CMO Message: June 2023

June 12, 2023

Our third edition of Medial Staff News is here! With four months on the job, communication continues to be a high priority for me. I am here to listen and receive feedback. If you have suggestions for future content in the newsletter, email And always feel free to reach out to me directly at:

This month’s Chief Medical Officer message includes information on three very important topics:

1) Communication and Feedback:

I have met with Medical Directors twice, the first Thursday of the month in May and June (thank you)! We have had some fantastic discussions and I appreciate being made aware of areas of opportunity. Important upcoming dates include:

  • Combined Annual Medical Staff Meeting – Tuesday, Sept. 19
  • Circleback program E3 – Oct. 3, 2023 –Physician informatics teams onsite to work with providers to help with inefficiencies in Epic and observe real time any struggles in the system (St. Peter confirmed, possibly also at PCH). Great opportunity for at the elbow 1:1 training all day, will send out tentative timelines/sign-ups closer to October.

2) What to watch: Length of Stay (LOS). Geometric Mean Length of Stay Observed to Expected (GMLOS O:E) for May increased  (St. Peter from 1.46 to 1.62 while PCH decreased to 1.18) and observed Average Length of Stay (Obs ALOS) decreased at both ministries for acute admissions, St. Peter to 6.68 and 4.45 in Centralia (goal of 4.0). Ongoing work with LOS is aligned across multiple areas:

a) Increase efficiency of Multidisciplinary Discharge (Progression to Discharge) Rounds – now meeting in person daily from 1:30-2PM

b) Enhance long length of stay collaboration (patients with LOS>10d/complex care rounds)

c) Improve Echo prioritization workflow

d) Maximize appropriate use of Hospice/Palliative Care and General Inpatient care (GIP)

e) Why not home? Analysis of therapy recommendations and shifting to a culture where discharge home is the default for most patients (actively asking why not home for my patient?)

f) Early Progressive Mobility (EPM): early mobilization and patient participation in mobility goals

g) Improving post-acute follow-up access and options (PMJCC, enhanced transition care, etc.)

3) Quality Matters: Evaluation of patients at risk for suicide. We remain in the window for TJC. National Patient Safety Goal (NPSG) 15.01.01 states that a hospital must identify safety risk inherent in its patient population and EP3 requires suicide assessments for all patients who have screened positive for suicidal ideation. The screening tool used in South Puget Sound is the Columbia Suicide Severity Rating Scale (C-SSRS), found under flowsheets (there is no order). All patients who have screened positive using this tool must have an assessment completed by an individual trained in assessing this patient population such as a Behavioral Health Counselor, Licensed Mental Health Practitioner, Psychiatrist, or Providers trained in assessing suicidal patients. Training is available for those with access to HealthStream at PROV: Care of Patients at Risk for Suicide-Direct Caregivers, we are working on an option for those without access to HealthStream.

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