New England Journal of Medicine: Immersion Day — Transforming Governance and Policy by Putting on Scrubs

Richard W. Bock, M.D., and Ronald A. Paulus, M.D.
N Engl J Med 2016; 374:1201-1203March 31, 2016DOI: 10.1056/NEJMp1600068


The U.S. health care industry has long been beset by seemingly intractable problems: incomplete and unequal access to care; perverse payment incentives; fragmented, uncoordinated care that threatens patient safety and wastes money; and much more. These challenges are particularly vexing to the people who oversee or set policy for health care organizations. The disconnect between health care in its intimate, real-world setting and the distilled information delivered in the boardroom or policy discussions is a key barrier to responsive governance and policymaking. Sometimes seeing with new eyes can lead to transformational understanding.1 At Mission Health in Asheville, North Carolina, we’ve developed one potential solution: we ask board members, journalists, legislators, and regulators to put on scrubs, and we immerse them in our daily work.

Our board views its responsibilities soberly: we operate the region’s only tertiary and quaternary medical center (763 beds), five small community hospitals (each of which is the sole hospital in its community), and a post–acute care organization. We are the region’s safety-net provider, and 75% of our patients have governmental or no insurance. Our board focuses on governance and critical issues — quality, safety, community needs, physician relationships, behavioral health challenges, employee engagement, and organizational sustainability. Regionally, the buck stops with us: if we fail, nearly 900,000 western North Carolinians will be without a provider.

Yet until 2013, none of our lay board members had ever been afforded the opportunity to see the complexities of care delivery, except when they were patients, visited someone in the hospital, or watched a TV show like Grey’s Anatomy. Like most boards, we did our work in the boardroom. There, management and our four physician board members did our best to paint accurate pictures of our system’s complexity: the workflows and the choreography, the opportunities for error, the forces behind increasing costs, and the good derived from serving all patients regardless of ability to pay. We shared our struggles and successes using PowerPoint presentations, graphs, spreadsheets, and patient statements.

The educators, attorneys, manufacturers, investors, and bankers on our board are all passionate about improving our region’s health. They asked probing questions, striving to explore realities beyond reports and recommendations, and seeking the best tools for governing a $1.6 billion enterprise. They knew that health systems are immensely complex, but they wanted to understand our operations as deeply and fully as they could.

We realized that we could simply show them — an idea that seems obvious in retrospect. So we created “Immersion Day,” when board members and thought leaders could spend 9 to 12 hours in scrubs, behind the scenes, immersed in the nuances of care delivery.

One of us has led Immersion Days thus far. The typical program begins at 7:30 a.m.; participants arrive, undergo orientation, and finalize confidentiality agreements. Together, we move to preoperative care, listen to patients’ stories, and watch as the surgical team prepares a patient, puts him or her to sleep, conducts a time-out, and performs an operation. We talk with anesthesiologists, nurses, and surgeons and see the “surgical supply cost” come alive — as, for example, an artificial vascular bypass graft is sewn inside an aortic aneurysm.

Next, we join multidisciplinary rounds in the intensive care unit, observing critically ill patients who may have diabetes and obesity, be contending with poverty and drug abuse, be noncompliant with treatment, and more. Participants sit in a cramped break room and talk with staff members. The day is never scripted. Nurses relate their successes and fears, hospitalists type their notes, case managers describe their challenges.

We walk to a surgical area — on one Immersion Day, for instance, the open-heart-surgery suites, where board members peer into a chest and watch as a heart is placed on bypass and goes still. The cardiac surgeon relates the patient’s history: “62-year-old female smoker, recent bare-metal coronary-stent placement, couldn’t afford Plavix, stent now occluded.” The patient has no resources, no insurance, and only a sixth-grade education. Her bypass is successful; Mission Health absorbs the cost.

We make rounds with nephrologists, pulmonologists, trauma surgeons, and hospitalists. Our finance committee chair sees physicians struggling with a new electronic health record (EHR), drawing a more vivid link between documentation and revenue than we could ever describe in the boardroom. Bankers and investors watch a neonatologist insert an intravenous line into the scalp of a 500-g baby and are later taught — by a nurse and patient who’ve been friends for 20 years — how a dialysis machine works.

We conclude in the emergency department (ED). Patients lie on stretchers in the hallway because the ED, as usual, is overflowing with patients. Participants observe calm, controlled chaos — very different from a TV drama. There are random unforgettable moments: a patient who’s taken a drug overdose is intubated just as he stops breathing; a previously healthy 37-year-old mother is saved after 12 minutes of cardiopulmonary resuscitation by a physician whose hunch that she had a saddle pulmonary embolism led him to risk a 50-mg dose of tissue plasminogen activator; a patient with chronic obstructive pulmonary disease pleads for a cigarette.

Board members have called their Immersion Day “eye-opening and endlessly fascinating,” “unforgettable and humbling,” even “the best-spent day of my life.” One said, “I learned more about hospitals and health care from my 10 immersion hours than 6 years sitting on our board.” Our staff benefits, too: when a physician or nurse meets a board member in scrubs, the encounter builds trust and admiration in both directions. Word spreads. Caregivers express gratitude that the board is spending time seeing what they do; many had never previously met a board member. Physicians’ relationships with the board and management, though imperfect, are far better than they’ve been in years, despite ever-increasing challenges.

Immersion Day insights have produced real change at the board level. Several Friday nights spent by finance committee members in our hyper-busy ED demonstrated the strains produced by North Carolina’s distressed mental health care system, as well as challenges related to compliance and substance abuse. When a significantly larger ED was proposed for a new construction project, the board quickly approved it, understanding the need — and authorized substantial spending for behavioral health staffing and training. In addition, directors’ first-hand observations of the “hassle factors” and frequent interruptions that can cause burnout and patient-safety problems led to the approval of a “reNEW Mission” program, which allocates substantial resources for direct observation of caregivers and funds improvements in the EHR and workflows to enhance their experience and help restore joy to the practice of medicine.

Other types of participants are now sharing immersion experiences.2 Aiming to move beyond governance to engage and educate our community, we created a multiweek immersion program for a local journalist who subsequently authored a series of articles explaining concepts such as cost shifting and indigent care and illustrating why our state’s failure to expand Medicaid was so painful for our community.3

We then realized that an Immersion Day might also benefit state and federal policymakers — who, after all, fund the care of more than 70% of Mission Health patients. So we created a Policymaker Immersion Day. The first participant wrote an op-ed about his experience,4 and his work in the state capital is now informed by what he learned. Other participants have followed, and we now offer the experience to national policymakers as well.

Immersion is not a hospital tour. Through careful preparation, we’ve built a transformative experience that can guide our board. Deep immersion in the work of our health system has strengthened governance and engendered trust in our community, staff, and physicians, while elucidating health care for policymakers. After three years of Immersion Days, we cannot imagine being governed by a board that hasn’t seen so intimately how a health system works.


Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From Mission Health, Asheville, NC.

References
1 – Shulkin DJ. Like night and day — shedding light on off-hours care. N Engl J Med 2008;358:2091-2093
Free Full Text | Web of Science | Medline
2 – Lee TH. An epidemic of empathy in healthcare. New York: McGraw-Hill, 2016.
3 – Ostendorff J. Special report: Mission Health at a crossroads. Citizen-Times, 2016 (http://www.citizen-times.com/story/news/local/2015/03/28/special-report-mission-health-crossroads/70520032/).
4Turner B. Lessons from a challenging day at Mission. Citizen-Times, November 13, 2015 (http://www.citizen-times.com/story/opinion/contributors/2015/11/13/guest-columnist-lessons-challenging-day-mission/75701894/).

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