Moving Care Upstream, Addressing Social Determinants

Health care in the US is not a system so much as it is a series of experiments—a constant state of flux where professionals are trying new ways to improve and deliver care. While there are certainly inefficiencies and we can do better than we have, what we do in health care is not only quite valuable but also quite extraordinary. We have developed a complex modern medical health system that is incredibly expensive but is also extremely productive.

The new American medicine is proactive. Physicians work in teams with nurses and other caregivers to guide patients along a pathway to health and wellbeing. Our main obstacle? It may be the stasis that sometimes grips major stakeholders—a group too entrenched in “the way we’ve always done it.” While progress has been made in crossing the chasm to a payment model in which providers are reimbursed based on their success in managing people’s care, the system still relies heavily on an outdated fee-for-service model that pays doctors and hospitals for the volume of services provided. While it may have served its purpose in the past, it’s a financially unsustainable model that has grown unwieldy through the years, like an invasive species wrapping itself around the care delivery system and choking out payment reform innovation.

As suffocating as that methodology may have become, there is a way out. When you change the way doctors and hospitals are paid, you change the way doctors practice and the way patients are cared for.

A value-based payment model promotes better coordination of care and reduces the incentive to refer patients for unnecessary tests and procedures. The goal is to create a proactive care approach to managing the overall health of individuals and communities. It is a methodology that promises high quality and efficient care with minimal waste and delay.

Truly taking care of a community by addressing the social determinants of health like income, access, and education, among many other factors, may be the most disruptive challenge to the US health system. That’s where the innovative spirit—long a core characteristic of American medicine—will need to be stronger than ever.

It is a revolutionary idea and it’s not easy to accomplish, but getting people to take a hard look at their lifestyles and how their choices are affecting their short- and long-term health has the potential to drive meaningful change. If we look at health care in terms of a river analogy, the goal is to have physicians lead, partner, and support efforts to move care upstream and prevent problems from occurring at their source. As the analogy goes, it is easier to rescue someone if you prevent them from falling in the river in the first place instead of trying to pull them out of the water downstream. When it comes to health, it’s a strategy that makes good sense. As the medical adage goes: an ounce of prevention is worth a pound of cure.

The two innovations are interconnected. Changing the payment model will cause a domino effect that results in an overall change to our national approach of health and well-being. That’s because when you change the way providers are paid, it means that clinicians will change their focus to more proactive care, which in turn means going back upstream and targeting social determinants.

There is no doubt that we need to fix those areas that need fixing. But changing the way we look at health and well-being is an important first step. By opening the door to change and innovation and looking at things differently, we create possibility.

For instance, at Northwell Health we’re knocking down the wall between psychiatrists and doctors treating physical maladies. Instead of psychiatric care being something apart from the normal practice of medicine, we’re incorporating primary care into psychiatric consultations. For every $1 spent on collaborative care, health care organizations gain back $7 in cost savings over the next four years. That makes good health and economic sense.

While cynics may adopt a show-me-first attitude, true innovators don’t wait. They are busy leading the way forward. One only has to look at our recent past to see just what the innovative spirit at the heart of American health care can accomplish. When it comes to the heart, for example, the progress we have made treating heart disease is one of the great triumphs of modern medicine. The age-adjusted mortality rate for cardiac disease has been reduced by about 50 percent over the past 50 years.

But the medical disrupters haven’t stopped there. They’ve improved health care in America – by improving quality, safety, and access. In addition to heart disease, we’ve also seen advancements in the treatment of cancer and stroke care, and the emergence of bioelectronic medicine, among so many other innovations that hold the promise of reducing our reliance on prescription drugs and all of the side effects that come with them. It has been an amazing run. And I think we’re in for another.

First Featured on Forbesbooks.com

Remember Who We are as Americans

At a time when we are confronted with near-daily reports about the dangers posed by immigrants, it is important to remind ourselves of who we are as Americans—immigrants and the descendants of immigrants. It is important for us to reflect on our history and to think of those who came before us, whose courage and hardship afforded us our every opportunity.

Let’s also reflect on the fact that many of our parents and grandparents came here to escape poverty, famine, oppression, and discrimination.

We all came from different places, and while our individual stories are unique, they share common elements. Being Irish and an immigrant, I too often heard stories of the Irish immigrants who came to America to make new lives for themselves. Yet, much like the reaction to many immigrants arriving today, they were accused of being lazy, unruly, and criminals whose only goal was to take jobs away from hardworking Americans.

Today, there are nearly 33 million Irish-Americans; about 10 percent of the total U.S. population. Irish-Americans are now regarded as major contributors to America’s success, but it wasn’t too long ago that they were reviled. Irish immigrants were ridiculed by politicians as well as the mainstream media and discriminated against in education and employment.

Thomas Nast, the famous 19th-century cartoonist, gained his reputation, in part, by portraying Irish immigrants as criminals, drunkards, and marauders. “Want Ads” in New York newspapers often specified that Irish need not apply. The most well-known nativist movement arose in the mid-1800s with the creation of a political party commonly known as the “Know Nothings” which blamed the Irish and Germans for social ills such as rising crime and poverty rates. The movement resulted in anti-immigrant violence during the 1840s and 1850s in New York, Baltimore, and Philadelphia, among other cities.

That level of scorn, discrimination, and distrust was inflicted, to varying degrees, on each successive wave of immigrants. Xenophobic rhetoric has a long history in America dating back to the late 1700s when a member of Congress argued that the nation had no more room for immigrants—an argument that has been rehashed by small-minded politicians for centuries.

Without a doubt, the question of immigration is an extremely complicated one, and there are valid points raised by those who argue for a cautious policy that carefully and efficiently vets each newcomer. However, we should all remind ourselves of a few key facts:

  • We are all immigrants or descendants of immigrants. As we debate immigration policy, we must temper the rational with the humane and balance our caution with respect.
  • These are people who are brave enough and determined enough—and who too often have no other choice—to confront danger and leave everything behind to try to forge a new life in America.
  • Lastly, and most importantly, the history and success of America is the history of immigrants and immigration.

Despite the hardships that they faced, our forbearers persevered and created this great country. They established businesses, they became corporate leaders and elected officials, many of whom are now considered American heroes. We are all the beneficiaries of their efforts.

The issue of immigration is central to my personal experience. Though I now have the privilege of serving as president and CEO of Northwell Health, New York’s largest healthcare provider and largest private employer with a workforce of 68,000, I was born in southwest Ireland to a family of very modest means.

Like so many other “dreamers” before me, I moved to America in search of a better life. Marching down Fifth Avenue in 2017 as the grand marshal of the St. Patrick’s Day Parade, I could not help but think of the millions of men, women, and children who left behind homes and families for a shot at the American dream—and an opportunity to contribute to our shared history.


First featured on Forbesbooks.com

What Not to Do as a Leader

Leading a hospital or health system is an undertaking that is nearly impossible to prepare for, so some of my past columns have offered advice to incoming executives on behaviors that I think are essential to success. Perhaps even more important than the list of things to do are actions that leaders must avoid if they hope to be effective.

Here are my views on what leaders must avoid at all costs:

  1. Becoming infatuated with yourself. Some leaders believe everything is about them, and whatever they say is right. When you become self-absorbed or have an exalted ego, you create your own sense of reality and it is impossible to get other team members to trust you. Trust is essential. Without it, leaders are unable to generate buy-in from team members at any level of the organization.
  2. Dividing instead of unifying. A true sense of community is necessary to move a health system forward. Everyone must be willing to put their shoulders to the wheel together, and that is impossible when animosity festers among team members. Some leaders think a highly effective, motivational tactic is to encourage competition among members of their C-suite, but you would be hard-pressed to find a successful sports team that thrives on this dynamic. The greatest teams in any sport come out of the locker room ready to fight for each other, and they understand that resentment undermines any chance of success. The same holds true for healthcare organizations, and leaders who think otherwise are doomed.
  3. Choosing the wrong people. Being a leader requires putting yourself under a microscope, which can be difficult and uncomfortable for many people. The worst way you can react to those feelings is by surrounding yourself with sycophants whose best quality is their affirmation of your insecurities. Some leaders would rather create a circle of unqualified “yes-men” than team players who have the courage to speak their minds and disagree with their boss. Don’t demonize those who disagree with you. And remember that ideological alignment is not the basis for effective team building, so don’t allow your need to be liked cloud your better judgment.
  4. Never saying you are sorry or wrong. In keeping with my previous point, while all leaders need to be confident, they also need to be openminded and willing to consider opposing views. Excessive self-confidence can lead to the unfortunate and often-disastrous consequence of believing that you are always right—even when the evidence shows otherwise. Taking accountability by admitting failure and acknowledging it is a strength, not a weakness.
  5.  Blaming your predecessors.  Rather than take responsibility for the state of their organizations, some leaders would rather blame their predecessors. While they think this clears their plate of any blame and gives them the air of infallibility, all it does is establish a culture absent of accountability, where blame passes from one employee to another. “Success is,” as Winston Churchill so aptly stated, “going from failure to failure without losing your enthusiasm.” All leaders make mistakes and all decisions have downsides. To burnish your own reputation by ignoring the accomplishments of those who came before and excessively focusing on the negative avoids an essential element of leadership—taking responsibility.
  6. Taking communication style for granted. Some leaders think content trumps communication, but how you spread a message is as important as the message itself. Make time for face-to-face interactions with team members at every level, and don’t be afraid to engage people through technology. However, never hide behind technology as a means of avoiding in-person interactions.

Some leaders think they should only communicate with team members within their organizations when there is serious news that will have a significant impact on day-to-day operations. However, if your only point-of-view is how bad things are, you will undermine organizational pride and hurt the overall morale of your team. Leaders should accept responsibility for their mistakes and create a culture of accountability, but also celebrate everyday wins. Never forget that attitude comes from the top down, both in what you say and how you say it.

  1.  Lowering the bar on civility. Leaders set the example for how employees should treat each other, and must be able to apologize to people they may have wronged, which demonstrates the value of humility. If leaders do not embody these positive values, the bar for civility will be lowered for all employees, and the results can be toxic and destructive.

For more leadership advice and a critical look at the state of healthcare in America, pick up a copy of my book, Health Care Reboot: Megatrends Energizing American Medicine.

First featured on Forbesbooks.com

Michael J. Dowling: If It Can’t Be Done, You Haven’t Tried

This interview with Michael J. Dowling, chief executive of Northwell Health (formerly North Shore-LIJ Health System), was conducted and condensed by Adam Bryant.

Q. What was life like for you as a kid?

A. I grew up in Ireland in a very rural area. We had a small piece of property. It was an impoverished area, especially back in the ’50s and ’60s. Our home had mud walls, a thatch roof, three small rooms and a mud floor.

We had no electricity, no running water, no bathrooms and no heat. There was a big open fireplace where my mother cooked everything. Most of the families around us were farmers, and I thought they were very wealthy when I was a kid. As I grew older, of course, I realized they were not that wealthy.

My father was a laborer. At the age of about 40, he no longer could work because he had rheumatoid arthritis in every part of his body. My mother was deaf. She lost her hearing when she was about 7 years old. She never considered it a disability, though, and learned to lip-read. To get her attention, we would kick the floor. She’d feel the vibrations; it’s amazing how one sense takes over when you lose another.

There were five kids, and I was the oldest, so I started working at a very young age. Both of my parents had little formal education, but my mother was unbelievably interested in reading and learning. We always had books at home, even though we didn’t have much else. I remember reading Shakespeare by candlelight as a kid.

I didn’t think life was that tough at the time, but it was. And I’m not one who likes to complain too much. I dreamed about getting an education, even though I wasn’t really sure what that was.

Nobody ever thought that people like us would ever go to college because it was a very two-class system in Ireland. If you had some money, you were obviously geared to go to school. If you didn’t have money and you were at the lower end of the totem pole, you were not expected to succeed.

But I did well enough in my high school to make the cut to get into college. I had saved enough money to pay for my first semester of college, and I hitchhiked on a truck to get there.

And when I was waiting in line to sign up for my courses, I saw that I was in the line for liberal arts. I didn’t know what liberal arts meant. I was sweating because I have no artistic ability, and that’s what I thought liberal arts meant.

But college was just absolutely fantastic and wonderful. Fortunately for me, I was also very good at athletics. I played sports, and I got on the college teams.

In the summers, I would come to New York to make money and work on the docks. I sent home most of the money I made because my family was in a pretty bad situation. My happiest moments were sending money to my mother.

Any favorite expressions that your parents would repeat often?

You’re not entitled to success. You’ve got to work at it. You have to be trusted. You’ve got to earn the respect of others. Just because of what you are and what you might become, don’t expect that anybody’s going to like you just for that. You’ve got to earn their respect. Trust is the key to success, in many ways. If employees don’t trust you, and you don’t trust them, we aren’t going to get anything done.

And my mother always said, “Don’t ever let your circumstance interfere with your potential or limit your potential. You have unlimited potential to be successful if you work hard enough and if you work with people in a caring way.”

That is why, to this day, I do not like it when people talk to me about how something can’t be done. I don’t want you to tell me you can’t do something. You may not get there 100 percent of the time, but you can get there 80 percent, so don’t start with the presumption that you can’t.

There’s an old saying: “The same boiling water that softens the potato hardens the egg.” It’s what you’re made of; it’s not your circumstance. People like to play victim too much. And obviously circumstances influence you, but they should never hold you back from succeeding.

Tell me an aspect of your leadership style today.

I’m not big into organizational charts because they can put people in silos. People have roles, but they should be porous because if you’re working in a larger organization — just like if you’re on a sports team — you can be the defender, but that doesn’t mean you don’t help the offense. That concept to me is very, very important.

One of the things I always look for in people is whether they’re comfortable with disruption and comfortable with a degree of confusion. If somebody wants total clarity, they’re not the person for me.

And how do you get at that in a job interview?

I ask them about their social situations, their family situations, what motivates them, and how they like to work with other people. Is there a hunger, an intellectual curiosity? I will often take them on a tour of one of our facilities and see how they interact with people.

I look for their relationship skills and a positive attitude. Instead of their I.Q., I want to know their C.Q. — their curiosity quotient. To what extent are you focused on figuring out how to improve whatever it is you’re going to be doing? Nothing is perfect, so you should always be trying to figure out how to make it better.

Sometimes with candidates we’ll give them a schedule for the day they’ll spend with us. And then when the day comes, I switch it all around. I want to see how they react.

And they’ve often asked me, “Well, why’d you do that?” I said, “Because that’s life. When you come in in the morning, you think you’re going to be doing X. By the time you get to the office, you’re doing Y. You’ve got to be flexible.”

You’re going to be thrown curveballs all the time. It’s a question of how you respond. Don’t get frustrated over it. Roll with the punches.

Now More Than Ever, CEOs Need to Learn Good Leadership

In this time of upheaval, we need good leaders more than ever.

For the first time in American history, we have a president who ran for office largely on the strength of his business acumen. What America needs right now, Donald Trump argued, is not another politician but a seasoned CEO who knows how to run a smooth operation. America agreed, and soon approaching a year since the election, is as good a time as any to ask ourselves just what we expect a good CEO to do.

It wasn’t always a question I thought I’d be in the position to answer. I emigrated to New York from my native Ireland with no money and no prospects, and I made ends meet by working in a variety of manual jobs. I worked hard and got lucky, and eventually made my way from the docks to the corner office of New York State’s largest private employer. But no matter my position on the corporate ladder, one question continued to preoccupy me at every turn: the question of leadership.

When you run an organization of more than 62,000 people, as I now have the privilege of doing, leadership may seem like an amorphous, almost theoretical question. It’s easy for a CEO to feel like he or she needs to do little but worry about the big picture stuff. But having observed men and women who’ve successfully led companies, organizations and even nations, I’ve come away with a few insights on things they all do that make all the difference in the world.

First, great leaders proactively set the vision and culture of their organization, and communicate their goals and expectations clearly and effectively. And, since no objective is more critical to success, the time to start doing this is at the very beginning.

For the past 15 years that I have been CEO, I’ve started off every Monday in the exact same way: with a three-hour meeting with new employees. We hire more than 150 of them each week, and whether they’re custodians in charge of keeping the bathrooms clean or senior executives managing millions of dollars, they all start out by meeting with me, hearing about the collective vision for the organization, and having an opportunity to share their own ideas, observations and concerns. This kind of hands-on approach may strike some managers as needlessly time-consuming, and a poor use of a chief executive’s valuable time, but the moment we fail to set a common vision, we also lose with it the capacity to truly come together as a team.

And that’s a tragedy, because being part of a team is a fundamental human need. Ask people what it is that makes them truly happy about their jobs, and they may talk about their compensation or their benefits, but, more likely, they’ll say that they love coming in to work every day and doing something meaningful, something that makes them proud. Employees don’t just want to work for a company – they want to belong to something.

To that end, it’s well-worth the investment in giving employees precisely that feeling. The vision of the ultimate CEO as a cold and calculating cost-cutter who cares about nothing but bottom lines is deeply outdated. The only way to succeed in a complex global economy—in which everything from the products and services we provide to our ability to reach new and diverse markets is rapidly changing—is to have leaders who are as emotionally savvy as they are intellectually sharp. Such a passionate and attentive outlook doesn’t come naturally to many of us, but—thankfully—it can be taught. To this end, our company decided to invest in creating a “center for learning and innovation,” an in-house corporate university that teaches life-long learning skills to people at all levels of the organization, including how to get better at listening, empathizing and inspiring their teams. It took a considerable investment, but I’m happy to say it has proven tremendously effective in nurturing a much more fertile and nurturing work environment.

Finally, there’s the matter of change. All good leaders, to some extent, are expected to take their organizations through a transformation of one sort or another. Politicians understand this best, which is why they always promise to be the candidate of change. But as great leaders know, once you start implementing change, you run into what experts call the “change paradox,” namely how to evolve for a better future while keeping the here and now as stable as possible. This is an immensely complex question, but one simple answer is this: because we are all human, and because change, by definition, may lead to mistrust, we would be well-advised not to challenge the status-quo unless we’re certain that the change we’re about to implement is sustainable over time. By first creating and reinforcing a common culture and investing in leadership, we are able to face the change paradox head on—when we truly understand our environment, know its pressures and appreciate its opportunities, we put ourselves in a position to decide how to make it even better.

In this time of upheaval, with so many of our notions and our traditions—economic, political, cultural—challenged and repealed, we need good leaders more than ever. If the men and women fortunate enough to shoulder the burdens of directing not only our government but also our corporations and our institutions speak clearly and listen intently, if they constantly hone the great craft of empathy, and if they strive for change while always remembering that change isn’t something to be taken lightly or practiced irresponsibly, we will all thrive.

MARKET SHARE STILL MATTERS: 3 WAYS TO WIN

For CEOs, market share is critical. But measurement of it, and tactics to grow it, are getting more complicated as patients connect with providers in more sophisticated ways.

This article appears in the July/August 2018 edition of HealthLeaders magazine.

Health system CEOs have always worked to meet their mission of caring for the poor and underserved and improving the health of their community. They often cite that mission as their top priority. But in truth, they are evaluated by how well they grow revenue and margin, both of which come through expanding market share.

Market share used to be easy to define. CEOs counted on a reliably increasing reimbursement model that exceeded inflation and an aging population that meant more hospital days every year. No longer. But even though market share growth is much more complex now, failing to achieve that growth could mean termination.

To win the market share battle, healthcare organizations must first redefine what it is (see the sidebar on new market share proxies) and then build strategies that take advantage of the shifts in healthcare delivery. Here’s how three healthcare leaders are doing it.

NORTHWELL: ‘THE CONSUMER IS THE DETERMINANT OF SUCCESS’

Michael Dowling, president and CEO of Northwell Health in Great Neck, New York, acknowledges the need to provide access, value, and convenience for consumers who are increasingly looking for a wide-ranging array of services offered by a single health system. The key to this strategy is the consumer as the focal point of healthcare decision-making.

Northwell is currently investing heavily in home health and digital care access, including a major initiative in telemedicine, but tying it all together into a seamless consumer experience is critical.

“You need hospitals as anchors, but the strategy is very consumer-focused in providing access and convenience,” Dowling says. “We’ve been doing this for 10 years, and it’s one of the reasons we’ve grown to being one of the biggest players in the New York City market. It’s the interconnection of all these pieces that makes all the difference.”

Although it’s not a perfect analogy, Dowling says Northwell wants to emulate Starbucks’ approach to market coverage. It’s not a location on every street corner, but it’s close.

“The traditional way of looking at market share isn’t valid anymore.”

—Chris Van Gorder

Also, getting critical market share mass in a variety of modalities is necessary to becoming the viable narrow network that employers and insurers are looking for. Smart health systems are spending more on smaller facilities, like micro-hospitals, or on freestanding ERs, homecare, urgent care centers, and telehealth capabilities. Such investment aims to meet the everyday health needs of consumers, not just provide for their increasingly rare inpatient stays.

This means focusing on organic growth that complements or even stands alone from the inpatient realm rather than buying hospitals, for example. Specialized areas of investment in both inpatient and outpatient care are the usual profitable service lines, such as orthopedics, neurology, and cardiac care, says Dowling.

He says he seeks two kinds of market share when it comes to reimbursement: Medicare and Medicaid, and commercial. Both kinds are needed to serve the community comprehensively, he says, but only one of the two makes a margin. Patients don’t see that distinction, though, and Northwell must serve them all.

“[Commercial] is what everyone’s going after,” he says. “So, you try to be the preferred provider. You take market share from competitors by developing the physician relationship and by the expansion of ambulatory. We’ve built a massive ambulatory network with over 650 locations. It’s a marketing and consumer experience strategy. If patients are not happy with experience, they will go somewhere else, so it’s multifaceted.”

Sidebar: Healthcare CEOs Using New Proxies for Market Share

Sidebar: Geography Should Inform Your Market Share Strategy

Hospital-centric organizations used to measure market share in terms of inpatient volume or discharges, but as more services have moved outside the hospital environment, those have become less reliable measures of success.

“We’re all moving toward understanding that the consumer is the determinant of success, rather than just the patient care business,” says Dowling. “The consumer is going to be determining how they want care and where, and since more of it is not needed in the hospital, you have to create locations for cancer care and imaging and surgery where it can be done on an ambulatory basis.”

SCRIPPS: ACCENTUATE YOUR STRENGTHS

Chris Van Gorder, the longtime president and CEO of Scripps Health in San Diego, is content with a level of uncertainty around market share, and says that growing it depends partially on instinct in a time of upheaval.

“Market share’s an odd thing. Everyone still wants to gain commercial market share, of course,” he says. “But today we’re not so focused on the inpatient side. We’re doing total hips on the ambulatory side. So, the traditional way of looking at market share isn’t valid anymore.”

Even though the discharge-based methodology isn’t as relevant as it used to be, it’s still important. Rating agencies still use discharges as an important tool to measure financial health, and with the relative lack of precise alternatives, discharges can be an important factor in how they determine borrowing capacity and interest rate terms for healthcare organizations.

“As an industry, we have to figure that out,” Van Gorder says. “Rating agencies use discharges, but you could be reducing that number and getting stronger as an organization.”

Chris Van Gorder (Sandy Huffaker/Getty Images)

Scripps went through its rating agency sessions about three months ago and has seen a small decline in those traditional market share measures, but Van Gorder says those measures don’t tell the full story anymore. Scripps’ market is dominated by three major players: itself, Kaiser Permanente, and Sharp HealthCare, so fluctuations in discharges are often small and at the edges.

Rating agencies are smart enough to recognize that healthcare is changing, Van Gorder says. For example, they know it’s the right strategy to move to ambulatory, and Scripps experienced growth in covered lives in its health plan, which is part of Scripps’ strategy to build its own narrow network. But even rating agencies are frustrated that there’s no metric to enable consistent comparisons, he says.

“We still talk about market share because I still need to make sure the hospitals are occupied enough. Half-full hospitals are the fastest way to go bankrupt,” he says.

Scripps is strong in cardiovascular services, particularly interventional cardiology. “So, we focus on maintaining our strength in that area and in ortho, which is becoming much more ambulatory than it used to be,” says Van Gorder.

One area where it’s not as strong is cancer, he says, even though Scripps is a major oncology provider in San Diego. To maintain and even buttress that market share, the health system has partnered with Houston’s MD Anderson Cancer Center to build a new comprehensive cancer program that started treating patients this summer.

“[MD Anderson] is building a network strategy, and they have 23,000 people just working on cancer, so we are taking advantage of their knowledge to make us stronger,” he says. “It was a market share play, but it’s much more than just that, with increased access to research and clinical trials.” (See related sidebar on seeking out partnerships.)

John Haupert (Dustin Chambers/Getty Images)

Facing fierce competition in ambulatory, Van Gorder says the health system is focusing on areas where it’s strongest and trying to grow there.

In all areas, he says Scripps must aggressively focus on cutting costs, because he sees cost as a proxy for quality. In fact, he notes, cost may be the major limitation for most health systems in growing market share for the foreseeable future.

“People are paying more out of pocket to come in, and insurance companies have gotten so good at narrow networks,” he says. “People tell me you can’t lead with cost, and I say no. Cost is a quality indicator.”

GRADY: INVESTING IN SPECIALTY SERVICES

Safety-net hospitals, such as Grady Health System in Atlanta, have historically been overrun by mission patients—that is, patients who do not bring margin, such as Medicaid patients. But its leadership has recognized that the health system needs to be more competitive in commercial patients.

For Grady, that hasn’t meant investment in traditional service lines, but instead investment in highly complex tertiary and quaternary services that can’t easily be found elsewhere in its market, says John Haupert, its president and CEO. With seed funding from philanthropic sources, Grady has made multimillion-dollar investments in stroke and neurological surgery, interventional cardiology, and surgical subspecialties.

“In our case, it was a matter of survival. If all your patients are Medicaid or unfunded, you’re not going to be in business. Part of Grady coming back to life 10 years ago involved developing strategies to grow in funding the mission,” says Haupert.

The complex cases that have come from Grady’s recent investments weren’t previously present in the market. Unlike many organizations, Grady needed to create additional inpatient capacity to maximize those investments in capital and talent. It will soon be operating around 700 occupied beds; 10 years ago, it was barely operating 400. It’s building new outpatient facilities as well, expanding ambulatory surgical and oncology capacity across the street to free up space in the main facility where its cancer center is now.

“In the next three years, we’ll have 750 beds in operation,” Haupert says. “We’ve gone from 9% to 20% commercial. That helps with sustainability.”

Michael speaks with administrators

The urgency of change

With patient demographics shifting nationwide and new technologies transforming how care is delivered, medical education has yet to receive the thorough review required to keep pace with the dramatic changes affecting our industry.

Physicians of the future need to embrace a more interdisciplinary approach to delivering care than the purely clinical focus our medical schools have cultivated for decades. Thanks to the new wave of medical schools that offer joint medical degrees and other changes in the way we train doctors, new physicians entering our hospitals and other facilities are much more diverse and well rounded than we’ve seen in the past.

Medical schools offering a mix of programs that include business, law, molecular medicine and other advanced degrees in conjunction with medical degrees will continue to become more appealing and diverse in the coming years, as physicians of the future seek more options for professional growth. Of course, diversity not only relates to a physician’s course of study but to the increasingly diverse patient populations served by providers.

It is difficult to deliver effective care if you are not attuned to patients’ cultural differences, and medical schools must teach physicians how different cultures approach care and perceive physicians. If they do not understand that their patients may react differently to care options as a result of cultural nuances, physicians struggle to form the genuine bond that is at the heart of every clinical interaction. It is imperative medical schools offer this kind of complementary education in conjunction with their clinical curriculum.

Perhaps the most dramatic mindset shift medical schools must embrace to adapt to a changing industry is to acknowledge that memorization is outmoded. It is unbelievable how much time medical students spend memorizing facts and figures, only to forget many of them when it comes time to learn new material for their next exam. Memorization does not imply understanding, and in an age when Dr. Google holds all the answers in a single click of the mouse, it is a waste of time.

When education focuses solely on the diagnostic or treatment aspects of medicine, physicians are ill-equipped to reconcile that medical care is only one component of health. There are many other factors that contribute to a patient’s overall health, including social determinants, geography, diet and a multitude of other lifestyle choices. To create a well-rounded care plan that keeps patients healthy and out of the hospital, it is imperative for physicians to truly understand how to engage patients and learn about all of the factors that impact the health and wellness of each individual. While technology continues to advance at a dramatic pace, it should never provide a substitute for human contact.

At Northwell, we partnered with Hempstead, N.Y.-based Hofstra University to form the Zucker School of Medicine, which welcomed its first class in 2011. In creating a pass-fail curriculum, we identified aspects of traditional medical education that we thought should be retained and modified it to create an entirely new experience for physicians in training.  It began with the concept that students don’t have to sit down in a classroom and be lectured at all day by professors. At our medical school, students meet in small groups and engage in facilitated discussions guided by faculty members. However, we did not simply update the way medical students engage with academic material, but changed the very academic structure of medical education.

Usually, medical students sit through two years of classroom instruction before they engage in clinical work. We found this model counterproductive to the ultimate goal of preparing physicians for the unpredictable and challenging job of delivering care. To give them more hands-on experience, students begin training as emergency medical technicians within the first nine weeks of school. They ride in ambulances and travel to patients’ homes, helping them to better understand that the patient’s personal circumstances have an undeniable effect on their health. Students then follow up with these patients along the entire continuum of care to help develop a holistic understanding of how people interact with our health care system.

Understanding that the majority of care in the future will take place outside the walls of the hospital, our students gain experience in many different care sites, including ambulatory practices and community health centers, giving them practical experience starting on day one of their education. Instead of multiple-choice exams, students utilize small-group assessments to present cases on an individual basis, then test their skills every 12 weeks at our simulation training center.

Though physicians are some of the most highly educated professionals in the world, even after medical school, residency and fellowship training, the most important lessons of their career come from day-to-day experience. Even if providers are not associated with a formal medical school, hospitals and health systems are in the business of education. Organizational leaders should be mindful of the educational nature of their work and provide opportunities for their clinical teams that foster a sense of continued learning throughout their careers.

Long-established medical schools, some of which have been in existence for more than 200 years, may be hesitant to adopt changes that shake their foundations. Some have become slaves to history and tradition within organizations that move at the lethargic pace of bureaucracy. However, during an era when consumerism is spreading into all areas of healthcare, traditional medical schools must be mindful of the outside players that are disrupting so many facets of healthcare. As we have seen with hospitals over the past 15-20 years, if they do not evolve and embrace change, they risk extinction.

How a ‘Shark Tank’ approach can help organizations find the next big healthcare innovation

Every health care organization relies on its senior leaders for ideas that will help set them apart from their competitors, but it’s often the people on the front lines of clinical care, research or day-to-day operations who are the true innovators.

The biggest problem most health systems face is not a lack of good ideas, but a lack of opportunity for employees to express those ideas. Every year, Northwell Health puts forth an open call to our employees to submit innovative ideas they think can significantly improve patient care or our day-to-day efficiency.

Our efforts to tap into the creativity that exists within all health care organizations date back more than a decade ago, when we launched an initiative called the “Idea Forum” to solicit suggestions from our employees about how to improve efficiency and save money.

We were flooded with a plethora of good ideas that came from employees at all levels of the organization, from the laundry crew and maintenance teams to departmental heads.

Recognizing the gold mine of innovation that rests within the minds of our employees, we created a “President’s Award for Innovation” in 2007 to honor individuals and teams for their pioneering ideas at our health system’s Annual Meeting. Beginning in 2017, we pushed our culture of innovation a step further by holding what we call a Made for Big Ideas showcase, where we hold an “Innovation Challenge” modeled after the Shark Tank TV show.

Each year, we put out a request to all employees for innovative ideas that could potentially be spun off into a commercial venture or standalone business. A committee of Northwell leaders involved in both our clinical operations and our venture capital fund reviews and selects what they consider the top ideas, which are then presented to a panel of external judges. Similar to the TV show, the panel receives a written proposal about each idea and the employees have five minutes to give their best sales pitch and answer questions about how their ideas could impact the health system or be transitioned into legitimate businesses. These presentations are filmed and broadcast throughout our health system. The judges select one winner and a first runner-up, each of whom receive a $500,000 investment, while the next two runners-up each receive $100,000 to further advance their ideas.

The showcase has undoubtedly fostered a culture of innovation across our organization, providing us with ideas we would not have otherwise received, but it also enhances employee morale. This kind of engagement makes employees feel like their talents and knowledge are recognized and appreciated, and encourages them to look at their daily responsibilities through a creative lens. The most influential and out-of-the-box ideas often come from people who are involved in the day-in and day-out delivery of patient care.

At this year’s showcase, two of our medical researchers presented their proposal for a first-ever, non-invasive method for diagnosing endometriosis based on the analysis of menstrual effluent, which took first prize. Second place went to a team of IT-proficient doctors and nurses who are developing an “EMRBot,” which has the potential to significantly improve physician-patient encounters by utilizing chatbots to transcribe speech directly into the patient’s electronic medical record.

Not only do these innovations have the potential to significantly impact the way we deliver care here at Northwell, but we will utilize our venture capital resources to give these employees the proper backing to ensure that their innovations can be commercialized and made available to providers across the country. The employees who came up with the ideas also receive a financial stake in those businesses so they may reap the rewards of their ingenuity.

The ideas that we have been able to commercialize are not only coming from clinicians and researchers. Several years ago, one of our environmental services supervisors helped develop a new patient privacy curtain called Hand Shield®, which includes a 10-inch-wide panel of cleanable laminate along the outer edge of the curtain where most people grab it, making it easier and less costly to clean, and reducing the build-up of bacteria.

The Hand Shield® is now being used in hospitals across the country.

Many healthcare leaders ask me what the hurdles were for implementing this program. It takes commitment by leadership, trust in your employees and talented people to organize. If you give employees the opportunity to share their thoughts and suggestions, you will be overwhelmed by the amount of good ideas you receive. There is a palpable hunger within our industry for this kind of innovation.

Leaders must establish a culture in which people are free to make suggestions without fear of being humiliated or ignored. A culture without fear of reprisal, and one that doesn’t present unnecessary hurdles, can quickly cultivate innovation, boost employee morale and improve day-to-day operations.

To succeed, organizations must prioritize these 4 soft skills

Organizational success and performance require a continuing focus on key strategic and operational issues – most often reflected in business metrics dashboards. The ones that get the most attention are financial, capital investment, quality outputs, supply chain, market share and personnel – often referred to as the “hard issues””  All are extremely important, of course, but there is another side of the business that deserves equal attention – and are key to organizational success, especially in healthcare. These are referred to as the “soft issues.”

Soft skills provide a necessary complement to the knowledge and talent that employees bring to their jobs, and ensure that the many individuals involved in a patient’s care are able to communicate and interact effectively. Though some make the mistake of thinking that an organization’s success is based on the financial bottom line, it is a series of more qualitative, intangible measures that truly determines success or failure.

Here’s my take on the four most important soft skills for leaders to prioritize within their organizations.

1. Trust: Trust should not be regarded an abstract concept without real-world consequences, but instead as a fulcrum that promotes productivity and reduces the risk of dissention. If employees do not trust their supervisors, they are less likely to take direction or work to the best of their abilities. Mistrust deflates employee morale and decreases engagement. If employees feel coworkers or management cannot be trusted, productivity suffers.

When leaders of hospitals or health systems attempt to secure funding from financiers, the strength of their word is often as important as the data they present. Unless money managers trust that leaders are responsible financial stewards, they will be skeptical of the information they are given.

Trust and credibility are powerful factors in any relationship. Leaders must also prioritize trust when hiring or promoting individuals to maintain credibility with colleagues at every level of management.

2. Loyalty: People often mistake loyalty as obedience to a particular individual. The kind of loyalty that I emphasize is not blind loyalty to the potentially misguided actions of a superior, but to the greater mission of an organization. It is vital for leaders to clearly establish that employees’ greatest priority is a commitment to the organization. Creating a culture that discourages petty office politics comes from the top down, because without the right kind of loyalty, departments run the risk of becoming siloed and leadership teams can become splintered. Like players on a successful sports team, every employee must be loyal to the goal of winning — not the team’s captain or coach.

In our field, the overarching goal is obviously to ensure the best patient outcomes and experience. In the end, our collective loyalty must be to the patients and their families.

3. Interpersonal Relationships: Delivering and paying for healthcare is unbelievably complex and requires the cooperation of many different parties. To make the process as effective and seamless as possible, everyone in a healthcare organization must have excellent relationship skills – from the parking attendants to the physicians and nurses. Unless people know how to properly interact with people inside and outside the organization, they will create friction and negatively impact the experience of our employees, patients and their families.

People with what I call sandpaper personalities will always rub others the wrong way. In a people business like ours where forging new partnerships is essential to an organization’s success, it is imperative for leaders to recruit those with this attribute and focus on continually developing the relationship skills of all their employees.

4. Teamwork: Simply put, healthcare is a team sport. No one member of the care delivery team can succeed without the partnership of others. We hammer this point home by including all frontline staff during simulation trainings conducted at our corporate university. When we simulate a surgery, a baby’s delivery or a medical emergency, the surgeon, nurses and all other support staff involved in caring for patients in those situations need to be active participants in the training to make sure we get it right. Without everyone working together to the best of their abilities, we cannot deliver the most effective care. Whenever our chair of cardiac surgery speaks at a news conference or presents to our board or other leadership, the first thing he does is thank his fellow physicians, nurses, perioperative staff and other members of the surgical team — and underscore the fact that without their hard work and dedication, success would not have been possible. It is a CEO’s duty to instill this belief among employees and avoid the ego-boosting that can sometimes fester in our field. If employees do not observe a collaborative and generous spirit among their leaders, they will have no incentive to practice it themselves.

Every Monday morning, I meet with about 150 new Northwell employees and spend the majority of my time emphasizing that they do not work alone. From the moment they begin their first shift, they are part of a team. Working as a team not only means supporting each other, but also ensuring there is enough respect and professionalism to speak frankly and perhaps critically when needed. This freedom to share views and influence the behavior of others only comes when there is trust and loyalty among team members. It all helps support our mission to improve the health of the communities we serve.

So as much as we value the knowledge and technical skills of individuals in our workforce, hospitals and health systems need to place a high priority on the importance of soft skills. Organizations that promote trust, loyalty, relationships and teamwork among their leaders and other employees are more successful over time and can survive periods of instability because of the strong foundation of comradery they’ve built. It is also critical to promoting a culture of innovation, continuous learning and transformation. To learn more about this topic, I encourage you to read, The Soft Edge: Where Companies Find Lasting Success, authored by Rich Karlgaard.

8 timeless pieces of leadership advice

When it comes to offering leadership advice, Michael Dowling, president and CEO of New Hyde Park, N.Y.-based Northwell Health, has vast experience to draw from.

Mr. Dowling has led Northwell Health since 2002. Before that, he served as the health system’s executive vice president and COO. Prior roles include senior vice president at Empire Blue Cross/Blue Shield and various roles in the New York State government, including director of Health, Education and Human Services and deputy secretary to the governor.

At the helm of Northwell Health, Mr. Dowling has guided the system through numerous accomplishments, including the expansion of its footprint across New York, the launch of a health plan that covers more than 100,000 people, a systemwide rebranding and the creation of an office dedicated to population health management.

Mr. Dowling’s leadership style is refreshingly candid with high integrity. A regular contributor to Becker’s, Mr. Dowling has shared innumerable pieces of valuable advice with our audience. Here, we’ve collected some of the best.

On health system strategy
Hospital and health system CEOs deal with a myriad of responsibilities every day of their long work weeks. It’s critically important not to get bogged down in the daily distractions. Instead, we must keep our eye on high-level objectives, such as ensuring the organization is on track financially and supporting our clinicians as they provide high-quality care. At the same time, we strive to promote a positive and engaging culture for the workforce.”

If your organization is in the transformation game, keep pushing the agenda forward in 2017. A lot of people are concerned about what’s going to happen in Washington with the new administration and Congress, particularly the fate of the Affordable Care Act. Irrespective of the outcome of those debates, healthcare leaders should never let their organizations be completely controlled or constrained by them. If you’re already transitioning your organization to deliver value-based care, my advice is not to be perturbed by the craziness that goes on in Washington — keep transforming.”

We thought long and hard about launching a health plan before committing to do so. It’s a risky venture. Creating an insurance product requires building an entirely new infrastructure, hiring the right people and a significant investment in data analytics.”

On population health management
The definition of population health is broad and contains many elements. It is the notion that healthcare providers must take a more proactive role in patients’ health outside of the hospital walls. Instead of ‘sick care’ — only engaging with patients when they arrive at the hospital with an illness or injury — population health places strong emphasis on prevention. It also accounts for the social determinants of health, such as an individual’s socioeconomic status, housing, employment, access to transportation, mental well-being and relationships.”

The growing momentum behind population health management represents a marked departure from traditional healthcare, in which providers saw patients when they were ill or injured, treated them and sent them on their way. At its core, population health management requires a fundamental reconstruction of our mindset as providers.”

On innovation
The culture and DNA of an organization has to be one of innovation and transformation. Innovation can’t be a one-off project for a small group of people. If it is, it is unlikely that any effort to implement something new on a systemwide scale will yield much success. Instead, innovation must be regarded as a fundamental component of the organization’s strategy, of which all employees play an important role.”

While CEOs have traditionally viewed technology as a responsibility belonging only to the CIO and IT department, that mindset can be detrimental to healthcare organizations in today’s rapidly changing environment. It will lead to missed opportunities for innovation and growth. Although IT professionals provide expertise and support, CEOs must be closely involved in technology strategy and management.”

On having gratitude
Given the work that we do, healthcare professionals should feel unbelievably privileged to have the opportunity to do our jobs and be in a position where we can touch people’s lives in such an intimate way. In some cases we are performing miracles for people who are in terrible situations. We are blessed by the opportunity to put families back together who might be broken apart by mental health problems, addiction or other major illnesses. There are not many professions that offer their employees the ability to provide the kind of care that we do.”