THE REAL TIME HEALTHCARE PODCAST · Jan 21 · 20:49 min

#25 - Jim Scheulen, CAO, Johns Hopkins Capacity Command Center

In this Episode:

On this podcast, Jeff is joined by Jim Scheulen, Chief Administrative Officer of Capacity Management and Emergency Medicine at Johns Hopkins Medicine. As one of the principal architects of their Command Center, Jim discusses what they’ve learned, the impact of the investment, its role during the pandemic and much more.

Jeff Terry:

Hello and welcome. I'm Jeff Terry. Very happy to be joined today by Jim Scheulen who's the Chief Administrative Officer of Capacity Management and Emergency Medicine at Johns Hopkins Medicine. Among his duties is the Leader and one of the Principle Architects of the Judy Reitz Command Center at Johns Hopkins. It's our honor to have served him and his team now for many years. Jim, good morning. Welcome.

James (Jim) J Scheulen:

Jeff, hi. It's good to see you always.

Jeff Terry:

Yes, sir. Thank you. This month, January 2021, is the five-year anniversary of what we see behind you, which looks great, by the way. So I thought a great time to reflect with you on all that we've learned. Maybe a first question, I know it's near and dear to your heart, is what has been the cultural impact of the Command Center at Johns Hopkins?

James (Jim) J Scheulen:

Yeah, Jeff. Thanks for the opportunity to talk with you. This is a pretty special place, and I can't believe that we've actually been up and operating now for five years and worked with your team for close to two years before that in planning for this major change in what we have done.

Look, thinking back on it, what we were really trying to do is manage this big healthcare institution differently than it had been managed in the past. And I've since come to understand that what we were really trying to do is bring this concept of system engineering into healthcare, a way of managing that other industries have used, that I don't think we used very well here in our healthcare world. And I think we've been very successful in that and I think that's a cultural change that has happened. 

This Command Center has become the center of gravity for operations for the Johns Hopkins Hospital. So every day decisions about how we flow patients, where they go, the procedure and operating suites, all of the information that we need to manage this place on a daily basis flows through the Command Center.  

I think the planning and preparation that we did before opening the Command Center deeply impacted that. Because of that planning, we were able to hit the ground running, score some early successes, and that developed a level of confidence and trust in the leadership of the organization and in the operational teams in the departments, so that it snowballed from there and we were able to be successful.

Jeff Terry:

And do you think it's fair to say, just to use a term, breaking down silos a bit and getting more of that system-wide thinking to be common and embraced, that it was-

James (Jim) J Scheulen:

Yeah, that was a huge piece of it. Most academic medical centers are comfortable in their silos and we still have .... We didn't tear down every wall. There's value in having specialized departments and the specialization. But I think everybody was willing to hear about the possibility that really coming together in a different way had its benefits for everybody.

Jeff Terry:

Absolutely. And, of course, a big part of that on an ongoing basis is the day-to-day, and week-to-week and monthly governance or that the committees and things that connect people to the Command Center and the system dynamics and that thinking. So please, how does the governance work at the Command Center?

James (Jim) J Scheulen:

Yeah, Jeff, that's a good question. And I think that actually has been, in my mind, one of the most important changes that we've seen. We've actually been able to create a function in the hospital called the Office of Capacity Management. So the Command Center, this wonderful tool that we have behind me. is a part of the Office of Capacity Management.

That office brings together all of the people who lead the Command Center, the groups in the Command Center, physicians from around the institution, other administrators from around the institution, data analysts, statisticians, and modelers are all part of the Office of Capacity Management reporting up through a formal structure that look at our operations on a day-to-day basis.

And so every day we have a team of people that wakes up thinking about nothing other than, "How are we going to manage the capacity of the Johns Hopkins Hospital today?" And that's different. That governance structure then reports directly up to the CEO, the Chief Operating Officer and others, where we meet absolutely regularly with them to think strategically, but also to think very practically about next steps on the projects that we're continuing to work on.

Jeff Terry:

Could you give an example of a type of project that might appear on that agenda?

James (Jim) J Scheulen:

Sure. As with many academic institutions, we are interested in trying to match our incoming demand and our outgoing patients. And so continuing to work on improving our discharge process right, is a very ground level thing that we're continuing to do. But here during the pandemic, very, very frequently we're talking about redistributing beds between services, between COVID and non-COVID. "How do we manage, how do we still maximize the surgeries that we can do while still serving the needs of the COVID patients?" And so, that's a constant source of conversation.

Implementation of the new triaged physician role that we may talk about in more detail in a moment, but the status of that, where does that stand, where do we take it next? Those are the kinds of things we talk about.

Jeff Terry:

Perfect. Wonderful. Let's go to impact. So you've published quite a bit about different KPIs that have moved from this program, but five years on, how would you summarize the impact of this investment and this work?

So, right. When we created the Command Center, we certainly had a return on investment that was based upon bringing in appropriate numbers of patients into certain departments. We've certainly hit all of our return on investment targets. We've increased the number of patients that we bring in through our Hopkins Access Line. We've decreased our ED boarding time. We've decreased our overholds.

 So all of those operational metrics have improved and we still drive for further improvement, right? But again, I think that some of the biggest changes that we've seen have been in our daily operations, how the place runs. It's different now than it was before. So, sure. Again, I can always go back to say, "Look, the functional work that we've done is to essentially increase the size of the Johns Hopkins Hospital by 15 or 16 beds, without actually opening 15 or 16 beds, just by virtue of being more efficient with how we use the space."

 That's a number that's important because as anybody who runs a hospital knows, a bed is expensive to operate on an annual basis. And so the fact that we were able to squeeze that much more efficiency out of the existing space is important. But I think it's also important that we now routinely have discussions with clinical leaders about the operation of the department.

So every Friday morning we have a meeting of the perioperative group that looks forward into next week and makes changes to the plan as necessary so that we are efficient next week. We meet with the Department of Medicine every week, and we look forward to the number of patients that we expect in and out to see if we can plan better for how we operate.

 And so we're trying to be much less reactive and a bit more proactive. And, and honestly, Jeff, I think that kind of thing makes enormous differences and has had a huge impact on our operations.

 Hmm. Thank you. That's brilliant. You've alluded to this a little bit. The triage physician is one example, but five years on it's been constant iteration and improvement. So, yeah. Share a bit about that evolution and recent evolution in particular.

James (Jim) J Scheulen:

Yeah, we're very deep into thinking this has been a great five years, but what's the next five years? And so, our vision for the Command Center has always been that it would ultimately serve not just the Johns Hopkins Hospital, but the system. And we've begun doing that. Irrespective of the pandemic, which really has exploded what we do at the system level, right, but even before the pandemic, we were routinely moving people through our system differently than we ever had before.

So still, our vision is to continue to increase what we do at the system level. We believe that there's work to be done in monitoring clinical performance, quality and safety indicators or real clinical data. We think there's an opportunity for that. We certainly think there's opportunity for asset tracking, where are the wheelchairs? Where are the monitors? Where's the ... You name it.

We know that there's further operational improvement that we can make. One of the things that we really wanted to do though, was to maximize the use of our ICU beds. And so our former model really was that there was disparate management. So each ICU had their own way of managing their beds. What we are in the process of doing now is rolling out a more centralized way to manage ICU beds. 

And again, we're trying to be careful and respectful, and so we're not trying to just strip away all authority from anybody who's had that authority for all of Hopkins history, but we're trying to make sense of making sure that we absolutely maximize the use of that precious resource. Right?

If you think about what is system engineering at its core, it's absolutely you understand that you have a set of fixed resources that you want to maximize utilization. And so hospital beds, well, that's a fixed resource. ICU beds are an even more finite resource that need to be managed carefully.

Jeff Terry:

Absolutely, and under pressure during COVID, obviously-

James (Jim) J Scheulen:

It's in.

Jeff Terry:

You mentioned this a little bit, that the role that the Command Center's played in COVID could you say more about that? What has been the role in supporting COVID?

James (Jim) J Scheulen:

Yeah. It's a little bit funny, actually, that as the pandemic began to roll out, now close to a year ago, the emergency managers who were getting really ramped up and getting really ready to manage this well, it's a disaster, right? It's a mass casualty incident. And they were very, very, very worried that we didn't seem to have a plan for how we were going to manage this.

And I tried to tell them, and what's played out over the course of the last year, is we didn't need a special plan. We just needed to do what we do. Because what we do is match patients with available resources and part of that, obviously, is knowing where your available resources are, being able to access those resources, having all the people sitting together with all the information they need, right, to make those decisions.

I'm pointing over my shoulders because that's what happens back there. And so I think people were amazed, actually, that we didn't need a disaster plan. We just needed to do what we did and we needed to do it well.

Jeff Terry:

Yeah, which is the ultimate compliment to the program, is the systems are in place, people, process, technology, you hit it with a massive stress and you keep operating.

James (Jim) J Scheulen:

Right. So I think that told me that all of that pre-planning, all of that work that we had done to think about what we wanted to accomplish with this Command Center, I think we did a pretty good job, Jeff.

Jeff Terry:

I think we did too. And part of that, I remember immediately before COVID, unknown to us, we upgraded one of the tiles behind you, Capacity Snapshot, which came in handy because we had to keep up with the changes to the bed base that you were doing. And that made it easier for us to be nimble with that.

So let's talk a little bit about the tiles and, for our audience, you can see a couple over Jim's right shoulder in the background and over his left shoulder too. But five years in, what are some of your favorite tiles?

James (Jim) J Scheulen:

Ha. That's unfair. That's like asking me which is my favorite kid. Well, I'll tell ya. So, for those of you who don't know, and haven't been here, our tiles really do fall into three categories, right? There's a whole category of situation awareness tiles. There's a whole category of what we call action tiles, something comes up, somebody reacts, and then there's a series of predictive tiles.

Well, I have favorites in each category. Look, the ED tile, quite frankly, makes it very simple. In a second you get a picture of what the emergency department is doing. And so, and that's a favorite situation awareness tile, even more than the Capacity Snapshot.

But I'll tell you, I do lean towards the predictive tiles. I have to say that we have a tile called The Inbound Patient Transport tile, and that's a tile that now looks out three days. And in a few days, actually, your team has restructured it so that it will look out a week.

And again, I am really driving us to be proactive. I am really trying to make us think about what's coming up so that we can think ahead, rather than scramble to catch up. And I think that's going to be my ultimate favorite tile.

Jeff Terry:

Absolutely. Which makes total sense as we think that, "Of course, that's in your role as you're steering the ship into the future." So that makes complete sense, that visibility that it gives you and you've kept us on our toes to make that better and better over time.

James (Jim) J Scheulen:

Sorry about that, Jeff. I'll stop.

Jeff Terry:

No way. So simulation. So the space behind you is a part of the program. The tiles are a part of the program, obviously the great people and processes are part, but the other thing is the simulation model, which is actually a year older than the Command Center itself. It's now six-years-old. Could you share a little bit about how that supported the system dynamics thinking?

James (Jim) J Scheulen:

Well, Jeff, quite honestly, even before we thought about having a Command Center of this sophistication, one of the drivers was I had been convinced that using simulation models in making decisions was critical. And so it was the development of the simulation model that I felt was incredibly important to everything else that we were going to do.

We have typically used the simulation model at least twice a year, certainly once a year to make financial decisions. What does our patient population look like next year? Can we handle that patient population? That's critical. And I can't tell you the number of times that we've asked what-if questions. What if we do this project and it results in reduced length of stay? What will the benefit be? What if we add beds? What if we subtract beds? What are we likely to see?

And so being able to run those what-if questions through a simulation model and not have to go through endless pilot programs of, "Let's try this and see what happens," has been incredibly, incredibly valuable. So, any number of times, any number of ways that the simulation model has been [inaudible 00:16:33] to us.

But more to the point, I'm sorry to keep rambling on, more of the point. Again, it goes back to my initial comments about system engineering, Jeff. In my mind, again, there's a number of components to this way to manage. The first is co-locate all of the people who need to be together to make a place run.

The second is, give them all the information they need to make the place run. The third is, give them authority to make decisions. And the fourth is, use data, sophisticated analytics and simulation modeling in order to make decisions. And so that's where the simulation model fits into the master plan of using system engineering as an approach.

Jeff Terry:

When you say ... I sometimes think of it as the simulation model has designed the system to be efficient and then the Command Center and the tools are run it minute-to-minute

James (Jim) J Scheulen:

That's correct. That's right.

Jeff Terry:

Brilliant. So last question, Jim, and thank you again for giving us this much time. Lessons learned. So five years on, obviously a hundred lessons, but what sticks out as big lessons learned from this work?

James (Jim) J Scheulen:

I think there are two. The first one is plan carefully, think carefully about what you're trying to accomplish because that's what you're going to accomplish. And so I'll say that we were incredibly successful. We set goals to reduce boarding, to reduce overholds, and to increase inbound patients through the Hopkins Access Line, and we hit them.

If I was to go back now and think about it again, I'd have the same targets, but I'd also think more about total throughput of the organization. I think about the other end. Right? So a lesson learned. Really think carefully about what you're trying to accomplish because if you do your planning correctly, that's what you'll hit. So think carefully about what you're trying to accomplish. Think long-term.

And then, a little bit more practically, if you're going to have a Command Center co-locating people, then make sure they have information that they can react to and that they can act upon. Action needs to be the word in the Command Center.

Jeff Terry:

Action.

James (Jim) J Scheulen:

Action.

Jeff Terry:

Absolutely. It's so funny that for both of those, but going back six or seven years, I mean, just the idea of creating this thing seemed just mega ambitious, but we did it and achieved the goals. And then to your point, it's almost like, "Be more ambitious even than you thought," which seemed pretty ambitious.

James (Jim) J Scheulen:

We're ambitious but, then again, also then end up, when all was said and done, being very focused. Again, and the focus should be on action. What are we going to do with this information? Act on it.

Jeff Terry:

Absolutely. And of course, as you know well, that we've learned that together. We've really, as we've continued with you and with others, as we introduce the concept to people, say things like, "This whole thing boils down to one word: action," right? It's not interesting information, actionable information which, as you also know, is a surprisingly difficult concept to put into practice because people's ...

Because once you get data and AI, you can produce all kinds of insight, but it's tricky to make sure we're spending our time, energy, money on things that are actionable, not just things that are interesting. It's an endless challenge.

James (Jim) J Scheulen:

Absolutely. Jeff, absolutely. In fact, what you find is once you have access to this kind of information, you can almost drown in information. And that's all well, and good. It's great to have a lot of information, but you really have to figure out what matters-

Jeff Terry:

What matters.

James (Jim) J Scheulen:

... and what's important, and that's what you're you're really [crosstalk 00:20:23]-

Jeff Terry:

And actionability is the first test, at least. Brilliant.

James (Jim) J Scheulen:

That's right, Jeff.

Jeff Terry:

Awesome. Well, Jim, thank you so much. It's been a real honor and pleasure to serve you and Johns Hopkins for seven years. Thank you for giving us some time today and thank you for sharing with our audience and long may our work with you continue.

James (Jim) J Scheulen:

I agree, Jeff, it's been a pleasure. Thank you for having me and hello to everybody out there.

Jeff Terry:

Brilliant.

James (Jim) J Scheulen:

Take care.

Jeff Terry:

Thank you, Jim.

James (Jim) J Scheulen:

Bye now.

Jeff Terry:

With that, we'll close the podcast.
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