The Joys of Christmas and Building Relationships in Health Care

Having just experienced Christmas, both in its secular and spiritual aspects, it is hard not to reflect on the many blessings we have experienced during the year. Certainly, if we polled the 28,000 Associates and 6,000 physicians in CHRISTUS Health, I’m sure the majority would say that their most important blessing is their immediate family.

However, I believe many would also include in their list of blessings the relationships that they have formed within CHRISTUS Health, including those they have developed with their leaders and even with the Senior Leadership Team, including myself.

Because of the complexity of health care and the speed at which we must move, many times we don’t have the time to explain in detail the rationale for the decisions we make and the directions we take as a health care system. It is in those times that people must depend on the trust and loyalty they have for their leaders, based both on previous successes as well as current actions.

Although we have identified the competencies for CHRISTUS leaders, perhaps their ultimate success pivots on the depth and quantity of the positive relationships a leader has established with the people whom he or she expects to follow him or her. So if building relationships are important, how is this accomplished?

Looking at what makes a successful health care leader over the last 40 years, I would say that the driving force for strong relationship-building is making yourself visible to as many people as possible in your organization in an open and honest way. This includes showing them not only that you are knowledgeable and intelligent, but that also that you understand all aspects of the work force, what it takes to be successful (including in their job), and participating with them in activities in which they are comfortable.

I look forward to the Christmas season because, as a pianist and organist, I have had the ability for 41 years now to bring together a group of health care Associates and physicians to Christmas carol in the lobbies of health care facilities. I now have the opportunity to carol in many CHRISTUS facilities—normally around 10 a year—with the Associates and patients/residents there. I also have the chance to visit some facilities of our sponsoring congregations and carol with the Sisters there.

People often ask me during the busy Christmas season--when we not only have the pressures of work, but also the increasing pressures associated with holiday activities--why would you spend time traveling to multiple locations to sing and play familiar carols for an hour?

Clearly, this would not be worth it if we were measuring how many songs we sang or how many Associates actually attended the caroling or how many patients and their families walked through the lobby while we were singing. Its success also cannot be measured in the amount of punch and Christmas cookies that are served to those who participate.

Instead, the true benefit is that relationships are strengthened, both with the people who participate and with the multitudes of Associates and physicians who could not attend. The people who are able to attend often tell stories about it to their coworkers, and in this way the Christmas spirit is spread and relationships are strengthened even with those who could not be there.

Relationships are the one leadership competency that cannot be taught; instead, they must be lived out. Therefore, leaders must determine how they can best do that through interactions with their Associates and physicians. I feel truly blessed because I learned and refined a talent that permits me to do something very common throughout every health system in which I worked.

At the end of the day, you may find CHRISTUS Associates who would have a hard time describing in detail our Journey to Excellence, our service guarantee or our enhanced international strategy. However, most of them would be able to tell you that a tradition in CHRISTUS Health is caroling with the CEO and other members of the Senior Leadership Team. Is this not what relationship building is all about?

I would challenge each of you, as you enter the new year, to think about the key things you as a health care leader can do to build the strong relationships that are required to lead health care in 2008 and beyond.

Growth and our Identity

As we journey through the final weeks of 2007, it seems appropriate to reflect on the major activities that will occur in the new year for CHRISTUS. Obviously, one of our largest and most important facets in 2008 will be our growth initiatives. These will involve building new hospitals like the one under construction in the Westover Hills area of San Antonio and in Reynosa, Mexico; acquiring health systems like McKenna in New Braunfels, Texas; and partnering with health systems and/or physicians like our joint venture with physicians in Houston and our partnership with St. Vincent Regional Medical Center in New Mexico.

Each growth opportunity obviously has its own business plan and is driven by unique assumptions and market assessments. However, they all share our desire to expand our ministry with commitment to our mission, vision and values and branded by our Journey to Excellence.

We at CHRISTUS Health believe that there is a true advantage to being a Catholic, faith-based organization and expanding our Catholic identity and faith-based principles of behavior into new facilities and programs.

What do we mean exactly by “Catholic identity?” Although one might believe that this would mean the desire to impose the Catholic faith onto the people we serve, the reality is just the opposite. Because of the teachings of the church, CHRISTUS Health adheres to the belief that all people are equal and should be treated with the highest quality and service possible, delivered in the most kind and compassionate fashion. This means that all people of all races and faiths--as well as non-believers--will be welcomed and cared for within CHRISTUS hospitals, outpatient clinics and in all other facilities.

In the U.S., Catholic health care is guided by a set of principles which are captured in a document called the Ethical and Religious Directives for Catholic Health Care Services (ERDs). These principles are very robust, and dictate the need to be focused above all on the dignity and worth of each person. These principles mandate that not only our patients, but their families, our Associates and our physicians must be treated in just and fair ways.

As a result, we put into place a Service Guarantee for our patients in 2000 and created an Associate Covenant in 2001 as well as a Physician Compact in the same year. The latter two documents clearly state what CHRISTUS is pledged to do for its Associates and physicians, and articulates CHRISTUS’ expectations in return.

After studying these documents carefully, one would see that the major focus is on the development of positive relationships and the commitment to create the ideal workplace, where again, all people—regardless of their spiritual orientation—are treated justly and fairly.

Our Catholic identity also gives us the ability to create environments within our facility (such as chapels) where people of all faiths can meditate and reflect and hopefully gain strength to face the problems which they are often encountering when they are within our facilities.

Catholic identity also allows people to be comfortable in expressing their fears and the ability to openly ask for spiritual support during their difficult times, whether this takes the form of a visit from a chaplain of their faith, a request for a prayer, or merely a conversation with one of the Associates or physicians. Yes, our Catholic identity and the ERDs compel us to be open to spiritual requests from all and to create an environment where there is zero tolerance for prejudice from a racial, economic, or religious viewpoint.

I have repeatedly said since becoming the team leader for CHRISTUS Health nine years ago that if I was seeking another job opportunity elsewhere, it would have to be in a Catholic, faith-based health care system. Although I have worked in three other systems in the past where I believe people were comfortable in treating everyone who presented themselves, it is the well-documented principles in the ERDs and the resulting policies and procedures that guarantee on a consistent basis that everyone will be treated equally and with dignity regardless of their ability to pay, their immigration documentation, the color of their skin, or their religious tradition. To me, this is an integral part of excellent health care and energizes CHRISTUS’ Journey to Excellence. Embracing the ERDs is a strong, visible demonstration for everyone with whom we will partner, assuring that the care rendered in connection with the CHRISTUS name will be equal for all and of the highest standard possible as we continue our Journey to Excellence.

Exciting News!

On Friday, we received word that two of the hospitals in our Southeast Texas region, CHRISTUS Hospital – St. Elizabeth and CHRISTUS Hospital – St. Mary, received Magnet designations. Although this is a goal for all CHRISTUS hospitals, these two are the first in the CHRISTUS system to reach this significant achievement.

This is a victory that deserves recognition, and I was privileged to listen in on their phone call with representatives of the American Nurses Credentialing Center (ANCC), who awarded the designation. The representatives had many positive comments, and I am confident that our Associates at CHRISTUS Hospital will have many learnings to share with other health systems and other CHRISTUS facilities who are pursuing Magnet status.

I will talk further in a future post about the importance of pursuing the Magnet designation, but for now, I have included more information about the announcement below.

CHRISTUS Hospital – St Elizabeth and CHRISTUS Hospital – St. Mary first in system to achieve Magnet Status

CHRISTUS Hospital – St. Elizabeth and St. Mary were notified this morning that both campuses are one of only three percent of hospitals in the country – and the first in CHRISTUS -- to be a recipient of the Magnet Recognition Program® from the American Nurses Credentialing Center (ANCC). ANCC established the award program to recognize health care organizations that provide nursing excellence and also provides a forum with which to share best practices in nursing.

“This honor is a true testament to the commitment that we have to our patients and to our community,” said Ellen Jones, president and chief executive officer of CHRISTUS Health Southeast Texas. “We are honored to be bestowed with the most prestigious nursing award in our industry and will continue to embody the excellence in nursing care that this designation carries.”

Recognizing quality patient care, nursing excellence, and innovations in professional nursing practice, the Magnet Recognition Program® provides consumers with the ultimate benchmark to measure the quality of care that they can expect to receive. Other renowned institutions to receive the Magnet designation include the Mayo Clinic, Cedars-Sinai, Johns Hopkins, as well as M.D. Anderson and Texas Children’s hospitals in Houston.

The Magnet designation process includes the appraisal of qualitative factors in nursing, referred to as “Forces of Magnetism,” as determined by the American Nurses Association's Scope and Standards for Nurse Administrators. These quality indicators ensure that patients receive high quality nursing care, more experienced and certified nursing staff and most importantly improved patient care outcomes.

During the phone call from ANCC this morning, the primary reviewer of the CHRISTUS Hospital application said that “all the appraisers involved in the process were very impressed with the leadership, quality of the staff participation and the enthusiasm of the nurses about quality excellence..” She went on to say that this recognition “validates to the general public and to the profession what a great job CHRISTUS Hospital is doing.”

“We’re proud to receive this mark of distinction by our peers and know that nursing excellence is more than just an award – it is our spirit,” said Mary Eagen, regional chief nurse executive of CHRISTUS Health Southeast Texas. “Magnet designation is not our final destination, but it is a major milestone on our Journey to Excellence.”

Tort Reform in Texas

We are very fortunate in Texas because tort reform successfully passed the legislature and has been guaranteed by changes to our state constitution. The need for tort reform is being questioned nationally and being strongly advocated for by physicians and hospitals in many states.

The importance of tort reform in Texas can be seen by reflecting on the results it has had in the CHRISTUS Health system. We have always believed that if a true error occurs in our delivery processes, the patient and his or her family should be told the truth and should be financially reimbursed for those costs which have been caused by the error. This is the foundation for true transparency, which has driven CHRISTUS since it was formed almost nine years ago.

However, prior to tort reform, the size of payments required to resolve litigation claims both inside and outside the courtroom were--in our estimation--excessive, and in fact continued to rise year after year. In addition, the major cause for these increases had to do with pain and suffering or loss of quality of life, including relationships with spouses, etc. These are both areas which are fairly subjective, in contrast to physical disabilities, which certainly need to be compensated for, and are fairly objective.

With tort reform, caps are placed on these settlements, and as a result, lawyers and jurors are forced to focus more on the objective results of medical errors. Specifically in CHRISTUS Health, since tort reform was passed, our expenses for litigation have been reduced dramatically. During this period of time, we also focused a great deal of energy on improving our quality and safety initiatives throughout the entire system. And as a result, we believe both the number of claims and the size of the claims have been even reduced further than as a result of tort reform alone.

Both of these outcomes are justification for other states as well as the federal government to continue to seek ways to support tort reform nationally. However, perhaps the greatest outcome of tort reform for CHRISTUS was that we were able to utilize a significant portion of our savings to fund and accelerate further improvements in our quality and safety programs. Each of our 13 regions can submit projects which they believe, if implemented, would accelerate improvements in their quality of care. Based on competitive reviews, several of these are funded each year from these savings. Programs in the past which have received such support include certifying all nurses in the reading of fetal monitors, providing standardized competency testing for all nurses, and providing the latest and safest way to lift heavy patients from one location to another. These programs were designed, funded and piloted and are now being universally implemented across the entire system.

We have known for years that the legal system put into place to deal with less-than-favorable quality outcomes in health care were necessary but inappropriate as long as the potential settlements were uncapped and limitless. Supporting tort reform means that you support paying what is due, admitting what was done incorrectly and doing everything possible to mitigate the negative outcomes and create the positive solution for patients and their families. Achieving tort reform in Texas, therefore, was a high priority for CHRISTUS leadership, and its success has given us the opportunity to not only create significant savings while being fair to our patients and their families, but also to utilize these savings to accelerate our improvement processes.

In the end, when we talk to patients who have had less-than-favorable outcomes, we believe that they truly want to be treated fairly and to do whatever is necessary to make sure the error does not recur. Tort reform makes both of these goals possible and creates a win-win situation for both the health care providers and the patients who receive our care. Therefore, it is our hope that tort reform continues to be high on the agenda of other state and federal leaders, for based on our experience, it has provided some of the best outcomes possible as outlined above.

No Common Voice in Health Care

Being an advocate in health care is critically important in order to impact the three most vocal voices of change with regard to health care policy and positioning. These three voices are: government, business and patients and their families. If these groups are to effectively improve both quality and service in the health care sector, we must ensure that they have clear and accurate information to redesign the health care delivery system appropriately.

Reaching a consensus on this issue, however, is getting increasingly difficult, because there is no common voice in health care today. It would be wonderful if one person or a small group of people could stand before our federal and state lawmakers and say, “This is what patients want and this is the reason why,” or “This is what physicians want and this is the reason why.” However, getting this consensus is almost impossible today. Younger physicians think differently than older physicians. Highly-paid specialists are thinking very differently than lower-paid primary care providers. And women physicians, understandably, as a group, often think differently than their male counterparts. Because of this difference, we have seen a declining membership of physicians in the American Medical Association (AMA), which in part is caused by the fact that some physicians believe an association cannot represent the myriad voices that are being expressed. This issue also permeates the common voice for the continuum of health care.

It would be ideal if hospitals, physicians and nurses could stand as a strong, cohesive component of the delivery system and say in unison, “This is what we are thinking, and this is what we want to happen.” However, as health care has gotten increasingly complex, as capital needs have risen with the introduction of more and more technology and as federal funding has decreased (only exaggerated more recently by the extreme amount of expenditure required by the Iraq war), the polarity between these groups has been increased. Obviously, this is because if the federal government is to give more money to physicians, they must take it away from hospitals, and vice-versa. Hence, when we come to the table to advocate for increased funding, the solution is often one that enhances polarity and therefore further decreases our chances of finding a common voice.

For example, before CMS instituted its current reimbursement system based on DRGs, we were cost reimbursed, so hospitals earned money by keeping patients in the hospital longer as the result of a daily fee, and physicians made more money because they were paid a daily visitation fee. In the current DRG system, however, hospitals are rewarded for getting patients out of the hospital quicker, and physicians have lost a revenue stream. Therefore, giving one group more money necessitates taking it away from another group and has heightened this polarity.

This challenge also permeates the clinical arena, and is obvious particularly in such areas as end-of-life issues and the treatment of people with life-threatening or potentially terminal diseases. Although most people when not directly involved with a serious illness would indicate that quality of life is much more important than quantity of life, when they are in the midst of a personal experience with a terminal illness that involves themselves or their families, they often develop the reverse position and many times opt for treatments and procedures which are expensive and in fact useless.

Getting consensus around treatment protocols and care management--although improving--is still challenging.

So in the end, while consensus is challenging in many arenas and advocacy remains very important, advocating for the appropriate care for the poor will be essential when the redesign of health care becomes a reality. Hopefully this will occur with the election of a new president, but regardless, we all must realize that coming to the table with a strong consensus from all of the three voices will probably be impossible.

So what’s my answer?

It goes back to a very simple position that I believe I have expressed in the past: we must choose people to represent and participate in redesigning the health care delivery system who are analytical, open to listening, can interpret and understand the data, can have their minds changed by persuasive discussions and will always keep what is best for the patients and their families as their ultimate priority.

At this point, we cannot depend on a consensus regarding health care reform to be our guide. If we wait to hear the common voice regarding health care change before we create the direction for tomorrow, I am fearful that we will have waited too long.

Physician Leadership – A Necessity for the Future

Many people throughout my career have asked me if all health care leaders should eventually be physicians who have moved into administrative roles. My answer to this question has always been, and will likely continue to be, “No.” That doesn’t mean, however, that I don’t believe an increasing number of health care leaders should be physicians or other clinicians. The key, however, is not in their clinical background, but whether they have actually developed the core competencies to become capable leaders.

It is clear that the additional knowledge that clinicians--including physicians--bring to the leadership table because of their health care experiences at the bedside or in the exam room is extremely valuable, particularly in determining what creates the best care management outcomes. However, if this knowledge is not combined with the core competencies of leadership, many of which have been discussed in prior blog posts, this knowledge is often worthless. In fact, with clinical expertise often comes an arrogance which is a barrier to good leadership.

Hence, it is my belief that physicians and clinicians make great leaders if they can develop the necessary competencies, and that more of them who have these competencies are needed.

To be a physician leader, one must be extremely comfortable with the “grey areas” that exist in administration because every decision in health care is not black or white, and the pros and cons must be evaluated in each case to make sure the correct administrative decision is being made. However, physicians have this capability, for we are constantly faced with identifying a list of differential diagnoses for each patient so that we have alternatives to consider if our primary diagnosis proves to be incorrect.

In addition, physicians must be extremely comfortable with change, although for many this is a struggle. However, I believe that most physicians, like myself, have had to learn to utilize new technologies over the years. For example, the open subcostal surgical procedure I did for gallbladder extraction in the past is totally unacceptable today, and if surgeons who trained in my generation could not adapt to this new technology and laproscopic procedure, they actually cannot be practicing in 2007.

And finally, physician leaders must be extremely comfortable with making difficult and tough decisions, particularly if they are in the “grey area” mentioned above. However, once again, I would propose that physicians in their clinical practices are making tough decisions on a quite regular basis.

So, in summary, I do believe that physicians make excellent leaders if they can develop those additional competencies as mentioned, and constantly reflect on the similarities between clinical decision-making and leadership decision-making. It is clear to me that more physician leaders will be sought in the future, because all organizations are putting more emphasis on improving quality of care. Outstanding physicians are well-prepared and best positioned to bring the knowledge of how to accomplish excellent quality to the table.

Second, all organizations like CHRISTUS must eventually go on a journey to excellence similar to the one we have been undertaking for the last eight-and-a-half years. Physician leaders understand the need for a balanced scorecard, which is learned by balancing the patient’s quality of life with his or her quantity of life. Our balanced score card requires us to focus on the simultaneous improvement of four areas: clinical quality, service delivery, business literacy and community value.

Third, excellence must be seen as a necessity, not as a luxury. I believe that physicians understand this, and for the most part, understand each day that they have an awesome responsibility to care for patients’ lives and therefore truly understand what I mean when I say that we have been called to do sacred work.

Fourth, a positive alignment between physicians, hospitals and health systems is key today to overcome the negativity which has been caused by increasing governmental regulations and the polarity of reimbursement between physicians and hospitals. Physicians will listen to many people, but will most intently hear what other physicians are saying, and therefore, physician leaders become critical in this physician alignment process.

Based on the knowledge and understanding garnered from many years as a physician leader, I would reiterate and stress that although non-physicians are key and critical as part of leadership teams, the future of health care will be enhanced if physician leaders can not only increased in number, but can be integrated with present leadership teams to maximize their effectiveness in reaching all the goals which are central to a journey to excellence.

Giving Thanks

As we approach Thanksgiving, I am sure we are all most thankful for our families and friends, the loved ones who support us each day as we continue on life’s journey. However, for those of us in health care, I am sure that a close second on the list would be our thanks for being called into health care and the ability to serve those in need. However, as in any profession, our work has its share of clouds and sunshine—there are successes and failures, and there are opportunities and challenges. Those of us who work in health care, physicians, nurses, and all the support teams including the people who park our cars, cook our food and keep our patients’ records, we must demonstrate a continuous positive outlook and be resilient when challenges loom ahead.

How do we create this optimistic outlook and the ability to climb the highest mountains and run the most difficult marathons? First and foremost, we must celebrate our incremental victories.

As I have observed the health care industry for over the last 40 years, I have come to believe that health care improvement is never linear, but rather is incremental, with the slowest improvement seen in the earliest part of the initiative. Consequently, frustration can occur when we pause and evaluate just how little progress has been made over an extended period of time. But knowing that a tip-point will be reached when improvement will be accelerated gives one the ability to pause when each incremental improvement is made--however small--to celebrate what I have called the “incremental victory.” It is in this celebration, whether it be a mere thank-you note, an ice cream social, or a pizza party, that our Associates and physicians will find the energy to journey to the next success point on the improvement schedule.

Secondly, our resilience must come from reminding ourselves each day that we are doing sacred work. Our work is not necessarily sacred in the sense of religion, but sacred in the sense that every day, people turn their lives over to us. Knowing that people have put their most precious gift into our hands—the life of their child, mother, etc.— means to me that they must trust us explicitly. This knowledge should energize us and create in us a total commitment to our ministry and to ensuring that every miracle moment that we create for our patients and residents is of the highest quality possible.

Third, we should be creating for our Associates and our physicians the very best place in which to work. This means that we should be providing to the best of our ability, the latest equipment and knowledge to help them carry out their work as effectively and as efficiently as possible. But even more important, we must be hiring and retaining the right Associates and physicians—those who have a strong commitment to our mission, vision and values and who prioritize teamwork over individual performance.

Yes, this Thanksgiving is a time when we can express sincere thanks for being called into the health care profession. We are doing sacred work, we can create incremental victories and we can be a strong member of a team that ensures that the trust which our patients and their families place in us each day is well-deserved. And hopefully, they, too, will be giving thanks that when they needed help, they discovered CHRISTUS and its people.

The Role of Partnerships in Health Care Systems

Last week, CHRISTUS Health announced that we have signed a non-binding letter of intent to form a partnership with St. Vincent Regional Medical Center, the largest provider of health care in Santa Fe, N.M. It is our hope that as a result of due diligence, which is presently being performed, that the partnership agreement and the transition to CHRISTUS leadership and management can occur on or before Feb. 1, 2008. For the readers of this blog, this report should probably elicit the following questions: 1.Why would St. Vincent regional medical center want or need a partner? 2.Why would CHRISTUS Health want to enter a new market? 3.Are partnerships rather than total ownership a viable option for expanding health care in the future?

In addressing these questions, let us begin by briefly reviewing an article published in Trustee magazine in September of 2007 entitled, “Standing Alone: Assessing a Hospital’s Long-Term Viability”. This article begins with the statement, “The trend of the past decade is clear: Hospital-health system affiliations are up, and the number of independent community hospitals is down. In 2005, 55 percent of hospitals were part of health systems, up from 46 percent just five years earlier.”

This article continues to indicate that stand-alone hospitals may be challenged because of economic changes occurring in their markets, stronger competitors competing in their markets and, therefore, the challenge of generating sufficient operational margins to support their capital needs. In prior blog posts, we discussed that from our future planning, we learned that declining reimbursement and the need for new, non-invasive technology would be the drivers of the health care of the future. Both of these trends require a new approach to obtaining capital funds. It is this knowledge and understanding that drove the St. Vincent Regional Medical Center board and its leadership to contemplate the need for a partner at a time when they are the sole community provider and are fiscally sound. Their timing is critical, for many stand-alone hospitals wait far too long to review a potentially innovative and new strategic direction, and consequently are often facing significant cash-flow challenges approaching bankruptcy levels. In this wounded state, it is much more difficult to find a viable partner or a workable strategy. Such was the case reported recently with a hospital in New Jersey that has been unsuccessful in obtaining a partner after a two-year search, and have reported that their doors will be closed before the holiday season.

So specifically, St. Vincent Regional Medical Center decided that they needed a partner to ensure that access to appropriate capital would be available in the future, but they also agreed that being part of a larger system would give them exposure to best leadership and management practices and also best practices in regards to quality, service and community health delivery.

By utilizing that criteria, St. Vincent did a national search and determined that CHRISTUS Health was its best partner opportunity. Because the management expertise in CHRISTUS was also deemed as a positive contribution to the partnership, St. Vincent has agreed to sign a management contract with CHRISTUS so that their leadership team will in fact become CHRISTUS Associates and fall under CHRISTUS management.

Once the partnership agreement is signed, I will highlight more specifically our other partnership characteristics in a future blog post to give you a better understanding of one workable model for a partnership in American health care. We will also discuss at that time other partnerships which CHRISTUS has undertaken and do a contrast and comparison of those models along with the full ownership model, which is how we predominately operate throughout our system.

With regard to what’s in it for CHRISTUS, in our strategic planning process over the last 8-and-a-half-years, we have determined that to be an excellent organization, we need to be growing and expanding our ministry through a number of models, not solely through acquisitions. Therefore, we formed a partnership with Baptist St. Anthony’s Health System in Amarillo, Texas in 1998. We followed this with the Mexico partnership with the Muguerza health system in 2000, and hence began a formal partnership journey within our system. To eliminate the need to examine each partnership independently, we developed guidelines for such partnerships as a result of our decision to expand our portfolio to become one-third acute care, one-third non-acute care and one-third international.

For our acute care ventures in the U.S., we have indicated that we will only partner with organizations having the following characteristics:
1. Similar mission, vision and values;
2. Located in organically growing communities (i.e., new populations are entering the community);
3. Surrounded by geographical areas which are in need of expanded health care;
4. Located outside of our present markets, many of which are in the hurricane belt and
5. Markets which have stronger business literacy so that we might have more resources to care for the growing uninsured.
With these criteria in mind, we answered the invitation to begin discussions with St. Vincent, which as indicated, ended in CHRISTUS being chosen as their preferred partner.

With regard to the final question, partnership vs. ownership, regardless of the financial viability of any organization in health care, capital requests and appetites always exceed capital capabilities. Therefore, partnerships permit an organization to expand its ministry--particularly if it provides high-quality care--to new areas while not being required to provide all of the capital itself. So growth with less capital is possible. Hence, introducing partnerships into your expansion portfolio seems appropriate, provided that at the end of the day, your partners look as much like you as possible.

Transformational Leadership: Changing Ahead of the Curve

The average life span of Fortune 500 Companies is 40 to 50 years because many do not embrace transformational change ahead of the curve. Organizations that will stand the test of time will require innovative leaders who are able to change ahead of this curve.

This is most important in the health care industry, as more affordable health care will not come from an injection of more funding, but rather from innovations that aim to make more and more areas of care cheaper, simpler and more accessible to our patients.

This will require not only innovation, but resilience as well. Resilience is the ability to bounce back from difficult or challenging experiences, manage pressure and adapt quickly to change while continuing to produce excellent results. Luckily, this trait can be learned and improved over time. I believe the four characteristics of resilient leaders are the abilities to:
1. Accept reality
2. Find meaning in difficult situations
3. Make plans for a better future and
4. Improvise quickly to solve problems

As we prepare to change ahead of the curve, we can no longer benchmark ourselves against our historical progress or our peers, but instead must know our new competitors like technology vendors and retail providers such as CVS, WalMart, etc. We must become increasingly skilled at predicting the toxic side effects of change, and become more comfortable with the controversy change can cause if we are truly to take our appropriate place in the future we are predicting to provide the highest quality care in the most convenient ways possible.

To become truly transformational leaders, we must embrace five key mindsets.

Mindset #1 is maintaining the right balance between market–making and disciplined execution. This is not an either/or, but a both/and mindframe, and will require flawless execution balanced with our future thinking (3 year planning, 10 year plans, our Futures Task Force). To develop this mindset, a leader must avoid false tradeoffs and commit to a dual focus on the present and the future.

Mindset #2 is obsessively identifying and multiplying talent. We must always be on the lookout for new talent and support our leadership training so we continue being a talent multiplier. To develop this mindset, a leader must invest a disproportionate amount of time in recruiting and developing people.

Mindset #3 is the commitment to continuing to use a selective scorecard to measure business performance with rising benchmark scores. We must continue to support total transparency, including our quality data, financial information and community benefit numbers. To develop this mindset, a leader must rely on simple, memorable ways of measuring success and use every occasion to share those success stories across the organization.

Mindset #4 includes continuing to recognize technology as a strategic asset. Our clinical performance, business strategy and IT strategies must converge, and we must carefully and thoughtfully evaluate our adoption of new technologies in a timely manner. To develop this mindset, a leader must invest in technologies that will demonstrably lead to better business performance.

Mindset #5 is an emphasis on continuous renewal and “must haves.” Leaders must be continuously alert for our own competitive softness and vulnerability, always be on the lookout for new market opportunities, demonstrate fierce pride in their organization’s history and articulate its relevance to a rapidly changing future. Storytelling is important to lift spirits, raise expectations and talk about the pain that accompanies change. A leader must put in motion the powerful mindset of continuous renewal so it becomes the self-sustaining engine for innovation and better ideas. To develop this mindset, a leader must ensure that everyone in the organization understands what to preserve in their current way of doing business and what to do away with.

Our greatest challenge as CHRISTUS leaders is that we must get 30,000 full- and part-time Associates and 6,000 physicians, in multiple countries from multiple cultures, to think in similar terms about the purpose of our ministry and what they individually must do to accomplish that purpose and be aligned. We must all share the same mindsets. We must believe nothing is impossible.

Passion and vision

As I travel around the CHRISTUS system, and often when I present to other organizations, two questions that I often receive are: 1) how do you become a visionary, and 2) how do you create passion in an organization?

Although the answers to these questions must be filled with artful thinking rather than scientific approaches, they have been asked so frequently that I recently forced myself to reflect on a more meaningful articulation of the answers to give a better understanding of how you incorporate vision and passion into your professional competencies and therefore into the organization which you lead.

Let’s begin with vision. I think many people believe that visionaries are in some ways sprinkled with angel dust so that the future actually becomes real in their dreams. However, for me, vision must come from people who are embedded in the realities of today, having a clear understanding of how today works, so that their predictions for the future are made with this reality in mind (which hopefully will lend credibility to these predictions).

Footed in this clear understanding of today, a visionary then takes the time to look back and ask the question, “What changed from the past, what caused these changes, and hence, what are the results of these changes that made the present look like it is today?”

This knowledge, then, is helpful in determining the similar causal events that will change today to create a predictable future. An example of “visionary thinking” is my belief that numerous diseases will be cured in the next 10 years, and some new diseases will be introduced. I say this because I have watched tuberculosis, polio and nine types of childhood leukemia--which were prevalent 25 years ago--be cured. The causes for these miraculous events were the focus on understanding the infrastructure of medications and how they worked at the cellular level. This knowledge has been magnified at least a million-fold in these 25 years, which guarantees for me that we will more rapidly eradicate present diseases in the future. I am predicting that more childhood leukemias and adult cancers will be cured, and that Alzheimer’s and Parkinson’s disease may in fact be so well controlled that they can be managed much more easily at home or in outpatient settings.

And yes, there will be some new diseases identified. Why do I believe this? When I look back on my 40 years of travel, I can recall that AIDS was not a recognized as a disease for the first 32 years, and Fifth disease, a viral self-limiting disease in children, was never listed in the pediatric text book which was my bible in med school for child care. Today, however, we are all familiar with the prevalence of AIDS, and studies show that 40 to 60 percent of adults worldwide have laboratory evidence of a past infection of Fifth disease.

So what diseases might be identified in the future? I would definitely expect some in the area of infectious disease, and perhaps several new types of cancer that will appear in the very elderly, as we are seeing people living 100 years or more who will have at least 30 years more exposure to environmental contaminants than previous generations.

In addition to understanding the reality of today and the ability to look back and use the past as a barometer of the future, true visionaries who are creating believable and worthwhile visions also are constantly monitoring environmental, social, political and technological trends based on current data. There are an array of articles and organizations that can provide this information, and a true visionary devotes sufficient time to incorporate the learnings from these trends into their predictive processes.

And at the end of the day, I would also have to admit that if you are comfortable as a visionary, you will take some educated guesses and, occasionally, make a prediction which is less sound (but still possible), with the intent of socking your audience so their ears will always be attentive.

Although we have many futurists and visionaries speaking on the national circuit today, my concern is that many of them are not working in health care or have not worked in health care, and hence their predictions of the future are not based on their clear understanding of today and their ability to look back and use their past experience as a strong predictor of the future. The absence of these two competencies gives me less confidence in the visions that they are seeing.

With regard to passion, I consider it the ability to believe in the vision you have created and sign people up to follow you toward this vision. For me, passionate people who are able to create passion in others are—first and foremost—fully knowledgeable regarding the content of the subject they are delivering. They are able to “connect the dots” between everything they have done in the past, are presently doing and planning to do in the future. They are able to provide believable rationale for what they are doing, and they are able to create soundness in their vision by driving it via the pieces that I outlined above.

Clearly the second competency of creating passion is a passionate style of delivery. And although this will vary from person to person and is best done by delivering charismatic, engaging and rapidly-moving speeches on stage, there are many people who are passionate but are uncomfortable with this type of delivery. The common characteristic of a passionate style is delivering your thoughts in such a way that people truly believe that you mean it and somehow feel the passion exuding from every pore in your body. Consistency of presentation, whether it be the hand-waving type or with quiet style, is a key ingredient, because the one thing that causes people to question passion is inconsistency in leadership performance.

And this leads to the final ingredient: people will only believe that you are passionate if you are credible, which in today’s world means that you “walk the talk”: do what you say you are going to do, do it in the timeline to which you have committed and hold yourself accountable to the goals you have set.

If you are to be a visionary and passionate leader, you must work at developing these competencies, devote the time necessary to studying and dreaming about the future, and people must see a halo of vision and passion over your head when they see you coming.

Effective Teaming

Although I talked at great length about teaming in my last post, I would like to share some additional thoughts about the qualities of strong teams which I shared with the CHRISTUS Senior Leadership Team as we sat in Chicago waiting to accept our leadership award last week.

It has always been clear to me that teams are grown, rather than born. Consequently, I particularly wish to share with you what I believe has helped to fertilize the growth of our team over the last nine years.

First and foremost, teams must become comfortable with making individual sacrifices for the good of the whole. As we formed CHRISTUS Health and determined that our new location would be in Dallas rather than in Houston or San Antonio (where the two current corporate offices were housed), numerous team members had to make the sacrifice of moving to new geographical areas. For some, the timing was not right because of children’s ages or because they were fully integrated into the communities where they presently lived. In addition, the simultaneous movement of spouses always presents a challenge. But when the decision was made that certain senior team members needed to be in the Dallas office, they voluntarily made the moves and overcame the challenges. In addition, new office space needed to be developed, and because it wasn’t ready immediately when we transitioned to Dallas, we needed to sacrifice and meet in a hotel or other location for an interim period of time. Developing a strong team with a large number of moving parts at the beginning is not always ideal, but yet this was a building block for our strong team’s functioning as we continued our Journey to Excellence.

Secondly, strong teams have to tolerate high anxieties. The original team members were designated as “interim” since they did not know if the new CEO (that is me) would want to continue to support them, nor did they know whether they would want to work for him or her. However, they continued to be very loyal, focused and hard-working as we formed together an outline of what we would need to accomplish in CHRISTUS’ first 60 days. I would like to point out that every member of that original team is still part of the team nine years later.

Third, strong teams need to develop trust—a trust for each other’s judgment, knowledge and commitment to do what we say we are going to do. This trust develops over time and is only enhanced through the years by a team that is strong. Clearly, this may be the hardest competency to develop because we are people with all the characteristics of imperfect human beings. Everything we have done has not turned out perfectly, but our trust in each other is enhanced by debriefing on and learning as much from our failures as our successes.

Next, excellent teams manage transitions well. We have had two COO transitions in the first eight years of our journey, during which I served as the COO for a nine month period in 2000 and a two-and-a-half year period from 2004 to 2006. In August of 2006 we recruited another member of our Senior Leadership Team who fulfills the COO responsibilities. He has transitioned onto our team quickly, becoming a full-fledged member and fully accepted into the organization.

Also, excellent teams are innovative. Once again, our team has demonstrated this in many ways. Some examples of this include our movement into Mexico and our transition of our portfolio to one-third acute, one-third non-acute and one-third international.

Excellent teams must also take risks, and our team’s list of risks would be quite extensive. It would include our willingness to enter international markets as well as our acquisition of the Stehlin Foundation for Cancer Research. Although we were loosely connected with this center before we acquired it (they were located on one of our campuses), we recently became full owners of it, and have, therefore, entered the drug development field. We are taking this risk not because we think it might bring a great financial reward, but because we believe that the Stehlin Foundation has a great possibility of introducing several life-saving drugs for severe cancers that people all over the world now endure. It is important to note that CHRISTUS also took a risk and spent over $20 million in developing the artificial rib for children born with a hemi-thorax in the late 80’s and early 90’s. This apparatus is now FDA-approved and has been touted recently as one of the 20 most significant advances made in the orthopedics in the last 75 years. This serves as just one example of a risk supported by a strong vision which resulted in a life-saving legacy for many people.

Excellent teams also need to know how to “garage sale,” to go through their assets and determine what no longer makes sense for the good of the ministry. Our team has taken this task to heart, and through our eight-and-a-half years, has exited markets and programs, leaving in their places much more innovative ways to provide new and better services in those communities.

Strong teams also plan and manage growth. They are willing to adopt new “children” and assimilate them into their family. We have many new locations and new partnerships which have strengthened the CHRISTUS family through geographical distribution, service expansion and diversity of people.

Resiliency is the next trait that is critical to strong teams. Resilient people remain optimistic during difficult and challenging times, and although they may temporarily find themselves in a valley or on a detour on the journey, they never lose sight of the destination regardless of how high the summit might be. Our Journey to Excellence, although it has be steadily progressing, has had leveling off points where we have gotten stuck in some of our improvement plans, but as a team we have never given up nor lost sight of the end point.

And finally, excellent teams like ours are committed to continuous, life-long learning. We are constantly sharing articles, reviewing journals, pouring over environmental assessments and networking with others to determine the latest trends, technology, etc. As a result, we are developing an innovation institute which will bring together—in a virtual way—all the programs and people necessary to build the future health of care on our successes, one that will serve a greater number of people in a larger number of places, giving them the right care at the right time in the right place.

A strong team is essential for any organization to reach excellent goals, and I hope my last few posts will give you better insight as to what those competencies are required for those teams and how they might be developed.

What Makes an Outstanding Leadership Team?

Last week, CHRISTUS’ Senior Leadership Team was at the Top Leadership Teams in Healthcare conference in Chicago to accept their award as the 2007 Top Leadership Team in Healthcare for large hospitals and health systems from HealthLeaders Media.

The team was recognized for embarking on a steady path to excellence in leadership teamwork since it was created in 1999 and using a commitment to excellence in clinical quality, service quality, financial performance and value to the community as the pillars of an organizational turnaround.

You can read more about the award here.

In a prior post, we reviewed the competencies that health care leaders need to incorporate into their toolboxes in order to be successful during the present times and for at least the immediate future.

These competencies are all developed by fully integrating knowledge and experience, and are often enhanced and grown by having a coach or mentor who can teach--and more importantly--demonstrate them in their activities of daily leadership. However, it is clear that the presence of these competencies in individuals will not necessarily guarantee that the team with whom they work will also share them, and as a result, be efficient and effective.

However, it is my observation that while the competencies for strong leadership teams are identical to the necessary individual competencies, they in fact must be looked at in relationship to team interactions and team building.

This is best understood by looking at several examples. An extremely important competency is always the ability to listen to others and determine the meaning of what you’re hearing. For much of our day’s activities, this could refer to individual listening, but for team building, this means you must be listening to multiple voices simultaneously and analyze what the collective voices are saying. You also must develop the ability to be a good team player, to weigh the rationale behind each voice (particularly if the voices are in disagreement on an issue), and make a determination regarding which rationale is most accurate which will then lead you to support any or all of the part of the voice which it is driving.

So in summary, your listening skills for teaming must go to another level, one which is more complex and more demanding.

Expressing your views based on sound knowledge is also an important competency. For individual conversations, this is often driven by more limited knowledge and can be more quickly influenced by emotional interactions. In a group setting--where you have many more minds that likewise hold knowledge--it is much more necessary to clearly articulate what you know about a subject and to minimize the emotions in the presentations, since this will often cause polarity in a group, which is certainly more detrimental than if one person is dissatisfied with your position for a period of time.

Therefore, my hope is that you will revisit the core competencies that were presented in last week’s blog post and determine--like I did with listening and expressing your views based on knowledge--how the other core competencies may be interpreted and applied in the same way to a team setting.

In addition to these competencies, strong teams must believe that the value of the team interaction is more valuable and creates better decision-making than would occur if the members of the team made the decisions in isolation. Team interaction includes four steps:
1. being open to listening to the views of others
2. expressing your views in a way that creates credibility and clear understanding of what you believe are the facts and what should happen
3. being open to having your mind changed based on what you have heard from others
4. supporting the consensus of the group, not only at the conclusion of the meeting, but particularly when you are leaving the room.

These behaviors are the essence of a strong leadership team.
Strong leadership teams are built of people who exhibit all the core competencies and also have the ability to interact well with other members by adhering to the above four behaviors.

Core Competencies for Leaders in Health Care

Just as the practice of medicine has changed significantly over the last decade (an example of which is the use of laparoscopy surgery vs. open incisions), leadership competencies have significantly changed for people who want to create excellent organizations. In fact, in the past, most leadership capabilities have been centered around courses included in a core curriculum in Masters of Health Care programs. However, recently most training organizations and accrediting bodies for health care leadership have come to understand that although these courses provide a foundation for necessary learning, they don’t necessarily create the core competencies that are required for leaders to reach the goals for excellence in their organizations which we have described in prior posts.

This knowledge must be combined with experience to create an integrated approach to developing competencies which we in CHRISTUS Health have clearly defined. Our 23 core competencies are listed below, and were based on what we as a senior team determined were the leadership skills necessary to reach benchmark practices in our four directions to excellence within the next three to five years in all parts of our international system.

Core Competencies:
Dealing with ambiguity
Business acumen
Conflict management
Creativity
Customer focus
Timely decision making
Decision quality
Managing diversity
Ethics and values
Hiring and staffing
Innovation management
Integrity and trust
Learning on the fly
Listening
Motivating others
Perspective
Planning
Priority setting
Problem solving
Process Management
Drive for results
Strategic agility
Managing vision and purpose

To understand core competencies in a practical sense, I would use my own medical training as an example. In medical school, based on the traditional medical student curriculum, I was exposed to and learned the basics of anatomy (how the body is put together), physiology (how the body works) and pathology (how the body functions when it is broken). However, in order to become a competent surgeon, I needed to combine this knowledge as the basis for understanding and learning the surgical competencies that were required to perform and have positive outcomes in procedures as simple as a hernia repair and as complex as a whipple procedure for pancreatic cancer.

In specialty training, it would be unthinkable for anyone to believe that the curriculum-driven courses that we took in medical school would have been adequate to permit us to practice particularly interventional specialties following graduation. Therefore, for many years, specialty training had to be accrued through a residency program driven by clear evidence that you not only performed an adequate number of procedures, but that the mortality and morbidity levels associated with the procedures you performed were within an acceptable level.

The same principles now hold true for executive and administrative leaders in health care, and therefore not only do our leadership training programs have to embrace the core curriculum, but also the integrated core competencies and teach them to their maximum level in our graduate training programs as well as in our organizational development programs within CHRISTUS health. This is essential, because health care is so complex and is forever changing. A leader in health care today who does not commit to continuous core competency-driven lifelong learning should as quickly as possible transition out of the health care profession.

Toxic side effect: Valley Baptist and Evidence-Based Medicine

Recently, a group of physicians in the Emergency Department (ED) of Valley Baptist Hospital in Harlingen, Texas, announced they would resign in December, claiming the hospital administration’s focus on metric results could reduce the doctors’ income and compromise patient care. Specifically, they said the hospital’s goal of reducing emergency room wait times and operating-room turnaround time was putting patient care in jeopardy. Hospital administrators said their goal is to maintain high standards of patient care, and that staff and physicians are expected to adopt the new standards.

Meanwhile, at an emergency meeting, 121 of the hospital’s 136 physicians voted to support the ED doctors’ decision to resign, saying the physicians’ departures served as an example of “poor administrative leadership” by hospital leaders. The doctors said they would ask the hospital’s board of directors to investigate the reasons behind the vote and take action. You can read more about the disagreement here.

Luckily, the two groups were able to reach an agreement last week that will allow the physicians to continue practicing at the hospital for at least the next five years. (You can read more about that here.)

The actions of this medical staff’s vote of no confidence for the administrative team could, on the initial blush, be seen as a vote of non-support for evidence-based medicine. However, anyone in health care would be hard-pressed to state that utilizing procedures and processes in the treatment of patients that is not supported by evidence create better and more sustainable health care outcomes.

So in essence, what is the problem here? Rather than coming to the conclusion that evidence-based medicine is wrong, it is best to reflect on the following missteps, which were probably undertaken when the administration’s otherwise acceptable protocols on evidence-based medicine were introduced into Valley Baptist Hospital.
1. The administrative staff did not reflect adequately on the toxic side effects of these changes, i.e., the expected pushback one gets with the introduction of guidelines—and discuss them openly with the medical staff so that all parties were prepared for the physician’s professional pushback. The importance of determining in advance the toxic side effect of any change was discussed in my post, “The Toxic Side Effects of Change.”
2. The distribution of these guidelines in draft form for vetting by the physicians or at least the medical executive committee of the staff appears to have been lacking. This process would have given the physicians an opportunity to present their acceptable exceptions to these guidelines and provided the administrators with an opportunity to determine where flexibility might have been appropriate in their implementation. Ownership of guidelines based on evidence-based medicine is required by all members of the health care team, but especially by nurses and physicians.
3. It appears that the administrative staff might have ignored one of the best ways to develop ownership of what could be considered controversial guidelines: by implementing them in several pilot areas in the organization, after which administration and physicians could together commit to reviewing the findings of the pilots (the lessons learned), and then make any changes necessary and acceptable before the guidelines are instituted hospital-wide.

As I have stated in prior posts, health care is complex, and making appropriate transitional transformational changes in health care is a mammoth undertaking. But because there is wide variation in the performance and outcomes of health care providers in the U.S., as proven by multiple reports over the last several years, including “To Err is Human” from the Institute of Medicine, the development of practice guidelines based on evidence-based medicine is essential. And because it is my belief that most physicians and nurses want to practice the very best that health care has to offer because of the sacred work we are doing to care for patients and their families, they willingly and quickly want to support and implement evidence-based guidelines. Therefore, I believe that the resistance we have seen specifically in this instance (but we recognize occurs in most organizations when change is fostered), is predominately the result of the process of implementation rather than with the evidence-based guidelines themselves.

Hopefully, the several steps outlined above will make this process better and could provide learning both for Valley Baptist and other organizations that are implementing these necessary changes.

Big News in Mexico

As I have mentioned before, we know our ministry in Mexico is one of the regions of CHRISTUS Health that will significantly help us restructure our portfolio and drive us closer to our innovative one-third acute, one-third non-acute and one-third international portfolio.

I know I have previously posted about our ministry in Mexico, how we got started there, and our now swiftly growing medical travel program. As I mentioned previously, before we partnered with the Muguerza health system in Mexico, our due diligence clearly demonstrated their high quality as well as a shared mission, vision and values.

However, we were able to provide the Muguerza system with a formal organizational structure through our Journey to Excellence that required them to know their quality and measure it, and stressed the importance that all their Associates must be able to articulate what their quality measurements are and their individual part in assuring that excellence is achieved and sustained. It quickly became clear that a renewed focus on transparency and measuring quality outcomes would serve as the catalyst to propel them to excellence.

So the Associates and leadership at CHRISTUS Muguerza embarked on their own journey to achieve external confirmation of their high clinical quality. They began this journey by pursuing CAP certification in the laboratory of one hospital. Today, CHRISTUS Muguerza Alta Especialidad Hospital’s Clinical Analysis, Pathology and Cytology Laboratory is the only one in Latin America to be certified by the College of American Pathologists (CAP). They are planning to pursue this certification in each of their hospitals’ labs in the near future.

Their next goal, which is part of the CHRISTUS brand, was to achieve accreditation from the Joint Commission International. And last week, we were informed that CHRISTUS Muguerza Alta Especialidad Hospital is the first in Mexico to receive international accreditation from the Joint Commission International, which granted the hospital their Gold Seal of Approval, their highest level of approval awarded. It is rare to receive this high level as a result of an initial survey.

For those of you not familiar with Joint Commission International, it is a prestigious international health care accreditation organization, and is a subsidiary of The Joint Commission, which is the largest accreditor of health care organizations in the United States.

Joint Commission accreditation criteria focus on key functional areas such as patient safety, consistency in the therapeutic processes and infection prevention. During the inspection, hospital Associates, physicians and patients were interviewed and a detailed audit of the hospital’s practices, processes, facilities and systems was conducted.

This accreditation signifies that CHRISTUS Muguerza Alta Especialidad Hospital meets the highest international standards for quality and safety in health care services, and we expect that the remainder of the CHRISTUS Muguerza hospitals will pursue Joint Commission International accreditation as well.

I would like to take this opportunity to again congratulate all of the leadership, Associates and all the physicians at CHRISTUS Muguerza Alta Especialidad. You are living proof of my assertion that we are not in the health care business serving people, but we are in the people business, providing them with compassionate, high-quality health care in the U.S., Mexico and beyond.

Sharing Best Practices

In any organization—whether great good, satisfactory or “needs improvement”—there are always some islands of excellence. Some people find innovative ways to overcome the barriers that organizations often create so that they can form excellence in their area of responsibility. And with their persistent focus and attention, they can even maintain these isolated islands of excellence while they are surrounded by chaos or mediocre performance.

I recognized this phenomenon early in my career, and sought ways to identify what was different in these islands of excellence. What were the processes, policies, competencies and skill sets that gave them the ability to excel? Often, the person to whom they reported and certainly a majority of their colleagues either did not posses these qualities or were not motivated to achieve or maintain excellence in their departments or programs.

After studying these islands and determining their unique qualities, it became clear that this was an opportunity to share these learnings with other parts of the organization. Hence, my commitment to the identification of best practices and the development of a process to share these best practices among others in the company was created. I know this is the best way to move an organization from islands of excellence to a continent of excellence as quickly as possible so the brand and brand promise are clear and uniform throughout. It is so essential that an organization’s Journey to Excellence can be accelerated by eliminating the need to “reinvent the wheel.”

It is this learning and understanding that has resulted in CHRISTUS Health developing a formal methodology to foster sharing of and rewarding best practices from around our system. The cornerstone of this process is our Touchstone program and award ceremony. The development of best practices is encouraged throughout our system, and if certain benchmark criteria are met, the practice has sustained itself for a reasonable period of time and has fostered measurable and reportable outcomes, these practices can then be entered into the CHRISTUS intranet for review and sharing across our international system.

Each year, any best practice that has been submitted via the intranet by April 1 can be considered as a finalist in our Touchstone program. To accelerate the Journey to Excellence, each best practice must fit into one of our “four directions to excellence,” which are: clinical quality, service delivery, business literacy and community value. The finalists are reviewed by staff “reviewers” who utilize a uniform set of objective criteria to rank and rate them. These selections are done in a blinded fashion, so as to prevent any prior relationships from influencing this process. Then these best practices are reviewed by the appropriate Senior Leadership Team members (those who are considered the experts in each of the directions). This process results in naming finalists in each of the five categories.

The finalists are then submitted to the appropriate committees of our System Board of Directors, and the board members select the winners. (Specifically, the Quality committee of the board selects the clinical quality and service delivery winner, the Finance and Strategy committee selects the business literacy winner, and the Mission and Ethics committee selects the community value winner.) This process provides high-level recognition and credibility to the participants since their projects have been elevated not only to the CEO and senior leadership, but also to the international CHRISTUS Health System Board.

In addition, this gives the committees of our board a clear understanding of the excellence which the Associates and physicians of CHRISTUS Health are creating on our Journey to Excellence.

In order to stress the importance of this program, an awards ceremony is held annually in association with our September leadership retreat. It is formatted much like the Academy Awards, and is a time of celebration of the highest level within the CHRISTUS family in order to provide enormous energy for all Associates to create and submit best practices throughout the following year.

This year, on Sept. 20, we will be holding our seventh Touchstone awards ceremony, which means we have reviewed over 400 submissions, named over 120 finalists and selected 32 winners. I consider this a clear representation that the “continent of excellence” has evolved during CHRISTUS Health’s eight-and-a-half year history.

In order to stimulate sharing of best practices--which is the ultimate end goal of the Touchstone awards—in the second year of the program we added one more category, the spirit exchange award. We utilize this category to reward facilities that have “stolen” a best practice from another region and implemented it in their own, providing clear evidence of positive results. In addition, we obviously recognize the facility or group that originated the idea and submitted it on the intranet so that it could be viewed and taken to other locations. We are hoping that through this part of the program, we will encourage more and more best practices to be shared. One of the major criteria for winning in any of these five award categories is that the best practice must be easily replicated and transported to another location in almost a turn-key process.

In the end, an excellent organization must move as rapidly as possible to benchmark levels of performance, and it is clear that developing and sharing best practices is the ideal way to accomplish such. It is best if this can be done via a formal, operationalized program such as the one we have described, to not only align the incentives to develop these best practices, but also award the true winners and heroes of an excellent company in a very high level fashion.

The Importance of Behavioral Services

As we have been reflecting on the future of health care in many previous posts, it is clear that among our many successes, we have failed miserably in one area of health care delivery: behavioral health.

Although 10 years ago many futurists would have predicted that the rapid development of medications to treat psychiatric illnesses would clear our inpatient mental health facilities, we have found that today there is more confusion and controversy not only on the diagnosis but of the efficacy of many of the drugs that at one time were thought to be miracle cures for mental disabilities. Unfortunately, before the facts were known, inpatient facilities were cleared and closed, driven for the most part by the rapid decline of reimbursement both by governmental and private insurers.

Consequently, our streets became filled with people unable to work or care for themselves, which has added to the growing number of uninsured and underserved in our country.

In addition, because of the aging population, we are seeing mental illnesses such as depression as well as medical diseases now occurring in the elderly that only once occurred in younger people. Consequently, we are seeing the need to open up geriatric psychiatric centers, both in inpatient and outpatient settings. Also, because of the rising ages of our seniors (it was recently reported that there are now 80,000 people in America over the age of 100), we will see more memory loss maladies such as Alzheimer’s or chronic senility. These will require new medications, new settings for care and new surgical treatments.

Hence, in our transformational strategy, we must make sure that we address the issues outlined above and attempt to correct. How might we do that?

1. Require that every region in CHRISTUS Health have a senior strategy that includes care for people with behavioral illnesses.
2. Require that every region have access to both inpatient and outpatient memory stimulation units. One example of this would be an intergenerational program in place in our Utah region or our “animal partner program”, which we are now encouraging not only in our senior centers, but also in our acute facilities.
3. Strengthen our advocacy program to encourage both the government and private insurers to re-establish reimbursement levels which are appropriate to care for this increasing population of senior behavioral problems.
4. Advocate for more research dollars to be spent identifying both causes and treatment for behavioral diseases, including the support of developing more outpatient procedures and safer anti-psychotic medications for this population.

At the present time, CHRISTUS Health has three geriatric psych units which can be studied thoroughly to determine the best treatment plans and can also be utilized as pilot sites for experimenting with new programs and processes which we may represent a breakthrough in care.

In addition, by demanding that these diseases be focused on in our new senior centers, hopefully we can continue to be leaders in advocating for enhanced services for behavioral health in all ages for people both in the U.S. and in our international ministries.

Organizational Redesign

As we discussed previously, for reasons that we believe are quite sound, we are transforming the CHRISTUS Health portfolio to one-third acute care, one-third non-acute care and one-third international. In order to accomplish such, it is necessary for our senior leadership team to review the leadership capabilities not only within our own team, but also within the leadership teams of the 11 regions that presently comprise our health system.

As the team reviews these capabilities, it may be necessary to look at both the organizational and governance structure of the system to make sure that our peoples’ capabilities are appropriately aligned. Although I will not discuss specific organizational changes that might evolve over the next several months or year on my blog, I think it would be appropriate for us to converse about several principles which might guide this process.

First and foremost, this transformation will require a clear understanding of not only what is included under the umbrella of non-acute care, but also a clear understanding of the rapidity of the growth in non-acute care as the factors driving it seem to be accelerating its growth at an unprecedented rate. Presently, we are defining non-acute care as “care which does not require a traditional inpatient bed in an acute setting.” However, this definition does include care that requires beds in non-acute settings, such as rehabilitation medicine, and our nine hospitals providing long-term acute care. Of course, all outpatient services would be included in this category, and this division will also include new ambulatory care programs which will evolve due to the technology advancements we discussed in detail in past posts.

At the present time, we are categorizing our non-acute care in four categories:
1. Outpatient care, facility dependent;
2. Outpatient care, non-facility dependent (visiting home nurses, etc.);
3. Inpatient care requiring non-acute beds (rehab) and
4. Housing, including both senior campuses and housing for the underserved.

In addition, our senior care is broken down into independent living, assisted living and nursing home, including memory units. It is clear by reviewing this list that both present and future leaders will need to possess new capabilities and leadership skills if we are to add needed competencies into our leadership portfolio, which has been developed mainly through educational courses and experiences which have been garnered predominately in acute hospital settings.

Then how will we gain this knowledge? Since many of our bachelor’s and master’s health care programs in the country have historically been driven by hospital knowledge, we believe this non-acute care training must occur predominately through our own capabilities. To do this, we have strengthened our organizational development department and are now offering formal courses and experiences in the following four areas:
1. Coaching and mentoring - We are identifying those people who we believe have strong capabilities to be future leaders, but perhaps do not recognize such or feel confident enough to apply for the 3 levels of training outlined below. Consequently, we are assigning each of these people to a coach from our senior teams for a one-year period. Formal training in coaching and mentoring has been provided for the over 60 people who are now serving as coaches, and a formal evaluation by the mentee is done at the conclusion of the year-long program. Now in its fifth year, we have proven that based on this coaching and mentoring—which is usually done by a mentor and a diverse mentee—that these people have gained the confidence and knowledge to apply for and be selected for our more advanced leadership programs.
2. Center for Management Excellence – This four-day workshop has been designed through a Senior Leadership Academy project (see below) to train all managers in a very focused way in the basic skills that they need to manage both the acute and non-acute areas of operations. All present CHRISTUS managers have gone through this course and all new managers go through the course in the quarter they were hired, since it is now repeated every three months during the calendar year.
3. Senior Leadership Academy – Now in its sixth year, a multidisciplinary committee selects 30 candidates from an applicant pool of strong directors and managers in CHRISTUS Health who have demonstrated the skills and motivation to take on additional leadership responsibilities. Through five three-day sessions, and by working on one of four assigned projects, which when completed should help CHRISTUS advance on its Journey to Excellence, these academy members gain a broad exposure to both operational and strategic issues including detailed business literacy and an enhanced focus on governance, which is rarely experienced at this stage in one’s leadership pathway. It is important to note that these graduates are given the first opportunity to apply for leadership openings throughout the organization, and over 30 percent of academy graduates have been promoted.
4. Talent management and succession planning – In order to make sure that there is always a potential internal leadership pool from which to fill the top senior leader and regional leadership team spots, the first class of 16 outstanding leaders have been organized to participate in succession planning and talent management. These participants, who are identified by having outstanding performance in the prior three years as well as outstanding potential based on statistically significant testing, are assigned external coaches for 1 year. During this year, intense developmental plans are implemented to address necessary growth opportunities so that at the end of the year, these 16 people should have the full array of skills necessary to be the transformational leaders of CHRISTUS Health tomorrow.

Yes, at the end of the day, transformational leadership and organizational structural changes must be made to move an organization such as CHRISTUS Health from its traditional hospital inpatient focus to an exciting to one-third acute care, one-third non-acute care and one-third international portfolio. At present, this transformational knowledge must be gained internally, providing future leaders with the knowledge and experience required to be successful.

CHRISTUS’ Changing Portfolio: 1/3 Acute Care

As I mentioned in previous posts, there are several significant drivers that are rapidly shifting the delivery of health care. Much of the care that was traditionally delivered within hospital walls is now delivered in a more non-invasive and safer way in outpatient settings.

Therefore, it is appropriate to pause and reflect on what will be left in acute care settings and what the hospital of the future will look like. We know that there will be critical services that must be delivered in the inpatient setting because of the severity of illness and the safety factors involved. These—first and foremost—include trauma, which in the 1960s was the leading cause of death in children 7 years old and younger, and has now risen to the leading cause of death in people 51 years old and younger.

It is my prediction that trauma will become the leading cause of death in people 56 years old and younger by 2016. Why? Again, this reflects some other observations which we outlined in previous posts. Many deadly diseases have been eradicated or at least mitigated to some degree, cancer being a prime example. In addition, we have observed a shift in the health level of seniors as well as the baby boomers. And finally, we know that the growth of drug and alcohol addictions world-wide brings with it a large growth in violence and traumatic incidences. Consequently, healthier people are more vulnerable to a traumatic occurrence, and therefore a major percentage of inpatient stays will be related to trauma care, which is very expensive and has a low margin of profitability since it requires a high intensity of supplies and personnel.

A second area of growth in the inpatient setting will be neurosurgery. Many past neurosurgical diagnoses can now be treated with non-invasive interventional technologies such as stents and arterial occlusion devices. It is my belief that a new set of procedures, however, will be developed to treat memory and tremor illnesses such as Alzheimer’s and Parkinson’s disease, and these treatments will require open craniotomies. Any time the skull is invaded, even with minor procedures, inpatient settings are required for post-op monitoring.

A third category of patients who will continue to be treated in inpatient settings will of course be the elderly who need care in their final days. They will most likely succumb to a neurological event, such as a stroke, or a cardiac event, such as a terminal heart attack. However, their stay in the acute setting will be much shorter than in the past, and most of them will very quickly request to be transferred to inpatient hospice settings which may or may not be housed in the acute facility.

Because the cases that we see in the inpatient setting will be different in the future, this will also change the types of physicians and caregivers who will work in these acute settings. From my view, I see the predominant types of physicians that will staff inpatient beds will be predominately limited in the next decade to hospitalists, intensivists, (both pediatric and adult), neonatologists and perinatologists. Obviously, we will still have an array of general obstetricians and gynecologists, but with the advances in these areas, the women’s hospital of the future will much more parallel non-acute settings than they do the more intense acute setting which we described above.

If all of this is true—and we believe our data is proving more and more each day that our vision of 5 years ago is becoming reality—CHRISTUS Health should limit its acute care expansion in a very focused way. In fact, we are doing this by utilizing certain criteria to guide our expansion plans. If we are expanding acute services, they must meet one of the four following criteria:
1. The area must be organically growing, i.e., new populations must be entering the community.
2. The quality of the present services or new services at the facility must be so high that patients who were going to the competitor are demanding that they now be admitted to CHRISTUS facilities, and therefore the present facility needs more space.
3. We will explore the acquisition of facilities where we are called as potential buyers or partners. If they extend our mission, give us a more wide geographical distribution, provide distance from the hurricane-prone Gulf Coast region where many of our facilities are located, or enhance our fiscal stability (so we will have more funds to extend our care for the underserved), we will consider the partnership.
4. We will also consider replacing facilities where we have met our benchmark metrics in all four of our directions to excellence. Obviously, these replacements must be scheduled according to our capital capabilities and, when built, must be designed as hospitals of the future, which will take into consideration all the changes in acute care outlined above. In addition, these hospitals must understand the patient-centricity which the baby boomers will require, the diseases which are present today that will not be present in the future or require inpatient settings, and the importance of providing appropriate environments for end-of-life care which will be demanded—as we as previously discussed—by a large portion of seniors who will require limited acute care but want guaranteed hospice and palliative care with strong pain management.

One inpatient setting that we did not discuss at this time is that required for behavioral services, which will also be changed significantly because of our senior aging process. We will discuss this in detail on a future blog post.

CHRISTUS’ Changing Portfolio: 1/3 Non-Acute Care

Historically, CHRISTUS’ portfolio has been predominately focused on acute care, which are services provided in inpatient settings and require a hospital bed. However, because of the factors I outlined in the previous post, we believe this needs to change, and our portfolio must parallel our increased focus on non-acute care.

I believe that one of the most significant enhancements in non-acute care will involve advancements in technology, specifically long-distance monitoring. Through long-distance monitoring, health care providers can now examine nine different parameters of a person’s wellness: blood sugar, weight, blood pressure, urine pH, etc. We believe that number will increase to 26 - 30 parameters so that health care professionals will have a more accurate picture of a person’s health without requiring an office visit. By distance monitoring, patients can retain the best level of care possible without leaving their homes or staying in the most independent living option offered in a senior community.

In fact, distance monitoring is becoming so effective that in our independent living and assisted living campuses, we have applied for and obtained licenses to provide certified home care to their residents. Receiving these home care services and perhaps utilizing visits from a home health nurse enables seniors to live much longer in independent living situations, move into assisted living later, and perhaps never have the need to enter a nursing home.

In my last post, I also addressed the changes in the senior aging process and the large number of baby boomers who are reaching retirement age. In response, we are increasing our focus on palliative and hospice care programs as well as geriatric psychology programs, as we are seeing increased instances of depression in people living to 80 and 90 years old. Also, as people live longer, we are seeing new series of diseases in seniors that we previously would perhaps have only seen in a younger population. As we continue to see these types of diseases (most of which are propagated by environmental conditions, stress, dietary exposure, etc.), we will have to come up with new treatment modalities for older patients who will not opt for highly invasive treatments which have known high mortalities and morbidities.

For instance, I recently heard of an elderly man who developed colon carcinoma in his 80s. When I was in medical school, that was a disease of white males 40 years of age or younger. However, we are staying healthier, living longer, and are now prone to these diseases when we are older. The 80-year-old with colon carcinoma did not, understandably, opt for radical surgery. Instead, he chose minimal, non-invasive surgery, and immediately wanted to be enrolled in our hospice and palliative care program in his region. As a Catholic, faith-based organization, we pride ourselves in not only acute interventions and non-acute programs, but also every sophisticated and innovative palliative and end-of-life care.

Some people say that because boomers are aging and most health care is required later in life, health care are expenses going to rise. However, as discussed earlier, we are choosing not to build hospital beds for the elderly. Instead, we are depending on technology and changing attitudes to move as much care as possible into the most independent setting possible. And as you have heard, we’re so committed to this that we’re changing our entire portfolio.

It is our observation that already, every level of care after an inpatient hospital stay has been changed in some way. For instance, skilled nursing units are now doing what long term care used to do. This will change health care significantly, and we are hoping that this movement from acute (expensive and often invasive) to non-acute (less expensive and often non-invasive), may cause health care costs to decrease instead of increase. As we move toward becoming a more non-acute organization, we will do more of the following: acquiring distance monitoring systems, acquiring Visiting Nurse Associations, developing memory units so we can treat Alzheimer’s more effectively (instances of which will increase). Memory loss is a function of time, and we need more innovative ways to stimulate memory as patients age to be added to our inter-generational Alzheimer’s program in Utah, and our in-house animal programs in all of our senior campuses.

This inter-generational program pairs Alzheimer’s patients with children in daycare for 4-6 hours a day. Animals, including dogs, cats, birds and fish and plants placed into our senior facilities seem to foster companionship and provide enormous energy and stimulation for the residents. I believe that we will have a greater understanding of the mind in the next 10 years (much like our increase in understanding of the heart in the last 25 years). We still may not be able to cure diseases like Alzheimer’s, Parkinson’s, etc., but we may be able to stabilize them and mitigate the most serious side effects.

We recently acquired a senior care facility in the Dallas area and, like our international operations, especially in Mexico, is proving to be a great “learning-laboratory” for us to study and treat innovative models for senior wellness. Historically in the Mexican culture, children took care of parents as they aged. However, we are finding that elderly people in Mexico are considering alternatives so that they do not need to live with children unless they have no alternative, and children are looking for more stimulating environments for their parents. Also, in a recent trip to Japan, I discovered that country has a major issue in providing care for their elderly. They had a goal of funding long-term care for all aging people, and now they have a healthier elderly population who do not want to go to into a nursing home environment, and instead want to be in assisted or independent living facilities.

When we chose to shift our portfolio to focus more heavily on non-acute care to mirror changes in our culture, we signaled a shift in our own culture. Instead of seeing ourselves as a health care delivery system serving people, we must now move to seeing ourselves as an organization that serves people by delivering health care in the most appropriate setting to maintain wellness as long as possible. We now, at CHRISTUS Health, are in the people business.