical and nonclinical. And within three to four days we were able to get some staff trained and start initiating those phone calls.

Dan:
It sounds simple, right? You know, grab an iPad, throw it in, have two-way communication with patients, nurses and family members. But I know from working in large systems, there's a lot of red tape and concerns about even bringing devices into the facility. What were some of the hurdles that you had to overcome related to policy or equipment or procedures? What was that like?

Kelly:
That was why we were so focused on creating a team quickly that had multiple perspectives and skillsets. And so, how Mollie mentioned that we were able to engage partners from the school of nursing, Duke is a large academic center, as you know. And so partnering with the School of Nursing was a strategic thought on our part in addition to also partnering with nonclinical, but more administrative director team members that we have in our clinical service area, which happens to be the Heart Center.

Kelly:
Then we also decided to engage some of our senior leadership very quickly and explaining to them our concerns. Mollie's experience with knowing firsthand what was going on in the Northeast was helpful for us because we knew what they were going through in regards to very quickly eliminating visitation in an attempt to keep the staff and patients in the hospital as safe as possible. And so we had a little bit of a headstart in knowing what was coming towards us.

Kelly:
And with that, we, of course like you mentioned, knew that there was going to be red tape. The use of FaceTime or other electronic methods such as Zoom or Skype are not typically used in the healthcare setting as frequently as maybe they should because of policies, procedures, privacy concerns. And we quickly engage, also, one of our clinical practice leaders who really helped us guide through the policy aspect of it.

Kelly:
And we kind of joked the way through saying that it was the fastest we were able to update and turn a policy around, it was about 12 hours. And so Mollie and I sat at a table over a weekend and drafted these policies and workflows, and we created policies and workflows that were flexible enough that we could insert some restrictions as we needed to. For example, our organization prefers Zoom versus FaceTime because it's more secure.

Kelly:
So, while we are supportive of that, we wanted to make sure that we could support folks that didn't have access to Zoom and maybe were not as technically savvy as those of us who are use to using Zooms for work now. Some of our patients, many of our patients are older, they may have a phone but it might not be an iPhone for example. So we really had to identify ways to be flexible throughout that process.

Kelly:
And when we explained the practices that were ongoing in then Northeast, again just from hearing from others who were on the front lines there, we were able to describe to our leadership who previously may have been concerned about using technology in this way and really help them understand the burden that this would put on our patients and the families and the staff, to be honest, which we can get into. But they were quick to be supportive and engage folks from our technology services, our clinical practice teams, and then additional senior leadership. And that's really how we were able to tackle this so quickly. And it was just really a nice partnership where we're all sharing a goal and how to shared drive to make sure that patients and families were supported.

Dan:
That's awesome. And I know from doing something similar before the pandemic, the lawyers like to get involved around HIPAA and concerns about putting devices in and once you put a device in, it's going to be everyone's going to be on Instagram and posting pictures of everything. And it kind of goes down this slippery slope. So being ahead of that, it sounds like you addressed a lot of that. How did the patients respond? Were they ever... Well, I guess both sides. Were the patients ever worried about their privacy related to this? And how did the nurses who were helping the patients use the technology, how were they concerned about the privacy?

Mollie:
That was actually built into our workflow. With these patients that came in preoperatively, we called them, that was stage one of the workflow. We called them prior to their admission at the hospital, ask them what their preferred method of communication was, who their support person was and who would be the best person to contact and give those updates.

Mollie:
The families really, we had fantastic feedback. It was nice too, for the nursing staff to have one designated nurse. We had a small team of nurses who volunteered to participate based on their interests. And that provided a lot of consistency and built rapport with the families and the patients and the other staff members that they were working with and provided a lot of structure, so the families trusted the staff and what we had built.

Mollie:
And also, getting feedback from the staff in a very informal way, they really appreciated it because that bedside nurse was able to focus on the clinical picture of their patient. And a lot of our patients are very high acuity, so we don't as clinical staff, don't always have time to update the family multiple times a day. So having that person kind of step away from the bedside, who's designated to go around the unit and have these scheduled calls, I think was a real game changer in the whole big picture.

Kelly:
I will say too, I think that we benefited in the sense that we began this work initially in the cardiothoracic ICU. And so, Mollie mentioned, pre-surgical patients or preoperative patients. At that time, we were not harshly canceling elective cases yet, I will say. The majority of the patients in the cardiothoracic ICU are not elective. So we care for patients who are post cardiac surgery, thoracic surgery, heart and lung transplants. We do a lot of mechanical circulatory support. The benefit of starting in that environment was that we had a little bit of control in the sense that the majority of our patients are scheduled at least one day in advance.

Kelly:
So Mollie's team would know who's on the OR schedule and call them, educated them about the reasoning for our restricted visitation, that allowed to just have conversation, build some trust, provide the education and then ask for their consent to participate. And then also ask who is it that you'd like us to talk to and call. So in that way, the patient felt like they had control over who'd be on both sides.

Kelly:
From there, we were able to spread this work into the cardiac ICU who cares for more medicine patients, which are not scheduled admissions. And I think that beginning in the surgical environment helped prepare us to implement this work in a less controlled environment. And in that space, the difference, I think, is that in the cardiac ICU, there's less patients who are unable to communicate because of having a ET tube or a trach or being sedated. And so I think we had a little bit of leeway in that sense where we could just verbally ask for their consent in the cardiac medicine ICU versus the surgical. So in both instances, it was a little bit unique, but we did have some leeway due to their clinical condition.

Dan:
That's great. And that's a great place to pilot when you have a little bit of control and it's not the chaos of the emergency department or admissions coming from the ER, those types of things, you can actually get people prepped. Tell me how this has spread since you've started. So you started in the CT ICU, did it go beyond that unit?

Kelly:
It did. In fact, after we piloted it for several weeks, our chaplain services actually picked up the project for other areas throughout the hospital. And the reason for that is because they had a controlled group and they felt like they had the workforce to be able to spread across the platform at Duke. Mind you that, they are very involved in conversations with patients and families anyway. So oftentimes when we would facilitate a conversation, the chaplain was a participant. So it made sense that they would lead the conversations. Again, offloading this concern from the bedside staff members who were really wanting to focus on patient care.

Kelly:
And at the end of the day, all of us were dealing with various stressors and the nurses were bringing personal stressors with them at the time. Schools were closing, people had childcare issues, this was very real for our staff. And I think that any little thing we could do to offload the burden of our frontline teams while maintaining the quality of care and communication with the families was what we strove to do.

Kelly:
I think this is where our leadership really stepped up and had a strong understanding of how our staff felt at the frontline and really supporting their decision-making and helping offset whatever we could. And so the chaplains really got engaged and they're still doing this, actually. They have electronic devices that they bring around with them into patient rooms and facilitate calls, either scheduled calls or discussions that might include plan of care for a patient.

Kelly:
And now we do have lesser restrictions on visitation. However, we're still quite limited, but what it's allowing us to do is have family conversations with multiple family members, despite only having one at the bedside with the patient. So it still has a great place with our current status and I do think that the work that we were able to do in the heart center paired with the work of the chaplain services, we're really going to be able to support families in using this mechanism for communication in the future when family members either might not be able to come because they live out of state, they don't have the means to travel and stay in a hotel room, or maybe they're themselves compromised in their health and don't want to be in the hospital as a visitor. So I think that there's a lot of things that we were able to do as we've learned through the translation, across our platform.

Dan:
That's a great spread of the initiative. And it's great to have those, in innovation research they're called opinion leaders, but it sounds like the chaplains where the champions or opinion leaders helping drive this as well. And it's always nice to have that third party outside of operations as well that can advocate for this. And now they're taking it around and using it. That's awesome.

Dan:
I want to dive into the leadership piece because I think there's some takeaways there. But I'm curious what you were talking about is, now this could be a practice that stays forever. Even when visitation's 100% back, there's always a chance and situations where family can't make it, the decision makers can't be site. So one thing, when I was at one of my organizations, we actually thought about this a number of years ago where we actually created this scenario where we brought family members through in this hypothetical situation where a bad diagnosis was delivered to the patient and to the family at the same time using video. So I'm curious, has that case arisen in this new practice that you have and how do family and patients take receiving really critical news over video and not being there in person?

Kelly:
It's certainly a struggle and it's certainly not the best mechanism, of course. And I think that we would all share that. I think at the time we were all seeing on the news and social media the patients in the hospital and the concern from line staff that they were sick alone or even passing away alone. And that was a real fear of all of ours is, what is it that we can do to mitigate the fear of the patients and the families.

Kelly:
And mind you that, these patients in the two units that we started this with didn't have COVID. And I would say that the biggest impacted population that we had was in our transplant population. Getting a new heart or a set of lungs is a good thing, except, imagine being a lung transplant recipient and being dropped off at the front door by your spouse and them driving away? And the next time that they're going to see you is when you walk out.

Kelly:
I think that when we were really thinking through the impact, outside again of not doing this initially with COVID patients in our two units anyway, that was where it really hit home for us. And we really had to figure out, what is it that we can do to most effectively converse with families who can't be at the bedside when these complete life altering surgeries are taking place?

Kelly:
And yeah, we had to deliver bad news over the phone. Either if the surgery didn't go well or a patient wasn't progressing like we thought. I think that the consistency in which we were able to have conversations via video, considering the circumstances, helped support our ability to build relationships, not only between the patients, their loved ones and the family, but we also had our intensivist on the calls, our advanced practice providers, our respiratory therapist and it really was an interdisciplinary conversation that we would have.

Kelly:
They would see our whole team at the bedside with their loved one, doing everything that we can do. And while it wasn't ideal, I do think that with everyone seeing the same information on the news and social media, it was better than what was expected given the circumstance. And I know Mollie has a great positive story that's kind of similar in regards to a patient whose birthday it was and was really upset that they were alone on their birthday. I don't know if you want to tell that story?

Mollie:
Yeah. We actually had some really cool stories just across the board. This one man, his wife or daughter had called and asked the facilitator if she could set up a surprise Zoom birthday party. So the nurses had all decorated his room for his birthday and at like 1:00 PM the whole family logged on. And there was probably 8 to 10 of his family members from all across the United States on there surprising him for his birthday, which was really, really sweet and really appreciated by the family.

Mollie:
And to piggyback on what Kelly was saying, is that yeah, COVID is at the forefront but there's also people that are still dying out there from heart disease and lung disease. And people are having these life-changing procedures that are positive and we still want to be able to celebrate that, even though there are so many people out there suffering from COVID.

Mollie:
To give you another example, we had a patient who came through and received her third lung transplant, which is incredible given that many transplant centers weren't even transplanting at the time and how rare it is to have a third lung transplant. So that was just an amazing celebration that was had and she did super well and went home back to her family. So I think you take the good with the bad and I think our nurses definitely, it gave them some positive energy as well to see how much the families appreciated and were just so unbelievably grateful for their work.

Dan:
Yeah. And I think that's the key. In any change, there's always the hesitation to adopt it. Like, "Why would I consider video when I can go in person?" And then you're suddenly presented with the fact that you can't do what was always done in the past. And all of a sudden the fear or the hesitancy to adopt the new way is lowered and you realize it's not as bad as you thought. So it lowers that adoption curve, which is awesome.

Dan:
When we did that pilot at my other facility, about 50% of people said, "Yeah, I'd love to hear this news. Or I'd love to chat with my providers via video around really critical points of care." And about 50% said no, they'd rather do it in person. But I think that's, obviously, changed.

Dan:
So I want to dive into the leadership piece too, because I think there's a lot of takeaways here. So you mentioned you were able to do this really quickly, you've got a lot of buy-in from different people. But, tell me how you specifically convinced some of the executive team that this is the way to go.

Kelly:
The executive team was again, really supportive. And what I really did appreciate about the senior leadership team at Duke is that the frontline team is the priority in regards to innovation and thinking about things differently. And when we were making this quick change, which you know, is incredibly fast for the size of the organization where we work. But the point was that we really had a thoughtful idea to solve a problem that was relatively practical. It wasn't going to cost us anything. And if we were able to facilitate the workflow, provide the team members to do the facilitation, then there was really in their minds and our senior leader's minds, there was no reason not to support it. Because there isn't an alternative other than just simply doing a phone call.

Kelly:
I think that when we were able to very quickly explain to them the frontline team's perspective on only using phone calls without a structured approach, meaning, if my husband's in the hospital having heart surgery and I can't visit or see anything, I'm probably going to call my nurse five times a day. And one, I'm probably not going to get effective communication that way. But two, it also burdens the frontline teams and distracts them from the care that they're delivering.

Kelly:
And so when we were able to really explain that to our leaders, they understood and were really supportive. We also have many senior leaders who are frontline workers with us. One of our leaders who helped publish the paper with us about this work, she's an advanced practice provider who works in the cardiothoracic ICU in addition to her leadership job. Our hospital president is still a practicing physician. And at the time they set up basically a command center where senior leadership team was working through our [inaudible 00:20:50] structure, we had different stations there. And we had very easy access to all of them.

Kelly:
And it was as simple as us going down there and having a conversation with them and just presenting the idea, talking through what hurdles might be such as the policies, such as just general workflow concerns that may come up and they were supportive of that. Again, we built the workflows to be flexible enough that we could alter them as we went with the input of the frontline teams who were hosting the conversations for us in the facilitator role.

Kelly:
I think that the genuine understanding of our leaders in regards to what our frontline teams are going through every day, in addition to just their support of the frontline staff, really helped. I think, particularly in the heart center, we've done a really great job at building a strong foundation for a healthy work environment. And with that comes strong relationships between the frontline staff and the leaders. And so we're really able to have open, productive, transparent conversations with each other about how do we think about an idea, what will work, what wont' work.

Kelly:
When we came in and said, "Hey guys, this is what we're going to do," there was no pushback. The staff trusted our decision, even though it was a quick one, that we were going to implement the use of virtual visitation while visitation was restricted. And they were really happy about it, more so because they got to be involved, they felt like it could decrease the burden on them and they knew that they had input into the decision and the ongoing flexibility of the workflows.

Dan:
Tell me about that piece of it. Change is going to be more successful when you include the people who are experiencing the issue, which in this case is the frontline nurses. But also at the same time, they're super busy, they're on an hourly payroll and so sometimes it's hard to get time and energy from them. So talk through how you engaged them, what was the process, what are some tips for nurse leaders to engage their frontline staff in these type of innovations?

Kelly:
So I think the first step for us was that we've been engaging our frontline staff for a long time. So, going with this project was not a new engagement opportunity for them. But historically, over time engaging your frontline staff is really built upon the relationships that you have with them and the trust that you're able to build through just honestly, presence, consistency, and being their advocate. And I think that when you start there and over time really support the staff through the good and the bad and show them that you're truly there to support their growth and their development, both individually and collectively. And you are their priority, along with the patients and the patient's safety. I think that nurse engagement comes naturally.

Kelly:
I think that leaders need to provide opportunities for nurses to be engaged. Meaning, in this example that we're discussing today, we provided the opportunity for nurses to be involved and engaged in what we called the "iPad project" and of course we asked specific people who we knew were looking for opportunities to be involved, but we opened it up. It didn't matter to us if they were a brand new nurse or someone who was really experienced.

Kelly:
What we needed for this particular project is people, one, who were interested and two, who were good communicators and prioritized patient family center care. And we found that the core group of nurses who expressed interest really took this and ran with it. And that's what I love about being a nurse manager is providing nurses with opportunities to become engaged, help provide them comfort through education and just support while they learn whatever engagement opportunity it is. And then you let them fly and you support them as they go, but you allow them the flexibility to make things their own or individualize it to the department or whatever workflow it is that they're trying to achieve.

Kelly:
I think that this was a good example of that. I think that in the translation outside of the cardiac ICU and the cardiothoracic ICU to the chaplain services, for example, they'll take it and make it their own as well. But we always maintain the shared goal and don't alter, or I should say, move away too much from the workflow that it can't then be replicated. Because we always want to make sure that we have our checks and balances and making sure that we're staying on track and are as consistent as possible when we can be.

Kelly:
But I think that engaging frontline nurses or any healthcare worker, to be honest. This could have been, like it's a chaplain, it could have been a respiratory therapist. It could have been an app, it could have been anyone. The point is that we really wanted people who were prioritizing the needs of the patients and the families through communication. And again, it goes all the way back to that initial nurse leader presence and building trust and relationships with the staff. And if we didn't have that in March or April when we started this, then this project probably wouldn't have been successful.

Dan:
So tell me where you personally learned these leadership characteristics. Because what you're saying is like textbook change management, textbook good leadership. That doesn't always happen within healthcare and within nursing, so I'm curious what experiences in your past have led you to have such an amazing view of leadership which led you to be able to engage your staff and actually create something super fast where across the country people tried similar things and failed very quickly.

Kelly:
Sure. I'm that textbook bedside nurse who got tapped for back in the day, I wouldn't say how long ago. But I said yes to the opportunity when I was approached about becoming a nurse manager, because I saw that there was a gap between the strategies with nursing leadership at the time and the frontline staff. And I didn't know that I was the right person for it, but I knew that there were simple things that could be implemented that could lead to better relationships between nursing leadership and frontline staff that then could be the catapult for nurse engagement, improved retention, improved, healthy work environment, all the things.

Kelly:
I didn't know at the time that that was textbook, to be honest. It just made sense to me. Now over the years, as I am helping to mentor and coach new leaders like Mollie, we have clinical leads in our departments and nurse managers. I do use the AACN healthy work environment framework to do that, but I didn't know about that back in the day. And it was something that came naturally over time that I recognized that there was not one silver bullet, that if I do this, then the unit will then be a healthy work environment. It really was a culmination of a lot of things and a lot of hard work to, again, build and foster those relationships and it takes time.

Kelly:
What I always say is that being consistent is the most important thing for a frontline nurse manager. And that once you understand what your values are and how you can live them, if you consistently do those things and consistently lead the individuals of your team, along with the collective team, meaning I don't treat one person one way and another person another. Everyone is the same and provided with the same opportunities, then it leads to a culture change. And it's not just about me or the nurse manager.

Kelly:
But we do know that the nurse managers are incredibly influential in the culture of a department. And without a nurse manager who lives the organization values or the department values or has some framework to guide themselves by, then the unit will not be founded or really built upon a framework that will allow them to be successful. And I think that we are compounded with the challenges of turnover right now, and that's no secret to anybody. But I think the challenge is that it's no longer that we're going to have nurses become engaged after a year or two years, three and then sustain that to 10 years, 15 years, 20 years. We know that that's no longer our norm. So we have to shift our focus and be okay with the fact that we want to engage nurses as soon as they join our team and help them support the department in whatever way they're interested and knowing that we're likely only going to have their engagement for two, three, four years.

Dan:
You're exactly right. The culture dictates what people's behavior will be. There's research out there that says the nurse manager is actually the most critical part in all of that. In general nurse managers are the number one reason why evidence-based practice fails in organizations, they're also one of the main reasons why it succeeded. So they're a critical piece of the entire process from culture to approval to buy in to all of it. So to have the viewpoint of, "It's my responsibility as a leader to demonstrate behaviors that create the culture I want in a unit," that's the way to do it. And it's clear that that was a major factor to the success of this. The last thing I want to hit on, is it sounds like you guys are working on a study. So can you talk a little bit about that and what outcomes you're measuring and the whole process there?

Mollie:
Sure. So when we initially started the whole workflow process, our friends at DUSON, the school of nursing were really helpful. And we definitely took the opportunity to make it something where we could present outcomes and show that virtual visitation is beneficial, and if not somewhat equal to or superior to in-person visitation depending on the circumstances. So we looked at different measures for telepresence, which are pretty far and few between. We used what we could find and kind of made our own, so to speak, and measured, "Overall, how did you feel like the conversations that you had were with the providers or were all the people that you expected on the call present on the call?"

Mollie:
After a patient was discharged, we followed up with them. We asked them these questions on a Likert scale. The outcomes have been fantastic. We've also allowed them to provide narratives of their experience. But the overall communication within the ICU team meets expectations, 95% of the patients so far have, or patients' families, have said that they always meet expectations.

Mollie:
We initially presented some data at the AHA conference, which I guess was a couple months ago?

Kelly:
November. Yeah.

Mollie:
But it's been a really positive experience and the families really appreciate it. And like you spoke to, at a certain point when you realize you don't have another option but doing virtual visitation, I think something is better than nothing. And that's definitely reflective in our outcomes.

Kelly:
Speaking back to what we were discussing earlier in that not everyone has the ability to visit, COVID or not. And the value that being at a health system like Duke brings and the partnership, the academic partnership, that we have is that while we were so focused on the operations of this project along with just the workflows and whatnot, our partners at DUSON really saw it from a different perspective. In that, we'll likely not have an opportunity again to cleanly study the value that virtual visitation brings in the cardiac ICU or the cardiothoracic ICU.

Kelly:
And so while the circumstances were unfortunate, in the spirit of innovation and quality improvement taking the opportunity to step back and think, "How can we learn from this," was a smart choice and I think, again, it's the value that the academic partnerships bring? Well, one of the values there's many.

Dan:
That's great. And I'm sure there's impact to HCAHPS scores and all those things that the system wants to improve as well. And so I think there's a lot of opportunity to share how innovation directly impacts the things that we care about at a system level and also at the individual level. So when are you working on publication and wrapping all that up?

Mollie:
We are currently in the process of getting our manuscript drafted. So hopefully by-

Kelly:
Hopefully in the next few months.

Mollie:
Yeah, summer.

Dan:
This is such an awesome example of innovation and a textbook example of how you lead innovation correctly in the face of a pandemic. To, not only help patients, but also staff. I mean, it's just such a wonderful example and I hope we can amplify that message and you guys should be sharing this all over the place. Because it really is a great example that nurse leaders can learn from. So we talked about a lot today. What would you like to hand off to the audience? That nugget that they can take away and maybe implement tomorrow on their units?

Mollie:
From my perspective, my biggest takeaway from the whole experience is that it never hurts to ask. And your idea may seem crazy or unconventional, or you may not take it seriously yourself. Which, quite frankly, at the beginning I don't know if I took myself seriously when I suggested FaceTiming families. But you can take an idea and run with it and present it to whoever and the worst that that person can say is no. And you can always go back to the drawing board and ask again.

Mollie:
I definitely realized how grateful I was to work in such a supportive healthcare institution that I just asked once and we were able to mobilize it and it was responsive to it. It wasn't I had to wait weeks and weeks to get a phone call back or an email back. So yeah, I think that's my biggest takeaway, is it never hurts to ask and if you thought of it, someone else probably has too and just hasn't spoken up.

Dan:
Yeah, no is one step closer to yes, right?

Mollie:
Exactly.

Kelly:
I think from a leadership perspective, being a nurse leader, particularly a nurse manager is hard. I think being a nurse manager is the hardest job you can have. And the reason why I say that is because it is a marathon for sure, but I think that staying true to the mission of establishing these healthy work environments allows you to provide frontline staff with these engagement opportunities that really lead to impactful work that improves our patients, the care that we deliver. And I think that being an advocate and supportive of the frontline staff is the best thing that leaders can do. And being able to do so consistently really paid off in this instance. And so for the nurse leaders out there, I would just say, stick with it and really figure out how you can maintain the consistency over time that will then generate a true trusting and stable environment.

Dan:
Yeah. Two great nuggets and pearls in the leadership world. So thank you for those. And thank you, both Mollie and Kelly for being on the show. Where can people find out more about your project and maybe engage with both of you if they have questions or want to learn more?

Kelly:
We both have our LinkedIn shared and we can be engaged through there. And then we were also happy to share our paper that's currently published along with the one that's coming down the pipe.

Dan:
Awesome. We'll put those in the show notes and make sure that people have access to that. Thank you so much for being on the show and keep innovating out there. Hopefully you continue with future projects, we'll have you on and you can be the gurus of innovation soon.

Mollie:
That sounds awesome.

Kelly:
Thank you.

Mollie:
Thanks for having us.