After her first year with SSM Health, CEO Laura Kaiser talks about 'shifting our expensive rescue care system to one that is more broadly focused on preventive care, wellness, and affordability.'
The board of St. Louis-based SSM Health needed to find a blend of qualities when it searched for a new CEO in 2017. CEOs who can acquire more hospitals aren't that difficult to find these days, but leaders with a proven track record of getting multiple hospitals to work together are gold. SSM Health needed a CEO who was ambitious and yet grounded; after all, this is the first health system to win the Baldrige Award under the firm hand of Sister Mary Jean Ryan. And they needed a CEO who understood the values and people of the Midwest. Laura Kaiser hit every check on the list.
A St. Louis native, Kaiser took over as SSM Health CEO in May 2017 to replace the retiring Bill Thompson, who was an SSM Health employee for more than 37 years. Kaiser brought hospital leadership experience from many years running hospitals for Ascension Health in Florida and other markets. She was most recently chief operating officer at Intermountain Healthcare, what many in the industry consider the model for integrated delivery of healthcare.
In taking over SSM Health, she faced a system with a history of clinical innovation and quality that had experienced substantial regional growth in the previous decade, most notably the acquisition of Madison, Wisconsin–based Dean Health System in 2013, followed in 2018 by the acquisition of Fond du Lac, Wisconsin–based Agnesian Healthcare, and Monroe, Wisconsin–based Monroe Clinic.
Kaiser's first year hasn't been without tough choices. In November 2017, SSM Health announced the elimination of a few hundred positions or approximately 1% of its workforce.
HealthLeaders Editor in Chief Jim Molpus sat down recently with Kaiser at SSM Health's corporate headquarters to ask Kaiser about her leadership plans.
HL: What lured you to SSM Health?
Kaiser: I grew up in St. Louis and was very familiar with SSM Health. It provided a wonderful opportunity to return to my hometown and to my roots in Catholic health care. As a servant leader, I strongly identify with our mission, and it's what makes SSM Health such a special place.
Our first CEO, Sister Mary Jean Ryan, built a strong legacy focused on quality, diversity, and preservation of the earth. Bill Thompson, who followed her, continued that work and also began expanding our ministry. My focus is on continuing to grow, partner, and transform our ministry to ensure our patients and communities have access to high-quality, compassionate, and affordable care.
HL: Where do you see growth and partnerships fitting into SSM Health's future? How might it look different than SSM Health's regional expansion of the past few years?
Kaiser: Growth is one of our key strategic areas of focus. SSM Health has doubled in size over the past nine years and we will continue to grow and partner with others where it makes sense—to best meet the needs of those we serve. While much of our growth over the past few years has been through traditional transactions, we expect to build more collaborative partnerships in the future. Our partners will be both traditional and non-traditional, bringing clinical and healthcare expertise, but also experience in virtual care, technology, and human services.
HL: One of the changes with potential for the largest impact has been in governance. Your board grew substantially. Not many CEOs would eagerly embrace a larger board to deal with. Why the change at SSM Health?
Kaiser: In order to take full advantage of their skills, talent, and expertise, our board migrated from the Carver Model to a contemporary model. We have also recruited several new board members, growing our board from seven to 17 which includes well-known and highly respected business, civic, and opinion leaders from our communities as well as across the country. By strengthening our board overall, we ensure strong oversight and direction for SSM Health.
HL: To "focus on the health and wellbeing" of an entire community is a huge statement. It's a goal every health system has somewhere in its mission. How do you make it real for SSM Health?
Kaiser: Good health and well-being has been a personal passion since the early '80s when The Aerobics Way was made popular by Dr. Kenneth Cooper in Texas. Helping each person live his or her healthiest life is obviously important for each individual, but it is also essential to shifting our expensive rescue care system to one that is more broadly focused on preventive care, wellness, and affordability. We all need to actively pursue this to create a system of healthcare that is sustainable in the United States.
At SSM Health, this priority is consistent with our mission and strongly supported by our board. We have set specific goals to identify community health needs and then partner with others within our communities to improve overall health. We actively track our results to ensure we're making a measurable impact. It is difficult and critically important work.
Additionally, we are working to improve the health of communities through our health plan and various risk contracts, as well as employee wellness activities. Even something as seemingly simple as making it easier for our employees to make healthy meal and snack choices on our campuses can have a positive impact.
HL: At Intermountain, you had all the parts of the machine necessary to deliver integrated care: providers, payers, risk, data. You don't necessarily have all those same parts at SSM Health. So how do you make integrated care work here?
Kaiser: SSM Health is also an integrated delivery system pursuing the delivery of high-quality accessible services at an affordable cost. For example, in Wisconsin, we have Dean Health Plan, the SSM Dean Medical Group, several hospitals, outpatient and post-acute services, and a pharmacy benefit management company. All the ingredients are there, and we are continuing to build on those resources in our other markets as well. We've also added a Chief Clinical Officer to SSM Health to accelerate our work in care management across the enterprise, and this is work that will continue to grow over time.
HL: We feel a growing vein of frustration for health system executives over their IT expenditures and the value they get from them. Do you think that in the next few years we will finally see technology that can truly shift the paradigm of better care/lower cost? In what particular areas are you most hopeful that will happen?
Kaiser: There's no doubt in my mind that EHR systems have helped us improve patient care. When providers have access to complete and accurate information, they can provide better diagnoses and treatment plans, while also helping prevent medical errors. For example, EHRs keep a record of each patient's medications and allergies, and automatically check for problems when a new medication is prescribed. EHRs have also improved revenue cycle by enhancing our documentation and coding of claims, which of course leads to improved charge capture and reimbursement.
Over the next several years, I expect EHRs to play a fundamental role in population health management. They will be used more and more in developing risk segmentation and standardized care management plans that offer the potential to further enhance outcomes and reduce costs, particularly for high-risk patient groups.
HL: How will SSM Health embrace a new relationship with the patient/consumer? How do you move the dialogue into areas that patients really care about, such as access and transparency?
Kaiser: Access and transparency are both very important to consumers. We must learn to meet people where they are and ensure our communities have affordable and convenient access to the right care, whenever and wherever they need it. That's one of the reasons SSM Health is working to further strengthen our ambulatory platform, expanding virtual care, senior care, postacute, and behavioral health services. This will enable us to provide access to the best care possible—at all stages of life.
At the same time, we have invested in technology and systems that make it easier to access our services, including online appointment scheduling, same-day appointments, and virtual visits with both primary care providers and specialists. Last year, SSM Health also launched a price transparency program that provides patients with their estimated out-of-pocket costs. At the same time, we began publishing physician ratings and comments from patient surveys on our website. These are just a couple of the ways we are trying to assist patients in making more informed decisions for themselves and their families.
Ultimately, we must work with our patients and communities to find out what they actually want and need from us—instead of telling them. This requires research and a lot of listening. We don't always get the answers we expect, and we have to be open to that.
Costs are rising. Reimbursement is shrinking. In this environment, innovation is obligatory. How do you make it happen?
Hospitals and health systems can't wait around to innovate. The health consumer won't wait, and neither will market competitors ranging from Amazon and Walgreens down to the startup entrepreneur who are all poised to take away as much healthcare business as they can.
Competition and value and pace were common topics for presenters at the NEXT Hospital Innovation conference in Dallas on Monday. Health systems, including Baylor Scott & White, Lifebridge, Massachusetts General, Intermountain, Providence-St. Joseph, Atrium, Northwell and others, shared a growing energy and concentration among health systems to innovate. The clear theme: with costs growing and reimbursement shrinking, innovation isn't optional.
Four takeaways from Day 1:
1. Be Quick, But Don't Hurry
Nick Reddy, chief digital officer for Baylor Scott & White Health, said that the national pool of venture capital headed toward healthcare is an estimated $6-8 billion, one of the largest pools of venture capital since the dotcom days.
"The venture capitalists and entrepreneurs are moving in with you or without you," Reddy says. Likewise, the next generation of healthcare consumers "is not going to give us 20 years to fix healthcare."
That said, however, healthcare innovation may be a bit slower to innovate than other industries. "Do no harm is an oath for our industry. It's okay to be careful."
2. If You Are Not Digital by Now…
Embracing digital technology is not a trend, or a strategy. Health systems that have not embraced digital healthcare as a cultural shift may struggle to keep up with increasingly engaged consumers.
From digital tools to manage migraines developed by Atrium Health, to messaging apps that use automated conversations to communicate with patients developed by Northwell, speakers shared that the customers are willing and eager to embrace digital tools. The not-so-secret sauce: make it easy, make it valuable to the customer, and commit.
Baylor Scott & White has rolled out a strategy to "be digital," including the development of MyBSWHealth, an online and mobile portal that allows patients to access medical information, payments, and scheduling. The free app has a rating of 4.7 out of 5 on the AppStore with more than 8,500 reviews, making it one of the highest-rated health apps available, Reddy says.
3. Don't Overlook the Simple, Elegant Solution
Not every innovation needs to be downloaded from Google or the AppStore. Too often hospitals may overshoot the problem with the tool.
Jonathan Ringo, MD, chief operating officer of Sinai Hospital of Baltimore and senior vice president of LifeBridge Health, said an offshore call center developed by Lifebridge has been successful in engaging patients and reducing costs. But they still faced a challenge: getting patients to appointments. The solution was to use Uber and other ride sharing programs, he says.
"We now spend $22,000 per month on Uber to transport patients to their appointments," Ringo says. While ride sharing is not traditionally a cost that health systems embraced, Ringo says "if you can get patients to make their appointments and take their medication, you can dramatically reduce readmission rates."
Overall, LifeBridge has seen a 21.5% reduction in congestive heart failure and chronic obstructive pulmonary disorder readmissions since the beginning of the program.
Innovation should also look to take away needless pain for patients.
"When empathy is combined with curiosity, that is when we have innovation," says Todd Dunn, director of innovation at Intermountain Healthcare's Transformation Lab. Intermountain was looking for a way to reduce the nearly 500 million inpatient blood draws performed in U.S. hospitals annually. Needle stick blood draws are not only potentially painful but can disrupt sleep for patients in acute care.
Working with San Francisco-based Velano Vascular, Intermountain helped develop and test a needle-free technology called PIVO™, which connects to an existing IV catheter to draw blood from a vein. After initial testing of the device with 15,000 procedures and no adverse events, Intermountain has since rolled out the device to all of its 22 hospitals.
4. Be Merciless in Demanding Value
The stereotype of innovation brings up images of creative people playing with cool ideas and someone else's money. The reality for health system innovation is quite the opposite, speakers said.
"Innovation isn't sexy. It's grunt, hard work," Dunn said.
David Cerino, group vice president of digital innovation at Providence-St. Joseph Health (PSJH) in Seattle, says Providence and its innovation arm Providence Ventures has a disciplined process to evaluate a potential technology. Working with clinical and executive leaders, innovators identify areas of need for the system and evaluate if that technology is available or needs to be built. Part of the logic is that if PSJH needs the technology, "there are probably other systems that need the exact same thing."
Although any evaluation is based on demanding financial and clinical application metrics, PSJH always starts with a simple value question.
"We look at the customer value first," Cerino said. "Consumers, patients, and their caregivers are simply frustrated with their healthcare encounters."
Carefully curated content, a better user experience, and a renewed promise to identify actionable solutions are the hallmarks of our new look.
You are looking at the new HealthLeaders. We have listened to you and we have refreshed and relaunched our website and award-winning magazine.
We still aim to provide the best information to help you run a better healthcare organization. Here’s how our redesigns will help:
1. Solutions to Lead
Our purpose is to identify those ideas and strategies that will equip you to run a better hospital, health system, medical group, health plan, or any healthcare organization.
The temptation in healthcare media is to rehash the same problems. Not us.
Our renewed brand promise is to identify only the actionable solutions that add value. And as always, we look for tested solutions that have come from your peers.
2. A better user experience
"User experience" is a customer service term that encompasses many things. But we have simplified it: We get you to the information you need quickly and cleanly.
Our site navigation has been streamlined into core focus areas, including strategy, nursing, care, innovation and finance. Our content is built for mobile, so you can scroll through to find the content that engages you.
The font is easier to read. You'll see more images and illustrations interspersed by more white space for better viewability.
3. Calm among the chaos
We are all bombarded by too much media. In an era of media noise, we will be the resource for leaders to find only information that adds value.
The industry term is “curated” media, but in real actions, our experienced editors will comb through the daily healthcare headlines and pick the ones most likely to affect you that day.
Our senior editors will build new weekly newsletters in our core topic areas to harvest only the ideas and developments that you can use.
We invite you to dive into the new HealthLeaders. Look around. Use the heck out of it. See what you like. And if you think there is anything we can do even better, send me a note.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
Businesses merge or acquire other businesses for one reason only: growth. When the path toward organic growth seems narrow or a new competitor edges into your market share, the temptation is to look for a way forward, or out.
When health systems merge, they most often tout advantages of increased scale and efficiency, or their ability to provide a better experience and range of services for the community.
What's usually absent from the initial press release is clear evidence that the history of such mergers has indeed made care for a community of patients less expensive or more efficient. If all healthcare is local, as the saying goes, then are mergers counterintuitive?
What's always missing in the stampede to merge are the operational, financial, and cultural realities. Back-end systems may indeed be analyzed for redundancy and then streamlined, but the process itself is long and expensive. Physician staffs that once competed must now come together to share data or streamline care protocols.
Hospital campuses that once had clearly defined, local leadership and accountability may now report to a centralized executive team, in some cases, in another state.
The hard part is the human side. Always. Any good health system culture is held together by investment in relationships and trust. Any CEO will tell you that turning around a hospital culture is much more difficult than turning a balance sheet.
Mergers hit all of those reset buttons. Strong cultures and strong leaders can usually survive a merger. But struggle will follow those systems where there are already cracks in the key intersections of trust between executive, clinician, and community.
The view from the stratosphere may be that this recent round of large regional mergers is the inevitable continuation of years of local market consolidation.
HealthLeaders Media senior editor Philip Betbeze poses the question, "Healthcare M&A: Is It Different This Time?" as a feature in this issue. The article raises impactful questions about the reasons behind mergers, and new facets, including the concept of asymmetric mergers.
My answer to the questions is the reasons behind mergers are not different this time, but the outcomes may be.
We have a generation of healthcare leaders now who are perhaps tempered by failures of the past and aware of the pitfalls of chasing scale blindly. There is better data. Process improvement skills are much more ingrained. Consumers and external competitors are pushing for innovation.
The mix is just different this time, and maybe that's enough for the industry to get this one right.
This article first appeared in the January/February 2018 issue of HealthLeaders magazine.
I have been using the same brand and model of running shoe for a decade. I originally got fitted at a local running store for the "underpronation" that happens when a middle-aged tall guy like me plods along. They worked.
I could put in a few miles without feeling like my shins were cracking.
Each year, the brand puts out a new numbered version of the shoe, ostensibly to make it more useful to more people. Now they are promoting a lighter weight, but the cushioning for my high arches is gone. The toe is too narrow. I didn't ask for the fancy printing on the uppers that does me no good. They just kept "improving," and their changes ruined the product for me.
As publishers, we can be like that.
We keep adding features, or chasing clicks, or adding content based on what we want as a business, not what you need as a healthcare leader.
When I began my first day at HealthLeaders Media more than 17 years ago, our motto was "Information to Lead." That has remained our path ever since, but we have been perhaps guilty of cluttering it up.
With this issue of HealthLeaders magazine, we create a fresh new start based on that original mission: to get you the information and ideas you need to lead a better healthcare organization.
We started the cleaning with a new design by Doug Ponte, the best art director in our business. Our pages have more white space and a new font for better readability. Our infographics are streamlined to frame just the information you need. Even the cover design gets back to grabbing you, the reader, with an idea to improve your business.
The content itself is where I'm relying on your guidance. Our vision is to refocus our efforts on the types of stories that will help your healthcare organization improve, and that will help you plan a course for a changing industry.
In each issue of the new magazine, you will find at least three Solutions stories that share practical, proven solutions to common problems facing providers.
Our cover stories, including this issue's IT Spending Guide: Place Your Bets, looks at a dynamic challenge from a strategic view, not a rehash of its complexity.
The new magazine is only the first step of an overall relaunch of the entire HealthLeaders Media brand that you will see in 2018.
Along each step, please let me know how we are doing.
For an industry inundated in change, progress has been hard to find.
This article first appeared in the January/February 2018 issue of HealthLeaders magazine.
The narrative goes something like this: Scathing IOM report comes out in 1999, healthcare industry enthusiastically embraces improvement as a core part of its mission, and the industry gets better.
If only it were that simple.
The IOM report was one among several heavy levers (PPACA, meaningful use, ICD-10) that pushed hospitals into a new age of relentless improvement.
CEOs started to use words such as "Kaizen" and "value stream analysis." Internal and external quality measures multiplied exponentially.
Today's hospitals are an expanding web of concurrent improvement programs, all supposedly mapped to a single big idea to move the organization forward.
Change management has become so big, however, that leaders are beginning to question whether they are leading change, or if it's leading them.
Consider the seminal statistic: mortality. A 2016 study in the BMJ set medical errors as the third-leading cause of death at an estimated 250,000 per year in the U.S., significant growth from the 98,000 estimated in the IOM report almost two decades previous.
The counterargument to those statistics is that healthcare delivery has increased in scope and complexity since then, and that many processes within health systems have indeed chased down certain types of errors significantly (e.g., central line–associated bloodstream infections).
The root cause of this organizational disease is not effort, but skill, specifically change management. Hospitals have ramped up improvement projects on a massive scale that is potentially unfocused and unmanageable.
But healthcare leaders have absorbed the hard-won lessons from two decades of constant improvement.
Change management is now a blend of culture, process, investment, and a lot of pushing. If improvement is a collection of lessons learned, here are a few:
Know the difference between tools and values
An organization that tries to change merely by buying tools may see some results, but then must constantly "retool" when people or priorities change.
"We created a process that works today, but isn't going to work tomorrow, and working tomorrow is the key to sustainability."
—Kurt Barwis, president and CEO, Bristol Hospital
An organization that only approaches change from a soft cultural perspective may lack the process discipline to translate values into outcomes.
Jeff Thompson, MD, executive adviser and chief executive officer emeritus of Gundersen Health System, a regional integrated delivery system based in La Crosse, Wisconsin, says balancing tools and values is going to be different for every organization and its leadership team.
"To get change to move is a combination of the responsibility of senior leaders to set clarity on aspirational goals and activities that will get people excited about leaning into it," Thompson says, "and then giving them the tools to do that that are within their grasp and supported by the organization."
Thompson says as he advises other health systems about managing change, he often encourages them to keep the real purpose of the tools in perspective. A good tool makes change easier, not more complex.
So organizations may deploy Lean, for example, as a way to "actually get some traction in change management, so that the process will be more efficient and feel like a win rather than a burden to bear."
Make sure the measures aren't lying
Hospitals have multiple ways of lying to themselves about the progress they are making, or not making. It's a sneaky little trade secret that leadership teams may choose what to measure by what they are best at already.
And then there are process measures (Did we do what we were supposed to do?) versus outcomes (Did patients get better?).
Gundersen decided to follow advice set out by Jim Collins in Good to Great, which was to "confront the brutal facts."
"You have to measure on multiple levels," Thompson says. That may include measuring the organization's progress not just against past results, but against top performers.
"If you compare this mediocre year with your mediocre last year, and you are 1% better, you're still mediocre. So, you've got to compare with the best you can find. You've got to look at different measures, and with some real discipline, track them over time," he says.
Thompson says sometimes a CEO needs pushback on what a clinical or organizational team wants to measure.
"Sometimes they know what measure is best, but that's not what they're going to track because the really hard things don't always look so good," Thompson says.
One check for such measures is to install dyad teams of clinical and nonclinical leaders to coordinate a balanced set of measures that matter and provide the discipline to track over time, Thompson says.
Create a sense of purpose, not a collection of projects
Give up the idea that you can control every aspect of change. Change is organic. It may fight back. Things will happen.
Gundersen Health drew widespread attention and acclaim in the past decade with its commitment to save energy and reduce the amount of pollution it was generating as a health system.
Gundersen set an ambitious goal in 2008 that the system would reduce carbon emissions by 90%, and be 100% powered by renewable sources of energy, by 2014.
It all seemed to be going well, for a while. Then turbines that were supposed to generate power didn't work as planned.
A plan to use vented gas from a local brewery to power a generator failed when the brewery switched from beer to hard lemonade.
"There will be a project, and they'll hold it up and they'll celebrate too much and make too big a deal of it, and then it falls apart."
—Jeff Thompson, MD, executive adviser and chief executive officer emeritus, Gundersen Health System
So whether it is patient safety or mortality or the environment, leaders must keep the team focused on the end goal and not get too far down or too far up along the way.
"There will be a project, and they'll hold it up and they'll celebrate too much and make too big a deal of it, and then it falls apart," Thompson says.
Gundersen's team was able to "stay on the principles. The principles were that we were causing pollution and we believed we could lower the cost of care, improve the local economy, and address the pollution all at the same time."
By October 2014, they had reached their goals.
"You do short-term and long-term measures and you try and keep people focused on not dropping the short-term ball," Thompson says, "but knowing that we have a long-term goal because there's always going to be ups and downs."
Don't assume that thing you fixed is still fixed
It's a familiar problem that sometimes leaders tend to focus more on the latest initiatives, and that an area that was already thought to be improved—and supposedly "hardwired"—has slipped, and in the process brought the organization's overall progress back down a notch.
"We fall into this trap," says Kurt Barwis, president and CEO of 154-bed Bristol (Connecticut) Hospital. "We set our goal and whatever it takes, we're going to get it done. We put all these resources to it, and if one person leaves, you become short in that area again. We created a process that works today, but isn't going to work tomorrow, and working tomorrow is the key to sustainability."
Barwis says the solution that has worked for Bristol has been to be intentional and robust about continued reporting. Hardwiring may include, for example, asking the right questions in the clinical record so that leaders will be able to see if the process measures put in place are failing.
Celebrate the wins, and then move on quickly
Part of the problem is in the "triage" culture of healers, says Barwis.
"Healthcare culture has pretty much always been that we love a good crisis," Barwis says. "We feel good at the end of the day when we can say, ‘Oh my God, we dealt with this emergency and this crisis.' It has an appeal. It's an instant response thing, but as leaders, our responsibility is to step back and say, ‘Yeah, that feels good that we solved the problem, but how do we stop the problem from happening again and again and again?' "
Two decades of relentless performance improvement has a real human toll: It's simply wearing teams out.
One inspirational tool that's important is to recognize work—celebrate the small victories—because they will motivate people to keep going.
Knowing when to push on is among the hardest nuances CEOs must manage, Thompson says.
"You have to find that balance, because if all we do is drive people, they end up getting pretty tired of being driven," Thompson says. "But if all you do is celebrate every time they turn around, and everybody gets a trophy for participating, you're not going to get to excellence on that."
Thompson reiterates the importance of recognizing wins when they come, but it is up to the leadership team to keep making the transitions to the next step.
His message: "Please take a minute to celebrate and then remember, we're out there to serve our community to the best of our ability, and your abilities are immense. We haven't tapped them all yet. Please help me to keep working on this."
Barwis pushed an aggressive pace of change in his first years as CEO.
"I would just hit the wall with 100 things, and I would just kind of keep people off balance," Barwis says. "I was constantly asking, ‘Do we do this? How do we get this forward?' And I could always look back at the end of the year at what we accomplished. But it left people with a knot in their stomach. If you keep pushing and you never stop, the consequence often is that people feel like they're not good enough and they can't step up."
Barwis says he learned to shift his approach back to the "big measurable, quantifiable things" such as nursing Magnet® status.
Don't accept trade-offs
Cause and effect has been an occasional worry as health systems look to improve everything from quality to patient satisfaction at the same time, with the fear being that improvement is a zero-sum game that might boost one area but cause a dip in another.
Thomas H. Lee, MD, an internist and cardiologist at Brigham and Women's Hospital in Boston and chief medical officer of Press Ganey, says that a core set of goals work together at high-performing health systems.
"To get change to move is a combination of the responsibility of senior leaders to set clarity on aspirational goals and activities that will get people excited about leaning into it, and then giving them the tools to do that that are within their grasp and supported by the organization."
—Jeff Thompson, MD, executive adviser and chief executive officer emeritus, Gundersen Health System
A 2017 Press Ganey report, "Achieving Excellence: The Convergence of Safety, Quality, Experience and Caregiver Engagement," found "cross-domain analyses suggest that these elements are highly interrelated with one another."
"When you look at the data from thousands of institutions, as we've been able to, you don't see tensions," Lee says. "There is no trade-off, for example, between having shorter length of stay and a worse patient experience."
At high-performing organizations, Lee says, you won't see, for example, that nurse engagement is high and physician engagement is low. "The most likely explanation for what really drives an improvement is the culture," he says.
"Basically, our hypothesis is that the organizations that seem to have their act together, are ones that have cultures that seem to be more focused on improvement and on idealistic goals that all the personnel believe in, like zero harm."
Lee recalls that when zero harm first came out as a concept, he saw it as statistically unattainable.
Now he says he embraces the reason why such goals work: because to accept any less would be unacceptable. He's optimistic that so much change is heading to the right point.
"I actually feel like it's a Golden Age of tremendous progress," Lee says. "But Golden Ages never feel that golden to people who went through them."
As I write this note, Amazon is still looking for a city for its second national headquarters, or "HQ2."
This article first appeared in the December 2017 issue of HealthLeaders magazine.
The lure of 50,000 high-paying tech jobs and billions in economic impact will be the corporate HQ prize of the first part of the century, once it is announced.
I'm rooting for Detroit, because how often does a company get the opportunity to rebuild a great city? Amazon would fit right in in Austin.
Anywhere, please, but my home of Nashville. We can't handle the traffic and crowded suburban schools we have as it is.
Wherever Amazon lands, jobs will follow. The only sure prediction we can make, really, is that jobs always follow opportunity. Trying to predict anything else about a workforce is slippery, especially in healthcare.
In our cover story this month, senior nursing editor Jennifer Thew, RN, looks at our continuing grapple with the workforce "shortage" of physicians and nurses.
She points to conflicting studies and predictions that force us to ask if there truly is a shortage coming in the healthcare workforce. It seems like this predicted shortage has been around so long that we've accepted it as inevitable.
In the nursing workforce, the question may be less about an aggregate shortage of RNs but more about the supply and demand of a specific set of services that are likely needed in the future.
The growth of advanced practice nurses seems likely to continue its acceleration as consumer access and better technology merge to create demand. Will there be a shortage of bedside inpatient RNs in the future compared to what we have now?
I certainly hope so. If we need more bedside RNs going forward, that would be a clear indicator that the overall push toward keeping patients healthier and out of the hospitals has failed.
The aspect of the healthcare workforce that is of some concern is how we will find new ways to attract nurses and physicians to rural areas, where they can have a significant and personal impact on the health of the community.
Our cover story profiles the work that organizations such as Kearny County Hospital have done to flip the equation.
Rather than bemoan the recruiting challenges of being in a rural area, they embrace it by offering physicians the mission to care for a growing international population in the county but also spend time overseas on international medical missions.
In this case, the jobs followed an opportunity to serve.
It doesn't always take a massive corporate HQ addition to create opportunity.
Clayton Christensen coined the phrase disruptive innovation two decades ago as a way of embracing the deconstruction that is necessary when a new technology displaces an old one.
Ever since then, it seems healthcare has been waiting for a series of disruptions to alter the course of the industry.
If there is a technology that could put healthcare in a blender for the next decade, it's the increasing scope of telehealth and its close relative, telemedicine.
In this month's cover story, senior editor Philip Betbeze looks at "The Adolescence of Telehealth," an apt analogy to describe the critical juncture that telehealth is in.
Telehealth and telemedicine, after all, are using people and technology to alter two fundamental pieces of healthcare: distribution and labor.
Telehealth fundamentally shifts the distribution of a good portion of healthcare clinical and nonclinical services outside of the traditional brick-and-mortar structures that have been used by American healthcare for decades: the hospital and the physician office.
Telehealth visits were a novelty not too long ago, and now have caught the consumer mainstream.
A 2017 study by American Well found that 50 million Americans would be willing to switch primary care providers if it meant getting access to video visits, up from 17 million in 2015.
It's safe to predict that consumer habits will continue to chase convenience and cost, especially in quick care areas of minor aches and ailments.
What healthcare is just starting to appreciate are the seismic shifts that could come to the physician and provider labor market as telehealth moves outside the few areas where it began.
Of course, there will always be the need for hands-on medicine.
But anywhere the patient-to-provider interaction is consultative in nature, there will be someone looking to connect them via technology.
In a future where telehealth is more the norm, a midlevel provider may be the primary link across the screen, with the primary care provider being the expert sorting through data.
In a regional system with networked telehealth, one specialist in an area such as infectious diseases could cover many hospitals.
In critical care, where telemedicine has been rooted for decades, the discipline itself has become a blend of hands-on care and analyzing remote data.
The path is not all clear, however.
Reimbursements of telehealth visits remain a primary barrier to use, as do technology costs, credentialing, and other regulatory hurdles.
These barriers seem to be shrinking every year. Disruptive technology, after all, is about pressure.
In this case, consumers, employers, a growing telehealth industry, and even providers are pushing the industry upward. It's only a matter of time before telehealth grows up.
Retailers didn't change their business because they didn't want to. Are hospitals and health systems, when presented with the same shift of consumer preference, poised to do any better?
My dad is an architect, and one who was never afraid to have a hammer in his hand on the weekend. And that hammer was always a Craftsman tool, bought from the Sears location in Buckhead in Atlanta.
Every weekend without fail, he'd seem to find some reason he had to be there, with me in tow.
I saw recently where Sears Holdings, the ghost of what used to be the greatest retail company in America, sold the Craftsman brand just to generate some cash. Other brick-and-mortar retailers are filing for bankruptcy in record numbers. "Dead malls" are replacing what used to be the hubs of social life for suburban teens.
When was the moment their doom was sealed?
It's easy to say that many traditional American retailers didn't see the shift of consumer patterns to online early enough. Oh, they knew. They can read a Wall Street Journal, too.
The cold, hard fact is that they didn't change their business because they didn't want to. They didn't want to because they were not willing to risk quarters or years of operating revenue and stock performance to transform the underlying business.
Are hospitals and health systems, when presented with the same shift of consumer preference, poised to do any better?
In this month's issue, senior editor Debra Shute poses the question: "What's next for retail healthcare?" To be sure, many hospitals, health systems, and medical groups are making more-than-token investments in retail healthcare, either through direct competition with corporate retail and urgent clinics, or taking a market position in the growing telehealth market.
On the high road, it meets a consumer need, provides more convenience, and brings the price point down for some basic health services. All good. But as an industry overall, it's hard to ignore the sense that American hospitals and medical groups have not been leading the retail charge based on customer need, but have been dragged into it by disruptors who are posing a consumer threat. It's more protective than innovative at this point.
True, healthcare is the one service no one really wants. It's also the one that everyone will inevitably need. And when they do, consumers will have choices. Healthcare leaders must rethink how they listen to consumers and their dollars. And if what they hear means losing staff, current revenue streams, and some familiar ways of doing business, they'll have to weigh that cost against the risk of becoming obsolete.
Jim Molpus
Interim Editor in Chief
Leadership Programs Director
The health system is committed to a high-value, population health-focused, telehealth approach. "In our effort to work well with the consumer, we don’t dumb down the medicine," says Marc Harrison, MD.
For telemedicine to fundamentally shift the delivery of healthcare, and not just be another promising technology that came and went, it will need to change two patterns:
The healthcare-consuming public must choose telemedicine options because they are more convenient and still feel safe.
Providers must choose telemedicine because it is the most appropriate level of quality care for that patient at that time.
Few health systems in the country are testing the system dynamics of telemedicine at a scale like 22-hospital Intermountain Healthcare, based in Salt Lake City, Utah.
The spokes of Intermountain’s TeleHealth strategy reach into solutions in the hospital, clinic, and home.
An emergency department specialist at one of Intermountain’s rural hospitals may connect with a neurologist at the academic medical center within minutes of a potential stroke patient coming through the door.
An infectious disease specialist in Salt Lake City can track patterns of infectious disease across the system and spot potential trends before they worsen. Or a busy mom can dial up a provider for a $49 ConnectCare telemedicine visit, rather than take off work for a child's sore throat.
HealthLeaders recently caught up with Intermountain CEO Marc Harrison, MD, who took over the helm of the organization in October 2016, to hear his thoughts on telemedicine’s potential. The transcript below has been lightly edited.
HealthLeaders: Telehealth or telemedicine as a technology is not particularly new, and a lot of hospitals and health systems are deploying some form of program. What is different about Intermountain’s current approach?
Harrison: You usually set up these programs so there is a path of least resistance between the areas that are being served and the hosting organization, in hopes of getting lots of hospital transfers and increasing revenue, etc.
What I love about the way we have done this service is it is actually the opposite. We try really hard to keep patients in the least restrictive environment that is appropriate for them.
We try to make sure that patients don’t have to move their physical location as long as they have the right advice and oversight.
That population health-, high-value approach has really transformed telemedicine at Intermountain. Once our providers understood that, the number of ideas from our providers on how to use that exploded.
HealthLeaders: Can you share an example?
Harrison: Consider a high-risk mom who comes into one of our frontier hospitals to deliver a high-risk baby. Historically we would perhaps get that helicopter spooled up and get that baby out of there.
But now we may get our neonatologist from one of our big centers online with them, and possibly prepare the team for a resuscitation because maybe they haven’t done one in a month. Let’s make sure this person gets the same care they would in a major academic medical center.
What we find is that a lot of these kids can stay home, with great results, decreased inconvenience for the family, and reduced cost to everyone. It’s a fundamentally different approach, and that has led to accelerated growth.
HealthLeaders: Apart from telemedicine technology that is built on the physician peer-to-peer consultation model, increasingly we are seeing the move into technologies that touch the patient. Describe the adoption you are seeing from the public.
Harrison: I will share some anecdotal info. What I hear from patients is that once they get over the barrier for that first visit, their response is, “Why don’t I do this for all of my visits?”
No waiting rooms, service-on-demand, comfort of my own home. It’s inexpensive, and a lot of people have high-deductible plans these days. Once you get people over that hurdle of trying it once, then they don’t want to go back.
HealthLeaders: What about outcomes? This industry has a huge graveyard of once-promising technologies that were supposed to reduce cost and improve care. How is telemedicine different?
Harrison: Let me answer that in a couple of different ways.
First of all, I don’t see anyone going back from this. The question is how is it going to be provided, and what kind of refinements—convenience or cost or patient experience—will the patient demand? It is here. No one is saying that their bank website froze up last night so they are going back in line to see the teller every week to deposit their paycheck.
The key to getting these really good outcomes is that, in our effort to work well with the consumer, we don’t dumb down the medicine.
I’ll give you an example: One of our caregiver’s totally legitimate big concerns is that if somebody comes in the physician’s office for an earache, the doctor will not give them antibiotics unless they really need them.
The concern is whether we are going to tell everyone who has a sore throat or ear pain via ConnectCare to go to the nearest pharmacy and get antibiotics.
We have worked very hard to make sure that is not the case. These are the tricks—to make sure that convenience is terrific, but great safety and quality will become table stakes in the industry so everyone will get good care via distance.
And we will then be differentiated on some of the finer points. I’m not sure that is really the case yet.
HealthLeaders: What about the cost side? The technology is not free, though a lot of it is using ubiquitous consumer technology, like phones and tablets. How do you get the ROI out of the technology investment?
Harrison: This is the beauty of being a payer/provider. Roughly a third of our volume is at-risk volume, so it allows us to make very patient-centered decisions about how we do things. If we want to be purely fee-for- service environment, putting in things like this may be like cutting your own throat.
But we see the industry heading toward population health value. And in that context, serving the patient where, when, and how they want, and at the right cost, is good for everyone.
Although some of this volume would be great for (inpatient) revenue, we know that is not the way it should work. We are pretty realistic. Building this into our operating model is very important.
HealthLeaders: How about telemedicine as a data tool, such as infectious disease specialists using telemedicine to monitor and spot trends a lot sooner?
Harrison: I think that is a huge advantage. The other advantage is that some of these specialists are hard to recruit and hard to keep busy in the right way. For them to be able to serve appropriately over a large swatch of territory kind of works for everyone.
A) They get a lot of concentrated volume so they really know what is going on, and B) you don’t have redundant staffing costs of having an infectious disease specialist at every hospital.
Everyone benefits. The hospital benefits. The doctor benefits. Most importantly, the patient benefits.
HealthLeaders: Have you addressed the reality that tele-practice can be a fundamentally different way of practicing medicine than in-person contact with the patient? Have you stopped to think how it is creating a new discipline?
Harrison: It is. One of the things we try to do because the clinicians really want this, is we tend to rotate them through conventional face-to-face practice and tele-practice, so they are not solely dedicated to one or the other.
So for that neonatal resuscitation via tele-practice, it’s a real-life neonatologist who has cared for babies up close. One of the things that is interesting is when you are in a bunker looking at screens at a distance, your peripheral vision is sometimes a little better than when you are right up close to a very sick patient where the stress is high and it’s possible to lose your peripheral vision a little bit.
Having an extra set of eyes who are maybe a hair more remote is very helpful.
HealthLeaders: What’s next on the horizon? What ties this together from a collection of pilots into a connected system?
Harrison: A couple of things. I think we are only beginning to see what staffing models might look like. You might say to yourself, we know that critical care nurse practitioners are really capable of doing 80% of what an intensivist can do.
With really great tele-critical care support, can they do even more? What does that do to the cost basis of care? How do we extend our tele-infectious disease service with use of other mid-level providers?
How do we actually use predictive analytics to be able to let that tele-intensivist know that, based on algorithms derived from people’s labs and their vital signs, somebody is heading down a hole in a couple of hours when they look okay right now?
That next layer of predictive technology, even better monitoring, better teamwork, and even more people practicing at the top of their license… that’s where it starts to come together.
HealthLeaders: There is a lot of stress on reimbursement in general. Does that shift your view of telemedicine’s potential?
Harrison: In an era of regulatory uncertainty, we’re sticking to our guns and say we will keep value high. High quality and low costs is what we can focus on and execute regardless of the reimbursement system. I feel pretty confident telehealth plays a big role in this, particularly when we see people acting as consumers. It’s not a silver bullet, but I think it’s a component.
