October 13, 2022: UCSF Medical Center is at the forefront of digital transformation in healthcare. What tools should you have in place to make digital transformation possible? What are the foundational elements? Kay Burke, Chief Nursing Informatics Officer reveals what a nursing background can bring into this role of innovation. How can we make our many fragmented workflows more integrated or automated? What are the specific challenges that UCSF is addressing? How is UCSF thinking about technology and data in support of care?
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I feel like digital transformation is kind of a buzzword. But this is part of our, what we call vision 2025 strategic plan. And so there is Quite a bit of substance around how we're gonna be doing this. So your question is where do you start? And you start with defining the customer experience.
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All right. Today we are joined by Kay Burke, C N I O at U C S F medical center out in San Francisco. Kay welcome to.
Thank you. Thanks for having me.
I'm looking forward to this conversation. I was just telling you earlier that we have not had enough CNIO, representation on this show and so I really wanna delve into this today. We're gonna try to focus in on optimizing care for patients providers and staff and what that looks like. But before I get going tell us a little bit about U C S F.
Yeah, well, I, I hope most have heard of U C S F it's the university of California, San Francisco, and we're an academic health system. Across the bay area. We have four main hospital campuses we have over. 150 in growing clinics. And we're strategically continuing to grow our network and our, our affiliates.
So we have about 10 affiliate hospitals. We have about 250,000 employees. And we also have four professional schools, all graduate education, all of which are really consistently ranked as, as top programs nationwide. As far as patient care. We are a tertiary veterinary center, which means we really focus on complex care delivery. We have many specialized programs, so patients come from not just the us, but all over the world.
So, so you guys are part of the UC system which is a unique kind of, of makeup. Do you work closely with U C S D and
we do so there are five other health systems as part of the UC system, UCLA, UC Irvine, UC San Diego, UC Davis. And. And then new CSF. So we're part of the university of California office of the president. We are independent health systems and we operate very, very differently. However, particularly since COVID. We collaborate with them all the time and we learn from each other. And in some cases we, we share contracts, right? So we learn that UCI needs this. So does U C S F oh, wait, U C S D. You need it as well. So we'll go into contracting and RFP processes together, which, which also is relatively new.
Yeah. It's that's interesting. All right. Talk to me a little bit about the CNIO role at U C S F what's the focus of the role? What does the CNIO do at your health system?
Yeah, well, given that there's only been three other CNIO podcasts in the last several years, I'll describe sort of what nursing informatics and then I'll go into my specific role and my focus. So CNIO stands for chief nursing informatics officer.
So naturally what I do is I lead the nursing informatics program for the entire health system. But nurse informaticists. These are nurses who really advance technology through adoption of standardized tools and methods using technology, really creating value for the clinician's utilization of information systems.
How technology enables higher quality of care delivery, improving. patient Outcomes supporting nursing practice and really comes down to four key functions or areas of what they do. So the first is innovation and design understanding, using design thinking principles. What are the best workflows? What are the best products that we need in the care setting? Change management and service delivery. Believe it or not, there are a lot of skeptics in the clinical community who said, I went to nursing school just to be a nurse. Don't introduce that technology widget to me. They need to have technical knowledge as well as clinical knowledge so that they can communicate not just with operations, but also all of our tech technical product management teams, analysts, and then lastly management and leadership.
And they're not really managers of teams, but rather. They lead pretty complex projects and they need to see those through end to end. Wow. So with that, my role is really to lead them, but also to carry out my strategic vision to advance nursing informatics beyond just my team. And so we just launched, what's called an informatics champion program.
So we had like 130 nurses apply to be in this first cohort. So they're direct care nurses. I'd pay for 20% of their time to be out of clinical. Their clinical care setting and work on informatics projects and programs and evangelize why nursing informatics is important and then ultimately really driving informatics competencies to the professional nurse at the bedside.
So it's, it's not just my team that I lead, but it's really leading the vision and executing there in, across the health system.
All right. So what do some of those projects look like? I mean, you talked about innovation and design. You talked about change management, but there's also just the incremental innovation that goes on in the day to day. What do some of those projects look like?
Yeah, sure. So a couple of projects that are on the horizon, one is infusion pump integration. So if you think about pumps that are required for us to administer IV medications, We use an electronic health record. They don't talk to each other. So you have to document in the EHR and then you have to sort of start and stop the pump.
So an integration, interoperability project, that's an example of something that's about to kick off. Within the electronic health record there. There's now sort of mobile applications. We have nurses tethered to an iPhone every day. So they have a, it's a managed device. It's not their own personal device.
And so that's their communication platform. They can see the wave forms of the patients, right on their phone to see if there's any arrhythmias or anything that they need to tend to clinically. Now our EHR has an. In which you can do most of your point of care documentation, you can manage your line strains and airways.
You can administer medication on the medication administration record. You can look at the flow sheet documentation, which is basic vital signs, clinical assessments. So that's another project. That's an example of something that my team leads.
Wow. So, let me ask you this. There's a digital transformation that's going on clearly, U C S F is at the forefront of that. I keep reading articles of really cool things that are going on at U C S F. So I think some from the outside would look at it and go, well that's a forward leaning health system. It's not hard to get these projects done, funded, done that kind of stuff. But the reality is that as you said a big component of what you do is change management and organizational.
Change management and whatnot. But I wanna, I wanna go back to where you start with digital transformation. I would think that you've imagined an experience for the clinicians that utilizes technology to improve outcomes, to improve efficiency, to all those things. Where do you start? What does it look like to start those projects and to prioritize the right projects?
I feel like digital transformation is kind of a buzzword. Yep. But having been intimately involved in our journey over the past two years, this is part of our, what we call vision 2025 strategic plan. And so there is Quite a bit of substance around how we're gonna be doing this. So your question is where do you start? And you start with defining the customer experience. And so we have pulled together what we, what we think our customers are.
So when you say customers, do you mean. Patients or do you mean who do you mean?
Great question. That was where we started. Right. Okay. So initially it was, oh, are our patients are customers. Of course our patients are our customers. Have we ever referred to them as that? Not, not so often, but our physicians are our customers. All of our clinicians.
Even our learners, right? So we have so many medical students and residents and nursing students, they're our customers as well. So once we defined that, really everybody that we touch is our customer. We created these segments, which we called customer segments. And then we talked about what are the foundational and transformational capabilities that our customers might need in place in order to Carry out their job effectively, but also with empathy, we talk about empathy and really about the human aspects of what a customer is and how a customer needs to to be part of this ecosystem. And then we created sort of what our journeys are. And we had user design workshops. We gathered the feedback from a number of people who, some of whom raised their hands and wanted to be part of these design workshops and some of who we brought in and they were Painstakingly brought to the table and provide their feedback.
And with that, we actually came out with what we called signature experiences. This is an iterative process, so it's not like, okay, we have a white paper at the end of this. This is really ongoing persistent work. And we have now an operating model as well.
And I can share with you what the components of that are if, if you'd like, but now that we have an operating model in place and we've gone through this exercise of really defining the customer experience and then having that be foundational for all the phases seeking care and receiving care and post-acute care.
And so it's a journey. We've got a long way to go, but at least we've crystallized what we thought two years ago into what now we can almost use as our blueprint for moving forward.
It's interesting. I mean what you're defining is there's a listening phase that goes into the beginning of a strategic project like this. But what you're defining is an ongoing listening project because it could potentially be consistently changing or at least the priorities might change based on what? Well, I mean, the pandemic being a perfect example. Imagine if, if your project started before the pandemic, the pandemic probably switched the things that you were really focused on during that time is that pretty accurate of what the pandemic was like? It really impacted the priorities during that timeframe.
Yeah. It's funny. I read this meme or something about six months after the pandemic hit and it was like which. Catalyzed digital transformation at your healthcare system. And it was like Gartner McKinsey or this consulting firm.
And then it said pandemic. And it was funny because that is really what catalyzed digital transformation here. We didn't have the bureaucracy anymore. And so it was, you had to do things and you had to do things fast. Some of those things worked, many of them didn't, but when they didn't, you REPI. and you try it again. And so the spirit, I mean, in order for you to be successful in, digital transformation, it's about innovation, which has everything to do with the psychological safety of failing, but failing fast learning and iterating. And when you don't have these hierarchies or constructs of approval processes and getting the stakeholders in the room, you just have to do it.
And that was. That was a real benefit. If there's any positives that have come out of the pandemic, is that that's what we learned almost the hard way, but at the end the good way.
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we definitely moved fast during the pandemic. One of the things that sort of warms my heart, listening to you is we're talking about digital transformation and we're not talking about all the gaps.
It used to be, we'd say, well we don't have the platforms in place. We don't have the data in place. We don't have, there's a whole bunch of things that are keeping us from doing it, but it sounds like some of the foundational elements are in place that now we can start to be creative and look at different ways of delivering care or communicating with the patient or communi or just every aspect of connecting within the health.
system I'm not sure there's a question there. I'm just, it's more of a, more of a agreed, agreed. More, more of an observation. Oh, what are the foundational elements What do you have in place at this point that's making digital transformation possible? Is it, we, we finally have a consistent EHR and we finally have an analytics platform and we finally have a series of platforms that we can utilize to build these experiences on top of.
Yeah. So we use the term foundational capabilities as well, and We think of these as traditional work tracks, right. And they need to be in, in place in order for transformational work to to take place. These are exactly what you said, a fully integrated electronic health record work stations that are smarter and intelligent operations, asset management.
So having real time RTLS and having sort of nurse call and tele sitting. Of course the explosion of telehealth without those foundational capabilities, you really cannot can't build. And so when we talk about, we're talking about AI enabled virtual patient observation, well, absent current state tele setting, you can't really. Envision AI enabled virtual patient observation, if that makes sense. Patient room personalization and the like, and so we are, we are building, I will be honest with you in doing this analysis of defining what our foundational capabilities are. We actually don't have some of them in place.
We realize that we do have to go back to basics here and there. And we're being humble about that. We are a premier health healthcare institution. That's well known across the globe, but there are some gaps in our infrastructure and we realize we also have some silos in which there's foundational capabilities in this care setting.
But this campus, there's not a parody of experience. And as any health system grows, that's a big barrier. So I'm a patient. I go. This this campus for this service. And then next week I have to go to a different campus. And my experience is completely different because those foundational capabilities are not streamlined or scaled across the entire system.
I mean, when you talk about that thing that it reminds me of when Mark Harrison came into Intermountain, he was hired on and in his first presentation, in San Francisco, at the JP Morgan conference, he was talking about the first project he took on was clinical variation. And he took one specific area and he looked at it and he goes we're world class in this.
But we were not world class in this hospital. Yeah. And the challenge to the clinicians was, Hey, if we can be world class here, we can be world class here. Let's come together and figure this out. And it's interesting that you talk about the same, thing's true with the digital capabilities.
And I, I would say probably digital. When we went from system, we had 16 hospitals where I was at before we went from system to system. We still had work to do at a lot of places for adopting just the technology we did have in place. And that was one of the one, one of the bigger, bigger challenges for us was getting adopted have.
I mean, you guys are in San Francisco, you're right there at Silicon valley. You have very advanced people. You have the Benioff one of your hospitals is named after mark Benioff. So we would assume that again, I keep going down this path that your people are incredibly technology savvy but what's the challenge. How do you address adoption across the board? Is there something you've been able to do. To help with adoption or help people to get comfortable with the technologies that have been rolled out.
Yeah. It's funny that you say that. I just learned yesterday that we have a feature turned on in our production system in which it's called inpatient scheduling. So even though you're admitted, You have a scheduled physical therapy kind of appointment. The physical therapist is coming at 3:00 PM and you need to go down and get your MRI at 9:00 PM. Which is, as you can imagine, really supports not just throughput and capacity management. So we don't have 10 people going to MRI at the same time, but the patient experience.
So the patient knows. All right, I can visit with my cousin because I don't have to go to MRI until, until later this evening. Yet, nobody uses it and they have a shadow paper process to, to determine locally who's gonna be going where next, which of course is not. Visible to anybody else. And so when it comes down to it, that's an example of awareness, right?
That was whether it's training or a way in which this is where informaticists really need to be change managers and, go boots on the ground and understand why aren't you using a certain functionality that exists in production. And so I think it's awareness, I think back to your point of being in the bay area.
And I came from Charleston, South Carolina, where I was, it's certainly growing as a sort of tech innovation, geographic location, but when I was there not so much. And so being in the belly of the beast in my role I, I talk to a lot of startups and I'm part of making these sort of strategic. Vendor partnerships. And from small time startups that don't even have a product fully developed to behemoth health it vendors, and it's exciting, but when something isn't working, the product that we need, isn't the product that they have. It's hard to kind of. Say, it's not, you it's me but this isn't working.
Right. And so it's really exciting to forge those relationships and then it can be challenging to exit the relationship. And we're, we're learning. And as I said there's respect in what we need to, what we need to be and do as a healthcare delivery organization. We're not software developers, but the software developers don't know how we deliver care in our setting. And so it's just a very iterative learning cycle with the many, many partners that we have. And yes, mark Benioff's name is on two hospitals actually. Wow. One in Oakland and one in San Francisco.
Wow. All right. So you, you talked about room personalization, so personalization is one of those words that we believe digital transformation will bring about.
I'm gonna keep using the word digital transformation, cuz I think it, it has a definition that people understand it's applying digital technologies to existing processes within healthcare we can argue the transformation word it's in some cases it's not transformation as much as it is just iterating on the process with digital tools, but room personalization.
Talk about that room personalization project. And what does that entail? What is what's the underlying for it? And then what's the experience that you're creating as a result of.
I might push back on you on digital transformation and the definition, but before I do that, I think, oh,
please, please, please do
okay. Because we've also gone through this exercise as a group for the last 12 years as an executive technology executive team. That's what we call ourselves. And we landed on what the operating model entails and the transformation is actually. A radical paradigm shift in how we used to do business.
So for example, it used to be institution driven, right? The COO wants this and it meets her goal. It's really, it's no, it's customer obsessed, sorry, COO. But we're focusing on our customer experience and the journeys and feedback and that's hard. Right. And the second one is solution first. So personalization.
There's a project request for MyChart bedside, which is basically a tablet enabled access to your electronic health record, as opposed to problem obsessed. Like what problems are we trying to solve here? And obsessed. That's a, that's a deliberate word. And then also going from project oriented.
So these are loose groups of people that execute a project, and then they disband. To persistent cross functional teams. They live and breathe this problem, and they're persistently engaged. They don't necessarily report to the same person or cross functional. And then lastly, another, the last element of transformation is deadline focused, right?
Waterfall, project plans to outcome focused and however many iterations it takes to get to an outcome it's outcomes and key results. And then you move on to the next problem
That's interesting that you describe it that way. Cuz digital transformation that's business model transformation. That's a leadership exactly thinking transformation that's happening that enables you to do projects that are focused on the consumer that are focused on the solutions that's that's fascinat.
Precisely. Well, that's why I . I fought you on that one. yeah, no, I, because I think it's a misnomer is my point I think it's it's not digital transformation. It's business transformation as enabled by digital technology. Yeah. And. Back to the room personalization project. I'm gonna be honest with you. It's not a project. It's, it's a, a notion. It's how we are going to personalize rooms in the future. How does care delivery look like in 4, 5, 10 years we're actually building a prototype of what we're calling award of the future.
And so it's in some non-clinical setting and it's not just gonna be one hospital room, but an acute care. Critical care and then a perioperative space and we're going to test and it's bring in vendors and have them pitch well, what does nurse call look like in the future? And then let's go ahead and equip this hos, this ward of the future with, with your technology and try it on for size care delivery.
In eight years, isn't gonna look like care delivery today. There's gonna be hospital at home E I C U there's. This telehealth thing is not gonna go away. We're gonna have very different models of care with population health. And so we have to think about personalization as broader than a patient centric desire in a hospital room or in getting an appointment through.
A phone call versus an app. And so it's, I wish that we had ambient controls in our hospital rooms today. If that's something that's desired by patients. But when we talk about personalization and, and our customer experience and the journey mapping and all of the stuff that we're doing, it's much more futuristic than it is.
So when we think about care, I mean, you listen to the patients and the consumers in the communities that you serve, you listen to the clinicians let's talk about the patient experience a little bit. I I'm curious what you heard. Are you hearing we want a different experience at UCF?
Were you bound by ambulatory and acute, or are you more looking at, Hey, people want a, a partner in their care from I mean, they don't wanna partner at birth, but you know, you get the concept from birth until. In until we're end of life care, we wanna partner so that we can live the healthiest possible life possible. I mean, how do you frame, how do you look at that and how do you look at the consumer journey, customer journey, patient journey, however you wanna define it,
you know what we heard loud and clear and I'm sure I'm sure you're a patient in healthcare setting somewhere, is that what I'm calling NOI patient, that your preferences are known and you're not repeating them. You're not repeating the history of your present illness. You're not repeating that your primary language spoken at home is Spanish. You want people to know that this is the modality of communication. You prefer. You can't assume that I'm gonna use a MyChart app because I prefer to have a phone call.
I prefer to always have an interpreter out of the gate. Anytime I'm contacted by you or anytime I contact you, right. I want you to know that I rely heavily on my neighbor to help me make care decisions. I've given you her name. I've given you her phone number. You should have her somewhere in the system as an individual that. Able to be contacted alongside me. I've already proxy. My, my daughter who speaks medical more than I do, and I have her on my app, but none of the information goes to her. I've told you this, it's all about, I've told you this before. And so you don't know me if you're asking me again. And I mean, there are other answers to your question, but by and large, that was the predominant feedback that we got and we're, we're complex. Right? And we're, we grew from a medical center to a health system, almost overnight, many, many health systems have, and you're either there's all M and a everywhere. And so you're adopting other smaller medical centers, culture, and we don't actually have patient preferences top of mind when we make technology decision.
Right. And it's the EHR was not designed. To move the information you just talked about around, or at least surface it when I'm having the conversation with the patient, like we expect the physician to know these things, right. And they're already looking at 55 data points and it's just, it's on a different screen.
It's not, it's not readily available to them. So know me is one of the things you heard from the. One of the primary things you heard from the patient and that, that resonates. What was maybe one or two of the primary things you hear from the clinician in terms of the future experience that they're looking for?
Make my day easier. Yeah. a lot of folks, not in healthcare don't really know how many administrative. Everybody is required to carry out from surgeons to medical assistants to even non-clinical administrators and there's so much opportunity to alleviate unnecessary work from our clinicians from, excuse me, I mentioned learners earlier med students and residents are. Often appalled because they're fresh outta school. They're so excited to be a doctor and care for patients. Oh, by the way you need to respond to this nurse who has paged you 17 times and you're in the middle of doing a procedure and you can't go home when your shift is over because you haven't finished all of your notes and the attending hasn't signed off on your medications.
Therefore. You need to rep page the attending. It's, it's really a shame that we have so many fragmented workflows that are not integrated and not automated. And so I think loud and clear make my life easier.
yeah. as we're looking at this now the pandemic has, let's just call it subsiding there's a new set of challenges that have sort of popped up for health systems. And we talk about make my life easier, but there's a, there's a shortage. I was just talking to a health system that has 4,000 open positions. Now they're not all clinicians, but they have 4,000 open positions.
Is that something that we believe we're going to be able to apply some of this some technology and some new processes to somehow I mean, clearly you can't replace if 4,000 people aren't there, you can't replace 4,000 people not being there. But somehow alleviate the burden enough that they can continue to deliver the care that they want to the patients who are in the.
Yeah, I just got off the phone just prior to talking to you with a vendor and we are exploring various use cases in regards to virtual nursing specific to clinician wellbeing. They're burnt out. We're not seeing as much turnover, but we're, we're seeing a lot of absences unplanned absences, which is also an indicator of burnout.
And so what we're exploring. Nurses don't necessarily want to leave the field. In some cases they do. Of course they want their cup filled. They are tired. And the mundane day after day of we're not selling widgets, right. We're caring for incredibly complex patients. These are humans, so it, it really takes a toll.
And so there's As I mentioned the administrative burden of a lot of the clinical workflows. If you can offload what doesn't need to be done in person, for example, nurses do admission assessments, they're quite lengthy. Some of them do not require physical assessment social determinants of health do you have food insecurity?
Do you have housing insecurity history of present illness? Do you have any. Of this in your family, like there's all sorts of assessment questions and and things that need to be collected from patients that don't need to be done on the frontline. Likewise, on the back end, I need to educate you bill, because you have this condition and you need to know how you're gonna take care of yourself.
You don't need to be there in person to do this. So we're exploring how do you have nurses that are staying home? They're also, they're delivering nursing care. Maybe once a shift or one shift, every pay period whatever's necessary to really diversify how they're delivering their care, cuz they're in many cases passionate about the field of nursing. And so that's one example of what we're exploring here today. And. Literally today.
well, let me ask you this will be our closed question. there's gonna be a nurse out there. Who's listening to this saying I can do that job. I'd like to do that job. Talk about your path from being a nurse to really the intersection of technology and nursing and transformation and leadership. How did you make that transition in. What does your nurse background really bring to your current role?
Yeah, so I, I am fortunate to have such a diverse clinical background. It's a little bit atypical. A lot of times you come outta school, you're an adult critical care nurse. You stayed an adult critical care nurse. I was a pediatric chronic care long-term care nurse in New York city. And then I went into. Cardiac cath lab. So procedural setting, it was a pretty affluent community. Very episodic, obviously you're taking care of patients one patient an hour.
And then I went into ambulatory. So I was in Philadelphia and I ran an ambulatory care center in west Philadelphia. And lot of as an underserved community, a lot of adolescents and family planning. And so, I mean, that's inpatient, outpatient, adult peds Rich poor. I mean, it was really just again, I wasn't, I was fortunate, but through this, I saw a lot of problems.
Most notably when I was the leader at the ambulatory care center, I was frustrated. You know what I mean? I was frustrated for my staff. They were like this, this EHR sucks and these are all the things I have to do that I don't want to do. And so that's where I kind of entered the field of informatics. I decided to leave clinical operations. And helped solve problems. Technically I became an analyst kind of quit my job as a leader and entry level analyst. Everyone was like, what is she doing? But I had to earn my stripes to understand the technical landscape of how things are built and how things are maintained.
And then I kind of grew up in, in that space. So that journey, I think, has led me to to understand a number of aspects of he. I also ran an analytics shop for a while and nursing informatics for those that aren't aware it's based on this framework of data to information, to knowledge, to wisdom, that's like the cycle.
So you need to really have a keen understanding of data, the collection of data, but then how that transforms into what you do differently. And so I think that additional sort of analytics skill set and background has helped as well.
Kay. Thank you very much. This was a fantastic conversation. I really appreciate your perspective. I love the stuff that you guys are doing at U C S F. Thank you again for your time.
Thanks so much, bill. I 📍 enjoyed it.
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