In this conversation with SoundPractice co-host Cheryl Toth, Thomas Zoch, MD, Vice President of Care Management-Clinical at Ascension Wisconsin talks about his leadership philosophy and the use of morning huddles to engage physicians and staff from across the health system. Dr. Zoch discusses the genesis of why Ascension Wisconsin chose to deploy morning huddles, and how the focus on “getting to why” in these daily communications has resulted in open dialogue, effective discourse, and ongoing education. He also breaks down in specific detail the logistics and specific processes he uses to lead morning huddles at three different hospitals every Monday through Friday at Ascension Wisconsin.
Cheryl Toth: Our guest today is Thomas Zoch, Vice President of Care Management Clinical at Ascension Wisconsin. Dr. Zoch, I am really eager to talk with you today about the morning huddle and some of the other initiatives that you’re overseeing. And we’re really glad that you joined us here on SoundPractice Podcast. Welcome.
Dr. Thomas Zoch: Well, I’m really excited and pleased to be with you here today, Cheryl. Thank you very much for having me.
Toth: We have a lot to talk about today and some interesting things about you as well. I think the listeners are really going to find some of your background interesting. But let me first just give a broad overview of who you are and where you’ve been. Like we said, you’re at Ascension Wisconsin, where you provide leadership and direction for the care and utilization management teams. You work in collaboration with the Ascension Wisconsin Hospitals, of which I think there are 22, you told me, and 111 clinics and over a thousand physicians and clinicians. Before Ascension Wisconsin, you played the roles of Chief Medical Officer of Care Navigation, Clinical Documentation and Compliance for Ministry Healthcare. You’re board certified in four areas: internal medicine, emergency medicine, sports medicine, and clinical lipidology. You bring lots to the table. I thought we might start by you giving us a nice overview of your current role at Ascension Wisconsin?
Zoch: Well, thank you, Cheryl, for that excellent introduction. I feel really blessed to be a physician. I’ve been a physician for over 30 years. My current role in Ascension Wisconsin is that of Clinical Vice President of Care Management. As you mentioned, it’s over all of the hospitals within Ascension Wisconsin and the many clinics we have and all the very, very fine physicians and clinicians within the system.
The Clinical Vice President role helps oversee the denial management piece that takes place within Ascension Wisconsin—sadly all too often, but it’s there. I have the pleasure to interact with our health plans as well. Additionally, we have developed a new internal physician advisor program, and I’m really pleased and excited that we’re getting this physician advisor program up and running.
Other responsibilities include clinical documentation improvement—I like to call it clinical documentation integrity—along with interacting with our coders. So, clinical documentation improvement (CDI) more on the hospital side and the coders more in the outpatient realm, although they’re on the inpatient side as well. But in the outpatient realm, we review the hierarchical condition categories (HCC) and risk adjustment factor (RAF) issues, the hierarchical condition categories, and the risk adjustment factor scores that, in a population health management world, are so very important to address.
Toth: That’s just a wide array of things that you oversee. I realize I didn’t mention you’ve also had a role in a health plan too. The HCC, the risk adjustments, is something that’s in your wheelhouse that you add to this clinical role. Given all of the responsibilities you have and the fact that you’ve cared for patients, and you’ve been chief medical officer and you’ve evolved to this role, I’m curious what drives you to do this work at this point in your life? What’s that passion behind it?
Zoch: Well, the leadership role, that particular responsibility has become a natural fit. I’ll tell you why. As a young man, I was quarterback of our football team, and the quarterback is looked upon as a leader of the huddle. And we’ll be getting into huddles in a little bit, but it seems to be a natural fit to be leading huddles again after all of these years. At a young age, I learned leadership skills out on the sporting field. That then continued into my residency training, where I was chief resident in 1985 to 1986 at the Marshfield Clinic. That was a leadership role with much responsibility.
I have also been blessed to have achieved other leadership roles, including emergency room director. I led our emergency room independent team in the Fox Valley over the years. Then that transpired into the health plan medical directorship for some years at a regional health plan. You mentioned the chief medical officer role. And now, it’s this vice president clinical role. So there have been lots of leadership roles up to this point to hone me for this, I believe, very important role for Ascension Wisconsin.
Toth: What excites you about all of these leadership roles? Were you pulled into them? Or did you seek them out? Why do you think you migrated into these leadership roles along your career path?
Zoch: I’ve always looked upon the roles as an honor, in that many times they’re voted upon by peers, or you are placed in such roles by the leadership within the respective facilities where you’re working. So, first of all, it’s an honor to be considered a leader. But additionally, I look upon my leadership style as that of a servant leader. I like to think of that as an intersection between being authentic, being an authentic leader, and tying that into being strongly value-based. If we look at our values within Ascension Wisconsin, I remember them very well because I love to learn by acronyms. And I’ve learned the acronym Wisconsin Doctor: WISCDR. So, W for wisdom, I for integrity, S for service to the poor, C for creativity, D for dedication, and R for one of my favorite values, reverence. The reverence piece, when I was actively in practice, I had much reverence for my patients and their care. But I also now can apply that to my colleagues and help lead them, care for patients in a very respectful manner. So that reverence piece I really embrace.
Toth: You can really tell there’s a shift in you when you talk about that reverence, it’s clearly something you’re passionate about. Let’s move over to talking about the morning huddle a little bit. We talk about how you’re leading your colleagues, and what was the genesis of the morning huddle? How does it work, and how are you leading your fellow clinicians in doing this work?
Zoch: First of all, I’m so excited to be within Ascension Wisconsin because they embrace the huddle concept. Research has proven that open communication fosters employee satisfaction and increases retention. I look upon huddles as an excellent communication tool to use. Ascension Wisconsin currently is using huddles successfully at all levels to engage leaders and associates. The ultimate goal is to explain the why behind the work: what drives our business strategy and growth in an ever-changing industry?
The huddles engage, and they challenge, and they connect our associates to our system’s purpose while educating them at the same time along that journey.
So the huddles engage, and they challenge, and they connect our associates to our system’s purpose while educating them at the same time along that journey. The way this works in Ascension Wisconsin is that we have developed a daily connection calendar that assists the leaders with the huddle format. And every day, there’s a daily reflection that we use to start off the huddles.
That is designed to get at our organizational core values, that I’ve already discussed, and follows up with a discussion question. Then the huddle gets into recognitions, very important for our associates; key updates; there’s a communication piece; demand and capacity; safety; quality; projects; and improvements. All of that can be discussed at the huddles, which lasts anywhere from 15 to 30 minutes. So they can be very, very brief.
Additionally, at Ascension Wisconsin, we have huddle notes, which are distributed weekly via email to leaders, to inform about key strategic updates and important news. That helps further the system’s growth. Then we cascade that to our reports and to our associates, just to keep them on the cutting edge. I you look at our huddle note email opening rate, it’s consistently around 75%. So it is a popular communication tool, and we know that it’s being used.
Toth: Let me expand on a couple of points. You started by saying, “Each huddle begins with a reflection.” Just so people don’t gloss over that—and I actually have the benefit of having worked with Ascension for a number of years, not as an employee but in a project basis, and I was always very impressed—reflection, when you say that, you mean it’s a little daily spiritual reflection. They’re still doing it—the consistency with which the message and the values, the mission, vision, values get communicated through because it’s all about service to the poor and caring for everyone.
The other thing I wondered is, when you’re doing the recognitions, is that for patient care or could it be anything that you’re recognizing nurses, physicians, and others for?
Zoch: Correct. It is a recognition of work that’s being well done. To show gratitude for the excellent work. We’re all so busy, and time is of the essence. We’re always working around the clock, right? But to take a pause every day at these huddles and say, “Okay, let’s recognize really good work.” We need to do a better job, as a system, to recognize successes. Too often we hear about things that are not going right. And necessarily, in healthcare, that happens. Those issues need to be addressed. But we believe it’s very important to acknowledge really good work too and acknowledge, “No, we’re having daily successes, as well, that exceed some of the other issues by far.” So it’s an acknowledgement of the great work that’s being done out there.
Toth: How many huddles would you say are going on across Ascension Wisconsin on a daily basis? In many or all of the units? The clinics? How many are happening?
Zoch: I would say, at many of the units throughout Ascension, that really delves into, as I mentioned earlier, the safety issue, some of the quality issues, some of the capacity concerns we have. But at almost all of our hospitals, on a daily basis, that is happening. So, there are many, many huddles taking place. Now, I know you wanted to ask me about the huddles I currently lead.
Monday through Friday, I have the pleasure to talk to 19 of our 22 hospitals, and it’s divided into three different huddles. This all started in March of 2017, when we were advised that our observation days were quite high in comparison to some of the other states where Ascension exists. And so we decided to develop huddles to address our daily observation service patients, those patients who are in outpatient status and we’re providing an observation service to, and those patients who are classified as outpatient in a bed.
We have expanded that, to a degree, to involve some of the questions on inpatient status as well. But most of the attention is placed on the observation cases. So, one huddle is dedicated to our critical access hospitals. That’s typically at 11:30 every day, and we conduct it via audio conference.
On occasion, I will go to one of the hospitals and be there and be physically present. I try to visit all the hospitals to talk with our care management and utilization management associates and the clinicians and physicians at those respective hospitals. But every day, the huddle is designed to go 30 minutes. We’re usually done in 15, but it can go as long as 30 minutes. We discuss all of our observation cases and issues surrounding the observation cases.
Since the observation service is designed to last typically no more than 48 hours, at the 24-hour mark, we address these situations: what is our plan? Is it to discharge? What is a discharge plan? Or will this patient require an inpatient transition? Or if it’s “no” to both of those, what’s the barrier? So then we talk about barriers that may be leading to a longer length of stay. Or we talk about any other discharge barriers. What has evolved is that we get into very strong clinical discussions on the respective illnesses and entities that have led to the admission. We also get into good clinical discussions, many times with a clinician or physician caring for the patient.
That seems to have added significant value to the huddles. So 11:30, critical access; 12:30, we talk to our north region in Fox Valley Hospitals; 1:30, we talk to our south region hospitals. So it goes, Monday through Friday. And it’s very active. Debate is encouraged.
I should also say that at the beginning of the huddle, we do reflections. We get everyone centered and comfortable. But it’s very important that all understand there’s no question that’s a bad question and that there’s open debate on these cases. It gets quite active. It gets quite exciting at times.
Then when our discussion is done, if it’s a clinical entity that may be new to the nurses on the call or the clinicians, I will go into my library and find a good evidence-based article and send that to them, to help close that loop of communication, with the added assurance that we can talk about it tomorrow if there are any questions.
Toth: What would you say are some of the top two or three impacts that you’ve had with these huddles? The value, the benefits, the impact?
Zoch: Number one: it’s a communication connection. It’s a connection to a leader. For those hospitals, especially critical access, but for our other larger hospitals, there’s a leader talking to them every day; there’s a connection there. And if they have an issue, they have a place to at least start. So, the communication piece, that’s first and foremost. I think the teams involved would say that’s of most value.
When regulations change, we do use the huddle to address that with our respective teams.
Secondly, it’s a help in regard to understanding the regulatory state of affairs, which is ever-changing. When regulations change, we do use the huddle to address that with our respective teams.
Thirdly, the education that you mentioned. I believe they look upon this as growth in their work. That’s my prayer, that I’m adding growth to their work, day upon day. And they have a friendly voice that’s willing to listen to their issues and talk to them and communicate to them. So, I think those are the three top issues that have come out of this. The education piece, which initially was not a large part of our huddles, has evolved into being a major positive for the huddles.
Toth: Any metric differences that you’ve seen? You mentioned the observation services issue. Have you seen a move in the needle there?
Zoch: Our observation day rate has dropped considerably. We follow a leading metric called observation percent discharge—the number of observation discharges divided by total discharges. We have noticed a definite reduction in that, a big trend down, with just a few blips every once in a while. And then we round back to the hospital where we think there’s an issue, try to address any concerns there. It’s usually a resourcing issue, interestingly enough, that we find. We try to crack that. But the trend has definitely decreased, I think quite dramatically.
We get monthly updates, monthly trends that I can feed back to our respective hospitals if there’s any quality improvement that need needs to be done. I think, again, the teams have found that very valuable, especially during their monthly utilization management committee meetings. We try to share that information with them.
One other thing that comes up, and that’s the denial situation, where the denial rate is. I think we all know it’s on the rise from our payer sources, whether it be the government or third-party payers. This also gives us an opportunity and gives me an opportunity to coach the physician if they’re asked to do a peer-to-peer. To coach them to at least completing the peer-to-peers, and also how to complete them, because many physicians are, I think, frankly, a little nervous to do the peer-to-peers at first, until they get used to it.
Once they have done a few, the coaching sessions really decrease quite a bit. It gives me an opportunity to at least discuss when peer-to-peers arise, who needs to do them, and if there are questions around that. We’ve used the huddles for that as well.
Toth: That’s great. I imagine as you’ve rolled things out over time, some things work better than others. If you were to look back and say, “Gosh, if we could have done this a little differently,” save your colleagues some time, what would you have maybe thought about differently?
Zoch: Back in March of 2017 we started quickly. If I had to do that all over again, the communication would’ve been far better to begin with, because at first, I believe, that created a fair amount of anxiety on the hospitals who were on the huddle calls.
After we settled in, I think they got used to my very laid-back style, very open, nurturing style. I think that really helped them be more comfortable. Some of the care managers were social workers. And I’m so impressed with our teams. Their clinical background is very strong. There was, I think, some anxiety there that I wish, in retrospect, I had done more to alleviate and make that transition a little bit smoother. I really have to call out our teams. They’re great. They’re very engaged. I think they do look forward to the huddles. That’s the feedback we’re getting. The second thing that I think I would’ve implemented earlier on was the educational sessions. How this evolved was we would talk about “should this patient be transitioned to outpatient and why?” That gets into the discussion of the disease entity. We started a little modestly at first, but necessarily that grew. We could have started that a little earlier, but it’s grown into being one of the more popular parts of the huddle.
Toth: If you had a crystal ball over the next year, what would you like to see as the improvements that occur because of the morning huddles that you’re running?
Zoch: Cheryl, that’s a great question. The hope and prayer is that our work, on getting the status right up front, improves. Whether it’s inpatient or outpatient status, if we get that right, the denial rate, more often is reduced. Because we’re spending a lot of resources, expending a lot of time on addressing the denials. So anything that can help prevent denials from taking place would not only be appreciated by our system, but by the health plans as well.
Because they expend a lot of resources putting through the denials and doing the peer-to-peers. So our goal is to not to see how many we transition; it’s to get the status right up front. My hope is we see a trend downward that way.
Secondly, a year from now, with the new physician advisor program we’re building, I would like to see my young physician advisor colleagues take some of the huddles over, because I believe it’s refreshing to have that young infusion, that different perspective, on how to address some of these issues and perhaps a different way to educate. I think that’s really healthy. My goal is eventually to help delegate some of those duties to our physician advisors.
Toth: Well, and it sounds like this is a theme, this discourse and discussion, everything is what’s best for the patient. That under your leadership, that’s what you’re fostering, is this feeling that everybody can speak their mind.
Zoch: Well, I’m glad you brought up the patient. Ultimately, that’s our goal. We want to impact patient care in a very positive way, and getting the status right up front does help with that. But our educational discussions on, “Is this the correct diagnosis? And if it is, what additional things should we be doing?”also are important. My fervent hope and prayer is that that is impacting our patient care in a very positive way. I think it is, in that, to get the status right up front, we talk about quality and safety for the patients. It also has some financial ramifications for the patient as well. Anything we can do to positively impact patient care and think of their families is something really worth being passionate about and really worth getting right.
Toth: Final thoughts on those physician leaders thinking about implementing morning huddles or improving their morning huddles? What would you say to them?
Zoch: Some final thoughts: please consider this as one of your communication tools. It is wonderful. It is an honor to be able to interact with your associates on a daily basis, whether it’s face to face—which, I’m old-fashioned, I believe that’s ideal—or if it’s Skype. Because of our geography, I necessarily have to handle it that way. Sometimes it’s simply audio. Sometimes it’s a phone call. Just using that as a communication tool regularly is far better than, I think, a lot of the systems have performed up to this point. So that’s one thing.
Secondly, when you embark on the huddles, try not to cure world hunger. By that I mean try not to address all of the issues. These are brief 15- to 30-minute interactions. So hone in on issues that you can address and then be ready for tomorrow. You can go back and continue to address incrementally some of the other issues. To try to do too much in the huddle, there’s diminishing returns on the effectiveness of the huddle.
Toth: Great thoughts, great discussion. We really appreciate your time, Dr. Zoch. You went from the football huddle to the morning huddle. And it’s a great story. Your leadership is really producing great results, so thanks for sharing.