The Exec: Dartmouth Health Chief Clinical Officer Addresses Goals of Rural Academic Medical Center

Dartmouth Health has taken on a leadership role for several small hospitals in New Hampshire and Vermont.

Dartmouth Health is a unique healthcare organization, with an academic medical center located in a rural area and six affiliated members, says Chief Clinical Officer Edward Merrens, MD.

HealthLeaders spoke with Merrens about a range of issues, including the health system's mission, burnout, current clinical challenges, and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.

HealthLeaders: What is Dartmouth Health's clinical care vision?

Edward Merrens: We are unique to have a tertiary-quaternary medical center in a rural state. We have a National Cancer Institute-designated cancer center. We have the only children's hospital in the state. We are increasingly one of the only facilities that can deliver babies as smaller hospitals retract from providing obstetrics services. We are a Level 1 trauma center.

So, we have a responsibility to the region. As we think about that, our responsibility is to be able to serve complex needs but also to ensure that the smaller hospitals have a role in their communities. They have a lot of opportunities, and we have not only served as the place where complex care happens, but we have also reached out to ensure that we can provide care at smaller hospitals as well. We have committed to complex orthopedic care at smaller hospitals, developing hospitalist programs at our critical access hospitals, connected with smaller hospitals through telehealth, and unified our emergency medicine physicians across the system.

The other things that we are doing are enhancing our care capacity coordination center to coordinate patients moving across the system in the most appropriate ways. By being responsible for the region, we have dedicated ourselves to coordinating among all the hospitals in our system, mostly critical access hospitals. We have fundamentally changed the nature of what they do by providing them with an opportunity to fill their operating rooms. It is a great experience for our clinicians and an opportunity for patients to get care close to home.

HL: In addition to telehealth, in what ways are you directly involved with your affiliated hospitals?

Merrens: They are part of our electronic health record. I work with their chief medical officers and their CEOs. We look to develop joint programs. We look to develop outreach. We have membership on their boards. So, we are a closely aligned system—we have developed several system programs. It's not just putting a Dartmouth sticker on their doors. We have developed a system pharmacy and therapeutics committee. We have ways that we try to align our clinical practices to be the same across the system. We have tried to align care.

It has been rewarding to figure out how we can develop algorithms, policies, and procedures that work across the system. We have done that in several areas, which makes it easier for patients to navigate the system and for physicians to work within it. Once you share an electronic health record, and there is one way to do things, it brings you together.

Edward Merrens, MD, is chief clinical officer of Dartmouth Health. Photo courtesy of Dartmouth Health.

HL: What is the status of physician burnout at Dartmouth Health?

Merrens: We are similar to other health systems across the country—we are dealing with not only physician burnout but also healthcare worker burnout more broadly. It is affecting everybody.

We have done a lot of things to address burnout. We developed a well-being council as well as dedicated resources and staff members for a Department of Caregiver Well-Being that incorporates physicians, advanced practice providers, and nurses. We have developed a robust employee assistance program that is available 24/7. We have gotten chaplaincy involved. We have developed lifestyle programs, including nutrition and exercise.

We also recognize that burnout is about more than having enough healthy vegetables and enough yoga. We have developed support systems for people. We are working at add more resources. We are streamlining the electronic health record. We are trying to figure out if we need new roles in the organization such as scribes and other people to make the job easier for clinicians.

We are trying to raise awareness about burnout. We are educating people, addressing needs, addressing stressors, and trying to approach the problem on all fronts.

HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?

Merrens: The clinical challenges are meeting the needs of the region, including an increasing number of patients seeking our care. We are building a new inpatient tower that will have 64 new beds and we can ramp up to 100 beds. Remarkably, at a time when other hospitals are contracting, we are building more inpatient beds.

We have a critical shortage of staffing—mainly at the nursing level but it includes radiology techs and every area of staffing. It is partly a function of the labor market—New Hampshire has one of the lowest unemployment levels in the United States. We have a unique environment to recruit people. The critical shortage of staffing is a clinical challenge. It impacts meeting patients' expectations of how they want to receive care.

The staffing crisis is not just us. One of the big problems for our 400-bed hospital is that we are struggling with finding places to discharge patients because the skilled nursing facilities and rehab facilities do not have staff, and they have limited the number of patients that they can take. So, we have got several bottlenecks in the system that make our work challenging. These bottlenecks have led us to have long-stay patients in the hospital.

HL: How is the organization addressing workforce shortages?

Merrens: We have several programs, including programs that reach out to high schools—apprenticeship programs and training programs. We are focused on the core members of the care teams who make things happen. We have had a medical assistant program for many years.

We train people to become phlebotomists because someday they will be  licensed nursing assistants, then registered nurses, then nurse practitioners. We want people to focus on the stepwise growth in healthcare and what the starting point might be.

We have a health workforce readiness institute that reaches out and provides opportunities for people to be hired as employees while they are training. We have a dedicated relationship with the Colby-Sawyer College School of Nursing—they are our nursing school, and we hire as many graduates from there as we can.

Our focus has been to grow our own employees. We increased our minimum wage to $17 an hour in 2021. We may have to continue to adjust that wage. We have increased compensation for several roles, including nursing, medical assistants, LNAs, and techs.

We also have been innovative from a government standpoint. We were part of 17 organizations nationwide to receive a grant for rural healthcare workforce development. It was a $40 million grant, and we were awarded $2.5 million.

HL: What patient safety initiatives have been launched at Dartmouth Health?

Merrens: We have focused on the hospital-based and clinic-based measures that are important. We have looked at the infections that you have to be conscious of. We have reduced catheter-associated infections, central-line-associated infections, and communicable infections such as Clostridium difficile by 45% to 70% by paying attention to tracking infections and dedicating a quality team.

For example, with central-line infections, we started focusing on that area in 2019 and kept the work going through the pandemic. When we measured where we were in 2021, we had a 66% reduction in our central-line infections.

From 2018 to 2022, our urinary-catheter infection reduction was 60%.

From 2017 to 2022, we have had a 45% reduction in Clostridium difficile.

We also have an in-house team that looks at adverse events and does the root cause analysis. They look at adverse events and do the tracing to understand how those events happen.

We have an inpatient team focusing on patients who have high glucose levels and making sure that our best-practice alerts for managing sepsis are followed.

We also have thought about the safety impact on our caregivers. From 2021 to 2022, we have had a 37% reduction in blood-borne pathogen exposure such as needle sticks and exposure to blood products that happen in the emergency room and the operating rooms.

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