Speaker 1: You're listening to Intermountain Healthcare's podcast channel.

Anne Pendo: Well, welcome to the Intermountain podcast. I'm Anne Pendo. I am the Senior Medical Director for Experience of Caring, which is responsibility for patient experience and physician and APP experience. And I'm really excited to be here today to talk to Dr. Cara Camiolo, who is the leader in our rehab services. And I think let's start by talking a little bit about what your role you had thought of when you started and what it has become, and talk a little bit about what your responsibilities are. I think that's a great way to get us started today.

Dr. Camiolo: Yeah. So when I joined Intermountain, rehabilitation services was really locally based, as many things were here. And over the course of time we realized what the Intermountain restructure was going to bring. We realized we had a wonderful opportunity in rehab services, and it was to connect these caregivers that were working in so many like situations and connect them for the first time and connect them with purpose to provide that one Intermountain experience for patients no matter where they were in the system.

Dr. Camiolo: And so as we were thinking about what this might look like, my associate medical director and I, Rusty Moore, had the opportunity to sit with Nanette Berenson who is leading clinical services, and really talk about from a physician standpoint what this should look like, and talked about the patient journey and how we should be designing ourselves around the patient. And so Rusty and I often talk about those initial conversations that we had, because we would start the conversation with, "Okay. A patient with a new stroke arrives in the emergency department. How do we structure ourselves for that patient for their entire journey?" Or, "Patient with progressive hip pain presents to their primary care physician. How do we design rehab services to meet the needs of that patient, of that primary care provider?".

Dr. Camiolo: And that's where our conversations really were the foundation for the structure that we came up with, and everything that came after, it really was based in that notion of, "Let's organize ourselves for the patient. Let's not have ourselves married to a particular org chart or a particular structure because that's what we're used to, but really let's think about the patient." And that's where we are now, is we created a structure in rehab services that really looks and focuses on the patient journey, so that we can optimize that experience not just for the patient but for our caregivers too. Because what we were finding was, again, we had caregivers doing the same type of work in the same organization that just happened to be in different parts of the state, and they were never connected. We were never giving them the same resources. We were never giving them the same education. We were never supporting them in their work in the same way, and now that's where our focus I,s and that's what my kind of daily focus is in my role, is to help support that. And so it's been a really, really cool journey over the last year as we've done that.

Anne Pendo: Well, from the office of patient experience, we would like to say thank you for having the patient at the center of your decision making and the caregivers. So it sounds like you really brought both of those parts together. One of the things that I'm curious about is, how did you know you were on the right path in this work as you were getting this organized?

Dr. Camiolo: You know, there were challenges from day one, and one of the things that was top of mind for us as we were doing this work was we were one of the last shared services to come online, and as the rest of the organization was restructuring and transforming and making these big announcements, rehab was never included in those conversations. And we have a lot of caregivers in rehab services. Over 1,500.

Anne Pendo: Wow.

Dr. Camiolo: And so we had a lot of folks out there who were just anxious about what was coming ahead. And so initially we really wanted to make sure that we were communicating that we were addressing some of that anxiety, because the support back to the caregivers was as important as what we were trying to accomplish for our patients. And so that was probably some of our biggest challenges right up front, and that we continue to make sure that we're mindful of as we go forward. We wanted to be sure that we learned from the shared services that went ahead of us, and so we had a lot of their experiences to learn from, but at some point we had to make that meaningful for our caregivers. One size doesn't always fit all, and so we had to apply the lessons learned in other shared services, but really make it meaningful for what we were doing in rehab services. And the the anxiety component, and I know other folks have felt this during change, it was really strong, and it was one we had to, again, just be really mindful of.

Anne Pendo: Yeah. I appreciate the ... When you use the word anxiety, is I think that that was a word that many felt but didn't express it.

Dr. Camiolo: That is so true. And I think as leaders, we felt it, and we had to acknowledge it. And I remember some of the most powerful conversations. It gets back to your initial question about, "How did we know we were going in the right direction?" Some of the most powerful conversations were when we were sitting down with caregivers, and just acknowledging, "This is really hard. This is hard." And yes, I think both rusty and I wanted to project out that we knew what we were doing, and this was going to be okay, and we wanted to project that optimism.

Dr. Camiolo: But at the same time, some of the most powerful connections we made were when we sat down with caregivers and other leaders and said, "We don't know." And the ability to listen, I think, is one of the most important as a leader, and Rusty and I did a lot of listening, and that just speaks to all of the work that has to go into doing something like this, to transforming an organization. And we knew we were moving in the right direction when we could see the white knuckles start to go away. People were unclenching a little bit when we would walk in a room, and they felt more open to share some of those feelings with us. I don't think they would've been willing to do that had we not done it ourselves, and shown some of that, for lack of a better word, showing some of the vulnerability that exists in times of change.

Anne Pendo: Yeah. I was thinking vulnerability and human. That you guys, you, the leaders, were figuring it out as well.

Dr. Camiolo: Yeah. And being honest about that.

Anne Pendo: And I think we talk about psychological safety, and as you were talking, I was thinking that was what you created. Did you know that that's what you were doing?

Dr. Camiolo: I would say yes and no. I think to the extent that I am really quite grateful to have a partner in Dr. Moore that we can be very honest and open in sharing with each other, and I think we knew that in order to do the work ahead in rehab services, we were going to have to have those types of connections and allow that to foster. And so as we brought in new leaders, because again, almost all of our leaders had to apply for new positions, it was a completely different structure, and as we brought in new folks, it really was from the outset to say, "This is the culture that that we're going to create here."

Dr. Camiolo: As rehab enthusiasts, as we call ourselves, we're used to working in a very multidisciplinary type of environment. So some of that comes natural to us from our training, and I think that's a benefit, but I think it was just a, "Sit down and let's all connect to purpose," right? And we would have those moments where we would just talk about, "Okay, remember that first conversation about that stroke patient in the emergency room? Let's talk about that again." And we've done that now multiple times. Whenever we need to do a self check of how things are going, we often will say, "Let's go back to last year and the conversation we had about our goals and putting ourselves around the patient." Because sometimes in the heat of the moment you just start to think about operational efficiency and strategy and KPIs, and and you lose sight of that patient in the emergency room.

Anne Pendo: Yeah.

Dr. Camiolo: And that has been a really good way for us to refocus when things have gotten off.

Anne Pendo: Yeah. As you're speaking, in the patient experience work that we've done, that's one of my key takeaways, is having to come back to that patient, that sense of purpose, that talking about it once is not adequate.

Dr. Camiolo: Absolutely. And that's what connects our caregivers. I mean, again, we have 1500 folks on the front lines of care, touching patients every day, and rehab is a special place. We are working with folks oftentimes at their most vulnerable, after life changes, after trauma, after injury, and we often make really strong connections as caregivers in rehab services to our patients. And if we can't get our caregivers to appreciate those moments and support them as they provide the care in those moments, we're not doing the right thing. And to connect it back for them, that's where they see it. That's where they see the value and the purpose of what we're doing, and then the change becomes less scary for them.

Anne Pendo: Yeah. I really like that. You also have done a couple of things in terms of how you share and communicate with your teams, and I know that one of the pieces of feedback that we received from the caregiver survey was, "I don't know what's going on." And if you could share with our audience what you've done in rehab services to address that.

Dr. Camiolo: It gets back to that initial feeling that folks had, of that uncertainty, of that anxiety. And we knew right from the get go that we had to do a good job communicating back to our teams, because when we first introduced the concept of reorganization, again, the rest of the organization had already kind of been on that journey for several months, if not longer, and here we were kind of coming in at the back end, and the first question was, "Why did this take so long, and where have you been, and what's happening?" And so we were very deliberate in our communication plan. And I will say, we got it wrong at first. We didn't do it the most effective way, but one of the quotes we always come back to is one that Nanette Berenson told us, which is, "Excellence is iterative," and just continue to learn.

Dr. Camiolo: And so when we first kicked off our rehab services, we said, "Okay. We're going to do a town hall WebEx." In retrospect, doing a WebEx with 1,500 people is not the best idea. And it didn't go well, and we thought going into it, "This is great." One of the key pieces of advice we got from the shared services who went before us was, "Make sure you roll out all information at the same time to everybody, so that nobody feels like they're getting information before somebody else." Great advice.

Dr. Camiolo: That was interpreted on our part to say, "Okay, we'll do a WebEx. Everybody will hear it at the same time." It just wasn't effective, and they couldn't see us. They could only hear us. We couldn't see them, and so it was really challenging to have any type of dialogue. It felt very top down, even from me, who was giving the message. And so we learned from that, and then we moved to a video town hall, where everybody could see us, we could present our message all at once, they could ask questions. Again, we realized it just wasn't ideal, and so we moved into what we now affectionately term our rehab road show, where at the end of every quarter all of the folks from our system leadership team, and there's 10 of us, we divide ourselves up and we kind of travel the state, and we do about anywhere from 12 to 15 different in-person town halls.

Anne Pendo: Wow.

Dr. Camiolo: Sometimes there may be eight people there. Sometimes there may be 50, depending on our location and where we go, but we make sure that we get to almost everyone, or have everyone have an opportunity to get to us locally. We've also tried to commit that they'll see different leaders each time. There's 10 of us. We don't want them to see the same two or three people every time, so we rotate that a little bit so they have the opportunity to see us all. When you're face to face with someone, nothing can replicate that experience. They can see us, we can see their facial expressions, they can ask questions, they can interrupt. It's so nice of a conversation, for lack of a better word. But we learned, and we got there not because we knew right off the bat that was the way to do it, but we just kept trying.

Dr. Camiolo: The consistent thing that we did in that whole journey was make sure that our caregivers knew when to expect us. So when we had our first WebEx, at the end of the WebEx, we said, "We're going to do another one of these, and it's going to be on this date. Expect to hear from us, and we're going to give you updates, and we're going to tell you what's next." And then at the next one, we did the same thing, and said, "The next time you're going to hear from us, it's going to be in X amount of months, and we're going to be presenting on this information that we're going to work on between now and then." And now we continue to do that so they expect, they know when we're coming. They expect what they are going to hear from us. Obviously we're trying to create as many opportunities within that, that if they need us, they can reach out and ask questions.

Dr. Camiolo: But getting back to that initial emotion of anxiety and uncertainty, we knew we had to be deliberate in how we communicated and have made a commitment to do that. Now we're at the point where everyone says, "Okay. All right. We know you're coming. We know what's coming." We send monthly newsletters now that really just, in an email format, can summarize all the work that's being done in rehab services to connect folks, and so they expect the email now. Some of the best feedback we've gotten is just, "Wow, this is great. Thanks for sending this email." Whoever thought I'd get a thank you note for an email, right? Nobody wants that. Nobody wants more emails.

Dr. Camiolo: But the fact that we're making an effort to be consistent and they know it's coming, it makes change, it makes whatever change might be ahead less concerning to them, because they know what we're working on, they know that change is inevitable, but it's not hitting them all at once. It's a constant process of communication that creates that psychological safety. And I think back to your point of, "Did we know what we were doing? Did we know we were creating a psychologically safe place?" I think that was our aim. I'm not sure we were using those words specifically, but it certainly was one that we recognized we needed to do.

Anne Pendo: I love that. I love that, because when I think about "always safe," so you created the safety, "always present," so you were present, you've listened, you learned, you were curious. You understood that at the root of this was a lot of anxiety about change, and then you did it together.

Dr. Camiolo: Yeah. Yeah.

Anne Pendo: I love that. I love that. And I think you're also, you've got another initiative around standardizing work. Did you follow the same process? Did you think about it differently? How did you organize your work to get that started?

Dr. Camiolo: I will say, as folks have commented, I do have an ace in the hole with Dr. Moore, who is one of our medical directors in continuous improvement in addition to his role in rehab services. So we have the benefit of having a leader who is very versed in the CI process. In addition, we have a great partner in TJ Smith, who helps to support the shared services from continuous improvement, and we've been very mindful of making sure the frontline caregivers are engaged in continuous improvement, in the sense that we can go in and say, "These are our KPI, and this is what we need to be measuring, and this is what you need to be doing," and make it very heavy handed. But again, the folks doing the work are the ones that are the experts. They're the ones touching the patients, and when we think about the care that we're trying to standardize for the patient, we're not trying to standardize ourselves in the sense that it's us first.

Anne Pendo: Right.

Dr. Camiolo: It's the patient first. Let's standardize the experience for the patient and make sure that they have access to the best evidence based care that we can offer them, and so of course it makes sense to put the caregiver in charge of those CI type of initiatives, and in our inpatient rehab facilities in particular where Dr. Moore works the most and focuses his efforts, we've trained all of our frontline caregivers in the CI process, in the [inaudible] process specifically, and we said, "Okay, you know, as an organization, this is our KPI for inpatient rehab," and we told them what we'd like them to focus on, and then let each unit figure it out themselves. We didn't say, "You have to do it this way." We said, "This is the measure we'd like you to focus on. Figure out in your unit what makes sense for you, and your patients and your caregivers."

Dr. Camiolo: I think a great example is what has happened down at Utah Valley on our inpatient rehab unit. Our managers were helping to structure a [inaudible] project and identify the problem, and set up the experiment, and very quickly, I would say within a week or two, our frontline caregiver said, "Now we got this," and started to do it themselves, and kind of said to our managers, "Just step aside. We got this," and really have taken ownership of that. We had our first rehabilitation research and quality symposium last month, and those frontline caregivers got up and presented their quality project. That is still ongoing, but it was so empowering for them to be able to say, "Yeah, we know this work. Let's do this. Let's lead." I think our job as leaders is to provide the infrastructure for our caregivers to do the work that they are passionate about. It's not for us to dictate it. It's simply for us to help to facilitate it and remove barriers when they're there. And so I am most passionate about that part of the work, and have gotten the most joy out of seeing that really evolve.

Anne Pendo: I love that. So for those leaders or others that are listening, you've shared two great stories. What advice would you have them, as they either step into leadership roles or in their place of work, how to start thinking about things differently in a way that allows for them to own the work around them?

Dr. Camiolo: Anytime anyone asks about advice for leaders, I think the very first thing that always comes to mind is just listen. We tend to get into this mindset of when you're in a leadership role, particularly when you're in a new leadership role, that you have to have all the answers. You don't. And in fact, I would assert that most leaders don't have all the answers themselves, but it's the best leaders that can listen and draw out of the folks that they work with the best ideas. And as a leader, my clinical time has started to be cut back, and so I don't have as much of that face to face time. It's incumbent upon us to listen to the folks that are providing that care for patients, because they're hearing the patient's stories every day. They're hearing where patients are having a tough time navigating our system. And let's make sure we're listening and giving the time necessary to the folks who have concerns and have ideas.

Dr. Camiolo: I worked for a gentleman at one point in my career who you were not allowed to walk into his office with a problem unless you already had a solution, and he would just ask you to leave. He said, "Problem only? Okay. Come back when you have the solution." He wouldn't even give you the time. That taught me so much as a leader, to say, "Okay, let's listen, but let's also ask those folks. Let's work together in a solution." And as physician leaders specifically, and perhaps some of this is influenced by my rehab background, where again, we are, we are raised as rehab docs to work in a very multidisciplinary manner, but I think even just participation and huddles with your PSRs in an outpatient clinic, and your MAs, and your nurses, participating in that conversation can be profoundly helpful to the care of a patient. Because when the patient sees that we're all connected, that goes so far for the patient's comfort that we're together, always together, right?

Anne Pendo: Yeah.

Dr. Camiolo: And the patient can feel that. And when we're not connected with our PSRs or our MAs, or our nurses in our clinic, the patient can feel that for sure. And so I think as leaders, it's incumbent upon us to be present, to work with our teams. And sometimes I will hear that, "Oh, huddle. Ugh." But if you start to go and you start to participate, then it really can become a forum where we can be present together.

Anne Pendo: And learn from each other, right?

Dr. Camiolo: Absolutely.

Anne Pendo: I think the times when our other team members are sharing what's hard for them, I've learned things that I would never have known any other way.

Dr. Camiolo: Exactly.

Anne Pendo: And I think that would give me a better sense of maybe a better perspective and some thinking about ... Or trigger something that would say, "Okay, that's a problem that needs to be solved, and I bet we could do that in the clinic." But if I hadn't been there and listening, I wouldn't have even known that that was something to work on.

Dr. Camiolo: Exactly. One of the things I said in our last town hall specifically, when I was just reiterating the point of, "Please reach out. Please connect with your leaders if you're seeing things that you think we need to work on." And I said a line several times, which was, "I don't know what I don't know." And unless I give folks the opportunity to share those ideas, and as leaders that we give folks the opportunity to share in a way that's meaningful, then we don't know what we need to work on, so we need to do that. And then, I mean, frankly you need to circle the loop, right? You need to go back and make sure you close that so they feel not only that you listened, but you heard them. That there's two different things there, right? They need to feel heard. And it's when you write that followup email that says, "Thank you so much for sharing that." I've already done this little bit of work, I've already seen this, I've already escalated, the email back that says, "Wow, thank you. Really appreciate you listening to that," goes so far.

Anne Pendo: I love that. I so appreciate you being here today, and as we're closing our time together, I've been taking notes about things that you've shared, and I'm going to do my very best to summarize, and then you can add anything that you think I missed. But the ability to be vulnerable, to be unafraid to say, "I don't know. We're going to figure this out together," is an important factor in creating that safe environment. So the team then isn't afraid to bring things to you that they have concerns about. And your ability to listen, I'm going to call it "listen, hear, and learn," because you need all three of those, it sounds like, from what you did, to really make a difference both in how you communicated, and then with the standardizing work.

Anne Pendo: We talk about huddles all the time, about the importance of attending those. And I love your, the reason why we should attend. I think that is great, to learn. To learn from the others that are doing the work around us. Putting our patients first, and the caregivers, the folks that are doing the work. I think if we start there, we'll get so much right. And then finally, closing the loop and giving that feedback. And I think your examples of the rounding, the rounding road show, where it seems so simple but so powerful to know my group is going to get back together in three months, I know what we're going to talk about in three months, and in the intervening time, I know what is going to be worked on, and each month I'm going to get an update. That seems foundational and uncomplicated, and it sounds like it really met the needs of both your team and for you all to say, "Well, this is what we're going to be reporting on, so we need to be working on this. We can't just talk about it, we actually have to do it."

Dr. Camiolo: Right.

Anne Pendo: So I'm hoping that you will come back at a future time and give us an update on the great work of rehab services. Maybe next time we'll have you and Dr. Moore.

Dr. Camiolo: Yes.

Anne Pendo: A tag team.

Dr. Camiolo: We are quite the tag team.

Anne Pendo: A tag team podcast. My other observation is, and this is a podcast so you can't see it, but as Cara is speaking, she looks really happy, and it looks like you're having a lot of fun doing this work. And I know that the work has been hard and challenging at times, but the way you're speaking about it and the way you're describing it is incredibly positive. And that I think is ... Maybe my final takeaway is, just because it's hard doesn't mean it's not going to be fun. So thank you. Thank you so much.

Dr. Camiolo: Thanks, Anne. Appreciate it.