Marianna Bedway

Transcript

Interview 1 – November 13, 2013
01-00:00:06
Rigelhaupt:
It is November 13, 2013. I am in Fredericksburg, Virginia, at Mary Washington Hospital, doing an oral history interview with Marianna Bedway. As I mentioned, I wanted to start by asking you if you could describe your first shift at Mary Washington Hospital.

01-00:00:24
Bedway:
My first shift was over twenty-five years ago, taking me back to the old hospital on Fall Hill Avenue. That first shift was as a part-time evening nursing supervisor. It was filled with an excitement around a new responsibility and a new town. I moved here from Ohio and had worked in surgical nursing at Akron General. It was a whole different experience. A lot of people to meet—and I just remember being nervous but excited.

01-00:01:02
Rigelhaupt:
Part-time evening supervisor: you walk in, what are some of the first things you know that you’re going to be in charge of and working on that day?

01-00:01:11
Bedway:
Back then in that role during days there are a lot of resources, but during evenings and nights it’s less. The nursing supervisor was responsible for staffing the inpatient units, for getting meal trays for patients who were late, actually going to the pharmacy and mixing medications and delivering those because the pharmacist had gone home, meeting the local funeral homes to release a body, and handling any concerns family members had. You were really a jack-of-all-trades back then. Today, it is just a whole difference in terms of all the support and infrastructure that are there.

01-00:01:45
Rigelhaupt:
I’m just going to pause for a moment. So, had you had experience doing, as you described, the jack-of-all-trades at Akron General?

01-00:01:58
Bedway:
At Akron General I was a surgical orthopedic nurse. When I moved to Fredericksburg, I had the opportunity to work at Pratt Medical Center in many of the different physician offices as a float nurse, which really helped tremendously. I got to meet the bulk of the medical community that was here in Fredericksburg at that time. It really helped with the relationships and my supervisory role here. But no, it was a complete new role for me. There was a lot to learn, but I really enjoyed it.

01-00:02:24
Rigelhaupt:
What were you most excited about, working that first shift?

01-00:02:30
Bedway:
I would say meeting new people, really getting to know all of the nurses I would be supporting on the 3:00 to 11:00 shift, and getting to work so closely in different clinical service areas. It was everything from helping a surgeon get an OR case on the books for the next day to making sure that the ED was flowing well back then. The technology and everything was so very different then that it almost seems primitive, looking back on it at this point and where we are today. [03:00]

01-00:03:02
Rigelhaupt:
So, you were working, supervising, maybe not as much hands-on with the patients, straight out of surgery to the emergency department, you were covering almost everything?

01-00:03:15
Bedway:
Yes, on 3:00 to 11:00, as the nursing supervisor, you are covering the house, making sure that everything was staffed and resourced, and your pager would go off for whatever was going on. At the time, we didn’t have trauma services. If someone needed to be acutely flown out, you were making arrangements with James Monroe High School for the helicopter to land on the football field there and the ambulance to transport the patient over there to actually leave. You just didn’t know what the evening shift would bring when you came in to work.

01-00:03:49
Rigelhaupt:
Was that part of what made it enjoyable, this sense of seeing everything?

01-00:03:54
Bedway:
Yes. I think it’s really helped me over the years as an operational leader to understand how all the different departments function and how they all need to work together. That really prepared me for my future operational leadership roles.

01-00:04:09
Rigelhaupt:
So, what made you choose to accept the position at Mary Washington Hospital?

01-00:04:15
Bedway:
When I was in nursing school at Ohio State, I was in a university setting and at Akron General, that was a teaching facility also. We moved to Fredericksburg primarily for my husband’s job. I came to, at that time, a community hospital and it was the largest health provider in the community. It was the game in town. That’s why I wanted so badly to get on at Mary Washington Hospital, and that was the position that was available at the time. I did have my bachelor’s in nursing, and a lot of the nursing staff, at that time, didn’t have additional degrees. They thought, “Well, we’ll give her a try on this evening position.” And it worked out well.

01-00:05:02
Rigelhaupt:
How would you compare what you saw in a community hospital to Akron General?

01-00:05:09
Bedway:
The whole climate was very different, and not different good or different bad. It was just a different environment, not being an academic center. There was more of a sense of family. What did catch me off guard back in those days is that you would go on to a nursing station and the nurses and physicians would still be smoking at the nurses station and in the cafeteria. It was an environment that would not be seen in health care today. The staffing ratios and demands were a bit different because there wasn’t the same high-tech type of procedures being done here at that time as there was at Akron General. But we have quickly evolved to that now. [06:00] The medical staff was the local physicians. It wasn’t with the students, and that type of a setting with residents and interns.

01-00:06:18
Rigelhaupt:
This is a big, open question; but what did you see as the hospital’s core values when you started?

01-00:06:28
Bedway:
It’s interesting because we have evolved over the years in terms of what the stated core values are, but they’ve always been there. That’s one of deep caring for the patient and a high focus on quality. A curiosity for now it’s coined as innovation, but even then we were always exploring what we could do different, what we could do better, and what additional services we could add. I think over time, we have stayed pretty true to being a very caring organization and deeply-rooted in our values system.

01-00:07:04
Rigelhaupt:
Were the values as written out as organizations write them out now when you first started?

01-00:07:12
Bedway:
I do remember receiving a little pin that had the values in the circle around it and they were very similar to our stated values today. But when that really seemed to take hold was when Mr. Rankin joined us. He moved down from Pittsburgh. What he was able to bring to us was a whole attention and focus around our physicians, and the importance of our physician community and partnership with us as operational leaders. He reinforced that needed sense to stay true to values, which we had done, but it just feels like he formalized that quite a bit when he came.

01-00:07:51
Rigelhaupt:
How much did you interact with the administration, early as a nursing supervisor?

01-00:07:59
Bedway:
It’s interesting. As a part-time evening nursing supervisor, I was one to not take the elevators, but to run the steps a lot. I remember running into Joe Swedish and Mr. Jacobs. At the time our CNO was Priscilla Schuler. I was seeing them in the hallways, but not having a lot of interaction unless there was some certain hot activity going on. Then they would want the nursing supervisor to come in for their input. I remember just being in awe because they would be at the board table that I sit at now. They were inviting us at different times to different meetings when there were different events going on.

01-00:08:37
Rigelhaupt:
Do you remember any of the specific topics at the meetings, or things that you would have been called in for?

01-00:08:45
Bedway:
I think back then it was around some different activities—I’m trying to think. I got very involved with, of course, the planning for this facility [the new hospital]. That was when it was time to actually start the operational planning for the patient care and the patient move. [09:00] A lot of the design meetings related to the inpatient units and those things—those were the type of meetings that I would be brought into. Also, if there was something that was more event-related. I remember we actually had a bomb threat in the emergency department one night when I was working 3:00 to 11:00. I was about nine months pregnant with my son at the time. I remember we had to evacuate the emergency department to another area of the hospital. That certainly had a few administrators come in that night. Of course, there was no bomb but it took us all to a very different place than we had been before.

01-00:09:42
Rigelhaupt:
How close was the working relationship between the nurses and the physicians?

01-00:09:46
Bedway:
Very close. Back then you knew the physicians very closely. When the physicians came on—I was still a little bit old school then—you stood to offer them a chair or got the charts and made sure that they had everything they needed. Now with systems being electronic, it’s a matter of who needs to juggle to get to a PC, and they’re plentiful here. But back then, there was a very good sense of camaraderie and partnership with the physicians. There still is, but the medical staff has grown so much that it’s hard to know everyone’s children, their interests, and things like that. I still work really hard on that, but it’s tough to keep up with a medical staff of this size. Back then it really was a sense of family.

01-00:10:40
Rigelhaupt:
Were there a lot of conversations about medical care and new practices in the sense versus coming from a teaching hospital where research probably comes to the bedside quicker? How did you learn new things as you were working early at the hospital?

01-00:11:05
Bedway:
Early on at Mary Washington, it seemed when a new physician would join us from a different academic area—and the same thing with nursing leaders, pharmacists, and other clinical leaders—as we recruited they brought new knowledge and a new infusion of ideas, programs, and services. You have continued to see that in terms of the technology that was added in our critical care areas. We brought on the cardiac program and continued to enhance different services. It had a lot to do with who was coming in to the medical staff and clinical leadership, and that you would see that ongoing infusion. Certainly once Fred [Rankin] joined us, there was also that curiosity and partnership with the VHA and other wonderful organizations in terms of what is out there in health care for us to get more on the forefront. [12:00] He drove a lot of that quality and innovation once he came, as well.

01-00:12:07
Rigelhaupt:
Did you have an impression of the role the board played when you first started here?

01-00:12:15
Bedway:
I only had a sense of the role a board played because I had the good fortune to have a wonderful father who was a community leader; he was on several hospital and bank boards and college boards back home in Ohio. My dad actually helped bring up a community hospital in Cadiz, Ohio and was on the board there. I was familiar with the amount of time and investment he took as a private citizen to support local communities and health care. That has also helped me over the years to be very comfortable interacting with our board because I would look at them like it was talking to Dad and his friends, who were just deeply committed community members. We have a wonderful board. Several board members have been on and off the board for many years. You do, over time, develop relationships with them as community leaders and people that you do see out and about.

01-00:13:09
Rigelhaupt:
Thinking about those first few years before the move to the hospital we are in now, was there a sense that there were new practices coming on, or was the hospital itself really sustaining what it had been doing?

01-00:13:28
Bedway:
I think the whole impetus for obtaining the site and building this hospital was related to we were limited in that building. We were limited from an infrastructure of space and from an infrastructure of the technology that was about to come. Once again, we didn’t allow ourselves to be held back. You would look at a new service or a new program and try to figure out where and how would we offer that because we were pretty land-locked within the structure of the building. Within the confines of where that building sat we were completely surrounded by homes and the high school. Then it was the infrastructure and what technology we could run through those cinderblock walls.

01-00:14:13
Rigelhaupt:
Did you get a sense that there was a lot of interaction between the clinical staff and the administration, in general, that there was a close working relationship?

01-00:14:25
Bedway:
Back at the old hospital, we used to have regular quarterly town hall meetings. I felt that administration was very accessible, even though I worked on evenings. They may have been on their way out, but there was very good open door policy with Mark Zimmerman in human resources at the time, and then Walt joined us—Walt Kiwall in human resources. And like I said, with Joe Swedish, Mr. Jacobs, and Priscilla Schuler, you were able to go into the executive suite and access the administrators. [15:00] Of course, the leaders on the units—all the nurse managers and directors of the pharmacy and all—they were all very accessible. I think everyone collaborated real well back then, and had a common focus and common good.

01-00:15:14
Rigelhaupt:
So, speaking of the new facility that—well, I’ll still call it new, as we walk by the twentieth anniversary—what do you remember about the first conversations about this as a possibility? Not necessarily the real planning, but even the kind of water cooler talk that this might be happening.

01-00:15:36
Bedway:
The water cooler talk, especially with the working front lines staff was for them to get an understanding of why we needed to do it. They were coming into work, caring for the patients and the patients had a bed; and the whole understanding of how care was delivered outside of the Fredericksburg area may not have been as understood. Back then it was semi-private rooms. As a nursing supervisor you had a patient to place. You had to have the females together, of course, and the males together. But also looking at different infections and things like that. Who wanted what TV channel on because they had one common, shared TV between the two alcoves, if I remember. It would get very dicey, just trying to place patients. The whole concept of what we could move towards in terms of private rooms and as spacious as it could be. A whole different environment for care—I think it was difficult for the frontline staff to kind of envision it. I think they, very much like the rest of the community, were wondering, why does Mary Washington need to build a new hospital? The one we had was fine at the time, but by the same token, you would have some more progressive thinkers understand, wouldn’t that be cool if we were in a new building and had all these different resources available? It was a mixed bag, just very much like the community.

01-00:17:02
Rigelhaupt:
So, there was a sense of skepticism from the staff?

01-00:17:06
Bedway:
I think that there was a little bit of skepticism from the staff because they are part of the community. There was some skepticism on the part of the community at the time as well.

01-00:17:22
Rigelhaupt:
As you first started hearing about this, how did you think your job would change at a new hospital?

01-00:17:35
Bedway:
Looking back I don’t remember the exact thoughts I had, but it certainly was one of getting involved with it because you could just feel the energy and the excitement around the whole thought of moving to a different campus and building a new facility. I just tried to get engaged with as many planning meetings that they were interested in having me in, and being part of the planning. [18:00]

01-00:18:01
Rigelhaupt:
Do you remember what year and how early on you became actively involved in the planning?

01-00:18:09
Bedway:
The involvement with us came about closer to the time where they were doing design. The decision was already made. I am sure the land was already purchased, and all of those things that were more at that higher level and board level decisions. But pretty quickly when it came to time for designing rooms and space and things like that, they got focus groups in. That is when front line staff and myself joined in.

01-00:18:36
Rigelhaupt:
So, early on in the design process, you were among the leaders from the nursing staff, thinking about rooms and the space in which you would be interacting with patients?

01-00:18:45
Bedway:
I remember the nurse leaders at that time would have focus groups, and I was just one of the working staff that was part of it at that time.

01-00:18:56
Rigelhaupt:
What do you remember about the nursing staff emphasizing they wanted to see in patient rooms?

01-00:19:04
Bedway:
Having the private rooms was a very definite plus—storage, at the time, and having access to other equipment and supplies. Of course, none of us could have even imagined what technology we would be using. Back then, the whole idea of medication carts that you would be pushing around versus the technology we have now with scanning devices. At the time, I think it was just a matter of having the equipment and supplies you needed as close to the patient at bedside as you could get it. That was the key focus there. But there was concern about the size of the new units and walking the long halls. I remember everyone was a bit concerned about how large the units would be; and they have shrunk in time very quickly, if you know what I mean. Moving from that space [2300 Fall Hill Avenue] to this space [101 Sam Perry Boulevard], initially, it seemed like we had really gone to these huge units with these long, expansive hallways. Very quickly it kind of closed in on us as all the technology and equipment filled in.

01-00:20:23
Rigelhaupt:
What do you remember about the emphasis in layout, in terms of even where nurses’ stations would be in relation to patients? Maybe if you could talk a little bit about different spaces, in terms of even the layout of the emergency department versus a layout in an ICU, what the nurses were emphasizing?

01-00:20:47
Bedway:
It’s hard to think back that far because certainly, we have added on and changed the emergency department significantly from when we first walked into this building. I think the footprint of what was the ED is now the center of the radiology department. [21:00] I was involved more in the inpatient unit planning. Once again, it was designed so that there would be satellite nursing stations along the two corners of how the units are shaped. You would come on to the unit and there would be a little reception station and then the back work station. But all of that has been completely redone over the years, too, as different technologies come on. The architects were very involved as well. As experts who have built the newer, progressive hospitals they had a lot of direction they were providing so that we wouldn’t limit ourselves in our thoughts of how it could be.

01-00:21:51
Rigelhaupt:
Part of the focus groups you described was talking with architects, designers, and really thinking about how nurses would move through the space?

01-00:22:01
Bedway:
Yes.

01-00:22:10
Rigelhaupt:
The last walkthrough—I’m sure you had a last visit before there were patients here. Could you describe what it was like to walk through this brand-new facility that was ready to go, but there was no one there?

01-00:22:28
Bedway:
It was very exciting because we had the opportunity to provide tours. We were able to tour the staff before we came over. We had a large open house for the community. It was actually an opportunity that we tour the community through the ORs and areas that once we were open and it was show time, the doors are locked and the red lines on the ground. Those are not areas, unless you’re here for services, you really go beyond and explore. I remember how expansive it seemed and how bright. Once again, there was a sense of excitement that we’d have the opportunity to provide care in this location. I remember just being very, very excited, and also, almost overwhelmed and in awe of the level of detail that goes into building a structure this size and planning for critical services. All the testing that had to take place on everything from the elevators, to the food service equipment, to the clinical equipment; lots of testing and modeling before we actually brought the patients over that Sunday morning.

01-00:23:36
Rigelhaupt:
It sounds as though this was a real opportunity to educate the community, the fact that this was done and open, but still empty. Did you lead any of those? Were you on those tours, and were you talking about what this new hospital represented for the region?

01-00:23:53
Bedway:
We all had the opportunities to be involved with and lead the different tours, which was fun. [24:00] I just remember it being almost a festival environment when we had the community open house day here. You literally had small children and people just scampering through the hallways and looking in different areas. It was pretty exciting. So, yes, I think it was pretty much all hands on deck. Once again, that sense of family—that was the culture of Mary Washington Hospital at that time. There was that sense of family and just being very excited that we were moving in to our new home.

01-00:24:31
Rigelhaupt:
So, you were involved with the planning: do you remember any early conversations about that this would serve as a kind of anchor for a regional medical campus that it serves now?

01-00:24:48
Bedway:
You would hear the vision of the senior leaders when you were in the associate updates; those were the quarterly meetings that were held. You would hear that vision from Mr. Jacobs—and Fred had just joined us at that time. They felt this would be that anchor and could become a much more mature system. I’m not sure if we used the term “tertiary” back then or not. But once again, I was more of a front line staff level nurse in this supervisory role at the time. I remember just being inspired, if you will, because you could see that they were leaders that had a vision.

01-00:25:36
Rigelhaupt:
You played a prominent role in the move of the patients from 2300 Fall Hill to here. Could you talk about how you got involved and some of what your first goals were as you began that process?

01-00:25:50
Bedway:
Steve Ennis, who was the lead move coordinator at the time, had tapped Sue Hall, who was the nursing director of medical nursing and my boss as nursing supervisor. They were really in charge of the patient move, and it was an opportunity for me as a new, young leader, to say, “Me, too. Me, too. I want to help.” We had a ball planning together. We ran through every scenario of what it would take to move a critical care patient, to move a laboring patient, to having both ORs running, both L&Ds, both EDs running, and how we would stagger the moves over. We had great planning sessions with our local EMS community. We had ambulances from far and wide that morning. We did two mock moves to prepare us. We actually had our engineering department build something called a pump platform—it was a special little platform that could anchor the IV pumps to and would fit on the rescue squad stretchers so that we weren’t trying to navigate IV poles into the back of the ambulance bays. [27:00] It was quite exciting and very innovative. I don’t know. But it was probably a career highlight in terms of being part of the planning and then the actual execution of that plan on that Sunday morning. I was with a great team and, a young nurse leader, and had the opportunity to be mentored by Sue Hall and work collaboratively with Steven and some others.

01-00:27:29
Rigelhaupt:
What was something that went really well that morning, in thinking about a hard patient to move that you saw actually turned out to go exactly to plan, per se?

01-00:27:39
Bedway:
You know what; it’s really interesting that I don’t remember any significant bumps. I think at the end of the day, it was that “aha” of how smooth the execution went because we had what-if scenarios for anything that could kind of come up. A lot of that had to do with Steve Ennis’s background with emergency preparedness. I learned a lot about emergency preparedness, how our fire and EMS community really works and how they run incident command. I think just honing in on those project management skills and learning that new skill set has been valuable throughout my career here with other projects. That’s what really made that day special: we didn’t have any very tense moments. Everyone was handled with great care, with high quality, and it was a very effective plan that didn’t have any bumps in the road. I’m still in awe of how well it went, twenty years later.

01-00:28:50
Rigelhaupt:
So, what was your position, exactly, when this hospital opened?

01-00:28:57
Bedway:
When this hospital opened, I was moving from being an evening nursing supervisor to being promoted to the manager of the nursing supervisors and being responsible for the nursing administration office. I was responsible then for the nursing float pool and the elements of how we did staffing with an old, antiquated system called ANSOS. We’re just in the next couple of weeks going to be replacing it; it’s been out staffing software system for twenty years. Back then, I was transitioning from the point of being a part-time nursing supervisor to full-time and to my first manager role.

01-00:29:43
Rigelhaupt:
So, you’re coming on as a nurse manager, beginning that position, what do you remember about the first few days of watching your colleagues work with patients in this new space? Did it seem different, did it seem like it had been going on for years? What was your impression of those first few days of working, for nurses working in this facility? [30:00]

01-00:30:04
Bedway:
For the first few days, it felt like we were all out of place a bit, if that makes sense. You were used to running the halls and running the stairwells of the Fall Hill building and then here you’re going on to these different units. We were getting acclimated to the whole team in the new facility, and everyone was learning where things were, if you will, in terms of how to make their day flow. How do you round with the physicians? How do you care for the patients? Are you transporting longer distances? What I didn’t appreciate back then that I do appreciate now, is just the whole concept of workflow and how you need to have lean processes so that there’s not waste and everything’s value-added. I’m not sure we really understood all of those principles back then. There were some workflow issues that we needed to work out. We had lots of drills and different things here in terms of how care would be provided. But I don’t think we appreciated the long hallways, the extra transport time, and some of the inefficiencies of being in a larger building.

01-00:31:13
Rigelhaupt:
So, you were talking about workflow: could you describe—because you’ve worked in a lot of different departments—how that would affect you, being in your medical rooms and that nursing versus the emergency department, and some of the things that you noticed early on with the move here?

01-00:31:30
Bedway:
I don’t think it’s just with this move. As we do construction or additions on any department, it is just really understanding how the physical design of a space impacts how you work in that space. It’s not that there was necessarily anything specific. It’s just that in each unit, whether it was pediatric, medical, surgical, or in critical care, everyone had to figure out how that flow would work. Some changes that we actually needed to make were to some of where cabinets were located or equipment was originally located. But I think that’s just part of that always improving and always looking for opportunities to do things better. All in all, everybody was just happy to be in this beautiful, clean, bright, and large facility. The euphoria carried on for quite a while. People took pride in the facility, too, and they still do. I think that’s why the building looks so good. There’s a real sense of you see it, you own it; you spill, you clean up, and you don’t drop pieces of paper—just this sense of pride in terms of keeping it looking as good as it does. It’s not environmental services’ responsibility. It’s all of ours, taking care of the facility that we worked so hard to get.

01-00:32:54
Rigelhaupt:
Some of the ideas that are needed, or that come up about workflow, [33:00] maybe just imagining, like, the first year you were here, that time, did those ideas come from front line nurses? Did they come from nurse managers? What was the interaction when people start noticing that we could do things slightly differently?

01-00:33:19
Bedway:
I’m trying to think of what the timeframe was. I believe it was just a couple years after we were in this building that we actually had one of our senior leaders get very involved with the concept of organizational development and performance improvement. Ray Pittman started our first OD department, our first organizational development department. I remember we were, once again at an associate update, one of the large forum meetings. Mr. Pittman was standing before the group, talking about this concept of organizational development and doing performance improvement. He would be starting this department and that there was an opportunity for several of us to get involved with Ray and with what he was creating. I left the position of nurse manager of the nursing administration area to be one of the first nurses in the organizational development department. It was an opportunity to really learn and understand the principles of quality and performance improvement with Ray, and then be involved with performance improvement with different departments. Whether it was a case management redesign or there was a radiology improvement project—as a nurse, having the opportunity to be involved with those different departments to improve upon flow and help improve quality was exciting. Then over the years, it turned into us actually recruiting industrial engineers who are formally trained in that background, and that’s what it ended up evolving to. By that time, I had already stepped into the emergency department as the director of emergency services. Adding industrial engineers has been wonderful for this organization to improve quality.

01-00:35:15
Rigelhaupt:
Your mention of the emergency department is actually where I was going to head next. When did you become director of the emergency department, and if you could describe the process of taking on that role?

01-00:35:28
Bedway:
Wow. It was the December of 2003 and I was a member of organizational development doing customer service improvement work. I was working pretty closely with the emergency department leadership at the time. The nursing director at the time was departing, and they needed someone to step in on an interim basis. So, I stepped in interim, for two and a half years. It was at a time when we only had one emergency department in the community. Now, we have four. The volume was quite high. [36:00] There was the opportunity to really go in and do an examination of how we were delivering care and use wonderful benchmarks from different organizations—whether it was the Academy of Emergency Physicians or the Emergency Nurses Association—for really understanding what practices we were following. It was actually applying some of the Emergency Nurse Association standards for staffing and care delivery and then working with my great physician partner leaders at that time, Dr. Drew Garvie and Dr. Jody Crane. We formed a wonderful team within the department. We brought on a business manager, a quality nurse, and a clinical nurse specialist—as a leadership team, together, improved the processes of care. Jody Crane was very involved with his master’s degree at the time and we focused on applying lean principles there. That was the first lean department in the hospital, if you will, where we actually applied principles of workflow and got some great outcomes.

01-00:37:15
Rigelhaupt:
What did you see as the biggest challenges that you were going to face, being the director of the emergency department when you began?

01-00:37:25
Bedway:
One of the greatest potential challenges would be the fact that I was not emergency department nurse, in terms of my background or training. If you know anything about critical care nurses or emergency department nurses, they can choose to eat you for lunch if you’re not one of them. This wonderful group of nurses did not do that because they knew I respected their knowledge and the work they did at the front line. I was there to make sure that they had all the tools and the resources that they needed in order to deliver outstanding care. But I would hold them accountable to quality standards and human resource standards. I would be consistent and fair and provide whatever educational opportunities they needed, as well. The greatest challenge could have been that I wasn’t an ED nurse. The real challenge we were facing at that time was just an incredible volume. The department had just moved into the new fifty-bed ED. Once again, we moved into the emergency department without a real plan of how to work in that footprint. I know that we strategically looked at which areas of rooms could be broken out into different teams, and what teams needed to be opened or closed by day of the week and time of day based on the arrival patterns of patients. Instead of staffing most of your nurses on days, with less on evening or nights, like you do on inpatient units, staffing would be based on the care demands. The emergency department’s show time is really from 11:00 a.m. until 8:00 or 9:00 p.m.; there are the various swell of patients with a couple of peaks. [39:00] The biggest challenge was probably revamping the resourcing on when you scheduled staff so that you were meeting the demands of when the patients actually arrived. We didn’t need to do that just in the emergency department—you have to parallel that with the laboratory, with radiology, and all the other areas. Everyone came together beautifully and understood that we were the front door of the hospital and we were backing up into the streets, at that time. The only way to really address it was to address it from a very systems perspective. I had great support from the leadership at that time. We were working with Mr. Rankin, Walt Kiwall, and Kevin Van Renan to get those changes made.

01-00:39:51
Rigelhaupt:
Did working with radiology and the lab, other parts of the hospital, present challenges to ending the backup onto the street in the emergency department?

01-00:40:07
Bedway:
They were as invested as the emergency department was in terms of making it work better for the patients. That was the win-win and continues to be. There is still an interdisciplinary team that meets on a regular basis. It has everyone at the table—emergency department, radiology, lab, environmental services, case management—and everyone on the continuum to make sure we didn’t lose ground with that flow. When you think about that, there has been ten years of performance improvement that has continued consistently around that. No, all of the ancillary departments have been just wonderful, wonderful partners with the emergency department to keep the flow going.

01-00:41:02
Rigelhaupt:
Was the expansion, the doubling of size in 2000, about volume? Or did you have a sense already then that you wanted, as an organization, to grow some of the services that would be available in the emergency department?

01-00:41:20
Bedway:
The services that were continuing to be offered from the health system at large is what put us on the map of being that tertiary center that we’ve become. The emergency department needed to keep up, if you will. People were choosing to come to Mary Washington Hospital as our reputation was enhanced with the additional clinical services. The vision and strategic plan that the board and the senior leaders had at those times, to continue to add the services, did have the impact of more people coming to the emergency department for care. The plan to increase the size of the emergency department was very much driven by the board and senior leaders, and also with our vision of moving towards being designated as a trauma center. [42:00]

01-00:42:08
Rigelhaupt:
The trauma center was what I wanted to talk about as well, but were the discussions happening already as early as 2000, as part of that expansion?

01-00:42:22
Bedway:
Part of the expansion of the emergency department? I think every construction project that occurred with Walt Kiwall as our leader, whether it was the expansion in surgical services, the emergency department, the addition of the big ICUs and things like that—it was all geared towards what services would be coming on board, with trauma being one of them. Yes.

01-00:42:51
Rigelhaupt:
What year would you say the planning to start the trauma program really kicked off?

01-00:42:59
Bedway:
There was always the intent to move in that direction. But it was when a state study was released that really identified for all of us that there were two big gaps in the Commonwealth of Virginia, one around Winchester and one on the 95 corridor that needed trauma—being here in Fredericksburg. That became the real impetus. That is when the formal business planning occurred—that is, when we actually moved forward with the decision to recruit a lead trauma surgeon to help us build the program and all that work really started to take off at that point. That was getting closer to 2000—I don’t want to get my dates mixed up—closer to the 2006, 2007 timeframe, when we were in full swing with all of that.

01-00:43:58
Rigelhaupt:
So, you started in 2003 about two and a half year stretch with the emergency department. In that role, were you were having conversations about the need for a trauma program.

01-00:44:09
Bedway:
What I was doing at that time was actually developing the nurses so they were TNCC certified, trauma nurse certified. Actually, any opportunity that you had to elevate the clinical practice—after being the director of emergency services, then becoming the vice president for clinical support, I picked up the responsibility of the laboratory, physical medicine and rehab, and some other areas. Those departments all had a role to play with trauma as well. It dovetailed nicely because then you had the director of rehab at the time who knew what it would take to take care of trauma patients and the laboratory in terms of the massive transfusion plan and to form the blood bank. So, once again, you just had that wonderful collaboration of clinical leaders who all came together with the planning. [45:00] I don’t know, I just can’t describe it so much; it was based on having good working relationships, a lot of respect, and a common goal of what we’re trying to accomplish together.

01-00:45:19
Rigelhaupt:
Were you involved with recruiting or interviewing the physicians that helped start the trauma program?

01-00:45:25
Bedway:
Very, very much so. I was right in the center of that planning. We spoke to a couple of individuals who were interested in joining us once the program was up, but they didn’t necessarily want to roll up their sleeves to do the tough work of bringing the program up because they knew how risky that would be. It takes a lot to build a program of that magnitude that touches so many clinical departments. I really feel that we chose the right leader in terms of someone who had experience in terms of trauma, both on the military side and in the academic side. This was his first non-academic start-up, but he was very seasoned with his experience of protocols and had a very good way of partnering with me in terms of bringing the program up. We were able to get designation from the state at our first application and it went very well. In collaboration with Dr. Roberts, we were able to recruit a very first-class team of trauma surgeons and PAs. We ended up getting ACS verification; the American College of Surgeons verified us as a Level II trauma center and we’re the only ones in the state who hold that. I was very involved with bringing Dr. Larry Roberts here from West Virginia University. He was at San Diego and then prior to that was in the military as a Navy trauma surgeon.

01-00:47:05
Rigelhaupt:
I’m not sure how to phrase this question, but looking back on the origins, what seemed more challenging to start up—the bigger program or the medical side of it? That, you know, when a trauma case came in, that you would have physicians and nurses ready to treat right there, in terms of patient care, versus the bigger program that was needed?

01-00:47:34
Bedway:
The physicians and the other clinical expertise is all part of the program. I really couldn’t separate one from the other. The wonderful thing of where we had evolved as a health system is many of those physician specialties already resided here and those groups that needed to be here. The difference was the call response time and from an access standpoint. [48:00] But once again, there was collaborating with the emergency department physicians for them to understand what scope of trauma they had always taken care of and they would now have a trauma surgeon partner coming down to help run those resuscitations. We collaborated on what the role is with the anesthesiologists for the higher level codes and for airways; the difference from CT, in terms of if a patient would go from the emergency department through CT and right up to the OR or to the ICU as opposed to having a test and coming back to the ED because trauma patients move forward in their care. I don’t remember it being as great of a challenge as you would think because, once again, once we had made the decision that we are going for trauma designation, a lot of what could be perceived as resistance seemed to dissipate and everyone came around the table and came on board.

01-00:49:02
Rigelhaupt:
What do you mean by “resistance?” Who and where would that have been coming from?

01-00:49:11
Bedway:
There were members of our medical staff community who would say to me, “I came to work at a community hospital.” It is a different responsibility in terms of call and response time and things of that nature. But I think so many people have been touched by trauma, whether it’s one of their children’s friends who is in a car accident or the catastrophic events like the Boy Scout Jamboree with the electrocution. We were able to be there and be responsive to tragic mishaps that do happen, from construction accidents and other things. In the past, all those people would be flown from this community to other facilities rather than being able to be treated with our expertise here. The only resistance we had at first was how it was going to create a burden that they hadn’t signed on for when they joined the medical staff. But that has all dissipated—seemed to have dissipated over time.

01-00:50:09
Rigelhaupt:
Was this from anesthesiologists, radiologists, people who would normally probably be on call, or was it other physicians from other areas?

01-00:50:25
Bedway:
From other areas. But like I say, those who are qualified to take trauma call and enjoy it, they are the ones who have gotten on board and been very consistent through the program. Our anesthesiologists and radiologists have been just amazing partners, and we really have first-class anesthesiologists and radiologists. Their groups are very selective, as are all of our physician groups, in terms of who they bring on. It’s where I have received care and my family has received care here because you feel really good about the medical staff here. [51:00]

01-00:51:03
Rigelhaupt:
So, starting a trauma program, you mentioned the trauma nurse certification, it sounded like it hadn’t been done before. Were there other new things that needed to be done with the nursing staff to bring up for the trauma center designation?

01-00:51:19
Bedway:
Right. The state has requirements of how much continuing education physicians need and what nurses need. In the past, we would get trauma patients when the helicopters weren’t flying, and we would be managing them in the emergency department anyway; and then they would get transferred out. The focus of our work needed to be primarily past the doors of the emergency department; the additional education and training was offered to the OR nurses, to the ICU nurses, and to the step-down units. All of that was accomplished through a comprehensive work plan that we had for bringing the program up.

01-00:51:58
Rigelhaupt:
That took a couple of years, it sounds like, from roughly 2006 to 2008.

01-00:52:04
Bedway:
Yes.

01-00:52:09
Rigelhaupt:
Another part of trauma is working with the EMS community. Did starting a trauma program change the relationship in terms of bringing expertise or education to EMS providers in the region?

01-00:52:26
Bedway:
Our EMS providers were already responding in the field to these accidents or incidences. They already needed to be at the top of their game and were, but having the trauma surgeons here, they were able to continue to offer that continuing education with EMS. Working with our EMS providers—whether it was from the hospital move all the way through my time in the emergency department and the work that we had done in terms of pre-hospital care for the general population of emergency patients to what needed to be done with trauma—has just been a wonderful collaboration. When I look at the EMS community, they’ve gone from bringing patients to one hospital to bringing them to four emergency departments and to three hospitals. There has been a lot of change for them as well, and I really respect that. It’s really important for us to have all of our outreach program leaders, whether it’s our stroke liaison helping them understand how to more quickly recognize and be part of the appropriate treatment of a patient who has an evolving stroke, to patients who are having heart attacks. We work very closely with them to get equipment on all the rigs in the area for STEMI transmission of EKGs. We have a personal responsibility to continue to be great partners with EMS and I’ve really enjoyed that part of my career, being a good partner with EMS to make sure they have what they need. We can help support and provide so they are taking care of the community. [54:00] It’s all about a shared mission when you think about it, and that’s taking care of the people in this community. Many times EMS are the first ones that are on the doorstep, and then they transition that patient to us. Working very seamlessly is important.

01-00:54:19
Rigelhaupt:
Do you remember any classroom setting or where EMS would come in and the trauma surgeons would talk about latest standards of care? What were some of the most exciting to teach the EMS community?

01-00:54:33
Bedway:
I think that the exciting part is when we do the case studies. You actually have the EMS providers who were first on the field and they would present their part of that patient. Then if a helicopter team was involved, they would present. We would actually do the case study all the way through with what happened in the emergency department, in surgery, and up in the ICU. We continue to do those EMS nights; it is a lot of good PI and collaboration. We now have even involved patients, and we have what is called a patient speak out. We have patients who were pretty traumatically injured going out to our local high schools, talking about the dangers of texting all night and fatigue, or texting and driving, and actually doing a speak-out. It involves some video of the scene and when they were being cared for here. It is very, very powerful. Community outreach has also come out of many of our programs. We have a very comprehensive speak out program with stroke as well, and some of our stroke survivors from our stroke support group actually went and spoke at a big symposium in Washington, DC last week. We’re part of a system. We’re not a standalone system. I think that is what I’ve learned over time in the history of being part of Mary Washington Healthcare: it’s very important for us to be good partners with our community, whether it be EMS, former patients, the board, and benefactors who want to support our ongoing growth and development.

01-00:56:14
Rigelhaupt:
If I’m understanding correctly, part of a trauma program is education in the community and making sure you prevent as many traumas as you treat.

01-00:56:26
Bedway:
Yes. We had a motorcycle rally this summer where we actually had—hard to believe—folks on motorcycles kind of doing their tricks and all, and had the police here as well. We had the motorcycle rally. We do car seat safety checks. We get very involved with local high schools, especially around homecoming and prom time. It’s just an opportunity to be good partners in addition to the EMS education. We actually have some folks from physical rehab who have gone to nursing homes for the slip and fall program, for people who like their little throw rugs and all. [57:00] The outreach education that we feel responsibility for doing is to also prevent patients from having to need to come here—keeping them safe in their homes or where they live or play.

01-00:57:19
Rigelhaupt:
Do you remember instances, even before you moved here, while you were working at the Fall Hill facility, that as a community hospital, you were still trying to do some of these educational programs? Or is this more of a story of part of the expansion?

01-00:57:39
Bedway:
My memory is more of the community outreach from an education standpoint being more from this facility as programs grew. Back then, the education seemed to be more focused internally, if you will. We always had a good partnership with the Rappahannock EMS, but I don’t remember it being anywhere to the close to the level it has evolved to. Then we have our wonderful partnerships as well with the University of Mary Washington and Germanna Community College because so much of the workforce needs development; there needs to be a partnership there as well. That has been very helpful to have done more work in this role as CNO in terms of the workforce development with the partnership with the University of Mary Washington and Professor Finkelstein to bring in a BSN [completion program], potentially. There is the opportunity at Germanna Community College, working with Dr. Patti Lisk on how we can best prepare the nurses. Her coming up from the associate program to be ready to be able to provide clinical care, but also have the critical thinking that they need to manage well through their shift upon graduation. A lot of good partnership happening with local colleges and universities.

01-00:59:00
Rigelhaupt:
One of the things that any new service or program has to probably consider is a question of cost. Were there questions about what a trauma program would cost, and the financial viability for the health care system?

01-00:59:22
Bedway:
The question has been there since the concepts were conceived and through to when we sit here today. A program like trauma is certainly a clinical need that is there for the community. Being able to provide it in the most cost-responsible manner is critical because you need to be able to value all aspects of quality and patient safety; but also being viable in here for the community. That is something that we constantly are working on. What is the most effective but cost-effective way to offer the service as well? [01:00:00]

01-01:00:03
Rigelhaupt:
Have there been things you’ve learned, in terms of even some of the ideas that you discussed earlier, in terms of workflow, lean practices, in the five years that the trauma program has been running?

01-01:00:20
Bedway:
The trauma team has a Trauma Operations Committee and they are constantly learning and fine-tuning, constantly learning and fine-tuning. Starting out with our first resuscitations in terms of what supplies were needed; what volume of blood needed to be in the room and things of that nature? Absolutely, we have continued to fine-tune the protocols and even to the point of looking at having a method to videotape the team in the room—not necessarily the patient, but the panoramic view about the patient and of the different providers as they’re doing the resuscitation so that we can do performance improvement on the resuscitation efforts. That’s being done in other trauma facilities and is that something we should go to as well. Performance improvement is pretty critical and having that lean look. Then, there is also the point of clinical ethics and understanding from an ethical standpoint, with all of our programs, what are the ethical decisions that surround the different care and services we offer? We have a very robust clinical ethics committee as well that looks at what is happening in other health systems, other organizations. That committee tries to prevent us from slipping into one of the rabbit holes as it relates to clinical ethics and ethical issues. Also, if we’re confronted with that, how do we pull together our ethics team to be making the best decisions?

01-01:01:46
Rigelhaupt:
Have you participated in the clinical ethics program?

01-01:01:50
Bedway:
Yes. I’m on the clinical ethics committee and I have learned quite a bit. We have some wonderful leaders: Dr. Bigoney and Diane Brothers, who is certified as a clinical ethics nurse. It’s a whole different body of knowledge that they’ve introduced to the health system over the years.

01-01:02:11
Rigelhaupt:
What have you seen as the most significant benefits of the clinical ethics program to the overall health system?

01-01:02:20
Bedway:
I think it is the proactive planning that they have. Putting on the table case studies and issues that other organizations have had to deal with and have the needed discussion. If we were faced with this, how would we respond? From some of those discussions, there has actually been the policy development and discussion at a board level. If you are faced with the same kind of situation as there was in New Orleans, where your facility was compromised and you have to decide how you are going to ration care and handle care in a catastrophe, and things like that. Who gets the ventilator? Who gets the needed medication? Things of that nature. [01:03:00] We have really had some great case studies from other hospitals who have been hit by tornadoes and things like that of late, which is very unfortunate. But actually understanding the debriefs those hospitals have done when they were hit with a time of tragedy, and what would our response be in different scenarios; then that spills over nicely into emergency preparedness planning that we do. That, of course, is done in conjunction with a lot of local state and even federal agencies. The unfortunate, very, very sad, tragic incidents at Virginia Tech—what do you do if you have a shooter that comes into a hospital? Doing that kind of emergency preparedness with active shooters and all of that is just critical for us in order to be responsible for our community and to make sure that we’re prepared. To take us back to Fall Hill, those weren’t the kind of discussions we were having. We’ve really grown over the twenty-five years that I’ve been here.

01-01:04:09
Rigelhaupt:
You almost led directly to my next question, and maybe you could talk about it from some of the different departments that you’ve worked in, but on a day-to-day basis, from that first year, twenty-five years ago; what was a shift like for a nurse then compared to now, in terms of how they were working with patients, questions of technology, medicine?

01-01:04:39
Bedway:
Wow. Back then, twenty-five years ago, when you think about it, you would get a report on your patients and everything was on paper. I believe there was more direct interaction as an RN with your patient, just how you administered IVs, medications, did dressing changes, the supplies you used, and the equipment that was at hand. It has all just changed pretty dramatically. A lot of the equipment changes have to do with safety and quality enhancements that have come over time. You see that evolution of technology. The clinical documentation being computer-based, I worry, has really pulled us away from the bedside and really having that needed interaction with the patients at times. We are much more deliberate now. Our patient rounding and shift change time in that report is actually now happening in the patient room with the patient and patient’s family involved. As opposed to how a report used to be in the nurses station, with everybody kind of huddled around, talking about other things, and then going through their patient report. [01:06:00] We are trying to be much more focused on a patient, family-centered care philosophy where they’re very much part of their care and planning. From that first day back then, I don’t think it’s different in the respect that it was poor then. It was just different at that time. It was more of a high touch feel. With all the technology, you have to be very cautious that you get a little bit removed from the patient. You had to be more deliberate in your actions, so patients really feel cared for and cared about.

01-01:06:44
Rigelhaupt:
What do you see as some of the benefits of, as you described it, the high touch practices of nursing? Where you’re less removed from direct touch and interactions with the patients versus the way technology takes nurses away from that kind of practice.

01-01:07:03
Bedway:
When I have had my most recent town hall meetings, what I hear from nurses is they do miss the amount of patient time and patient contact that they used to have; they really do. That is why it’s incumbent on me to really make sure that we have our clinical electronic documentation working as precise as it needs to work so that we are not having a lot of delays in the computer system—the freezing, downtime, things like that—because that just further challenges our ability to be able to spend the time that is needed for the patient to feel cared about. It is also important for the nurse to feel fulfilled in what they are doing for the patient, and I worry about that at times, too.

01-01:07:50
Rigelhaupt:
Part of the reason I ask is that medicine in general always is that balance between the science and an art. I’m wondering, what are some of the ways you’ve emphasized trying to have both the science part, the evidence that can come through clinical documentation, the electronic medical records, best practices, and the art part of patient care and that is very important to nursing?

01-01:08:25
Bedway:
It is. And that is the balance that we’re all responsible for making sure that we keep. I really think it is. As different technology and different computer applications come through, we have to keep a balance with contact time.
[End of Interview]

Interview 2 – December 11, 2013
02-00:00:04
Rigelhaupt:
It is December 11, 2013. I am in Fredericksburg, Virginia, doing a second interview with Marianna Bedway for the Mary Washington Healthcare oral history project. And to begin today, I wanted to ask you to talk a little bit about some of the programs, in terms of nursing, that you’ve been most proud to help build.

02-00:00:27
Bedway:
Some of the programs that I’ve been most proud of would be the accomplishment of what it took, from a nursing standpoint, to prepare for and participate in caring with our Level II Trauma Center. That took the development and certification of nurses from our emergency department, through interventional radiology, the OR Services, critical care, our surgical units, and also the nurses in case management. There was really a system-wide perspective in terms of the influence of trauma. That is certainly one program that I’m very proud of. Also, the work that we have done with sexual assault nurse examiner program. That is a program that has gone from being non-existent to a place for adults, to actually introducing the child advocacy center, and being able to assess and intervene with the youngest people of our community who are victims of assault. That was another wonderful program. But the list can certainly go on because there are different areas that our nurses practice, from emergency services, through critical care, to general med-surg. This past summer, we actually introduced a new graduate program. We were able to take sixteen new graduate nurses, who applied for employment here, and provide an opportunity where they went through a sixteen-week internship, and then found placement on the units of their choice. It was a good developmental offering for them and provided great employment. Also, it provided an opportunity to bring in some new blood, fresh ideas, and new associates into the health system. There are nurses from our placement at both Stafford Hospital and Mary Washington. The list goes on. I’m very proud of a lot of the different new programs we’ve introduced.

02-00:02:23
Rigelhaupt:
And this is an open question, but particularly since you first mentioned trauma, if we stayed there, could you talk about how you build them? Really, the process. From the first times you’re really talking about trauma, what are the step-by-step that you have to go through to bring the nurses up to be part of that trauma team?

02-00:02:48
Bedway:
Our emergency department leadership years ago started something called a Trauma Nurse Certification course. That actually prepared our nurses to be able to take care of patients in our one emergency department at the time, prior to transporting them out, and before we had Level II designation. [03:00] Prior to me, there was that development and investment in the nurses. When it was time to look at becoming a Level II trauma center here at Mary Washington Hospital, it then required looking at the state rules and regulations and the professional associations in terms of critical care. We had to look at what the offerings should be and come up with the competencies for those nurses, offer those educational opportunities, and make sure that competency was there before we took the first patient.

02-00:03:38
Rigelhaupt:
Were there any rules or regulations that were the hardest or easiest to implement?

02-00:03:49
Bedway:
There was such enthusiasm and support from nursing for us to get Level II designation that I didn’t find any of them to be a challenge. It has also served as a great recruitment tool. Even if nurses aren’t working in emergency services or critical care, they’re proud to say they work at a hospital that’s a trauma center.

02-00:04:13
Rigelhaupt:
You mentioned the sexual assault program. Could you talk about the process of how that was implemented here?

02-00:04:20
Bedway:
Sure. We have a wonderful nurse leader that had been involved in the past as an emergency department nurse who was working in the recovery room at the time that I became the Director of Emergency Services. She had gotten away from forensic nursing for a while. I had asked Gail Perkins to come back to the emergency department and join me in rebuilding the adult program—at the time, it was called the SANE program, Sexual Assault Nurse Examiner. She brought the knowledge and the skillset to recruit the right nurses and have the right training; and it is extensive experience with exams, the ability to testify in court, et cetera. She did rebuild the adult program for us, so patients didn’t have to leave the community. That was back in 2004. She then embarked on a trip that the two of us took down to Richmond to see the Child Advocacy Center that Richmond was offering for their community. As we toured and spoke with their program director, certainly the opportunity to offer pediatric services was something we both got excited about. What I liked about the development of that program is that Gail and I worked with community leaders; it wasn’t a Mary Washington, solely, program. We worked with different community officials from several counties. That is who became the steering community and the board for the Child Advocacy Center. Mary Washington is very much part of the Child Advocacy Center, but it has a separate operating board, and a location that is very neutral to the service area. [06:00] Gail Perkins definitely deserves all of the credit. I was just the leader that partnered with her to help remove barriers, and with some project expertise to help get it off the ground. She ran with the ball. I am very proud of Gail.

02-00:06:17
Rigelhaupt:
You just said “barriers.” Are there some that you ran into with this program, or that are typical of starting a new program?

02-00:06:26
Bedway:
I think with any project or program it is about stating an effective business case and being able to communicate to those constituents that may be impacted by introducing a new program. Or at times, if there is a program that you’re sun-setting, then the reason to sunset a program. I’ve had experience on both ends as a hospital administrator. But it is really about having the appropriate business case that is objective and not emotional. That can be hard at times, especially when you’re dealing with programs that you just feel very strongly need to be here to serve the community. However, health care is in very trying times right now and there are a lot of financial implications that were not present in the past. We always have to do our due diligence to make sure that we are here for the community with all of our services. We continue to re-examine services that we have to make sure that we are managing them in the most cost-effective, high-quality manner that we can.

02-00:07:29
Rigelhaupt:
“Sun-setting.” You mentioned sun-setting programs. Are there some that you have decided that could be folded into other things? Shorter question. Could you elaborate on what you mean by “sun-setting” programs?

02-00:07:43
Bedway:
Sure. At one time, Snowden at Fredericksburg actually offered a school for children who needed to be in the appropriate environment with the right behavioral health support, as well as having their educational needs met. We partnered with the Gladys Oberle School and all the local school systems to transition that function of serving as a school and reporting to the State Board of Education back into the community so that those students could be well served. That allowed us to focus on our core mission, which is health care and actually expand an additional inpatient unit over at Snowden at Fredericksburg. It truly was a win-win: that the students continued to be served in a wonderful manner through that program and we were able to expand beds to serve the demand for behavioral health patients in the community. But that one, very much so, was very emotionally charged. In no way were we abandoning the educational needs. Partnering with the community was critical, but at the same time so was staying true to our mission to improve the health status of the people in the community that we serve. [09:00]

02-00:09:07
Rigelhaupt:
You mentioned the questions of finances in a business plan. What’s the process of finding a budget internally for something like the forensics program, or the child advocacy program, that undoubtedly takes some Mary Washington Healthcare resources?

02-00:09:26
Bedway:
There are a couple of different budget processes, if you will. There’s the operational budget for our respective cost centers and programs, and the budget is set up on an annual basis. Part of that budget can be looking at different revenue streams, such as grants from outside of the health system or funding through our foundation to support other revenue streams from the community in terms of donations and events. As each leader or program manager of the different program sets up their respective budgets with me, it is a matter of looking at where their sources of revenue will come from and making sure that we are as diligent as possible with keeping the operating expenses to the minimum, but enough to get the good quality and service outcomes.

02-00:10:20
Rigelhaupt:
Are there other programs that have been talked about being started that stand out in your mind, that you wanted to start, but have not yet gotten underway?

02-00:10:39
Bedway:
I can’t think of any programs that we have looked to propose and went through the business planning process and have not moved forward with them. Because usually, in the initial planning discussions and when you’re doing your due diligence, you get a sense of whether it’s something that’s viable or not. I can’t think of anything offhand.

02-00:11:07
Rigelhaupt:
In terms of starting new programs, with just the change in size of the organization from the time you started here to where it is now—how does that change the process of starting a new program? From going to a community hospital to a regional medical center?

02-00:11:30
Bedway:
With the size of where we are now and also our partnership and relationship with our board, it is just really critical that we are looking at the good of the whole, in terms of what is offered for the community, based on need, but also our ability to sustain and be here for the community. What has changed, probably, is the level of business planning and due diligence that we do, and the vetting is a little bit more rigorous, which it should be. [12:00]

02-00:12:10
Rigelhaupt:
Mary Washington Hospital has grown significantly in the twenty-five years you’ve been here. And I would really like to ask you in a very open, broad way, if you could talk about how the nursing units have looked different and functioned differently. And I know that’s a big open question, so maybe if you wanted to talk about one unit in particular as an example, to start? So, really talk about how the nursing program and how nurses work differently, based on the size and change in the organization.

02-00:12:47
Bedway:
Okay. When you think of our old location on Fall Hill Avenue and how we functioned, everything was very manual, and that’s probably the best way to say it. Your acquisition of supplies, your documentation, and communicating face-to-face—everything has really changed with the introduction of technology. That was one of the main reasons for building this facility here on Sam Perry Boulevard: we needed a building that could support all of the new infrastructure that was coming. And at the time, we had no idea of where technology would take us. But the difference of the old traditional unit was one where everything was manual. Now the amount of automation has increased exponentially, especially in the realm of information technology. Whether it is phone—we’re moving towards text paging with physicians—or the way we transmit diagnostic tests. In the old days, you would have the backlit readers for x-ray film; they were actually the old x-ray sheets that went up, and you had that bulky equipment on the unit. Now, everything’s pulled up, taken, looked at, and examined digitally. The documentation for the nurses—there were the old days of having all the thick charts and the chart racks and a chart hanging at the end of the bed and now it’s the computers on wheels that are transferred from room to room. It’s really the technology and automation that has dynamically changed, as well as the team. You have many more specialties and extenders working with us. In the past, you had your core group of physicians that rounded on all patients. Most of our physicians in this community and our hospitalists are using nurse extenders or physician assistants. That has really changed the complex of who is in the team, and has been a nice addition. The team itself has changed in terms of the complement. [15:00] The main fundamentals for nursing—you still have the RN, who is the coordinator of care, responsible for that initial assessment and the plan of care, collaborating with the physicians in terms of that plan, and re-examining what the plan is for the patient to get the best outcomes.

02-00:15:25
Rigelhaupt:
Well, you spent a lot of time in the emergency department, in managing it. And I’m wondering if you could really talk about, from a day-to-day perspective, a nurse coming in to work in the emergency department now, versus when you started here?

02-00:15:42
Bedway:
When I started here twenty-five years ago, and when I think back to the old emergency department at Fall Hill Avenue, you had a wonderful group of nurses and physicians who really did their best with what was in place at that time. But once again, it gets to today you have round-the-clock anesthesia here. You have round-the-clock access to the radiologists and all of the other services, along with all of the technology. You have clinical pharmacists here; where before, at the old hospital, if their emergency department needed a medication that wasn’t there, the nursing supervisor was running to the pharmacy to restock. The round-the-clock pastoral care, too, provides that needed support for patients’ families and patients in the emergency department. The list just goes on. We went from just a core team doing the best—and that was the standard of care with many emergency departments across the country—to being a very complex engine and truly that front door of the hospital. Dramatic changes, regardless of having trauma here; very dramatic changes in emergency services. It is very exciting to see how that specialty of nursing has really grown.

02-00:17:04
Rigelhaupt:
Have some of the nursing supervisors or charge nurses had to take on new responsibilities with, let’s say, staying with the emergency department, because it has grown?

02-00:17:15
Bedway:
When you think about nursing management and nursing supervisor roles, they have changed over time as there have been more and more changes in terms of what’s regulated, what we’re reimbursed for in terms of quality of care, and patient safety and patient satisfaction. There is a very defined focus around a nurse leader’s role in terms of very specific outcomes. They have to make sure it’s achieved, regardless of which inpatient or outpatient unit they manage. That has changed from twenty-five years ago to today. It’s more defined for us. There is the changing landscape from a human resource management perspective: if you are in a supervisory capacity, from both a workforce environment of what is tolerated and not tolerated in the past. [18:00] Once again, it’s just how the culture has changed nationally in external and different environments. It’s not just in health care. HR law has changed. The real quick quality and service and patient safety expectations are very different today. The nurse managers of old: it was to make sure you had qualified staff there and the patients got the best care that in your judgment could be provided. Now we are very focused on what’s the evidence-based practice. Every day, we’re looking at what nursing care gets the best outcomes, and making sure that is what our policies are based on. It is more academic-driven, it seems.

02-00:18:50
Rigelhaupt:
With evidence-based medicine, how do you locate the evidence and how is that evidence then communicated to nurse managers and the RNs on staff?

02-00:19:03
Bedway:
Several different ways. Part of our shared governance and our leadership within nursing, is we have a Clinical Practice Council and a Nursing Research Council. It’s very important that we don’t practice the way I was trained twenty-five years ago, or the way others were trained in their respective schools of nursing years ago. You’re continuing to keep up. It is incumbent on all of our clinical nurse specialists, our nurse educators, and nurse managers to stay very invested in what is current and on the horizon. Investing in our nurses going back to school and getting certifications—they all have their professional organizations that they stay very close to in terms of what the research is showing and how we should transition care. Our nursing shared governance provides that opportunity and forum for us to talk about different protocols and different pathways. A lot of those are in partnership with our physicians and medical staff. They too are very committed to evidence-based practice. Our IT solutions help us. Several of our IT solutions automatically update with evidence in terms of practice. That helps us as we are coming up with different computer workflows for nursing; the evidence of what should be done for different disease processes is updated through different applications. It comes from a lot of different angles in terms of keeping us up to date and abreast of the best nursing practice.

02-00:20:39
Rigelhaupt:
You mentioned the shared governance. Let me ask, actually, when did the shared governance in terms of medical practice and nursing programs become part of Mary Washington Healthcare?

02-00:20:56
Bedway:
We received Magnet status in 2009, but prior to that the shared governance structure was something that was very important to us. [21:00] The voice of the nurse at the bedside—and they’re the ones caring for the patients—was really part of our planning and very integral to our daily nursing operations. It was well before our Magnet designation in 2009 that a structure for shared governance was put in place. The exciting thing is on an annual basis now, we are looking at our bylaws, updating the structure, and making sure that our nurses—which is just a daily communication, it seems—really understand that their voice is important and their voice needs to be heard. Shared governance is the venue for that. We’re investing a lot of time and energy right now in making sure that that continues to function as effectively as it needs to be.

02-00:21:54
Rigelhaupt:
Would you be able to give an example of practice or an idea that came up from a nurse on the floor in their day-to-day practice that worked its way up to shared governance, and then became part of the organization?

02-00:22:10
Bedway:
Sure. Our wound care nurses are probably a great example. They are working directly with our patients and there’s some evidence-based care in terms of what products that we use for the patients to prevent skin breakdown. You hear of them called “pressure ulcers,” or decubitus ulcers. In terms of working with what evidence and best practice with the bedside nurses, different products came through shared governance and the Resource Council. Our Education Council, where our clin-specs [clinical nurse specialists] and educators reside, they’re actually able, then, to come up with a plan to partner with the wound nurses to get the education out. That’s one example where we have changed both application of skin care products and changed products to really impact care and decrease skin breakdown. That’s just one of many examples. There are a lot of different things, from new products to new equipment and equipment needs that go through Resource Council. Through nursing research, some great pain protocols came out because of a research study that was done through our Research Council and partnering with Dr. Shelton, our pain management physician. The last two years have been pretty robust.

02-00:23:28
Rigelhaupt:
Could you say more about the pain management changes that came through the council?

02-00:23:33
Bedway:
Our pain management in the past has really been driven, once again, more independently by different practitioners, physicians and nurses, in terms of appropriateness and understanding whether a patient is narcotic-sensitive or narcotic-naïve because of narcotics they may take on a daily basis. There was just a lot of education that needed to take place. [24:00] So we were able to use CE Direct, which is an online learning tool for our nurses to update their educational understanding of how we should manage pain, and servicing with our hospitalists. That’s where we took disparate activities around pain to more of the evidence-based approach, have streamlined protocols, and provided the education. We’re seeing some really good outcomes in that area. Everything we do seems to be interdisciplinary; where you have nurses and physicians with other partners, like pharmacy, lab, radiology, others, coming together working on this. Nursing definitely doesn’t work in a vacuum. We are part of a very important larger team here at Mary Washington Healthcare.

02-00:24:58
Rigelhaupt:
This frame of interdisciplinary nurses and physicians working together, say, on pain management or another program; this strikes me as different from when you started here. You alluded that it was an era in which a physician came into a room, the nurses—not always—but might stand up. A chair was provided. There was a hierarchy. And it sounds as though that may be less so, or more of a team enterprise. What are some of the ways you can think of that the organization has helped to support the lines of communication between nurses and physicians in terms of thinking about outcomes and implementing programs?

02-00:25:48
Bedway:
I think the collegial spirit has really been spearheaded from the top. I really think Mr. Rankin, as our executive leader, has really stressed the importance of the physicians being very involved with what’s operationally decided, which it the right thing to do. But at the same time, there is a respect for everybody who can contribute when it becomes to performance improvement. We have done a lot of great work that’s been facilitated with our quality department, and our industrial engineers and others. When you come into those rooms to make interdisciplinary decisions or try to improve outcomes for patients, everyone at the table needs to be respectful of one another. The hierarchy is no longer there because you’re collegial there as a team. You have a nurse practitioner with sources of evidence for the nursing application for a specific topic. You have physician leaders who are at the table. But like I say, you have respiratory, physical therapy, lab, and others. And at times, it really involves other departments that you wouldn’t really think about. [27:00] What is the influence of the folks from housekeeping? The folks from supply chain? Everyone is very important in the role that they play to make sure that the products are there for our patients and that there is safety for our patients, from infection control to all the standards are being met. It’s very important that when you have clinical and non-clinical people at the table and you’re working on the clinical issues, there are times those non-clinical directors are very active and part of that at the table, with the physicians present. You’re right, that is a big change from twenty-five years ago. It’s the right way to practice safe patient care.

02-00:27:43
Rigelhaupt:
I don’t know if growing pains is the right term, but were there any times that you can think of that it was hard to implement this team-based approach to patient care and really thinking about outcomes that you or your colleagues really tried to create a plan to overcome those growing pains?

02-00:28:04
Bedway:
Sure. And that is the rub with culture. Change is something that some folks really fight and others get excited and charged up. Then you have the folks in the middle who will kind of wait to see if things are really going to happen or not. That is in any organization. Some of the greatest challenges—but you have to prevent them from being barriers—are having folks comfortable with change and not feeling threatened in any way. A lot of that is just through facilitation of how the different meetings and groups are handled. No one wants to feel like something is being forced down their throat and they want to be part of the change. Bringing people to the table to be part of the change and planning it, you are usually a lot more successful than making decisions in an isolated manner and telling folks how things will be. That’s why it is important to be part of either the interdisciplinary teams or to also use the approach of shared governance: so as many folks as possible can be at the table. Now, there are still decisions, at times, that need to be made that are top down, but I try not to do that unless it’s necessary. And that is more in the regulatory realm. When we have a governing body who says, “thou shalt,” and “thou shalt by the end of the day,” and then there are things that are more of a directive nature.

02-00:29:31
Rigelhaupt:
Do you think that the implementation or more complex surgical subspecialties in cardiac surgery, neurosurgery to trauma, require a team? That this cannot be done by a single physician?

02-00:29:52
Bedway:
Absolutely.

02-00:29:51
Rigelhaupt:
Has this supported the collegiality and the kind of culture that you’ve described [30:00] as changing over the years that you’ve been here?

02-00:30:03
Bedway:
Absolutely. You still have to have great respect for that surgeon or physician who is that clinical expert for that service that is being provided. And that gets back to the respect component. It’s very important to respect their expertise and acknowledge them as the medical director for the program. The interpersonal dynamics of the physician are really key to how that team functions, and how that team develops over time. There is a lot of work with medical staff leader development, just like there is with leader development. It’s just been a joy working with Dr. Na from a cardiac surgery perspective, with Dr. Kauder from a trauma perspective, and Dr. Sherwood is just a jewel with all of his wonderful thoracic surgery. It really has to do with the dynamics of the individual and they are interpersonal. But you just have to have great respect for the physicians who provide those highly technical, surgical procedures. They’re amazing practitioners!

02-00:31:19
Rigelhaupt:
A part of what Mary Washington Hospital has started, and Mary Washington Healthcare, are these complex surgical programs, and at the same time one of the core parts of a hospital, for example, is labor and delivery. I’m wondering if you could talk a little bit about how, from a day-to-day basis, something—even from the time this hospital opened—how has new technology or programs around labor and delivery, for example, changed a nurse’s day-to-day work?

02-00:31:59
Bedway:
That has been an area that has evolved as well, in terms of the more acute patients that we take care of and manage. We have a comprehensive perinatology program here and a wonderful neonatal intensive care unit as well. When I think over the course of the twenty-five years, it’s not only how we’re able to serve more patients here. They don’t need to leave the community for their care and services. It gets back to the technology in terms of testing prior to delivery—if they have received prenatal care, services that are provided to the patients, in addition to the monitoring. You know, it’s really changed from an external environment as well. Things since twenty-five years ago in terms of substance abuse, addiction that you would not think of with the moms. What we’re faced with now in terms of managing babies that are born with fetal addiction syndrome and things like that. [33:00] It’s interesting. It has changed dynamically. There are also the regulations there as well. In the past, the date in which a C-section was scheduled—there are now requirements in terms of not having the early C-sections with better evidence-based outcome for the baby. There is more quality monitoring, just like every other specialty. Our requirements to make sure that the nurses have the appropriate certification and education to deal with these new complexities that have come along. I think women’s services is very similar to all the others. There’s more of a need to focus on certification education, a lot of the new technology that has come into place, and external environmental influences that make the patient a little different than in the past.

02-00:34:01
Rigelhaupt:
Do you see a similar trajectory in terms of nurses in the operating rooms? That it has become more complex? Or is it a similar practice to even when the new hospital twenty years ago opened?

02-00:34:15
Bedway:
The new hospital did not open up with nearly the amount of technology and instrumentation. When I think about the size of the OR rooms when we moved in twenty years ago—and we are in the midst of expanding the size of those rooms right now—it really is out of the sheer need from all of the different imaging equipment and IT infrastructure. Even the robot was not something that was thought of back when we built this facility; the weight tolerance of the floors for some of the weight of the equipment, and things like that. We are able to foresee a lot of things that will be coming down the pike with surgery, but it has exceeded expectations in terms of where we would be at this time. Looking at rooms that can function in a hybrid environment, both for the cardiology needs of the patient and then moving the patient right to a surgical procedure with hybrid OR rooms for cardiovascular services. It’s pretty exciting. That is also leaps and bounds, but once again, a lot is technology-related.

02-00:35:34
You mentioned technology a number of times. How would you talk about—maybe in a medical surgical floor or post-op with computers and all the technology in the room very much as you have described, does it have an influence on the hands-on care that nurses are able to provide on a day-to-day basis?

02-00:36:00
Bedway:
Sure. Something as simple as trying to figure out whether the patient’s bladder is full and if they need to be catheterized. In the past, you were using different assessment skills. Now you whip out the bladder scanner and you are doing a quick scan to see how full the bladder is and whether you need to catheterize. It has made a difference, even at the front-line med-surg level when I think of the tools and resources that folks have at their disposal now. You still need the good clinical judgment and clinical assessment skills, but there are these tools that are at their fingertips that help with that assessment now.

02-00:36:53
Rigelhaupt:
In the years that you’ve been chief nursing officer, are there particular programs, services that you have really wanted to see implemented?

02-00:37:05
I’ve been in the role now for almost two years. Trying to think from a programming standpoint—I think I’ve been in kind of a position of doing some wonderful rebuilding from an education perspective with the clinical nurse specialists and all. Where do nurses need to be from a workforce standpoint? That programming has probably been the most rewarding, and will continue for the next several years. Looking at where our workforce was from a BSN preparation, what was available in the community, and where we’re now able to head. In these first two years, being able to work with the University of Mary Washington to hopefully get the BSN program for fall of 2014 and continuing to work with Germanna Community College, which is bringing the UVA BSN program in. Also finding some different online options for people who want that. That is all being done in conjunction with working with our foundation and different revenue sources to help offset the expense for the nurses to go back to school. But really, further developing our nurses professionally to get their bachelor’s in nursing is probably a very key focus that I’ve had and that I’m working on. I’m very excited to see where we’ll be five to ten years from now in terms of the knowledge and strength of our nursing workforce as a result of this work.

02-00:38:37
Rigelhaupt:
So again, this is an open-ended question, but there are often many factors beyond acute sickness, medical problems that contribute to a person being in the hospital, or coming to the emergency department. [39:00] Are there ways that front-line nurses, in terms of new ideas, education you’ve mentioned, bring programs to patients beyond acute medical care? Thinking about some of the social issues that the Mary Washington Healthcare has become more acutely aware of, and tried to provide to patients?

02-00:39:17
Bedway:
Sure. Sure. One great example of a more of a community-based focus would be our ostomy nurse, Gail Erickson, joining forces with some folks in the community to start something called, “Kenny’s Closet.” There was a patient that Gail and others had taken care of and he was really the impetus for us having a way for patients who need ostomy supplies in the community who can’t afford or access them to have those supplies. That’s just one example of where it became a brainstorm of Gail’s, to a partnership with community members, to the organization supporting a location for not only the Ostomy Support Group, but this closet of supplies that can be utilized for patients who don’t have the resources for that. It’s such a win-win, especially on the weekends or after hours where those supplies couldn’t be accessed, even if people had the resources. That’s just a recent example. The outreach that is being done with teens with our Trauma Outreach group, and its focus primarily around the homecoming prom time, but just in general, the whole texting and driving. Those are some of the issues that are not part of acute care. It’s to really prevent acute care, and really helping people understand how to keep themselves safe. We’ve had physical therapists go out to different nursing homes for home assisted living facilities and talk about home safety and that constant battle with picking up the throw rugs. And I’m one of those throw-rug ladies—I know one day somebody will be pulling mine up as well. That’s just really important, once again. They may have had an acute experience here in their post-fracture, or to prevent a fracture. How can we get out in the community and really keep people safe at all ages?

02-00:41:16
Rigelhaupt:
And so that post-hospital care, longer-term health care, and certainly readmission is something that hospitals are dealing with in new ways over the last couple of years. Are there ways in which front-line nurses are contributing to thinking about questions of readmission, and the long-term—beyond providing outstanding care while you’re here, afterwards? What are some of the ways that the organization has supported nurses working with those issues?

02-00:41:50
Bedway:
You start preventing readmissions from the moment a patient’s admitted; you truly do. While you’re working with the family and planning for the care that they’ll receive after discharge, whether they’re going to an assisted living facility, rehab, or back into their homes. [42:00] Then we have our own wonderful home health agency that is very engaged with the patients. There are some partnerships with some different community groups as well. It’s all in this effort of the check-in phone calls, in terms of taking medication, and making sure that you’re weighing yourself. Have you gotten the immunizations that are needed? There’s work that is done while they are acutely here, and then throughout that period of time after, to try to keep people safe, keep people well, and prevent those readmissions. But it is a dynamic partnership with many different community agencies and groups.

02-00:42:42
Rigelhaupt:
Is that part of why the requirement for higher-level of education in nursing? That it’s more complex, that you’re thinking months out in terms of post-operative care? The nurses are asked to do more.

02-00:43:00
Bedway:
They’re asked to do more. During the acute phase here, the acuity of the patients while they are an inpatient now is very different from when I was a nurse years ago. People would be admitted for back pain and be in traction for a week. Nowadays, that is outpatient therapy. Patients who are having surgery would come in the night before, and that has gone away years ago as well. When a patient is here and they are in an inpatient setting, they are very acute; that knowledge base is critical for managing care. But yes, the additional education provides that opportunity to understand what the community care needs are as well. And how do you function, in terms of being that the good navigator so a patient is provided the resources out in the community? Having the education as well rounded as possible, I think, really well-equips us to get the outcomes we need for a patient. Yes, absolutely.

02-00:44:01
Rigelhaupt:
So it sounds as though nurses even in a medical surgical unit, they need to have some understanding of social services in the region, what kind of things would be available to patients. How does the organization get that information to the front-line nurses?

02-00:44:22
In many different ways. Our quality department is led by a wonderful nurse Eileen Dohmann. She takes each of the focus areas we have around readmission and has interdisciplinary teams that are working on it. Then a lot of that education comes back to the nurses through the different committees and councils that are working. It’s something that is reinforced with us. Our skills education—our nurse educators and clinical nurse specialists are, frankly, just through rounding have that ongoing communication, huddle messages with the staff. [45:00] Everyone keeps abreast of the importance of the different programs to keep patients well. It’s very multi-faceted, would be a way to say it. But yes, it takes tactics from all angles to keep patients well and to prevent readmissions. There are some that can’t be avoided. When that happens, we take wonderful care of the patients. And then you’re in that cycle again of preventing that next readmission.

02-00:45:28
Rigelhaupt:
So you’ve spent a number of years in senior administration. And I’m wondering if you could talk and reflect a little bit on what you’ve seen as you’ve ventured—the positions in senior administration—do you see nursing in different ways? Do you think about things that you didn’t think about, and as I asked about last time, your first shift coming on as a night nurse manager?

00:46:03
Bedway:
I think that everyone who comes to the senior leadership table comes to that table with a different perspective. That’s what makes it so rich, because we have such of a diverse group of senior leaders. From that, my responsibility as the nurse leader is to make sure that I am participating in the conversation by first listening and understanding the other perspectives, but also contributing from the perspective or from the vantage that I see as being the organization’s nurse leader. It feels like a huge responsibility at times. It’s very important for me to come forward with things from a very objective, data-driven perspective. Too often in the past, nurse leaders have been viewed as being more of the emotional and soft support; soft in terms of not having hard data when they are stating a business case. It is important as a nurse leader to make sure that you’re very well-grounded with what you are stating as a business case. That’s the one thing I’ve learned over time. But we really have a wonderful, diverse senior leadership group. We all have to take our responsibilities to be both good listeners and to participate effectively from our vantage points, whether we’re representing a medical staff, representing finance, representing human resources, or nursing.

02-00:47:31
Rigelhaupt:
What have you learned about how questions of cost or budget or different economic models from being a senior leader? How do they shape the experiences of front-line nurses at Mary Washington Healthcare?

02-00:47:47
Bedway:
I think it’s probably one of the greatest challenges: helping the front-line nurses understand at times that there are financial constraints and limits of what we’re able to do. [48:00] To get good energy around—if this is the bucket of funds that we have in order to achieve X, Y, Z, how do we come together and come up with solutions, rather than just be frustrated that the funds are limited? That is a very important role that I and all the nurse leaders that report to me have: understanding that the current environment in health care is what it is to some extent. Needing to be good stewards, at times, can be very frustrating because the nurses want to do what they have in their mind as the best for the patients. At many times, it involves additional resources. What we need to focus on is everyone functioning at the top of their license, making the contribution they can, and looking at different leaner, more effective ways to provide nursing care. Lean doesn’t mean cutting corners. If there’s waste in anything that we do—if you’re hunting for supplies that is a waste step. Your supplies should be at your fingertips. Helping the nurses understand if your workflow is not working for you—rather than being concerned about it and voicing it just verbally, how do you take actions and be part of one of the improvement teams, to actually make the environment as effective as it can be?

02-00:49:25
Rigelhaupt:
Do you think that the perspectives of nursing, and your expertise as a nurse, contributes to the newer models of integrated care? In terms of the Integrated Provider Network—what expertise and what perspectives does a nurse bring to something like an integrated provider network?

02-00:49:56
Bedway:
It’s interesting, because our Integrated Provider Network is in its infancy and it’s just being stood up. And now is the time when different nurse leaders that have expertise in different areas are having more defined roles. Whether it is the establishment of the health information exchange or all of the different evidence-based protocols and workflows that are involved with providing patient care, inpatient and out, that nurses have already been to the table with; it will continue to have that influence. That’s how they play in, as well. I had the opportunity to serve on one of the subcommittees as the IPN was forming. Nurses have been involved, and I think they will be making a real serious contribution, especially the nurse practitioners that are out there in an extender role. The nurses are involved with data abstraction, quality reviews, and, like I say, with evidence-based practice. Nurses are very much part of it. [51:00] It is an Integrated Provider Network and not an Integrated Physician Network. I think the naming of that was pretty critical because the physicians certainly are driving this, and behind many good physicians is that nursing care that is required. You just have to be a good partner in this. That’s what this network’s about. I am very jazzed about it. I’m very excited about it!

02-00:51:23
Rigelhaupt:
Do you think now, with almost two decades of having more complex programs that required a team from physicians to nurses, and the culture built around that made it possible to develop something like the Integrated Provider Network?

02-00:51:44
Bedway:
I think that we are poised for success with it as a result of that interdisciplinary care and approach we have used. I think we’re poised well for the IPN with the ongoing commitment to our IT infrastructure. There are a lot of steps that, in the past, have really primed the pump, if you will, to put us in the position to be as successful as possible with this.

02-00:52:12
Rigelhaupt:
What’s some of the evidence base that you drew upon, either from perspectives of nursing or senior leadership, that went into the Integrated Provider Network?

02-00:52:25
Bedway:
We had a group of very seasoned consultants that were in, and they had experience in other communities where the provider networks have been stood up and were strong. I think many people are familiar with what Kaiser has put together over the years. There were several different frameworks that we could look at and pull upon in terms of what the actual structure for the IPN needed to look like. We also had great consult with our legal advisors as well, because there are a lot of regulatory implications when you stand something like this up. I think we looked to our external experts in terms of consultants for support and drew upon our own knowledge in terms of the framework that was developed. And you know, this has really been led by a wonderful group of community-based physicians, too, in terms of the development of that. That is what is so exciting: even though we have our hospitalists that provide that primary hospital-based care and management for our patients, we have a very strong group of community physicians that are very committed to this, and have come on as full partners in the IPN.

02-00:53:40
Rigelhaupt:
So tell me if I’m wrong here. But I can’t help but wonder if for something like the IPN, or any program like this, to be successful, requires more than evidence, requires more than outside expertise in terms of consultants, that it requires people to stay committed to a kind of culture and values that are important. [54:00]

02-00:54:07
Bedway:
Oh, yeah.

02-00:54:08
Rigelhaupt:
How have you seen senior leadership and nurses and the physicians try and maintain the values of the organization as it enters into something new like the Integrated Provider Network?

02-00:54:26
Bedway:
You see our values in the culture play out when the framework and the rules of engagement are set up; it is in our program goals and things of that nature. The senior leaders and senior medical leaders in the organization are there to provide that influence and guide that. I think also, the leader for the IPN that was selected, hand-selected, was selected based on his alignment with the values of the organization. Travis Turner is a wonderful pick. He and the wonderful physician community partners that we have—they all have that culture and that value-based approach within them, as well. So you’re right on, yeah. I think it was really driven. You take the advice and knowledge from the consultants and make your own decisions in your program development. The program truly is ours, with them as a guide, but not them as the creator.

02-00:55:29
Rigelhaupt:
So that’s a very forward-looking question about values. But I also want to jump backwards in time, to ask about values.

02-00:55:37
Bedway:
Okay.

02-00:55:38
Rigelhaupt:
In our last interview, you said that values, maybe a clear articulation or a vision or an emphasis of them, really took hold when Mr. Rankin joined Mary Washington Hospital/MediCorp in 1992. I’m wondering if you can reflect backward, and maybe talk about how that happened, explain how you saw those values become more implemented in the organization.

02-00:56:11
Bedway:
Over the years, you were really able to see that whenever we were making any significant decisions or just in our day-to-day operations. You would see Mr. Rankin and other senior leaders bring us back to the values in terms of our decision making, whether it was a decision to get into a different business or service line or something that may be happening external to the community that we may or may not weigh in on. I don’t know. You just always seem to see Fred and the other senior leaders—even when I was not in the position of a senior leader he would go back to the justification of why we were doing something. I was sitting at a department manager’s meeting as a front-line manager at the time, and not part of the senior team. [57:00] You always saw in the presentation and approach Fred and other senior leaders took come back to the roots of who we are, what we’re about, really draw back to the mission of the organization, and who we are from a values perspective. That has really stood the test of time in terms of people really respecting Mr. Rankin as a very values-driven, strong character and leader.

02-00:57:26
Rigelhaupt:
Could you talk about some of the ways that those values-driven, decision-making processes in a culture that is built around those values is maintained with the exponential growth of the organization. Because I would think that would present a challenge in and of itself. Mary Washington Hospital has gone from a community hospital from the time you’ve been here to a regional medical center. And the growth and the size of an organization could shape how those values are implemented. So what are some of the ways you see those maintained, even during a period of exponential growth?

02-00:58:14
Bedway:
It’s part of the behavioral-based interviewing that we do, in terms of really screening people from a values perspective, the best you can with behavioral-based questions. Part of the orientation that is done—all the senior executives participate at different times. In terms of covering the values, I know I do a new nursing hire orientation and I facilitate a session. Your quarterly reviews—when we’re looking at our Living the Mission document and how each unit or department’s doing, there is a component there where you looking in from a values perspective. Then your annual performance evaluation, along with opportunities for reward and recognition with our ICARE program. I do think we have imbedded it in our selection, our ongoing evaluation, and our reward and recognition program. Culturally, that’s how we’ve embedded the values. No one’s perfect, so it’s something you have to stay very, very busy with. I think having it as part of the recognition, but also it is part of our coaching, counseling, and disciplinary action; it continues to tie people back of why we’re rewarding you for something you did well or why are we having this conversation about something that didn’t go so well. Tying it back to the values helps the values really be alive and not just a document on the wall.

02-00:59:40
Rigelhaupt:
Is it harder to maintain those values and the culture around them as you’ve become a multi-unit health care system? [01:00:00] Going from a single hospital to a health care system—how does that go out into the system?

02-01:00:05
Bedway:
Once again, it’s keeping the alignment from Mr. Rankin as it cascades to the senior executives, to the directors and managers, and to the staff and back up. As long as you are being consistent with your messaging, you’re cascading that communication through, and you’re using common tools—I think that’s why it’s been so effective. Cathy Yablonski, as she started Stafford Hospital, has done an amazing job with communicating the values and deriving their excellent outcomes from day one—very values-based. I think it’s about selecting the right leaders who also believe in the values and live them daily.

02-01:00:48
Rigelhaupt:
So you described them cascading from senior leadership, and also coming back up. What are some of the ways that perhaps you can—you as chief nursing officer have focused on this, that as the organization has gotten larger, that there are still avenues for these values and ways to implement them that have come back up to senior leadership? How have you facilitated that?

02-01:01:16
Bedway:
Part of that is asking for feedback. I know personally I round and I have town hall meetings with my staff, as well as the associate input that is received from the Associate Satisfaction Survey. Those are all different venues where the associates can also provide feedback on how things are going from a culture standpoint, and at times give us feedback. We all have to model, as senior leaders, the values as well. I want to know if someone feels as if I’m not displaying that. I ask for feedback and people are very honest; so it’s good.

02-01:01:55
So in our last interview, you also described a sense of family at the community hospital when you first started. And I imagine that facilitates some of the give and take from senior leaders to front-line nurses; a family dynamic with open discussion. How has that been sustained? Do you still have that close-knit sense of working relationship among nurses, even as the organization has grown?

02-01:02:28
Bedway:
There’s no doubt that as the organization has gotten larger, it’s more and more challenging for us to maintain that sense of closeness. But it’s just very important, as I said, to provide those forums to have that time to be with your staff, to listen, to have them know that you’re aware of the issues, and to be there as an advocate, but also to personally communicate tough messages when they need to be communicated. [01:03:00] And just showing that respect. But yes, as we’ve gotten larger, it’s more difficult. I used to pretty much know everyone, and at times when I’m out in the community and someone will say, “Hi, Marianna.” I don’t necessarily recognize them. It’s upsetting to me that I can’t really place which exact department. I know they’re part of our team, but don’t have the first name and don’t necessarily know their family like I did when we were in the old facility twenty-five years ago. It’s just something that we continue to each work at. That is why it’s important for me to make sure that there is a very good sense of span of control for the actual managers, for the different nursing units in the areas, and to make sure that they are having that sense of relationship at the unit level.

02-01:03:47
Rigelhaupt:
Could you talk a little bit about the origins of the organizational development? The team or the program, I’m not sure if I’m using exactly the right term.

02-01:03:57
Bedway:
There was a wonderful senior leader that was in place in the late 1990s, Mr. Ray Pittman, who was our first senior leader who started organizational development. I still remember the department managers meeting here at Mary Washington right after the move, and right after we opened twenty years ago. He was articulating his vision for this department that was going to focus on quality. It was before we were using benchmarking tools like dashboards, and things like that, but that’s what he was speaking of. It just sounded very intriguing and very exciting about this department called Organizational Development that was going to focus on quality and measurement, and all.
It was from that vision, I had that opportunity to be the first nurse in that department working with Ray and others. We had a wonderful accountant, Beth Gentry, who was part of our team. Marcia Floyd, who was in charge of nursing education at the time, was focusing on education from a system perspective. It was just a very strong group that pulled together. Then over time, it has evolved to be part of the human resource team, and certainly our industrial engineers are very engaged. But yes, that was a concept that started in the late 1990s under a wonder leader named Ray Pittman.

02-01:05:19
Rigelhaupt:
What are some of the perspectives in terms of quality that you as the first nurse, part of this team, articulated? Because there are perhaps lots of different ways to articulate quality and different visions for it. And it sounds like this was an interdisciplinary team, as well. So not that you were necessarily speaking for nurses, but inevitably, your background had to—what did you say was, this is the quality we should be thinking about?

02-01:05:54
Rigelhaupt:
It was interesting back then because I think we were all learning and doing our homework on this new body of knowledge of what is organizational development. [01:06:00] Back then was the very first stages of looking at how to work on teams and optimize care. We had some projects around optimizing in terms of care delivery that was definitely interdisciplinary. We had some projects around supply distribution. We had a big initiative around case management redesign; a radiology improvement project that I can think of very fondly, too. There were a lot of different clinical and non-clinical performance improvement processes that really over time—adding an industrial engineer to the organization to bring that true knowledge and skillset in was important. What I didn’t know at the time is, a lot of what we were attempting to do was industrial engineering, and we didn’t even understand that necessarily or have that skillset for that on the body of work. But that’s what it ended up evolving to here, which has just been great because we now have people certified in Lean, and Six Sigma and other applications of knowledge around performance improvement and quality. It was the very forefront of making us who we are today in our quality department and performance excellence.

02-01:07:22
Rigelhaupt:
Can you think of some of the non-clinical programs from industrial engineering that have since surprised you in how much they have influenced clinical care?

02-01:07:35
Bedway:
Certainly. There have been a lot of great projects around leaning out the registration process, and how we bring in that data to get someone even entered in. That has impacted and helped from a financial standpoint. There are many projects that are non-clinical in nature that I can think of; cueing in terms of cleaning rooms; the whole environmental services and time of day and day of the week, in terms of staffing and resourcing for room cleaning. There are many non-clinical areas that support our clinical.
[End of Interview]