Eileen Dohmann

Transcript

Interview 1 – February 9, 2015
01-00:00:06
Rigelhaupt:
It is February 9, 2015. I’m in Fredericksburg, Virginia, at Mary Washington Hospital, doing an oral-history interview with Eileen Dohmann. To begin, I would like to ask you if you could describe your first interaction with Mary Washington Hospital, or MediCorp, at the time.

01-00:00:24
Dohmann:
My very first interaction was when I was a consultant working for a home health agency and durable-medical-equipment company. I had a friend who was doing some consulting here at Mary Washington MediCorp. He asked me to meet with some folks from MediCorp because they wanted to do some work with their home health agency and their hospice program. We had a lunch meeting. I came down with him and then met with Kevin Van Renan and Dianne Tracy to talk about what they wanted to do for home health and hospice.

01-00:01:02
Rigelhaupt:
And what did they describe; that they were seeking to do?

01-00:01:07
Dohmann:
There was an opportunity with home health and hospice, at the time. Both organizations weren’t really performing at a level that MediCorp thought that they should and could. Dianne Tracy, who was the director at the time, was at a point in her career that she was looking to do something different. She was sort of moving towards retirement and wanted to do something that was a little bit less, I think, taxing. She had found another position within the organization that she was interested in. That left Kevin and her to come up with a plan for what they would do for leadership at home health and hospice.

01-00:01:45
Rigelhaupt:
What you described, that there was a sense that home health and hospice were not performing at the level that it could—what were some of the markers that they were using? And what were some of the performance targets—I don’t know if that’s the right word—that they were seeking to—

01-00:02:01
Dohmann:
I think most of the indicators at that time were financial. Really, what was relayed to me was we want to make sure that our home health agency and our hospice are performing well compared with other like businesses and other home health agencies and other hospices. The feeling was that Mary Washington was not. It was pretty early in the game where there were quality indicators from CMS. Even as those early indicators were being rolled out there was some feeling that Mary Washington home health could do better. I think it was the quality indicators as well as the financial performance that really raised some red flags that things could be better at home health and hospice.

01-00:02:50
Rigelhaupt:
What were some of the quality indicators that you were looking at?

01-00:02:53
Dohmann:
It was something that we deal with now, pretty routinely, in the hospitals. [03:00] Back in about 2000 to about 2005 or 2006, CMS is when Medicare and Medicaid rolled out quality indicators for home health. They were things like, when home health was seeing a patient and during the course of care did the patient get better at things, like their ability to bathe by themselves or their ability to ambulate by themselves? Did a patient have unexpected trips to the emergency room? Did they have unplanned readmissions to the hospital? It is kind of interesting because within the following five to eight years, where we now live, CMS looks at the hospital to say, do you have readmissions? Are people coming back to the hospital? It was really the precursor to what the hospitals are dealing with. Is home health really making a difference? Can it help to keep patients out of the hospital? Does it really make a difference when it’s caring for a patient and that the patient actually can demonstrate improvement because of home health being involved?

01-00:04:03
Rigelhaupt:
Did you and your colleagues in home health have conversations about why CMS had begun with some of those quality indicators in home health, rather than with hospitals?

01-00:04:14
Dohmann:
I think CMS’s approach was it had to start to start somewhere. They were also seeing a lot of growth in the money that CMS was paying for home health. About the late-1990s, there had been some concerns in certain parts of the home health industry that there were some less-than-optimal agencies out there. I think it was CMS trying to make sure that, in essence, they were getting what they were paying for—really, for the folks that were at home receiving home health services, that what they were getting was a quality service.

01-00:04:57
Rigelhaupt:
What had you learned during your interview that led you to accept the position as a consultant?

01-00:05:02
Dohmann:
It was a great lunch meeting. The really nice thing, for me, is I actually knew Dianne, who was the administrator at the time. Since I had been involved in home health for the fifteen to twenty years prior, she and I had worked on projects at the state level. I knew who she was. I knew a bit about the agency. Particularly on the hospice side, I was running a hospice program around the same time. Both hospice programs were about equivalent size and we used to bounce ideas off each other. So I knew a little bit about Mary Washington home health and hospice. To really hear that it wasn’t that there was a bad job or there was a difficulty with the current director: it was really that the director wanted to do something different. The organization was very invested in home health and hospice, wanted to do the right thing, and wanted to make sure that it had strong leadership to take it to the next level. [06:00]

01-00:06:02
Rigelhaupt:
As you just indicated, some of the quality indicators that were first part of home health were ahead of the curve, in some respects, for hospital care. Did you learn about why there was such a commitment to investing in home health, from this organization, during that initial interview?

01-00:06:20
Dohmann:
Absolutely, absolutely. What Mary Washington, or MediCorp at the time, identified was that home health and hospice were necessary pieces of the continuum that Mary Washington needed to have for that very reason. What we see today is there was recognition that by using home health well we could keep people out of the hospital. By using the hospice program well we could ensure that people at the end of their life had a level of quality of care. And MediCorp—now Mary Washington Healthcare—is very committed to the community. It’s not at all unusual. You see it in many parts of our history where Mary Washington has created or implemented services that don’t otherwise exist in the community or they do things because they can do them well for the community. I think that’s really what the commitment to home health and hospice was. The health system recognized that they were important and did a very good job of predicting the future. Now, what we see with health care reform is we really look at the continuum of care. Mary Washington was very invested in home health and hospice and wanted them to prosper going forward because they knew that they would be a necessary part of the continuum of care for our community.

01-00:07:40
Rigelhaupt:
Did you hear a conversation about the core values? What you mentioned, in terms of bringing services to the community—was that part of the initial interview?

01-00:07:51
Dohmann:
It was and I asked a lot of questions just to understand about the organization. I had worked in a large health care system before. I wanted to just understand what the culture of this organization was. I definitely got feedback both from Kevin and from Dianne that this organization valued its people and recognized that the people who work here made all the difference in its ability to meet the mission of improving the health of our community. One of the things that was striking to me was that I had never worked for an organization where so many people could tell you what the mission and vision and values of the organization were. I had never encountered that before. You could very quickly—no matter who you talked to—get a real sense that MediCorp really was very much part of the community here in Fredericksburg.

01-00:08:46
Rigelhaupt:
Did you get a sense, in that initial interview, that that had been a long-term part of the culture of the organization, that so many people could talk about the mission and values?

01-00:08:58
Dohmann:
It did. [09:00] What struck me is if you went around to a group of people and had them all memorize something, you can tell when somebody says something because it’s just a memorized, “I’m-supposed-to-say-it-this-way.” But that wasn’t the case. When you would ask people about the mission, it just rolled off people’s tongues. It wasn’t something that was practiced or rehearsed or memorized. People really believed it. They really did believe that we were the primary health care provider in this community. The community depended on us and it was our job to improve the health care of the community. That has always stuck with me as something that is unique and is very much a part of Mary Washington Healthcare.

01-00:09:45
Rigelhaupt:
Did you hear any initial conversations or any discussion of what this organization, as the largest health care provider in the region, could offer in terms of home health and hospice that, perhaps, a smaller program could not offer?

01-00:10:04
Dohmann:
We talked a little bit about that, too. The idea being, since we were the major health care provider in the community and who felt that home health and hospice were important, that would position this organization and their home health agency and their hospice program to be able to meet those community needs. It was obviously true from Kevin, to Dianne, to everyone I encountered during that early time that they really wanted to make sure that the performance of their home health agency and their hospice program measured up to a pretty high level. They kept saying to me, “It’s not just how we’re performing within the organization. We want to be able to say we’ll compare our home health agency to the best home health agency in the country.” We want to be able to say that ours can measure up—that quality was important.

01-00:11:08
Rigelhaupt:
In terms of quality, in terms of the program, and the core values and the mission of the larger organization—were they emphasized to you as much in this first few months, because you were a consultant? Do you think that would have been true if you had been hired as an associate in those first few months?

01-00:11:28
Dohmann:
I don’t think it was really any different, whether I was a consultant or being an associate from the very beginning. Remember, I was hired to be, essentially, the executive director for home health and hospice. I was in that leadership role. I got to encounter leaders across the organization and associates across the organization. Again, it felt embedded. It felt like it was part of the organization. And I don’t think it would have felt any different had I been employed from the very beginning. [12:00] It was just who the organization was, and is.

01-00:12:06
Rigelhaupt:
Okay, so I want to come back and talk, in a minute, about what you did after you started, in that first year or so in that position. But I want to ask if you could describe your nursing career before starting at Mary Washington, or MediCorp at the time. You graduated from Fairfield with a B.S.N., and I’ll let you take it from there.

01-00:12:32
Dohmann:
Sure. I grew up in New York and I went to college in Connecticut, at Fairfield and got my bachelors in nursing. I knew I wanted to work in a big-city hospital and I went to New York City and worked at NYU in their medical center. I chose to work on a medical unit because I really enjoy patients that were sick over time—people who had chronic illnesses. I worked on a floor that was cardiac and oncology. I loved them both because I got to know patients and because the patients came back. One of the things that always fascinated me is that I always wondered what happened to people when they went home. Particularly from some of the oncology patients: we would take care of them and they would be in pretty good shape. They would get discharged and then when they would come back to the hospital they would be so much sicker. I just found myself wondering, “Who cares for them when they’re at home? Or how do we keep an eye on them so maybe they wouldn’t get so sick before they came back to the hospital?” I had enjoyed my home health experience when I was in college, but that was always just an interest. I worked at NYU for two years and then got married. I came down to Washington and pursued home health. I worked for a home health agency here for a couple of years. Then we moved to Rhode Island for five years. My husband worked for the Defense Department. I worked up in Rhode Island for five years for a home health agency and moved into a supervisory role. I came back to Washington and stayed in home health. I had a great opportunity: the home health agency that I was working for wanted to start a hospice program. I had done some hospice work through home health. Actually, I worked with one of the first ten demonstration projects for the Medicare hospice benefit. The agency I was working for wanted to start a hospice program. I got that job to do that, which was exciting. We joked it was my graduation gift for when I finished my master’s degree. I got an MBA from Averett University here in Virginia. I did that program—actually I did the feasibility study and opened the hospice program. I ran that for about six years. It was at a time when the home health market was very much changing up in Northern Virginia. The agency that I worked for merged and became part of the Inova Health System. [15:00] But then, shortly after that merger—like two weeks—Inova carved off the hospice piece and allowed the hospice piece to merge with Hospice of Northern Virginia. So my business card changed three times in four weeks. Went from a private agency to be part of Inova, and then to be part of Hospice of Northern Virginia. I was there just for a couple of months and was actually asked to come back to Inova to run the home health agency and I did that for the next several years. Then I left that, and started doing some consulting. I was running a small home health agency and DME [Durable Medical Equipment] company in Leesburg when this opportunity came up. Most of my nursing career has actually been in home health and hospice.

01-00:15:51
Rigelhaupt:
Going back to early in your nursing career, would you be able to talk a little bit about the difference in bedside patient care between a busy, urban-hospital medical unit and working in patient care as a home health nurse?

01-00:16:11
Dohmann:
It’s a very different clinical setting. Probably what I love most about home health and hospice is that you never know what you’re going to walk into. I was always amazed at what patients, families, and loved ones would deal with in their homes and would just take, as well: this is just what we have to do and we just cope. That’s part of what I always loved. You never exactly knew what you were going to fall into. In fact, we used to joke: before we had things like GPS in cell phones you would get directions to a house, you would get an address, you would look it up in the map book and you would hope that the map was right and you would get there. I used to always say, “All I really need is the address, the phone number, and just tell me if they’re going to have a big dog that’s going to eat me when I walk in the front door.” The rest you sort of figure out when you get there and I loved that. I also liked being able to say if you made a difference with a patient, you would know that it was you making the difference. One of the different things in a hospital is there are nurses twenty-four/seven. If a patient has a good outcome, it’s really everybody that had a hand in that. Whereas in home health, you’re the only nurse that’s likely seen that patient. There may be a physical therapist or a home health aide, but it’s really a very small group. You really do get to see the fruits of your labor, and I always liked that. The day is very different in home health. A nurse here at the hospital may have four, five, or six patients—very intense and often very sick patients. At home, these are patients that were well enough to leave a hospital. They may still be sick. They may have a chronic illness. But now, you’re in somebody’s home. You are really, trying to understand, what is it about how they’re living that might be contributing to their illness or making things worse? [18:00] What could you do that might help to make things better? I think that one of the other things I enjoyed most is, you really get to know your patient, and to really understand the whole patient and what’s happening with them. It’s a very different clinical setting. You still use all of your nursing skills and all of your nursing education, but it’s not easy to turn around and say to the nurse in the next room, “Hey, can I ask your opinion about something?” You are it and you have to learn how to make good decisions, have sound judgment, and communicate with physicians over the phone. I worked up in Northern Virginia for twelve or fifteen years in home health and talked to many physicians many times on the phone. I couldn’t tell you if I bumped into them on the street or what they look like. But if they spoke, I’d recognize their voice because I was used to talking to them on the phone. It’s very different.

01-00:19:02
Rigelhaupt:
What were some of the clinical skills that you were most proud of having got good at and developed as you were working in the hospital?

01-00:19:11
Dohmann:
I think your assessment skills—being able to assess a patient and put the pieces together about what the results of that assessment really are telling you. And then to be able to have that critical thinking to put the package together and figure out if there was something that I could do in caring for the patient. Or did I need to talk to a physician to get some specific orders for the patient’s care? I think it’s your assessment skills and then your critical-thinking skills. You certainly learn those quickly in the hospital because that’s what your patients need from you.

01-00:19:50
Rigelhaupt:
What were some of the clinical skills you’re most proud of developing and being really effective with, in home health, over those first few years?

01-00:19:59
Dohmann:
Same things: your assessment skills and your critical thinking. The difference in home health is also the situational awareness. Now, you’re not in a controlled environment. For a patient that’s in the hospital, they eat when we tell them. They get their medications when we give them to them. They have a treatment when we do it. Whereas in home health, you’re a guest in the patient’s home. So if I was going to be able to be effective with the patient, I first had to make sure that I had a relationship with the patient, that they would allow me in their home, and allow me to intervene. I think it took all of my hospital skills and then I had to even ramp them up a little bit more by adding that situational awareness, which was pretty critical.

01-00:20:44
Rigelhaupt:
You mentioned contributing factors, in terms of health and improving outcomes for people who were, then, being treated in a home health setting. What were some of the contributing factors you noticed, contributing to outcomes, early in your career?

01-00:20:59
Dohmann:
Some things that you might expect. [21:00] Most of the patients that you see in home health are elderly. They’re over the age of sixty-five. Certainly, what I saw and have seen over the years is patients are living longer. They’re living longer with a chronic illness. Some of the challenges may be as simple, but as devastating, as not having enough money to pay for very expensive medications and their heating bill and their food. There were financial concerns and patients will make a decision. They’ll make a tradeoff that may not be the best decision for whatever their health status is, but there’s only so much money to go around. Another is the environmental. I’ve had a number of patients where they’ve given up their own home and now they’re living with an adult child. The patient may not smoke, but people in the house are smoking. That secondhand smoke is as devastating to somebody that has respiratory illness as if they were smoking the cigarette themselves. Those are the kinds of things. You become much more acutely aware of the patient’s environment. Stress in the household: patients living in a home with adult children and grandchildren and all the craziness that goes on in a home—and now you’ve got grandma or grandpa living there. That adds stress and that could certainly exacerbate somebody’s chronic condition.

01-00:22:31
Rigelhaupt:
What were some of the things you learned to do, to help treat those contributing factors, that are not traditional patient-care medical parts of improving health?

01-00:22:45
Dohmann:
Things like the financial resources. Usually, within a home health agency, you have a social worker. You get really good at community resources, things like the patient’s church. Are there other supports that can be accessed to help when there are financial concerns? When the stressors or tensions that were things actually in the household? Sometimes the home health nurse ends up being sort of the mediator between the two parties and to bring people together. I can remember conversations with adult children to share with them things that were happening that were causing stress or distress for the home health patient. And the adult children had no idea. Just bringing it to somebody’s attention would, oftentimes, cause a change to happen. The other is working with the patient and making sure that they understand what impact these stressors have on them. To help them with their own self-motivation and self-accountability: you’re putting yourself in a situation that’s placing additional stress on you and that’s going to cause an exacerbation of your illness. Can you think about doing something different about this? [24:00] There were multiple resources or approaches you would take, depending on what the challenge was.

01-00:24:13
Rigelhaupt:
You spent a very short amount of time with Inova?

01-00:24:16
Dohmann:
I was with Inova for almost four years.

01-00:24:19
Rigelhaupt:
Okay. So how would you compare what you learned there, and their relationship, as another, larger health care organization in home health? What did you learn about how home health fits within a health care system?

01-00:24:33
Dohmann:
I would say what Inova shares with MediCorp, and with Mary Washington, is Inova also valued home health and saw it as a necessary piece of the continuum. I think they have that in common. I think the difference, for me, and what has made me stay here at Mary Washington for the last eleven years has been the value of the people. I think that’s very different. Here, it definitely feels like, even as a large organization, there’s still a smallness about it. There’s still a sense of community. I think that’s a huge differentiator for Mary Washington.

01-00:25:14
Rigelhaupt:
In thinking about, maybe, those first few months—I don’t have a specific time period in mind, but just early, when you started here—what did you see as the strengths of the home health and hospice program?

01-00:25:30
Dohmann:
There were many strengths of home health and hospice. What was an eye-opener for me, but also for them, is that they existed in their own world and weren’t very well integrated with the rest of the organization. As we were tackling the financial challenges I engaged all of the leadership at home health and hospice. What struck me is how little they understood about financial management and the financial workings of the organization. They were very well-meaning, very well-intentioned, and wanted to do a good job. Really, it was that they didn’t have all the information. One of the things we did is implement a group that still exists now. It’s called the End of Month Group. At the end of every month, just like you do in every organization, you are wanting to make sure that you have gotten credit for all of your revenue and you have got all your expenses. Everything that belongs to that month gets reported in that month. I was running the organization and I knew how things were going, but I would get a phone call from Kevin and he would say something about the financial performance. What he was saying didn’t match what I was seeing in the organization. I thought, “Well, something’s not right.” We started picking it apart and learned simple things, like down at home health there was someone whose job it was to approve invoices to pay bills. All that person knew was how to put codes on the bills and didn’t really understand what happened to it. [27:00] Now, you code it so that then we can write a check to pay somebody for the services they provided. The person didn’t understand that. Instead of processing an invoice the day that she received it, she would wait until she had a big stack. If it happened to be the end of the month—say, for example, now, because we’re getting to the end of January—she didn’t look for all of the outstanding invoices for January so she could process them and could be done in time. She would just wait until she got a big enough stack and do a whole bunch. We explained to her that it was really important that any expenses that belong to a certain month should be processed in that month and finished before the end of the month—that’s a much better way of running the business. She was happy to do it that way. No one had ever told her that. Those were the examples. Many, many, many of them were people understood the task in front of them, but they did not understand how it fit into the larger organization of home health or hospice. And they certainly didn’t understand how it fit into the larger organization of MediCorp. We brought people together and we mapped out processes. Once people saw where they fit in a process and why what they did was so important to the next person who was involved in the process, they were totally engaged. It was very easy to correct things. I was amazed at how they didn’t even know other people within the organization who were doing similar things to them or who was the person that was going to get the product of their labor. They had no idea what happened. Really, just doing education and then telling people: “This is what the expectation is and we’re going to hold you to that expectation. This is your job.” People were fine. They were like, “I never knew that. But, now that I know that—oh, my gosh—I must have been making this person’s life so much more difficult and I never intended that. I can change what I do now. This makes much more sense to me.” That’s really how I spent the first several months at home health and hospice: creating processes or doing a better job of defining processes and educating people so they understood how they fit into a larger process and into the larger picture. We were very successful. Within a year, had a huge and significant turnaround on the quality side as well as on the financial side.

01-00:29:35
Rigelhaupt:
Part of what I’m hearing is that the first few months, first year, you discovered there was a strong foundation that could be improved through efficiency—

01-00:29:44
Dohmann:
Absolutely.

00:29:46
Rigelhaupt:
—and through processes and better organization. What did you identify as some of the clinical strengths, or the strengths of the bedside care the home health nurses and other clinicians were providing?

01-00:29:59
Dohmann:
There were, and there still are, great clinicians in home health. [30:00] That’s one of the things I always loved: being able to go out with them and do visits with them. I did that a lot in the beginning and throughout my whole time there. They were providing great care. They knew their patients well. They had very strong critical-thinking skills—the situational awareness about what they would encounter in the home and how they would intervene most effectively. They were great. The piece that was missing was how did what they do integrate with the rest of the health system? We started talking about patients that had had an unexpected visit to an emergency room and we dove into that to say, “Well, why is that happening?” If home health is involved, maybe the patient could call the home health nurse to explain what was going on. Maybe we could avoid some of these emergency-room visits if the patients understood that they could rely on their nurse. I was a nurse who was in a patient’s home. The patient was encountering difficulty. I called a physician to say, “Here’s what is happening right now with Mrs. Jones. Here’s some suggestions of what I could do.” I could do something there because I was in the home at the moment. The idea of saying to Mrs. Jones, “Well, I’m going to send you to the emergency room.” That was a huge disconnect for me. Now they’re going to get in a car, drive, wait in the emergency room, and be seen in the emergency room. Several hours are going to go by and I’m right here. If you want a lab sample drawn, I can do that. If you want medication given, as long as the patient has it, I can do that. That’s what I encountered in home health and that’s definitely what I saw at Mary Washington Home Health. The clinicians were astute. They knew what they were capable of. Then it was just taking that to the next level. When a physician says send the patient to the emergency room, offer them an alternative. Offer them a suggestion about what you could do while you’re in the home with the patient.

01-00:32:10
Rigelhaupt:
How would you characterize the working relationship with physicians at home health and hospice when you arrived here?

01-00:32:18
Dohmann:
The working relationship was a good one. And it’s always true: there are physicians who use home health a lot. There were very definitely those strong relationships. On the hospice side, we had an interesting challenge in that there was a very positive view from physicians that valued the hospice program. Remember, at the time, they were the only hospice program. Physicians recognized what Mary Washington hospice offered because they couldn’t get it anywhere else. The challenge we actually had in hospice is that at the hospital Mary Washington Hospice wasn’t always as highly regarded by the other Mary Washington associates. [33:00] Part of that was because they were the only hospice in town. There was a little bit of an issue that we had to work through. It was the Mary Washington Hospice way or no way. We had to work through that to say, “What does it say when other people within your own organization would rather not use you?” We tackled that pretty much head on, as well. We got both groups to sit down and encouraged the hospice folks to really hear what are your customers—the other parts of the organization—telling you are challenges in dealing with you? How can we do a better job to address those challenges? That was really a challenge we faced. The physician part was very positive.

01-00:33:50
Rigelhaupt:
What were some of the signs that you received that said hospice was becoming more welcome, in the hospital setting and with other associates?

01-00:34:00
Dohmann:
Direct feedback from the very same people that had said, in the beginning, if we had an alternative we would use it. Circling back with them regularly, whether it was the nurse manager on the palliative unit or whether it was the case managers. Going back to the very people who were the people that were using hospice the most and asking them for feedback. The other is that when hospice would get invited to participate in things at the hospital, those were also signs that the relationship between the two had markedly improved.

01-00:34:35
Rigelhaupt:
In general, is it harder to provide hospice care in the hospital than home? Is it more common? I figure this time period that hospice would be more of a home-based treatment?

01-00:34:51
Dohmann:
No. I think, truly, what was going on at that time is that Mary Washington Hospice was the only hospice program. There were some practices that they had in place that did make things more difficult for the hospital when they wanted to refer a patient. For example, it’s very common for hospitals to discharge patients on Friday. Patients want to go home for the weekend. If home health and hospice are going to be the next provider of care, that means they’re going to have more admissions—new patients to see—on Friday, Saturday, and Sunday. At the time, Mary Washington hospice didn’t like that because more people had to work on the weekend. They would try to sort of defer and wait until Monday. When we sat down again and said, “Now, you’re here to provide a service. Your patient is coming home on a Friday. It’s really not a good idea for them to wait until Monday to be seen by the hospice nurse. If the issue is we don’t have enough staff working on the weekend, then let’s get that fixed.” That’s something that is just a fact. [36:00] We’re not going to change it. People want to be home and we want to be there when they’re home. We might have to make a change to some of our processes and some of our scheduling so we can see patients when they most need us.

01-00:36:15
Rigelhaupt:
What was your overall impression of nursing at Mary Washington Hospital, at the time you started? I know it’s a big question. Even if you wanted to speak to a couple of units that, perhaps, you worked with most closely?

01-00:36:30
Dohmann:
Sure. I think one of the things that’s very particular to Mary Washington’s nurses is we have many nurses where this is the only place they have ever worked. Now, that’s bittersweet. The sweet part of that is that they’ve been here a long time and that this is the only place they’ve ever worked. There’s great history. There’s great connection to the organization because people come here and stay here. The bitter part of that is that this is the only place they’ve ever worked. When there are new ideas that come along, sometimes there would be resistance, as well—that’s not the way we do it here. I have to say, over the eleven years that I’ve been here that has changed quite a bit. We still have people that spend their whole career here, but I think there’s much more of a willingness and an openness to try new things. I think there’s also much greater acceptance of people who come into the organization that haven’t been here their whole career. There’s more of a curiosity about, “Well, how did you do this someplace place?” There’s a willingness to listen to that and then to see how we can improve what we do here at Mary Washington.

01-00:37:43
Rigelhaupt:
What are some of the factors you would point to that have contributed to more openness to doing things differently—openness to change within clinical practices?

01-00:37:56
Dohmann:
I think the profession has changed. I think there are technology changes. There are all sorts of advancements. There are procedures that we’re doing today that we didn’t do two or three years ago. There are procedures that we did two or three years ago that we’re not doing today. The science has changed. The other part is that I think there’s an innate trait with nurses: you want to do the right thing for your patient. You want to do the best thing for your patient. If you see somebody else doing something differently and getting better results, I think there is that natural tendency to say, “How did you do that? Why did you do it that way?” I think we’ve done a good job in these ten or eleven years, to try to empower nurses to own their practice and to be open to learning how they can do better.

01-00:38:53
Rigelhaupt:
So, about five years after you started, Mary Washington Hospital achieved Magnet status. [39:00] Could you talk about your involvement? Were you involved?

01-00:39:09
Dohmann:
Sure.

01-00:39:11
Rigelhaupt:
You were already vice president of nursing, so maybe I’m jumping ahead, by the time you had started that. So let me stay in those couple of years, before you became vice president of nursing, in 2006. Did you see parts of the Magnet journey already being in place, even if it was not as official as it became, as it approached 2009?

01-00:39:33
Rigelhaupt:
Probably not so much since all of my effort was focused at home health and hospice. For the first two years that’s really where all my attention was. Towards the, probably, latter part of the second year, I took on some responsibilities here at the hospital, and then, started to get more of an idea of what Magnet was, or what that journey was. But that really didn’t take hold until I came into the job as VP of nursing.

01-00:40:10
Rigelhaupt:
So some of the evidence-based practices, the shared governance, that were part of that—was that starting to be built up within the home health unit as you were working on it?

01-00:40:19
Dohmann:
No. Really, shared governance, for example, wasn’t a part of home health and hospice when I was there. It wasn’t until I got to the hospital and got to understand what that structure was like here that, then, we were able to reach out to home health and hospice and include them.

01-00:40:40
Rigelhaupt:
What would you describe as the most exciting part of the first few months, maybe up to the first year?

01-00:40:47
Dohmann:
The turnaround. The turnaround was huge. When I first started, and part of what I learned during the interview process is, I really believed that the right people were there. I didn’t believe it was a people issue. I just thought, “Well, if we just can show them what they need to do. If people embraced that there should be nothing that stops them.” That’s exactly what happened. People were so willing to learn more and to get involved: it was like once we took off, things moved very quickly. I really felt like I was the conductor leading the orchestra. As long as I gave people the sheet of music to follow they would run with it. I saw the rapid change, people get excited that what they were doing was paying off, and that things were getting better from a performance perspective. They could see. They could feel it. There’s an award here at Mary Washington called the President’s Award. That’s for significant performance improvement. It relates to the five pillars of quality, service, community, financial, and partners. [42:00] Home Health and Hospice won that award the year after I came. They had never even applied for an award before and they won the award. That was extremely gratifying: just to watch the enthusiasm. When the award ceremony happened, the room was filled with Home Health and Hospice folks. When it was announced, the roar in the room was those very same people who, a year before, weren’t sure that the organization would keep them. Would they stay in the home health-and hospice business? Now, to be, sort of, the jewel in the crown—that just created a tremendous sense of pride and accomplishment for them. That was very exciting to be part of.

01-00:42:49
Rigelhaupt:
You described educating people in home health and hospice about processes and organization, and improving those. People in the unit were very open to it, and it paid off with something. Got the award very quickly. What were some of the things that you learned about the people in Home Health and Hospice, that you were taking back and telling the administration, and people like Mr. Van Renan, and the hospital administrators, that you learned? And you were educating the administration about what was happening in home health and hospice?

01-00:43:23
Dohmann:
It was really important to me that Kevin and Mr. Rankin understood that the right people were in place, but that they didn’t have the processes or the infrastructure to support a lot of what they needed to do. I didn’t want there to be that sort of misjudgment that we have the wrong people in place. That wasn’t the case, at all. We needed to give the people that were in place the tools that they needed so they can run the business. That’s what I would be bringing back to Kevin: we created this process and this is what it has gotten us. We didn’t have a process for this and now we do. The other part was the accountability and really trying to build this sense of, if you say you’re going to do something, then you’re going to do it. If you can’t do it, then you have to own that, too, and speak up and say, “I said I was going to do this by this date and I’m not able to do that. But here’s my alternative.” To get people to have that sense of accountability, we even got buttons made. They were green buttons that said, “Ask me what I’m accountable for.” The Home Health and Hospice people would love when someone would say, “Well, what are you accountable for?” They would tell you what they owned, as far as the part of the organization, and how they did that follow-through, and how they really owned their part of the business.

01-00:44:49
Rigelhaupt:
You described processes and investment—often involves resources. Did the organization make investments in home health and hospice in that first year you were here? [45:00]

01-00:45:05
Dohmann:
They did. First of all, they had a consultant. They gave me latitude to do what I needed to do. They also gave us the resource of time. Not a lot of time, but they really wanted a good assessment of what was going on and gave us the opportunity to do that. The other thing is that MediCorp had already invested pretty significantly in home health and hospice when I came. All of the nurses in home health and hospice and the therapists documented on laptops. I had never worked for a home health agency where the nurses and therapists documented on laptops. Very early on, MediCorp had adopted this focus on technology. If we put technology in the hands of caregivers, will that make them be more efficient? They gave them those tools, but what we had to work on was, “Okay, so now if you have this tool. How does this tool make you be more efficient?” We were working through and building that sort of supporting infrastructure.

01-00:46:15
Rigelhaupt:
Could you describe who you worked with in senior administration, and what that working relationship was like that first year?

01-00:46:21
Dohmann:
Sure. I worked really closely with Kevin Van Renan. He and I would meet, initially, each week. Then, that became, sort of, twice a month and got to be monthly. I worked a little bit with Barbara Kane, at the time, particularly when I came to the hospital and took on care management because that reported to Barbara. I got to work with her. One of the things I joked about early on was going through the email system: it was like channel surfing. If I needed something, I could just look up someone and pick up the phone and say, “You don’t know me, but I’m Eileen Dohmann, and I’m running home health and hospice. I have a regulatory question. Can you help me?” It just seemed like no matter whom I picked up the phone and reached out to, the answer at the other end of the phone was always, “Sure, what do you need? What can I help you with?” Oftentimes, when you’re running a small part of a large organization, particularly one that’s not located at the hospital, you can sort of feel like you’re off in Siberia and nobody knows that you’re there. But that wasn’t the case. People were very willing to help. I had a lot of freedom to reach out to resources across the organization and tap into them to help home health and hospice.

01-00:47:41
Rigelhaupt:
Part of what you describe earlier was that there were financial questions. Certainly one of the things I’ve learned in this project is that there are lots of units within the hospital that don’t necessarily generate revenue above costs. Nothing lines up perfectly. What were some of the financial goals you were trying to achieve in that first year? [48:00]

01-00:48:03
Dohmann:
Within the industry of home health and hospice, you do expect your home health agency and hospice program—their revenue would exceed their expenses. Not hugely. And, actually, in home health, you’re usually pretty happy if you’re at a break-even. Hospice can be a little bit more financially successful, particularly as it received donations from grateful families. The task that I was given was to get home health and hospice to a level of performing comparable to other home health agencies and hospice programs. That’s really what we aimed at. I was also given the ability to roll them both together. And so, to say the bottom line for home health and hospice, we definitely have to break even. If there were an opportunity for our revenue to exceed expenses, that money would be invested back into home health and hospice. The way I would explain it to the home health and hospice associates is, “We weren’t being asked to do anything more than any other private home health agency would do. You have to have enough money to pay your bills. You have to have money left over at the end of the month, if you want to invest in something.” We really weren’t being asked to do anything more than what a private home health agency or hospice program was being asked to do.

01-00:49:34
Rigelhaupt:
Staying in the first year or two, what were some of the things that you and your colleagues in home health would have targeted as choices to invest in, if and when revenue became available?

01-00:49:49
Dohmann:
One thing that we did in that first year was, actually, we moved. When I first arrived, home health was over on Princess Anne, in an office. Hospice was in Fall Hill. We also had a private-duty component and that was in Fall Hill, but in a different suite. Here are three businesses that have overlapping functions and roles, but they’re in three disparate locations. You lose all efficiency. One of the opportunities that we took advantage of that first year is that we moved to a new location, down in Massaponax. It was pretty funny because, at the time, it was before a lot of development down in Massaponax. I remember some of the home health and hospice folks looking at me saying, “You don’t even know where you’re moving us to. We’re going to be in Siberia. There’s nothing down there.” Now, they clamor for another move because the traffic is so bad in Massaponax. We need to move someplace else where the traffic’s not so bad. What we got from that investment was co-locating all three of the businesses. Suddenly, we could have one billing department because they were all in the same footprint. [51:00] We could have one intake department. When somebody wanted to make a referral and refer a patient to home health, hospice, or private duty, they could call one phone number and we could figure out how to make that happen. When a clinician had an issue with their laptop, and needed to bring it to the IT resource, they all came to one place. Prior to that, the IT person used to have to run around from place to place. By co-locating the three businesses, we gained a lot of efficiencies. And, again, what was ironic to me was, I had people in Home Health and Hospice that didn’t know each other. You’re a physical therapist for home health or you’re a physical therapist for hospice and you’re both seeing patients in their homes, but they didn’t know each other. That just amazed me. Bringing these like businesses together in the same physical footprint made a really big difference—sort of a sociology study in and of itself. That helped us create a sense of team and of one business, not three separate businesses.

01-00:52:11
Rigelhaupt:
What you described, in terms of people being in contact and being in one location, sounds very logical. Did you hear about why it had developed where there were different locations, and why it had been allowed to persist in the years before you arrived?

01-00:52:30
Dohmann:
Home health had been around longer. When the decision was made to get into the hospice business, there wasn’t space where home health was, so we put it someplace else. At the time, some of the functions that we were able to bring together went in different places. I think it’s not uncommon. Other organizations have done the same thing. It’s not until someone takes a pause and says, “Well, now, these businesses are kind of related. I wonder if you gain any economies of scale, any efficiencies, by bringing these similar businesses together?” It certainly wasn’t anything that was purposeful to keep them separated. It was one business. Home health had been around much longer. Hospice was newer. They opened I up where there was space available within the organization. And then it just kept going that way until someone had the idea to think, “Maybe could we possibly gain some efficiency by co-locating them, because they’re related businesses?”

01-00:53:34
Rigelhaupt:
Were there physicians that you worked with that had a specialization, particularly in hospice care or palliative care? Who were the physicians you worked with the most?

01-00:53:45
Dohmann:
Great question. The physician I worked with on the home health side was Dr. Tom Ryan. He had been the medical director of home health since it started. It was kind of ironic. About six months after I arrived, at the end of that first year, Dr. Ryan let me know that because his responsibilities at the hospital were increasing, he needed to step down as the home health medical director. [54:00] I remember that day very clearly because I said, “Oh, Dr. Ryan, how do I go back and tell them—to home health—that I’m here six months and now you’re not going to be the medical director anymore? They’re going to think I’ve done something make you not want to be part of home health.” Working with him was a great thing. The nice thing is he had been the medical director for so long, was a physician in the community, and he understood the value of home health. Filling his shoes was a pretty big job, but we were fortunate to find two community physicians that shared that role. On the hospice side, we are very, very fortunate at Mary Washington, between our hospice program and our palliative program, we’ve had several physicians. Dr. McManus, who’s the medical director for hospice, has been certified in hospice and palliative medicine for a number of years. Dr. Bigoney, who’s our chief medical officer now, is also board certified. We’ve been very fortunate. I’ve never worked for a hospice program with so many affiliated, board-certified physicians. That’s another area where Mary Washington was even a little bit ahead of the time. When it created its palliative program here, it was unheard of that a community hospital would have an inpatient palliative-care program. Again, responding to needs of the community, and raising the level of clinical expertise by pursuing the board certification, which is very fortunate—to have those resources here at Mary Washington.

01-00:55:39
Rigelhaupt:
Now that you’ve mentioned it, I’m intrigued by the fact that the first two executive vice presidents and chief medical officers of the organization have close working relationships with home health and hospice. And I really don’t have a specific question, except why do you think that happened? What were some of the things they would have learned and gained in experience, that would have led them to be sought after as chief medical officers?

01-00:56:09
Dohmann:
If you talk about Dr. Tom Ryan and Dr. Becky Bigoney, both of them were primary-care physicians in the community. Both of them would have been, and were, high users of home health services. They understood, as a primary-care physician, that their patients would need home health. I think it’s not at all surprising that they would have that understanding. It was very fortunate for home health that they were willing to share their expertise in the medical-director role. I think if you also look at Dr. McManus, who’s been the medical director for hospice since it started, he’s also a primary-care physician. He also has seen, firsthand, from the patients and the families that he’s cared for, how much of a positive difference hospice can make. It’s a passion of his. [57:00] He’s seen the value in his own practice. He also knows the value of high-quality hospice care. Again, I think it’s his investment in the community. He wants to make sure that Mary Washington hospice offers that in Fredericksburg.

01-00:57:18
Rigelhaupt:
Did you get a sense the senior administration saw the value of the experiences that people like Dr. Ryan and Dr. Bigoney gained in home health and hospice, palliative care, as being valued in terms of the decisions to hire them as a chief medical officer?

01-00:57:38
Dohmann:
I think all three of those physicians are extremely well respected by the organization, but also by their physician colleagues. I think that’s what has helped each of them be so instrumental in the organization. They’re good doctors, and their colleagues—other physicians—see them as good physicians. It’s hard not to listen to them. That’s always been important to the organization. They’ve been great advocates for home health and hospice.

01-00:58:15
Rigelhaupt:
Do you remember in the first few months, year—no specific time period, but early, when you started here—your impressions of the board and its working relationship with the administration and clinicians?

01-00:58:30
Dohmann:
I didn’t have a lot of connection to the board early on, although home health has always had an annual report that it’s done to the board. That was a written report and I didn’t really have any exposure to the board when I was at home health and hospice. Although I certainly did hear from Mr. Rankin and from Kevin that the board was very invested in home health and hospice, and also saw the value that they brought to the organization.

01-00:59:02
Rigelhaupt:
Part of what I’ve learned in this project is that running a hospital involves at least three distinct units—the administration, the board, and the medical community. And, increasingly, nursing, but that’s a more recent phenomenon, I think, in most hospitals in the US. How would you describe the dynamics between those three group? What did you observe as you started working here?

01-00:59:28
Dohmann:
I think a couple of things. For the board of trustees, I think what’s always been very compelling, to me, is how invested they are in the organization and how seriously they take their job as those stewards of the organization—and how important the health system is to the community. The board members take their job very seriously: running the organization well is tantamount because our community depends on Mary Washington Healthcare. What I’ve always been struck by with the board is the commitment and the true passion for the role of the primary health care provider to our community. [01:00:00] Watching the interactions between, say, the board and physicians, there’s a tremendous amount of respect that the board has for the medical staff. There’s also a tremendous amount of interest. One of the things that the board does every months is, they get an update on something that’s new across the organization. The board has a quality committee. Throughout the year, if there’s something new that’s going on within the medical staff, there will be a presentation to the quality and medical affairs committee to update them on what our medical staff is doing. There’s genuine interest at the board of trustees to see what new things we’re doing, what new physicians have brought to the organization. There’s a great sense of pride by the board of trustees. I think, looking at the interaction between nursing and the board, our chief nursing officer has a seat on the board of trustees. I don’t think that happens in every health system. The board has always sent a very powerful message about how much they value nursing, and particularly in the last ten years or so. That’s been very positive and very strong. That’s important to a nurse at the bedside who may be having a rough day or may be wondering if they’re making a difference or wondering if anybody knows what they’re encountering. Our board is very interested in that. Our board wants to know. When we went through the Magnet journey, the board wanted to understand what that really meant and how that brought value to the organization. That connection that the board has to the physicians, to administration, to nursing—I think that’s pretty telling about the strength of the organization.

01-01:02:04
Rigelhaupt:
Do you remember, in the first couple of years you were here—and I imagine when you changed roles and became vice president of nursing, and you learned a lot more about the board—do you remember any disagreements, points of tension where you and your colleagues in home health were talking about decisions made by the administration or board, where there were disagreements? It would make sense. There’s not going to be 100 percent agreement all the time.

01-01:02:32
Dohmann:
Right. When I was at home health and hospice, I don’t know that I had enough involvement or understanding about situations like that. Certainly, as you said, when I came to the hospital, I had a much better understanding of what were decisions that the board was making, or why or why not.

01-01:02:53
Rigelhaupt:
So, before I get to the transition to the hospital, what led you to accept your position as a Mary Washington MediCorp associate at the time? [01:03:00]

01-01:03:04
Dohmann:
That was kind of a running joke that Kevin and I had. Every month, he would say, “Why don’t you come on board as an associate?” I resisted, I think mostly because I had made a commitment to the consultancy. He really thought it meant something to be part of the organization, and to not be a consultant. I have to say, after I was here for a number of months, I wanted to be part of the organization because it felt like you were belonging. You were part of something that was worthwhile and was good. So we talked about it every month and he used to joke and say, “Eventually, you will bleed MediCorp green. And you’ll know when that day is and you’ll become a MediCorp associate.” He was pretty confident throughout the whole process that eventually I would become an associate. And I did. I had the dubious distinction of going through orientation three times. Once was as a consultant. When I became an associate I went back through orientation and actually got it interrupted because we had surveyors show up at home health. I had to leave, so I came back a third time. I used to always joke that I had to do orientation three times to get it right, but it was well worth it.

01-01:04:23
Rigelhaupt:
Was the orientation the same all three times, or did you learn new things, having done it three times?

01-01:04:28
Dohmann:
I did. The very first time I was brand new to Fredericksburg and to the organization. I was very much focused on I’ve got a lot to do at home health and hospice. Your attention is, maybe, not 100 percent. The second time I realized, “I’ve got to pay attention now more because this is different. I’m not a consultant anymore. I’m an associate.” Then, the third time it was, “Now I’ve got to get it right this time because I don’t want to come back for a fourth.” I was probably different going through each of the orientations back then.

01-01:05:06
Rigelhaupt:
Could you talk about the process by which you came to accept the position of vice president of nursing in 2006?

01-01:05:11
Dohmann:
Sure. At the time, it was just when the organization was starting to do the planning for Stafford Hospital. Walt Kiwall was promoted to be chief operating officer for the health system. He was given that “little” job to build Stafford Hospital. Barbara [Kane], who was the vice president of nursing, was promoted to the chief nursing officer. She was given the “little” job to design nursing at Stafford, open it, and get it working. Kevin was promoted to be the hospital administrator at Mary Washington and he had two VP positions: the vice president of nursing and vice president for clinical operations. So in one of our monthly meetings he said that he would like me to be the vice president of nursing. I laughed at him. Told him I thought it was a crazy idea. [01:06:00] I was a home health and hospice nurse. I was not a hospital nurse. It would be like playing dress-up. Every nurse in the hospital would know that I wasn’t a hospital nurse and I just didn’t really think it was a good idea. “Thank you, but you’re crazy. No.” He persisted. My mother is a retired VP of nursing. Throughout my career she’s always been a mentor for me and a sounding board. I called her and I said, “Let me tell you this crazy idea my boss has.” I told her the idea and there was silence on the other end of the phone. She said, “Well, what’s your problem?” And I said, “Have you lost your mind? I’m not a hospital nurse. I haven’t been in a hospital for a very long time. Wasn’t even in one for a long time when I was, early in my career. It’ll be like playing dress-up. It’s going to be all bad.” My mother said, “Do you have other leaders within nursing? Do you have directors?” I said, “Oh, yeah.” She goes, “Are they good?” And I said, “Well, as far as I know. They’ve been there for a while, but they seem good.” She goes, “Well, then, they’re not going to ask you a clinical question. They know. He’s asking you to be a leader for nursing. He’s asking you to make sure that everyone knows what a difference nurses make. Those are things that are just part of you. So get over yourself. Tell him that you’d be honored to throw your hat in the ring. Give it your best shot, and if it’s meant to be, it’s meant to be.” The next time Kevin asked I said, “Okay.” I would do it. I went through the interview process, which was very rigorous. I was interviewed by a roomful of physicians. I think there were seven or eight of them in the room. I was interviewed by nurse managers and other administrators. They all kept asking me the question, “Why do you want this job? What makes you think you can do this job?” When it was all said and done, I was offered the position. I did that role for five years and, without a doubt, it was the best five years of my nursing career.

01-01:08:04
Rigelhaupt:
What were some of the things that made it the best five years of your nursing career?

01-01:08:07
Dohmann:
Being able to be passionate about nursing and to really help nurses take pride in what they do. Going through the Magnet journey was just an incredible, incredible experience. When we started and when I first came to the hospital and it was updated we were on this Magnet journey. I had to learn a lot about Magnet myself. I had been peripherally involved up at Inova when they went through the Magnet process. I knew a little bit about it, but I really had to get very immersed. And really, with the Magnet process, you can’t fake it. It has to be something that’s really part of the organization. Working with nurses across the organization to really instill this pride in nursing practice and the level of proficiency in nursing practice. That had to be there, that had to be convincing, and had to be real. [01:09:00] We worked with an outside consultant that came in to help us get ready. About six months before—it probably was seven months before the actual Magnet site visit—we had a visit with one of the consultants who came back and said, “You’re not going to get it. This isn’t going to work. You’re not going to get Magnet designation. There are pockets across nursing where it really isn’t entrenched the way that it should be.” The consultant even went so far as to recommend that we shouldn’t pursue Magnet. I sat down with nursing leadership at the time and just told them straight out, “This is what the consultant said.” A really proud moment for me was when that very same group of leaders said, “Yes, we are, and we’ll show that consultant that she’s wrong. We may have some areas where we need to focus our attention, but we deserve this recognition. This is who we are. If we have some weak links, then we’ll focus our attention to get them where they need to be.” They wouldn’t take no for an answer. They were going to move forward. When we got the information about the days that the Magnet surveyors would be here, it was just incredible. We had planned it out, the day that the surveyors arrived. We knew it would be a group of them. We thought it would best if Barbara and I met them at the front door. We told people. I mean, it was an announced visit, so it wasn’t a surprise. We told people across the hospital that this is when the surveyors would be arriving. When the surveyors arrived and we took them into the atrium, we actually had to plow a path through the crowd so we could get the surveyors into the building. One of the surveyors said, “I feel like I’m a rock star. I’ve never had so many people turn out for us walking into the building.” There were people cheering. Dr. Hine, our chief of pathology, had a picket sign. The picket sign said, “I’m a pathologist and we love our nurses.” Physicians were there. Nurses were there. I mean, every department came out just to welcome the surveyors into the building. Everybody wanted to show that sense of pride: we’re Mary Washington Hospital and we want to show you how good we are. As we took the surveyors around the building those three days—there’s always a joke that when a surveyor comes you want to hide because you don’t want to be the one that’s asked a question by the surveyor. We had people lining up to talk to the surveyors. They wanted to tell their story about what it meant to be a nurse at Mary Washington, why they took pride in their nursing practice, and what they were doing to improve things on their unit or in their department. It was just a really exciting, exciting time. The energy was just palpable in the building and it was a really fun thing to be part of.

01-01:11:54
Rigelhaupt:
You mentioned a couple of weak links, or some areas that a consultant identified. [01:12:00] Maybe you’d want to talk about those, but what I really wanted to ask about, what were the hardest things to overcome, in the areas that you’re most proud of having seen the improvements, to achieve Magnet designation?

01-01:12:13
Dohmann:
I think one of the things that I was really proud of is nursing doesn’t get the Magnet award. The hospital gets the Magnet designation. Nursing is a large part of it, but it can’t just be nursing. It has to be the whole organization. One of the things that I was really proud of is the partnership that I had with Marianna Bedway because she and I were colleagues. I was the vice president of nursing. She was vice president for clinical operations. Marianna made sure that all of her areas knew about what Magnet meant and went through the very same things that we did with all the nurses. To actually have other departments step forward, to want to be part of this Magnet journey, and to want to be part of that pride in practice, I think was huge, really significant, and was very evident to the surveyors. I think the challenge was, first of all, getting all that information out to so many people and helping make sure that people understood why we were doing Magnet and what the value was. Then as we identified where there were challenges or weak links, having the courage to address them. One of them was an area within nursing where we had had some turnover in leadership. Having that stability—you needed that to be able to instill some of the things that we did during the Magnet journey. How do we overcome that? It was, for me, very gratifying to watch the other leaders in the other parts of nursing step up to help the person who was leading that area now and supported her to do what she needed to do and to bring her area along.

01-01:13:59
Rigelhaupt:
What were some of the things that the physician community did to support achieving Magnet designation?

01-01:14:06
Dohmann:
Physicians were huge. We went to every division and their department meetings to educate them on what it meant to be Magnet. They participated in the Magnet site visit because there were several sessions with physicians and the physicians got to talk to the Magnet surveyors. They were an integral part. Like I said, it meant so much—whether it was the day that the surveyors arrived, throughout the site visit, or the day that we actually got the phone call that said we got the designation. To look out into the atrium that was packed with people and to see that there were physicians. We joked on the day that we got the phone call that said we were Magnet-designated—I looked up into the audience and I saw what I was pretty sure was the whole radiology department. It looked like all the radiologists and all the techs. I don’t know who was x-raying patients for those ten minutes, because they were all in the atrium. Everybody wanted to be part of it. [01:15:00] The physicians were part of that, too. That was huge and extremely gratifying. They gave us time at all of their department meetings to talk about Magnet. When we asked for help on different projects, or different things we were doing, they were right there as our partners to help us. They were as proud as we were about the journey and about the designation.

01-01:15:28
Rigelhaupt:
You mentioned radiology. Was a significant part of the support working with physicians who have more hospital-based practices like radiology? Or were there other divisions that also really were an active part of it?

01-01:15:43
Dohmann:
All of the physicians in the building, including our hospitalists because they work with nurses across the whole building. Our surgeons and physicians that are here, in the operating room. But it was physicians across the board.

01-01:15:58
Rigelhaupt:
What were some of the things the administration did? And if you can talk about some of the administrators that really played an active role in trying to support achieving Magnet designation.

01-01:16:12
Dohmann:
The resources. I mean, we had a consultant that worked with us for two years before the designation. That was an expense. It was a necessary part of the process, but the organization administration supported that. When there were things that we doing, specifically in the Magnet journey, some of our performance-improvement projects, administration supported and also administration participated. They also were part of the Magnet process. They were working with us to make sure they understood why it was important and the value that it would bring to the organization. Really, everybody in the organization was part of that process and were great supporters of it.

01-01:16:54
Rigelhaupt:
You mentioned investing in a consultant, and providing resources to achieve that. Certainly, I think one of the roles of the board is a fiduciary duty, probably not to the level of micromanaging the kind of expenses on a consultant. If the administrator wants to do that, the board probably is not weighing in on that. But did you have a sense that the board was also supportive, in investing in trying to achieve Magnet designation?

01-01:17:18
Dohmann:
Absolutely. At the time, Barbara Kane was the chief nursing officer and she sat on the board. She reported to the board at each board meeting: what was the update on us progressing towards Magnet designation? They were aware of the consultant. They were aware of the consultant’s feedback. She kept them very well-informed about how we were progressing on the journey. They also were there the day that we got the phone call. There were board members that were in the audience when we got the phone call to say that we got the designation.

01-01:17:52
Rigelhaupt:
Could you tell me a little bit more about that day? Describe the scene, and what it was like?

01-01:17:55
Dohmann:
Sure. The way that Magnet worked at the time is that you have your site visit. [01:18:00] Then, it’s six to eight weeks, minimum, that you would get a phone call. The phone call comes from the Magnet office. Really, what they’re doing is, they’re calling to schedule the call where they’ll tell you if you got it or not. I had been coached by other VPs of nursing at other places that were Magnet, that the most important question you ask when you get that first phone call—because they’re really just calling to schedule the next one—is, “Is this a phone call one that I can have people listen to with me or is this a phone call that I should just take privately?” The idea being, if you’re calling to get the designation, you can have other people in attendance. If they’re calling to tell you no, you might want to be by yourself because you’re going to need a few moments to compose yourself. You’re going to be very disappointed. I happened to be in a meeting here at Mary Washington in the boardroom. My assistant burst into the room and said, “Eileen, Eileen. Magnet is on the phone.” It was a Friday. It happened to be Friday the thirteenth, in September. I ran into my office and had to take a deep breath, but got onto the phone. Marianna was with me. Kevin Van Renan was with me. They told me that they were calling to schedule the call for the following week and they gave me the date and time. My hand was shaking so much I had difficulty writing it down. I kept saying it out loud so that Marianne and Kevin could remind me what I committed to. Then I said, “Is this a phone call that I can have other people listen in to? Or should this be a private phone call?” The person said, “Oh, by all means, you can have other people be there.” I said, “Oh, that would be wonderful.” I hung up the phone and let out a very loud scream with Kevin and Marianna. The call was scheduled for three days later. Now it was planning how we were going to do the call because we wanted to invite a large group of people to attend. The suggestion was made to do it in the atrium because we had had such a great turnout when the surveyors were here. We would do it there and set up a podium. We got a red phone so it was going to be like the red Bat Phone. When the phone would ring I went on a microphone and put the call on speaker. Everyone in the atrium would be able to hear what the news was. We sent the word out, and invited everybody across the organization to come. It was, I believe, on a Tuesday, at ten o’clock in the morning. I had a very special honor. I mentioned that my mother was a VP of nursing. When we were going through the process, she said, “You know, if you are lucky enough to get Magnet, I would love to be there.” She had never had that experience in her career. I had reached out to my parents and said, “If you want to be here, it’s Tuesday at 10:00. But you’ve got to be here at ten o’clock.” They came down the night before, from New York. Drove the six hours down. [01:21:00] They were to drive from my home here to Fredericksburg for that ten-o’clock phone call. We were getting everything set up. It’s 9:30, 9:40, 9:45, 9:50. My parents are nowhere in sight. The atrium is filling with people. Finally, a couple of minutes before 10:00, I see my mother’s head coming through the crowd and looking at me. And she’s like, “Dad’s just parking the car.” Well, what had happened is one of the security guards out front was the valet. When my father said who he was, the valet just took the keys out of his hand and said, “Mister, you’ve got to get in there quick. I’ll park your car.” My father came in and saw the throes of people. He said, “You’d better get a good answer because you won’t get out of here alive if Magnet says no.” And so I said, “No, Dad. I’m pretty sure they’re going to say yes.” He said, “Well, I hope so.” We were all there. Ten o’clock comes, ten o’clock goes, and no phone call. 10:05, 10:10, 10:15, no phone call. I have my father saying, “Did you get the date right? Did you get the time right?” My mother saying, “Are they on Eastern Standard Time. Maybe it’s an hour off?” So I had my assistant call to the Magnet office. The person that was calling was not in the Magnet office. She happened to be a hospital administrator herself and she had a crisis at her hospital. Eventually, I think it was about 10:17, 10:18, the phone rings. I just about died because we’d been waiting for so long and now it finally rang. I answered the phone. The person on the other end that said, “I’m delighted to let you know that Mary Washington Hospital has achieved Magnet status.” The place just erupted. I get choked up even thinking about it. They thanked us and told us that there would be information coming to us in the mail. The atrium just went wild. It was packed, again. I’m sure we violated some fire code with how many people we had in the atrium. I looked up and just saw a sea of people and a sea of pride. It was a wonderful, wonderful day.

01-01:23:09
Rigelhaupt:
Many years in building this.

01-01:23:11
Dohmann:
Absolutely, absolutely.

01-01:23:13
Rigelhaupt:
Looking back on it now, what would you point to as some of the most important factors that led to achieving Magnet designation?

01-01:23:21
Dohmann:
I think time was spent and it was the time that we reached out to individual nurses to help them understand what Magnet was about and to get them engaged. I think working with nursing leadership to get them engaged and to fire them up to really lead us through the journey. The partnerships with all the other departments in the hospital, including physicians and the board. This really was an organizational journey. It wasn’t a nursing journey. Nursing might have been out there and out front with it, but it really was something that the whole organization invested in and the whole organization accomplished. [01:24:00]

01-01:24:02
Rigelhaupt:
The amount of teamwork necessary, or, as you described it, organizational achievement—did you have a sense, when you started in 2004, that the foundation was in place to achieve something like this, that required that much synergy between different units and the entire organization?

01-01:24:22
Dohmann:
That’s an interesting question. I think, actually, my experience at home health and hospice probably made me feel that Magnet was possible. When I got to home health and hospice, as I said earlier, I found that the right people were in place—they just needed the right tools. They just needed to be set on the right course and then they would run the rest of the journey. I think that probably helped a lot in, then, doing the Magnet work when I came to the hospital because I found the same thing. The right people were in place. We just needed to make sure that we charted a course. We gave them a vision about where we were headed within nursing and on the Magnet journey. To engage people to understand that, then point them in that direction, and just get the heck out of their way. Allow them to do what they, certainly, had the capability to do. I think I did learn that at home health and hospice and that is absolutely what carried over to the hospital and to the Magnet journey.

01-01:25:25
Rigelhaupt:
Obviously, there would be less firsthand experience preceding 2004. But in those first five years you were here, did you learn about some of the changes that had taken place in the hospital, and some of the foundation that had been built, that had made this possible? What were some of the things that you learned, that had been put in place, to have made that last push over the five years possible?

01-01:25:50
Dohmann:
From my two years at home health and hospital, I saw what we could accomplish and the support from the organization to get things right. I think the other thing I saw when I came to the hospital, was focus—the results that can be obtained when you focus on something. For example, the trauma program designation. That was something that the state identified as a need within our community. Mary Washington quickly stepped up to the plate and said, “Yes, we’ll become a Level II trauma center.” That was a huge investment. It was also a huge amount of work. I saw it be successful. I think there were many, many examples where what I really saw in the organization was, when we identify a need, and you get the right people focusing on it, and they focus their attention, there really isn’t much that we can’t do. I saw that again and again across the organization. That’s really what also played out in the Magnet journey. Once we charted the course of where we were going and why it was important, then it made it much easier to engage people to be on that journey with us, and to let them run with it. [01:27:00]

01-01:27:04
Rigelhaupt:
Mentioning trauma, one of the things I’ve learned through these interviews about trauma, which I did not understand previously, is how much it involves many units. Not simply what you see on TV: that first hour that you’re treated in a trauma bay, and if you make it out of there, everything’s fine. And, of course, the amount of critical-care nursing, rehabilitation, or long-term care—were there things that you had learned and gained experience with in home health and hospice, and a more holistic view or providing patient care, that ultimately were important in planning and implementing the trauma program?

01-01:27:51
Dohmann:
Absolutely. I think in any program the perspective that I’ve brought, because of my home health and hospice background, is just as you’ve said: to be that more holistic. I think about what I said earlier. When I was a nurse early in my career working in a hospital, I wondered, “What happens when people leave the hospital?” When you’re a hospital nurse, just by virtue of the setting, you’re very focused on what the patient needs while they’re in the hospital. I think having that perspective of health care really is a continuum—the hospital is a small part of someone’s continuum of a long illness. Being able to understand the continuum, I think that helps when you are, then, trying to work on other big projects. You will now start asking more questions about, “Okay, is this just bigger than the patient that comes into the emergency room and now you’re a trauma patient?” That’s just the start of their journey. There’s so much more that goes into caring for a trauma patient. Really emphasizing the fact that you’ve got to look at the whole patient. You’ve got to look at their whole journey through this illness or this catastrophe. You have to have all the pieces in place. You can’t say, “Oh. We didn’t think about that, so we don’t have that available for you.” The patients are going to come. The patient is going to need what they need. We have to be prepared to be able to deliver it. I think my perspective from home health and hospice, of thinking larger than just what’s right in front of you—I think that does help in some of the projects and the things that I’ve been part of at the hospital and at the health system.

01-01:29:33
Rigelhaupt:
In the five years that you were vice president of nursing, in addition to the trauma and achieving Magnet status, what are some of the other areas that you would point to that are real signs of success, or growth, or expansion—however you would describe it—of Mary Washington Hospital and, in that time period, becoming Mary Washington Healthcare?

01-01:29:49
Dohmann:
Particularly during my time as the vice president of nursing, it was before Stafford opened, for the most part. We were busting at the seams. [01:30:00] How do we best meet the needs of our community when the community needed more physical space than what we could offer? There were a couple of busy winter seasons there where we had to figure out how we could take care of more patients than we had ever cared for before and how to do that in a way that we could still provide high-quality care to patients. Capacity was a big part of what I had to do during those five years, because we were the only game in town. We also had a very strong commitment that we didn’t want people to have to leave the community to get their health care. How could we continue to meet all of their health care needs when, on some days, there were, literally, no more rooms at the inn? How do we do that? And how did we do that well? That took a lot of our time and attention. Then when the decision was made to build Stafford it was how to do that best. How could we best serve the Stafford community? We didn’t want Stafford to be a Mary Washington, junior. We wanted Stafford to have its own identity. We also had resources here that could help with that. A lot of that meant sharing the folks that had a day job here, but, then, were also part of helping to design Stafford and putting together some of the care processes that Stafford opened with. It’s the increased responsibility and increased work effort with the same amount of resources. The one really neat thing about Stafford is there are many people that in the course of their career will never have the opportunity of opening a new hospital. We got to do that. We got to build it from nothing. So, to see, now, where Stafford is getting busier and is growing each month—that’s pretty exciting. I can remember a time when there was no Stafford. To see it taking hold and really developing into a very successful part of the health system is something that we all take great pride in.

01-01:32:15
Rigelhaupt:
What were some of the things you wanted to see emphasized, in either the nursing program, but, more, the larger organization or relationships between nurses and physicians, and all the clinicians and staff? What were some of the things you wanted to see happen at Stafford, as it was being planned, and getting ready to open?

01-01:32:35
Dohmann:
I think real push was to make sure that we were meeting the needs of the Stafford community. There was great work done at that time, too, in working with different constituent groups in Stafford, as far as designing what services would be offered at Stafford Hospital. It opened with a commitment to provide inpatient care, to provide OB services, to provide surgical services, and to provide outpatient services. [01:33:00] There was a real commitment to meet the needs of the Stafford community in designing Stafford and how it started.

01-01:33:11
Rigelhaupt:
Could you talk a little bit about, or introduce and explain your decision to accept the position as vice president of clinical integration in 2011?

01-01:33:21
Dohmann:
It was at the time when Barbara was retiring as the chief nursing officer. Marianna was selected to be the chief nursing officer. There was a decision made, too, that Marianna would also be in that role of the vice president of nursing. It was a reshuffling of the deck. Instead of having the nursing units reporting to me, I had other areas. It was also an exciting time to learn new parts of the organization and to work with other parts of the organization. The nice part was, since I had been here, and been in the vice-president-of-nursing role, I knew people. I knew the departments. That made a transition, certainly, that much easier.

01-01:34:20
Rigelhaupt:
The last thing I’ll ask you: the areas that were going to be part of vice president of clinical integration—what were they?

01-01:34:29
Dohmann:
I still had home health and hospice. They have stayed with me. Then I had cardiovascular services: so all of the cardiac testing areas and the cardiac cath lab—I was still working with those. We had done a couple of things, but, at the time, I also had women’s services. I worked closely with those two service lines, in addition to home health and hospice.

01-01:34:57
Rigelhaupt:
Okay. So we’ll stop there for today.

01-01:34:59
Dohmann:
Okay.

01-01:35:00
Rigelhaupt:
Thank you.

01-01:35:01
Dohmann:
Thank you, very much.
[End of interview]

Interview 2 – March 9, 2015
02-00:00:02
Rigelhaupt:
It is March 9, 2015. I am in Fredericksburg, Virginia at Mary Washington Hospital, doing interview number two with Eileen Dohmann. To begin today, I would like to ask you what you remember about the first conversations, maybe even the kind of rumor talk, water cooler talk about Stafford Hospital.

02-00:00:27
Dohmann:
Sure. There was lots of talk about needing more hospital beds at Mary Washington. Back to before Stafford was built to when it was under construction, we were really at a place where Mary Washington was literally running out of room at the inn. We were beyond capacity and trying to make sure that we could still provide care for patients in the community. I think everyone knew that something had to give. We needed to add beds somewhere. The first logical thought would be, well, you do it at Mary Washington since there are already beds here. We had already added to the capacity here at Mary Washington once, so maybe you would just build another tower. But, at the same time, I remember being part of some conversations about access to Mary Washington. We don’t have direct access on and off I-95. You have to deal with the Falmouth Bridge. I remember hearing some of those discussions. It was also the issue of where did those beds really need to be located. And the fact that Stafford County was growing so much seemed to make a lot of sense too. What about if you build another hospital and you built it in Stafford? Could that work? I wasn’t directly involved, but I was hearing about the meetings with the citizens of Stafford County and with the county board of supervisors. Would they embrace having their own hospital? That’s the positive feedback from the board of supervisors. The positive feedback from the community was, “Yes, we would love our own hospital.” Then that really fueled the fire to pursue building Stafford.

02-00:02:02
Rigelhaupt:
At the time, you were vice president of nursing. What did you think it would mean for the organization to be a two-hospital system in terms of the nursing program?

02-00:02:13
Dohmann:
A whole lot of things run through your mind. First of all, to have the experience in a health care career of actually opening a hospital. Lots of executives have the experience of moving from an old building to a new building, but to actually create a hospital where there wasn’t one, that’s once in a lifetime and not every career gets to have that. There was lots of, “Wow. This is exciting.” But then, really, the hard work of what does Stafford look like? And how do we do it? There was some feedback from the board of supervisors that Stafford wanted their own hospital. They didn’t want it to be an outpost or an extension of Mary Washington. Then it was really the health system making the decision about which services you would offer at Stafford. Would you do everything that you do at Mary Washington? [03:00] Would you just replicate it at Stafford? Would you pick and choose? At the time, we actually worked with several other health systems that had done similar things to see what the model would be for how we provide care. There was a lot of thinking about, will staff go back and forth? Will you still hire all the nurses at Mary Washington and then maybe deploy them Stafford? Or does Stafford have its own nursing division and its own culture? That’s really the approach that went out and really was right: it’s that Stafford has its own identity and its own culture. We’ve done really hard work to integrate across the health system, but there are lots of folks that worked here at Mary Washington that wanted to go to Stafford. In some regards, it’s a very different clinical setting for a nurse, being at a large tertiary care hospital versus being at a smaller community hospital. Some units, the work is very similar. In others, it’s different, because there will be things that we do at Mary Washington that they don’t do at Stafford. It was really growing and developing that. It was one thing to write it on paper and to say this is what it would look like, but it was very different to say, “Oh, my gosh. There’s a building there. Open the doors and patients will come.” You had to be prepared for what was going to present itself at the door. We did lots of brainstorming, lots of pencil and paper, and lots of planning. Even when the building was built and right before opening, it was actually practicing what it would be like to move a patient from the emergency room, through x-ray, and up to the floors. It was just that nobody had ever done it before. Oftentimes, you would hear people say that they were resistant to change because that’s the way they’d always done it. Well, Stafford didn’t have a “that’s the way we’ve always done it” because we had never done it. Really having to think through exactly how will this process work, and the folks at Stafford took the time to actually do it and to say, “Let’s really make sure that this process will work.” It was an incredible time in our history and, like I said, something that most health care executives do not have the opportunity to experience. It was a great opportunity for us.

02-00:05:25
Rigelhaupt:
In building a nursing program I imagine that you started years in advance, probably by the time the ground was broken, or even the foundation was going up. The meetings you described, the brainstorming, the pencil and paper, would you be able to describe one, or even if a few blend together? Who was in the room? What were you talking about? What were some of the ideas that came out of those brainstorming sessions?

02-00:05:48
Dohmann:
Sure. Our chief nursing officer, Barbara Kane, was really at the forefront of that and she led much of that work. We created teams around certain clinical areas. For example, one group I can remember was around labor and delivery because the models at both hospitals are slightly different. [06:00] At Mary Washington, when you have a baby, you come into labor and your baby is born in one area. Then, after the baby is born, the baby and mom move to our mother/baby unit, or our postpartum unit. At Stafford, we adopted a model after looking at lots of other hospitals, hospitals of comparable size and what model worked best. We use what they call an LDRP model where the room that mom comes into, for the most part, is the room that mom will stay in for their hospital stay. At least, that’s how Stafford opened. So I can remember a meeting where we had looked at all the different models, decided that this seemed to be the one that made the most sense, and then had to walk through. How does the staffing work? Or, what kind of nurses do you need? Here at Mary Washington you have labor and delivery nurses and you have postpartum nurses; they’re separate groups. Whereas, at Stafford, with the model that we opened, one nurse would take the mom through labor and now be the one to take care of the mom postpartum and also the baby. That again was a meeting where we had to sit down and list every single process that would happen and start to map out how those processes would work. We used the nurse manager who was here for labor or delivery, and who actually became the nurse manager up in Stafford, to help get it started. There was some staff that went, but then we also knew that we were going to have to bring on some new staff that was probably more familiar with the model that we were starting at Stafford. For those folks coming from Mary Washington, it would be a different model. To get some experienced folks that had experienced it differently might be helpful. Indeed, it was. It was those meetings that were very much letting us sit down and think about all of the things that we’d need to consider and then mapping them out as far as how they will work. But, I mean, building Stafford, there were opportunities. Up at Stafford, they have an intermediate-level nursery. We got to design it, and we were given how many square feet we would have in a rectangle. It looked like this and was located here. Everything in the room, the group got to design. Here’s where the gases will go. Here’s where the incubators will go. Here’s where the desks will go. Here’s where the monitors will go. It’s one thing to do it when you’re putting pencil to paper, or trying that, but then it’s not really until you get physically into the space that you’ll think or wonder why you put the light switch over there. We probably should have put the light switch over here. We essentially were building something from nothing.

02-00:08:47
Rigelhaupt:
Were there other people, such as industrial engineers, in those meetings?

02-00:08:53
Dohmann:
Yes.

02-00:08:54
Rigelhaupt:
Part of the reason I’m asking is that there are so many forms of expertise in a meeting like that. Do you remember any of the conversations [09:00] where people shared their expertise and how to design something, like the nursery?

02-00:09:06
Dohmann:
Absolutely. For the meeting where we were designing the nursery, you had the nurses and then you had respiratory therapy because they provide care in the nursery and they are very familiar with certain kinds of equipment. You had the neonatologists, the actual physicians and pediatricians that would be in the nursery. Then we had to involve transport. If we were going to be having to send a baby out from Stafford, what would that be like? We also involved the nurses who would be providing that care. Yes, and then the industrial engineers who I just think are a phenomenal group. They could listen to all the jargon, all the process flow, and then come back to us and say this was the process they think we had defined. Nine times out of ten, they’d get the process exactly right. Then we’d be able to look at it and say that there was something about it that we didn’t think was going to work. Or maybe we needed to try something else. Those meetings were filled with multidisciplinary people. Everybody was there because of their expertise to contribute to what the ultimate plan was going to be.

02-00:10:12
Rigelhaupt:
Are there any other units at Stafford Hospital that have distinctly different setups or processes, such as labor and delivery?

02-00:10:23
Dohmann:
Sure. Another area where there’s a difference between Mary Washington and Stafford is in what Stafford calls their CAIR Lab. They have one lab and that’s where they do their cardiac catheterizations and where they also do interventional radiology. Here at Mary Washington, we have four cardiac catheterization AP labs and four IR labs and they’re on separate floors with separate staff and separate physicians. To now have one at Stafford, which is what the volume would support, we now had to bring together two different groups of staff, with staff that are used to working in a cath lab and staff that are used to working in interventional radiology. They’re both procedural areas, but since they have been separate here at Mary Washington, they were separate. You had two groups of physicians, with the interventional radiologists and the cardiologists. They were a floor apart at Mary Washington. They can be territorial. Whereas at Stafford it was you have one room and you’re going to have to share. Defining what “sharing” means was something that weighed in. For those patients who were in the hospital that would need a procedure done in that procedural room, how would that work? When we had conflicts and when there was a cardiologist and an interventional radiologist that wanted to do a procedure at the same time, who trumps? How would we do that? We obviously couldn’t have two groups of staff. The staff was going to have to be cross-trained. [12:00] How do we cross train them? There were many, many things that needed to be worked through.

02-00:12:10
Rigelhaupt:
It sounds like, for the lack of a better term, increased teamwork, sharing space. Looking back on it, are there things that you saw a Mary Washington in the process of expanding clinical programs in your time here that you drew on? Or you saw colleagues saying that when they tried to do this, they learned from it, and were now going to apply it to Stafford? Is there anything that comes to mind?

02-00:12:38
Dohmann:
I think there was a delicate balance at Stafford because there were many things that we would have done at Mary Washington and we’d say, “This was what we had tried at Mary Washington, so maybe this was how it would work at Stafford.” There were multiple examples, such as how we dispensed medications. For example, we used medication cabinets. I mean, there are things that are done similarly, but then there are also things that are done very differently. One of the considerations was always that Stafford is a different physical location. It’s a different physical plant. The way that the nursing units, for example, are set up is different than most of the nursing units at Mary Washington. When you talk about industrial engineering and looking at motion and efficiency, we definitely had to take into account the physical plant of Stafford and how you can best make things be most efficient. I think we took lots of examples of, “Gee, this is a problem. Or this is something that we addressed at Mary Washington and now it’s working well. How would that work at Stafford?” And then we mapped it out while saying, “Let’s walk it out in the actual physical plan of Stafford to see if it would work.” So, yes, there were lots of those opportunities.

02-00:13:57
Rigelhaupt:
I doubt, from a patient care perspective, or the building of a nursing program, that something like the opening of Spotsylvania Regional Medical Center at the same time, and the fact that two hospitals were approved was at issue, but as vice president of nursing, that’s probably something that you noticed. In terms of what that would mean for the region and the medical health care delivery, to be going from one to three hospitals, do you have reflections on what came to mind when both Stafford and Spotsylvania Regional Medical Center were approved at the same time?

02-00:14:35
Dohmann:
Probably the most significant thing to consider, I think, was there are many nurses, or many staff, at Mary Washington where this is the only place that they worked, ever. What that does is, if you are a nurse or really are anybody that works at the hospital, who wanted to work close to home, in a hospital, you had one choice. It was Mary Washington. If you were willing to travel, you could go south to Richmond, or go north to Northern Virginia, but there were lots of people who came here and stayed here because this was home. [15:00] Well, now suddenly with Stafford opening and then Spotsylvania and those very same people had choices. What I remember thinking a lot about was that people were going to want to go check. They hadn’t had choices before. They may want to go check something out and the grass is always greener at a new hospital. Yes, we knew that there would be some turnover—turnover that we would like at Mary Washington because they would be helping Stafford, but then turnover that you might not like because you might be losing to another health system. That was probably, to me, the most significant difference. The people that worked here now had choices. They could get jobs similar to the job that they were doing at Mary Washington, at Stafford, or at Spotsylvania. Would they try? Indeed, they did and we also had a number of staff that went to Stafford or went to Spotsylvania and came back to Mary Washington over time. I think the most significant change was people had choices that they didn’t have before.

02-00:16:13
Rigelhaupt:
What were some of the things that this might have affected how you as a vice president were matching the nursing program, trying to emphasize continuity and keeping people? What were some of the things you did in response to that recognition?

02-00:16:30
Dohmann:
I think the first thing that would be really obvious was going to work some place new. While we are a beautiful facility, we’re not brand new and that was appealing to some. To some, the grass is greener and maybe they would try something better. I think the message that we really reinforce to our staff is that we’ve been here for a long time. We’ve been the hospital that has worked to meet our community needs. Whether you call it the mother ship or the flagship, the complexity or the acuity and intensity of services are definitely here. Those were the things that we would reinforce to staff. If they were just going to check it out, think about what you’re doing here and are you going to be able to take care of the same level of acuity of patients? Really, even when we liked the turnover of people staying and going to Stafford, it still meant people leaving Mary Washington and you still have to replace them. That’s expensive. It’s also disruptive, particularly for someone that’s been here for a long time. When you hire someone brand new, it may be a one-for-one, but you lose a lot of history and a lot of experience when someone who has been here for a while leaves the organization. That was something that we had to deal with, the turnover.

02-00:17:57
Rigelhaupt:
Do you remember people [18:00] from the administration that were most active, or that you worked with the most, in designing, planning and building a nursing program at Stafford Hospital?

02-00:18:13
Dohmann:
The key people that did most of the work to get Stafford launched were Walt Kiwall and Barbara Kane. Then, as the opening of Stafford came closer and closer, Cathy Yablonski was brought on as the administrator. Cathy then had the opportunity to declare what the culture would be at Stafford. That was fun because now Stafford started becoming real and started having an identity and a personality. How could Mary Washington Hospital best support Stafford? Where were there times that Mary Washington Hospital needed to take a backseat because Stafford needed to get the attention that it was deserving as the brand new hospital in the community? I know Marianna and I worked closely together with Cathy and her team to address the needs as they came up at Stafford. Those are probably the key folks. Then, Allen Bryan, who was sort of in charge of the whole construction. I can remember meeting Allen in the hallways and just saying, “Is everything going okay?” What was a field was now going to be a hospital. Allen would come back and say, “We’re on project and on budget.” Some of that was just incredible. You would drive past on Route 1 and it seemed like, from one week to the next, suddenly the building was taking shape and actually looking like, “Oh, my gosh, this is really going to happen. We’re really going to have a hospital there.” That was fun.

02-00:19:46
Rigelhaupt:
Do you remember your last walk through Stafford Hospital before it opened? And if you could describe what it was like to be in this building that was ready to take patients, everything was there?

02-00:20:03
Dohmann:
Yes. Shiny. It was shiny. It was brand new. It was pristine. It was crisp. It was beautiful. I remember walking through and some of the effects. When you’re up on the first floor, or the second floor, too, and looking out over the field and the pond. It just was the details that were paid attention to. How do you build a building to fit in the terrain of the land? Yes, I just remember being awed. It was amazing to think that we could plan this on paper and it actually looked like what we planned. Then, to really be able to experience that this was a hospital that hasn’t yet touched a patient and all of the pieces were there. It was kind of like when a new baby is born, and I always pay attention to the wrinkles on the fingers and that they’re in the right place. It’s all here. It’s ready to take care of its first patient. That was very exciting. [21:00]

02-00:21:00
Rigelhaupt:
What was it like the next time you went and there were patients in the hospital?

02-00:21:06
Dohmann:
Still the same and the sense it was a beautiful building. It was a beautiful place. Then, as the census started to build because, in the beginning, there were few patients in the building. We’d get excited when it was a census of ten. Or we’d get excited when it was as census of twenty. Walking through the building and knowing that there really were not that many patients here yet, but that the building still looked incredible. I think the other thing that has always been compelling about Stafford is, no matter when you went the staff was always just so excited to see you. Whether you were there to visit the building and the staff, the staff was just so excited and this was sort of their baby and they were bringing Stafford Hospital to life.

02-00:21:53
Rigelhaupt:
Did you notice changes as the census grew higher and there were more and more patients in the hospital?

02-00:22:00
Dohmann:
Changes in the excitement of the staff when they would hit certain milestones: the fiftieth delivery or the hundredth delivery. Great pride in the staff that it was actually working and patients were coming. That was a big part of it. Then they would encounter the processes that we put in place for maybe twenty patients wouldn’t work. We were at fifty. So what did we need to do? We opened with one nursing unit. Then we had to open the second. When you open the third, it was would we do anything different? Maybe we need to move different patient populations to different floors. As we’ve always said, having the growing pains: those were nice problems to have. Nobody ever begrudged or was concerned about the growing pains because we would quickly remind ourselves we were hoping that we would have these growing pains. So getting the right people sitting around the table again to come up with a plan was something that we always worked through.

02-00:23:04
Rigelhaupt:
You may not have been vice president of nursing, still, as the growing pains you described. But what you mentioned earlier about Stafford having a distinct culture, and it’s going to be its own thing, do you remember meetings or discussions about how you sustain this culture as it’s growing, and you’re opening a third unit? How do you maintain what was still a lot of effort to develop as it was being created?

02-00:23:36
Dohmann:
Sure. You have to really give Cathy the credit for that. I mean, when Cathy came and they hired the first group of people who would work at Stafford, they did off-site retreats where they would spend the day together. Cathy’s mantra at Stafford has always been “always.” We do things the right way, always. [24:00] New staff who started when Stafford opened went to that retreat where she essentially built that “always” culture and that sense of a Stafford “team”—anybody can do anything. If a patient needs something and you are the lab tech, you’ll help that patient. Or if a physician needs something, you’ll help that physician. It’s just that there was that sense of team and that sense of “we are Stafford.” Even as Stafford has grown and as new staff has come on board in orientation, Cathy takes a very painstaking effort to make sure she meets with every new associate who comes into the hospital to reinforce what those “always” expectations are. Those things have been sustained even as the hospital has grown. She does open forums with staff where she’s available to talk to staff. She’s made herself very much available throughout the building. It’s not at all unusual to see her walking through the building on a weekend with jeans and a sweatshirt on just because she’s walking through. People know who she is. People feel very comfortable going up and talking to her. You will always hear her talking about “We are Stafford” and “Always.”

02-00:25:15
Rigelhaupt:
I want to switch gears a little bit. Could you talk about your decision to accept the position as vice president of clinical integration in 2011?

02-00:25:25
Dohmann:
Sure. At the time when the decision was made that Marianna was going to move into the chief nursing officer role. There was shifting and shuffling of areas of responsibility. I took on a responsibility for a number of the clinical services areas. Then really the integration piece was how well we integrated, I believe, with nursing to make sure that we could continue to provide that same level of high-quality care. I had areas like cardiac services, the cath lab, home health and hospice, and some of those other clinical services that were outside of the direct nursing division.

02-00:26:11
Rigelhaupt:
Some of those areas that you just mentioned, the cardiac testing, the cath lab, home health and hospice, it seems like they have a longer history of teamwork, of being integrated, even if the term “clinical integration” wasn’t used. What were some of the things that you learned over the course of your career, having worked in those areas for decades preceding this, where you tried to bring it to an official title of clinical integration and build this into the broader culture of the organization?

02-00:26:42
Dohmann:
Probably the best example of the clinical integration would be home health and hospice. Having done that the longest in my career, I think where there are some similarities with the cardiac services, it’s that home health and hospice have to wait for a patient. They’re getting a referral from the hospital, but even the focus that we’ve seen in hospitals for the last five or ten years: hospitals are very focused on patients that have to come back to the hospital, or readmissions. [27:00] We don’t want that. We want that, if we take care of somebody. What lots of the regulatory bodies will say is that the patient shouldn’t have to come back to the hospital, usually, within a certain period of time. I knew from my experience with home health and hospice and having been the recipient of that patient coming from the hospital, what their issues may be. To be able to be in a position where I could go back, beyond the hospital side, to say that there’s something we could do about this so that when that patient is going to home health, or hospice, for services, it’s a smoother transition. Similarly, going the other way: if the home health or hospice patient has to come back to the hospital, what can we do to make that be a smoother transition. I think the integration part had a lot more to do with care transitions, where the patient moved along their continuum of care, and how we, the hospital, could do a better job in supporting some of those transitions that the patients go through when they come in and out of the hospital.

02-00:28:22
Rigelhaupt:
What were you most excited to work on in the new position?

02-00:28:25
Dohmann:
Most excited?

02-00:28:25
Rigelhaupt:
And that’s not specific. I mean, that’s just the way I ask the question. You don’t have to answer that specifically. What was the most enjoyable when you started working? Or however you would describe it?

02-00:28:39
Dohmann:
I think for me it was that I always loved being part of home health and hospice because that’s my biggest background. Working closely with that group and, for me, seeing that home health and hospice, which were always valued by the health system, but to now see more and more health care is moving away from just thinking about a hospital stay and thinking about the patient’s continuum of care. Suddenly we needed home health and hospice to be at the table in planning some things for patients. That part has always been very gratifying for me. I think the other is working with our physicians. A big issue within our cath lab is that it’s a high-volume procedural area. You’ve got inpatient and outpatients and you have multiple physicians that work in that area. As health care was changing and everyone needed to be much more efficient with their time, it’s really working on how we partner with physicians to help them be more efficient, but also to make sure that in the process we were also maximizing our efficiencies. I think working with physicians to understand and letting me know how you working in the catheterization lab fits into your day. Maybe there are some things that we’re doing that are making them inherently inefficient? [30:00] Maybe we could do that different? Working in some of those areas broadens the physician role and what was important to a physician and we were recognizing that what’s important to both of us is making sure we do the best job for the patient. Those were some things that were exciting for me in the new role.

02-00:30:24
Rigelhaupt:
Looking back at it, are there things that you can see that working with physicians proved beneficial to the new integrated provider network, that some of the clinical integration work that you were developing has had a role in Mary Washington Health Alliance?

02-00:30:43
Dohmann:
Absolutely. Absolutely. I think as the Alliance has developed part of what has helped that is some of the incentives have become better in line. One place that was always a challenge is that, in a hospital, we’d be worried about the length of stay and having a patient be here for just the amount of time that they need to be here, to get the care that they need, and to then get them discharged. The way our reimbursement worked at the time, it was that you were rewarded if you could be efficient in the care that you provided to a patient and keep their length of stay controlled. At the time, a physician would get the financial reward each time they saw the patient. A physician wasn’t necessarily incentivized to shorten a patient’s length of stay. That’s one example, but there were many where the incentives were not aligned. What has really happened over the last, probably three to five years, is that those incentives are becoming more in line. As we work with our Alliance physicians, now we’re at a place where physicians want to provide the very best care to patients, but they need to be efficient in how we do it. The hospital wants to provide the very best care to patients, but we have to be efficient. We are now just at a place where some of those incentives are becoming more in line, and so that’s the work of the Alliance. It’s how do we make sure that people get this, and you’ll hear the expression “the right care, the right place, the right time, at the right cost.” That’s what the Alliance gives us an opportunity to do. It’s to look at those patients, the high-volume patients that are getting a similar kind of care. Can we provide the care better if we standardize it and if we do it in a similar way? But the hospital can’t do that by itself. The physicians can’t do that by themselves. We really do have to be integrated to be able to do that most effectively.

02-00:32:43
Rigelhaupt:
For lack of a better term, do you think some of the work that you were doing, and again not necessarily you alone, but with your colleagues in terms of clinical integration, as a kind of practice, helped to create a culture of cooperation? [33:00] Did some of these changes, that have been made more recently and created more financial incentives to them, but you were already doing them, perhaps in a less formal way?

02-00:33:11
Dohmann:
Sure. I think hospitals have done that all the time, if you think about an operating room and surgeons doing surgery in our operating room or in any of our procedural areas or a doctor who decides to deliver babies here. There has always been the opportunity for the hospital to make our hospital be most appealing to physicians and that they want to come here. I think that has always been out there. I think the difference in the last three to five years, where the integration is important, is we really want to then work with those physicians. Say we do 3,000 deliveries a year, but we do them with twenty-five different physicians. They all do it just a little bit differently. If they all did certain things the same way, we could be more efficient and we might be able to make you be more efficient. Can we talk about it? I think that’s the change that’s happened in the last three to five years. It’s that now physicians are very much going to require certain things from a quality perspective. If we can help them be more efficient in how they spend their time, then they may be interested in hearing how we could do things differently to meet those needs.

02-00:34:35
Rigelhaupt:
You referenced quality. The position that you held after vice president of clinical integration was vice president of quality and patient safety. Could you talk about the transition into that role?

02-00:34:52
Dohmann:
Sure. At the time we had a person who was the vice president of quality and patient safety, Dr. Amy Adome. The position had been created when she came. She left the organization and then Mr. Rankin asked me if I would consider taking that role on. It was a little different than what Dr. Adome had been in. I kept much of my operational areas and then added on the quality and patient safety. For me, it was a great, great learning opportunity because I got to learn a lot about the quality and patient safety role from the data and statistics’ side of thing. Probably the most surprising thing to me was how much data on our quality metrics we had been sending to regulatory bodies for years. It was just a requirement. Hospitals do it. You send the data. But we, like most hospitals, never looked at the data that we were sending. Then, as we started getting more performance metrics back from regulatory bodies, readmission rates, for example. We started seeing that our readmission rates were higher than we wanted them to be. [36:00] It shouldn’t really have been a surprise to us because we had been sending the data for quite a long time. I think the thing that helped me a great deal being in the quality and safety role is having the operational responsibility. It would have been very easy, for example with readmissions, to say that hospital should be doing better. We should decrease the readmission rate. How to decrease the readmission rate? It wasn’t just that quality and safety got to be the scorekeeper: I got to be the one that could engage people on the operational side to ask why it was that patients are coming back. What could we do differently to prevent them from coming back? I think the part of the quality and patient safety role that has been most exciting for me is the blending of the clinical operational role, as well as the quality and patient safety. I always joke with people and say, “I can make anything be a quality or patient safety issue.” It also gives me lots of latitude to ask questions about how we do what we do and if we’ve got an opportunity to do things better. It’s pretty hard for people to say that they’re not about quality and patient safety. That has given me a lot of latitude for the kinds of processes and the kinds of things that we can look at and we can try to improve.

02-00:37:26
Rigelhaupt:
With decades of experience in home health, where obviously it’s a setting where there are less clinical procedures and it’s inherently patient centered, because you’re not doing, are there things that you’ve tried to bring from that perspective to how you approach quality, to really, as you said, make it a very patient-centered process to improve the quality metrics, the data?

02-00:37:53
Dohmann:
I think probably the most compelling perspective to bring from home health to quality and patient safety was the patient: walk a mile in the patient’s shoes. One of the things that has always amazed me when I see patients at home is how much people can deal with in their own home, and are dealing with, and you don’t know that. So to sort of take that message back to hospital colleagues to make sure we’re staying focused on the patient. Just because you have two patients that have both had a heart attack, their backgrounds and their homes can be so, so different. To not take things at face value and to ask more questions. If there is a patient that’s getting readmitted, ask questions about what’s going on at home. A patient that comes into the hospital who is frequently readmitted for heart failure or readmitted for COPD: you come to find out that the patient doesn’t smoke, but they live in a household where everyone else smokes. Well, that’s pretty compelling, and that answers the question about why does this patient keep coming back. [39:00] I think it was that home health and hospice has set a foundation for me that it always has to be very patient centric and to keep asking questions so that you can better understand this individual patient that you’re caring for.

02-00:39:21
Rigelhaupt:
Being patient centric, can you think back to any conversations that you had with nurses, in terms of trying to build this up in the nursing program, or with the physicians, to try and have them think along a wider patient-centric view? I think every nurse is running for the twelve hours that they’re on, to provide high-quality patient care, and the physicians are doing it, but there is a way in which it could be very focused on the care that’s provided here. Are there conversations that you’ve had with the nurses to try and bring that into the nursing program, or with the physicians to have them think about what it would be like when they went home, and if you remember any of those conversations?

02-00:40:05
Dohmann:
Sure. I can remember back to the very early part of my career. Part of what got me interested in home health and hospice is that I would wonder about the patients that we cared for and when they came back. What happened to them? We had done such a great job in the hospital and yet they were back in a couple of days, as if somebody else must not be doing their job. I find myself, even over the years in talking with nurses here, where nurses will say the same thing: they don’t know why this patient came back when they did everything right. It must have been home health didn’t do something. Or the patient didn’t do something they were supposed to do. Or, in working with physicians: a physician can be very focused on this was the procedure that they did for the patient at that time and that’s where their focus was, as it should be. But sometimes it is helping that physician or that nurse to lift their head up and see the forest through the trees. It’s to say that I know they may have operated on the patient’s heart or replaced that patient’s hip, but there’s the rest of the body that’s attached to that part that you worked on and there are other things that we might need to consider in making sure we put together a good plan for the patient. Sometimes that is exactly the role I’m in: it’s to remind people to not just be focused on what’s right in front of them, but to consider that there’s a larger picture to consider.

02-00:41:32
Rigelhaupt:
Part of what you described, in terms of being patient centered and considering other things in a wider view, is the cost of health care. [42:00] I’m thinking, and this is a hypothesis, that trying to learn a patient’s story, to find out if they’re smokers, and the time associated with something like that might not translate directly to a code, in terms of a reimbursement for a physician, or for the hospital. How do you try to emphasize that and build that into a nursing and physician program when even parts of the medical record are tied to codes and tied to billing? This doesn’t fit as neatly with that process.

02-00:42:26
Dohmann:
Except it does in that the care that I provide to a patient may get translated to codes, or the care that a physician provides to a patient may get translated to codes, but you’re still providing care to a patient. No physician can approach a patient and say, “You’re a J5206 because you’re a cath patient.” I mean, we’re still taking care of people and how you go about doing that. You still have to interact with patients. I think the challenge is, as you mentioned, where I may be focused on doing this cardiac catheterization and I may not be thinking at this moment that this is the fourth hospital admission that the patient has had this year. Or, for the nurse that’s on the floor, taking care of whatever is right in front of them today, but who does not look at the patient across the continuum of care. So, for a patient where this is the fourth time they’ve been in the hospital this year with chest pain, and each time we test them and we rule out that it’s not their heart. We tell them it’s not their heart, but we don’t tell them what it is because further testing is needed. The next time they have that chest pain, they’re going to do what they did before. They’re going to come back to the hospital. Who fills that role as far as really managing the patient? I think, traditionally, we’ve thought of the primary care physician as the one who does that. For those patients that have good relationships with their primary care physician and really do the follow-up, but sometimes that’s hard in our health care system because the primary care physician may refer them to a cardiologist. They may refer them to another specialist. We don’t always get as good a coordination as we might like. It can result in extra cost in the health care system. I know that’s one of the things that the Alliance wants to address. For these covered lives, how do we do a better job of managing health care for these people across the whole continuum? Whether you’re someone who is pretty healthy and doesn’t need much health care, what does that look like for you? Then for the person who has many chronic medical conditions, how and who does that coordination to make sure that you get the right care, at the right time, at the right place and at the right cost? That is a challenge in our current system.

02-00:44:52
Rigelhaupt:
Have you seen changes in how chronic care is treated at the hospital, and particularly thinking about if you’ve noticed it from different perspectives in the different roles that you’ve had? [45:00] Hospitals are acute care centers and that’s their history, more so than being particularly set up to treat chronic conditions. But, as you mentioned, there are people who are admitted to be treated for chronic conditions. How has trying to treat chronic conditions changed during your career here?

02-00:45:26
Dohmann:
I’d say probably the most significant difference is how we use palliative care. Palliative care is intended for people that have chronic conditions and is focused on comfort and quality of life. We always focus on comfort and quality of life. Really, in every disease process there’s a role for palliative care, but what does happen in most chronic conditions is that as the disease advances, at some point the focus on quality and comfort surpasses the focus on cure. One of the things that I think we’ve done very well is how we utilize our palliative care resources, particularly for people that have advanced disease. We’ve spent a lot of time working with our cardiac patient population, for example, and for those patients who have had chronic cardiac disease for a long time. At some point in their care, somebody needs to have the conversation with the patient about this is a chronic disease that ultimately will lead to their death. As that time gets closer, how do they want to live their life? What decisions do they want to make about what they want and don’t want? That can be a hard conversation for anybody. For a physician that has known a patient for a long time, it’s documented and well referenced that for some physicians that is a difficult conversation to have with the patient and family because it’s almost admitting failure that they couldn’t fix what the problem was. By offering our palliative services to actually help and work with physicians to have those conversations with patients, we’ve gotten tremendously great feedback where patients have said, “No one has told me that. No one has asked me to think about it that way. I definitely know what I want when I’m at that phase of the illness.” For family members, they welcome this because they’d much rather know what to anticipate rather than being in the ICU, in a very high-stress time, and then being asked to make decisions and they have no idea what their loved one wanted. I think how we have integrated palliative care into the care of people with chronic diseases has been very instrumental in allowing us to improve that care.

02-00:47:46
Rigelhaupt:
You mentioned that palliative care involves teamwork. Who are the team members on the palliative care team?

02-00:47:54
Dohmann:
It’s a palliative-certified physician, nurse practitioner, social worker, and a chaplain. [48:00] Here, they work very closely with our hospice team that’s in the hospital. Any physician in the hospital can order a palliative consult. Then one member of the team, whoever is deemed to be the most appropriate for what the patient needs, will respond. It could be that our palliative physician or the palliative nurse practitioner will see the patient. They may identify that really what we’ll call the goals of care discussion is really what needs to happen and they may engage the palliative social worker to sit down with the patient and family to talk about the patient’s stage of illness and what their wishes are as their disease continues to advance. Absolutely, it’s a team approach to palliative care. Then the team has to work very closely with the physicians that are caring for the patient and also the nurses that are caring for the patient. If we’re able to identify with the patient what they want, then it’s critically important that the people who are providing that direct care to the patient know what the palliative team has been able to learn from the patient and family. Absolutely, it’s hugely dependent on strong teamwork.

02-00:49:12
Rigelhaupt:
Have you seen the kind of emphasis on listening to patients and finding out the family’s needs, the family and patient’s wishes through palliative care has influenced the nursing program, even where it’s not specifically a palliative care case?

02-00:49:28
Dohmann:
Yes. I think that there are examples, time and time again, where the nurses at the bedside will see or observe the conversation that the palliative team has with the patient and family and then realizes that they could ask those questions. We hear it all the time. I can remember when we started introducing our palliative team much more aggressively in with our cardiac patient population. When they first started working on that unit with the cardiac nurses, you could see them back away a little bit because that was something that was unfamiliar. Now, many of those very same nurses will step in and do much of what the palliative team had done and maybe use the palliative team as their resource to say, “I’ve had this much of the conversation with the patient or family, but they’ve got some other questions. Can you come with me so we can talk to the family a little bit more?” I think it absolutely has helped our staff and some physicians get more comfortable with some conversations. There are conversations they are having now that they might not have had, had they not been exposed to the palliative care service.

02-00:50:42
Rigelhaupt:
Nurses have more time and spend significantly more time with the patients in the hospitals, more so than the physicians. They have an opportunity to ask questions, learn things about the patient’s needs, and wishes, and even if it’s not officially palliative care as you referenced. [51:00] But, probably, when you began your career, taking that information from nursing to the physicians was not as easy a conversation. If I’m to understand this, historically, the hierarchy has made those conversations harder. Have you seen that change, where the physicians are more willing to listen to nursing staff?

02-00:51:28
Dohmann:
Absolutely.

02-00:51:29
Rigelhaupt:
How have you seen that change in your time here?

02-00:51:31
Dohmann:
Absolutely, that’s true because physicians rely on nurses. The best example I can give you is—it’s happened intermittently over time—where a physician will call and say that they’re frustrated that a nurse on the floor had called them the night before with concerns about a patient, but the nurse didn’t give the physician enough information to be able to make a decision. Taking that message back to the nurse on behalf of the physician where the physician says, “That nurse is my eyes and ears. You know, it’s one thing when I’m in the hospital and I can see the patient, but when that nurse calls me in the middle of the night, I’m going to make a decision. I’m going to give an order. I’m going to provide care based on what that nurse tells me.” Their level of confidence that the nurse can do a thorough assessment and give them good information that they can act upon is key. Physicians will openly say and acknowledge that they are dependent on the nurses that are providing care at the bedside. Certainly over the last 25 and 30s years, seeing the physicians getting much more comfortable with, “You’re there: tell me what you see and tell me your assessment.” The physicians will even go so far as to say, “Okay, what would you like me to do?” For nurses that are very comfortable and confident in their assessment skills and plan, they’ll say, “Well, I think we could try one of these couple of things.” The physician will say, “I agree. Let’s go with the first thing that you suggested.” Yes, that happens all the time, and it’s very commonplace, but physicians are all the time reminding nurses that they’re dependent upon the skills of the nurse.

02-00:53:17
Rigelhaupt:
How does the organization try and support the nursing program and perhaps with more training and education so that they can make the assessments and decisions that are going to be most beneficial? This is not necessarily the physicians, but it really is about the patient and they can be more confident to give the physician the information that will be the best for the patient.

02-00:53:42
Dohmann:
There are lots of things that we do. If you think about a nurse that’s just coming out of school—nursing school is hard and they learn a lot of stuff. Even whether it’s two years, three years, four years or five years, there’s a lot of information that’s put into that curriculum. [54:00] Now you’re a nurse that’s out on the floor. This is your first job and now you’re going to be depended upon to do those very things that I talked about: to do those assessments, to be able to talk confidently to a physician, and to have a physician make a decision based on what you provide to them. How we orient new nurses is very different from what we do with nurses that have experience. We even go so far with all nurses—and this is something that you see in hospitals across the country. They are also pretty prescriptive in the format that they use for referring to a physician. We use something called SBAR, which is subjective information. The patient has a fever or the patient is complaining. Background: tell me a little bit about the patient and why this bit of information is significant. What’s your assessment of the patient as the nurse, and then what’s your recommendation? We really coach people through following that format because, from a patient safety perspective, if a physician knows that that’s the way that they’re going to hear the information, they’re listening in a certain way. Now they can act on that a little bit more efficiently and effectively. We do lots of training and retraining for nurses so that they can function in that role because we’re really requiring them to do a pretty high level of critical thinking. That’s not something that anyone is born with. It comes through experience. It comes through practice. I’ve also had a number of times where a physician will complain to me about a nurse. After I’ve done some background I’ll say, “Well, now, that was her first phone call to a physician.” Let’s see what we can do to help that nurse the next time to give the physician more thorough information, but let’s also remember that none of us were born knowing how to do this. Let’s be patient and let’s not miss an opportunity to teach someone how they can do things even better.

02-00:56:06
Rigelhaupt:
You have held a number of high-level executive positions in nursing that required wide ranging thinking, hard critical thinking. What are some of the things that you would most want the young nurse to know about their job and nursing that you have learned through the executive positions you’ve been in?

02-00:56:32
Dohmann:
Probably the message that I’d give to a nurse is the very same message that I got when I was deciding to be a nurse. My mother is a nurse and she actually was a vice president of nursing at a hospital where I grew up. When I first went to college I thought I wanted to be a doctor. After a year or so in school, I decided I didn’t really think that was it. I thought that I would either want be a nurse or an accountant. [57:00] I liked math. I liked science. Those seemed like the two things. Nursing I knew something about because of having watched my mother. I happened to be home on a break from school and having to sort of redefine my major. I had this conversation with my mother. I was taken aback when I said to her, “I think I want to either major in nursing or accounting.” She got a little indignant and actually said, “What makes you think you would be a good nurse? And what makes you think we would want you to be a nurse?” Her message really was, and it’s the same message I think I give to other nurses: don’t be a nurse because you don’t want to be something else. Understand what the profession is, and then as only a mother can say, put all your eggs in that basket and do your very best to be the very best nurse that you can be. I think my advice to a new nurse or someone that was considering nursing, is that it’s hard. It’s hard work and you have to be very smart. You have to use all of your skills. Now, you’ll learn those over time and you’ll fine-tune them. It is the most gratifying thing that I could imagine doing because people depend on you to be smart and to do your job well. Then, at the end of the day, you know that you made a difference every day. I think that would be my advice to a nurse today or to somebody that was considering nursing.

02-00:58:35
Rigelhaupt:
How would you define, think about and describe the community benefit part of Mary Washington Healthcare, and what you’ve learned about it in the various positions that you have worked in?

02-00:58:50
Dohmann:
I think the fact that we’re a not-for-profit health system—and I’ve always worked for not-for-profit health care providers. As a not-for-profit health system the focus is on community benefit, which has really caused us to pause and look at what we actually do in the community to improve the community’s health. I think I’ve shared earlier that one of the things that’s been most compelling to me for my time at Mary Washington is our mission is pretty simple. We exist to improve the health status of the communities that we serve. We can do that through a hospital, if you need to be in the hospital, but the other responsibility that we have is to the community at large. [01:00:00] I think our community benefit work has actually caused us to really focus on, “What are we doing to improve the overall health status of the communities that we serve?” Not just what we do in the hospital or not just what we do in home health, but for the community. I think it’s been an educational opportunity for us and things that we may have looked upon historically as nice to do for the community. Suddenly now people understand it’s our responsibility to be doing these things. How do we do them most effectively?

02-01:00:35
Rigelhaupt:
The organization for over two decades now has supported something like the Moss Free Clinic. Is that now even more a part of something that’s efficient clinical integration, and that it’s not just something you do, and it’s not just the responsibility, but that it really is serving the purpose of health care delivery?

02-01:01:06
Dohmann:
A need. I think the other thing that the community benefit work has caused us to do is actually do that formal community needs assessment. To take that look and ask what are the health needs of our community? Then how do we best use our resources to meet those needs? So absolutely, the community benefit work has actually allowed us to focus on making sure we’re meeting needs.

02-01:01:30
Rigelhaupt:
Something like the community health needs assessment involves a lot of data, probably a lot of information as you’ve alluded to your interest in accounting, and probably an organic interest in the kind of information that comes through. How do you take that information and filter it down to and make it accessible for every-day nursing practices in the hospital so that it’s part of the nursing program and that you’re thinking about the community health needs?

02-01:02:05
Dohmann:
First of all, a lot of what we do is driven by data. Looking at the results, we’re not good just because we say so. We have to be able to prove it. You have to be able to use data to say this is what we need and this is how we’ve gotten better. I think the community benefit piece is where we’ve gone out and done the community needs assessment. To some degree, some of the information or some of the data that comes back, it’s not surprising to anyone, or as far as from nurses, but it’s sort of a validation. It is, “Well, we knew that, but now we’ve got the data to support it.” So, for example, if you talk about childhood obesity. I don’t think anyone would disagree that it’s an issue, but when you’re looking at a bunch of community needs and you suddenly see that one of the needs has much more data or is much higher than some of the others, it helps you. [01:03:00] It validates what you may already know. It also helps you prioritize to say you’ve got these fifteen community needs, but there are three that are really much higher than the others. Now, we’re going to focus our efforts on those three because that’s really where the need definitely is. I think data helps you prioritize while it can also validate what people have already been thinking. By having the data, it makes it that much easier to say, “No. Now this is the priority.”

02-01:03:34
Rigelhaupt:
What would you most want the public to know about your job? You’ve held a number of them in the organization and maybe you can answer that question for one or all of them. But, what would you most want the public to know about being a nurse leader that might not be common knowledge?

02-01:03:53
Dohmann:
It’s a great job. It’s always changing. No two days are the same. I think the message, from my perspective for the community, would be that nurses work really hard. They come to work every day with the goal of wanting to make a difference. Sometimes, that’s easy and sometimes that’s more challenging. My job, as a nurse executive or a health care executive focused on quality and patient safety, is to really support those folks that are at the bedside trying very hard to do the very best thing for that patient and loved ones. And I love it. I love being able to think, “Is there something that I can do to make care better for people in our community? Is there something that I can do to make things better for the staff that is working really hard to meet community needs?” I’m not so sure that that is not known, but it is certainly something that I’m very passionate about. I do believe it’s a privilege to have had the experiences that I’ve had and the roles that I’ve had. My job is to help facilitate the work of others.

02-01:05:11
Rigelhaupt:
What are some of the things about the organization, about Mary Washington Healthcare that you have seen through your years of experience, that you would most want the public to know about that might not be common knowledge or takes place behind the scenes?

02-01:05:28
Dohmann:
I think that one of the things that has kept me with the organization for the last eleven years is the overwhelming commitment to the community. Like I said, I’ve worked for not-for-profits before and the approach of a not-for-profit is that you’re essentially owned by the community that you serve. I was familiar with that before coming to Mary Washington, but that is how Mary Washington lives. It is here to meet the community health needs and every decision is made with that consideration. [01:06:00] As we’ve talked about before, whether or not we became a trauma center was driven by whether or not the community needed that. Then of course we would do that. We’re now doing work on a structural heart center to bring other cardiac surgical procedures here. I was recently involved in getting that business plan approved. Again, the question was the same, why would we want people in our community to have to go elsewhere for that? Of course, we should bring that here. For me, the most compelling attribute of Mary Washington Healthcare is its commitment to its community and to the health care needs of the community it serves.

02-01:06:49
Rigelhaupt:
The way I like to end these is with the last question, which is actually two questions. Is there anything that I should have asked, and I didn’t? And is there anything that you would like to add?

02-01:07:01
Dohmann:
I don’t think there’s anything that you didn’t ask that you should have asked. And, no, I don’t think that I have anything else to add either. I think your questions have actually been very good.

02-01:07:19
Rigelhaupt:
Thank you. Thank you very much for the interview.

02-00:01:07:21
Dohmann:
Thank you.
[End of interview]