Happy New Year

Like in years past, as 2011 unfolds, the CHRISTUS family will again experience many blessings and face numerous challenges. As we prepare to celebrate the 12th birthday of the CHRISTUS Health ministry on Feb. 1, 2011, we should all pause not only to reflect on our accomplishments, but also embrace the clear action plans which will be necessary to address and hopefully mitigate future challenges.

Truly, our blessings have been many:
• Our culture is alive and well, seen in the lived experiences of our Associates, physicians, and volunteers, who daily are driven by our mission, vision and values.
• Our brand is strong and well-recognized, both internally and externally, built around our 4 directions on our Journey to Excellence.
• Our business literacy has achieved the highest performance metrics in our history, including days in cash, operating margin, investment income, labor and supply costs, and accounts receivable.
• Our community benefit contributions continue to maintain a leadership position among Catholic and not-for-profit health care providers, both in the U.S. and Mexico.
• Our futures planning process, including Futures Task Force II, which completed its work in 2009, has positioned us well for health care reform based on the identification of 3 strategic drivers, 5 strategic directions and 8 strategic enablers to guide us through the next decade.
• Our support and learnings from important improvement initiatives begun in 2010 which will continue in 2011, including: Medicare profitability, labor productivity, asset sales, physician integration, evidence-based clinical protocol development, stringent capital review process, revenue cycle enhancement, supply chain improvements, clinical information upgrades, refinement of continuing care and non-acute strategies, and clarification of international strategies.

Yes, with all of these blessings and accomplishments resulting from much hard work and effort from all members of the CHRISTUS family, we are positioned well for the continuation of our Journey to Excellence in the new year. But because of the complexity of health care, which only seems to increase, we will also have to face again some significant challenges. Because it is the right thing to do, we must embrace the positive innovations embedded in health care reform and transform CHRISTUS Health totally from a claims/payer system mentality which drives fragmented care, to a value-added partner mentality, with our patients and residents supporting seamless coordination of care. Fortunately, the initiatives articulated above, which are well under way, should address or significantly minimize the challenges which clearly are forthcoming. However, to be successful, we will have to embrace even more change and do everything possible to accelerate our Journey to Excellence for the continued success of our ministries.

Based on our effective team effort, we are strong today so as to be able to stand alone as a sustainable health care business model into the future. In addition, because of our significant growth over the last 12 years, we have the size and scale to create and finance further growth plans that can thrive in each of our ministries in our acute, non-acute and international divisions.

Facing and addressing challenges is nothing new for us. For the last 12 years of CHRISTUS Health--and for the entire 144 years since the founding congregations answered Bishop Dubuis’ call in 1865--we have faced fires, floods, epidemics and hurricanes. Although they have occasionally slowed our journey, we have been able to overcome each of them, learning from these experiences and renewing our energy and enthusiasm to continue our forward momentum. Such will be the case also in 2011.

Each of us is truly blessed to have answered the call and to continue to serve in our sacred ministry, CHRISTUS Health. In this new year, the successes will even be greater, and the challenges will be different, but most importantly, the call will remain the same: to carry out the healing ministry of Jesus.

So as we travel toward a new year, let us pray that it will be filled with much peace and happiness for all who enter our doors, for all members of the CHRISTUS family and their loved ones, and for those throughout the world who suffer hardships and pain. Let us ask for the strength necessary to use our hands and hearts effectively, to replace as much of these sufferings with our miracle moments. Happy New Year to you all.

Happy Holidays

When we first think of the Christmas season, many images initially pass through our minds – presents, decorations and parties. But as Christmas Eve approaches and some of the flurry of holiday activities subside, the image of the Christmas miracle – the birth of Jesus – becomes clearer. It is that miracle centuries ago that set the stage for the CHRISTUS Health mission – to carry out the healing ministry of Jesus.


With all the major challenges that health care systems face each day, including global challenges, it is important to remember that it is the miracle moments, however small, which happen in our ministry each day that truly make the difference in people’s lives. Although we may wish to believe it is our technologies and facilities that drive our outcomes, the positive results we all hope for only occur when CHRISTUS is filled with person-to-person interactions – assessing and treating an injury, offering words of encouragement, extending a warm hand, a big hug, or quickly saying a prayer.


We must always remind ourselves that the broader picture of sustained improvement would never get painted without the strokes of many artists, including our Associates, our physicians, Sisters, volunteers, board members and many others. These miracles are the true expressions of our incarnational spirituality. This is who we are. This is how we are seen. Whatever our role is in the ministry, we are the healing hands. We are CHRISTUS Health.


On behalf of the entire senior leadership team, I wish each of you many blessings for peace, hope, prosperity and happiness at the holiday season and throughout the New Year.

My Thoughts About Tort Reform in Texas

Many of you have probably read an article published this weekend in the New York Times about tort reform in Texas which featured a story from a patient at CHRISTUS Santa Rosa in San Antonio, Texas.

In an effort to protect Americans and their personal information, federal privacy laws (like HIPAA) threaten us with legal action if we comment on the care of any patient. Therefore, I can’t discuss Ms. Spears’ medical condition or treatment at our facility in detail. I can, however, extend to her my deepest consideration and compassion for what must be an extremely difficult situation for her and her family.

I can say that I have reviewed the documentation related to the incident described in the article, and it is my opinion that we provided care that was entirely complete and appropriate.

Because I can’t provide any further details, I would like to take this opportunity to add my voice to the dialogue regarding the focus of the article, tort reform in Texas.

Let me be clear: if an error occurs in our delivery processes, the patient and his or her family should be told the truth and should be financially reimbursed for the costs which have been caused by the error. In all my years as a practicing physician and even now as the president and CEO of an international health care system, I understand the great responsibility we are given by our patients and their families when they choose to place their lives and the lives of their loved ones in our hands. This is why I have always said that for CHRISTUS Health, excellence is a necessity, not a luxury.

Tort reform in Texas does not do away with financial awards to patients who have been wrongfully harmed by inappropriate treatment. It merely caps noneconomic damages at $250,000 per health care provider, with a maximum award of $750,000. Since tort reform was passed in 2003, these suits have continued to be filed, including against Emergency Room physicians, and damages have continued to be awarded.

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. Support for tort reform does not mean refusing to accept responsibility, nor does it mean that providers are held to a lower quality standard. Instead, it means supporting paying what is due, admitting what was done incorrectly and doing everything possible to mitigate negative outcomes and create a positive solution for patients and their families.

Since the passage of tort reform, physicians have also begun to see Texas as a more attractive environment in which to practice medicine, and some studies show that our physician population has increased 31 percent. As we contemplate a current and worsening primary physician shortage, this is good news for Texans, who have more access to health care than they did before.

Specifically in CHRISTUS Health, since tort reform was passed, our expenses for litigation have been reduced dramatically. We have used these savings to further improve our quality and patient safety by reinvesting them in programs and projects throughout our entire health 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.

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 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.

The first program funded this way involved certifying all nurses and re-educating physicians in the appropriate use of fetal monitors. This was because, as many of you are aware, catastrophic events for the baby during the delivery process account for the largest number of lawsuits past and present in most hospitals and health systems. This signaled to us that improving “fetal monitor literacy” in our caregivers would result in an even higher level of safety for our youngest patients. After requiring this higher level of proven clinical competence in applying and reading fetal monitor strips during the labor and delivery process, CHRISTUS Health has successfully, in the last 12 months, delivered consecutively 17,000 healthy babies without any fetal abnormalities.

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.

I, along with the CHRISTUS family of 30,000 Associates, am dedicated to our mission of extending the healing ministry of Jesus Christ every day. We understand and take very seriously the awesome responsibility of caring for the health and lives of our friends and neighbors, and will continue to provide high quality, compassionate care at our facilities across the U.S. and Mexico.

Critical Success Factors for Accountable Care

As health care reform is seeking to restructure how care is delivered and reimbursed, the Accountable Care Organization (ACO) has come forth as a preferred model. A myriad of articles and conferences have appeared in response to the direction from the federal government in the hopes of educating both providers and insurers of not only what will constitute an ACO, but how they must operate to be successful.

Although many of the articles have little value, one written recently on behalf of the Advisory Board Company provides a wealth of knowledge in a well-organized fashion on this proposed model. Entitled “Health Care’s ‘Accountability Movement,' ” this article identifies and expands upon the 15 imperatives for success under accountable care. These 15 are organized into four categories:
• Physician alignment,
• Clinical transformation,
• Payment transformation and
• Information-powered health care.

As conversations about reforming how care is delivered continue and ACOs receive more and more focus, these considerations will become increasingly important.

The Importance of Our Cultural Competency

Since CHRISTUS Health began Feb. 1, 1999, its Senior Leadership Team has had performance goals to enhance diversity focus in our health care ministry. In 2000 when we embarked on our journey across the border to work with the Muguerza family in Mexico, we knew we would have to develop a culture competency as we worked with and developed health care delivery processes for the people who lived in another country. Although we have been extremely successful in our initial international effort, the senior team, in collaboration with the board, is increasing our focus on diversity by implementing multiple initiatives, including the formation of a system-wide diversity council and our hiring of a System Director of Diversity and Inclusion.

We are all in agreement that a diverse organization that develops a wide range of cultural competencies is best positioned for success. The various positive outcomes and competitive advantages of such organizations are articulated an article which appeared in the September-October 2010 edition of the Physician Executive Journal of Medical Management. Entitled, “Cultural Competency in Health Care Organizations: Why & How?,” this article describes the important strategies that are necessary to implement in creating a cultural competent workforce which ultimately helps patients in various ways, including reducing the risks for medical errors and malpractice claims. The article stresses that, “race and ethnicity concordance alone do not make cultural competence. Providers need specific knowledge and skill sets to provide culturally competent care.” As always, we are hopeful this information will be helpful as we continue our commitment to enhancing our cultural competency.

Renewed Focus on the Determinants of Health

The U.S. Department of Health and Human Services today unveiled Healthy People 2020, the nation’s new 10-year goals and objectives for health promotion and disease prevention, and “myHealthyPeople,” a new challenge for technology application developers.

The Healthy People program aims is to improve the quality of our nation’s health by producing a framework for public health prevention priorities and actions. The Healthy People 2020 program includes new topics of focus, including:
• Adolescent Health
• Blood Disorders and Blood Safety
• Dementias, including Alzheimer’s Disease
• Early and Middle Childhood
• Genomics
• Global Health
• Health-Related Quality of Life and Well-Being
• Healthcare-Associated Infections
• Lesbian, Gay, Bisexual and Transgender Health
• Older Adults
• Preparedness
• Sleep Health
• Social Determinants of Health

Part of this program will examine what makes some people healthy and others unhealthy, and how we can create a society in which everyone has a chance to live long, happy lives. They recognize that solutions must address a broad range of personal, social, economic, and environmental factors that influence health status, which are known as determinants of health.

I have written many times on my blog about Canada’s seven determinants of health, and still firmly believe that if health care reform in the U.S. is to be successful, we have to address all the issues that affect overall health, not just hospitals/primary care. Therefore, I am glad to see this focus on all the factors that influence health besides health care providers, since it is clear that sectors such as education, housing, transportation, agriculture, and environment can be important allies in improving population health.

Giving Thanks

As we approach another Thanksgiving Day in the U.S., it is appropriate to pause and give thanks for the many blessings in our lives. I am thankful of course for my family and friends, but also for the wonderful CHRISTUS Associates, volunteers and physicians who provide excellent care to our patients, residents, consumers, and their families every day. It truly takes a sacred calling to work in health care, and I am thankful that each of you were called to travel with us on our Journey to Excellence.

Thanks to each CHRISTUS Associate, my colleagues, and readers of this blog. May this holiday season be filled with joy, peace, and happiness for each and every one of you.

Patient Satisfaction: My Continuing Focus

Patient satisfaction has been one of our main areas of focus since CHRISTUS was formed in 1999. As we have moved through this journey to ensure that our care is compassionate as well as excellent in clinical quality, we have seen other health systems take note of the importance of patient satisfaction, especially with the national HCAHPS survey.

When I have confronted physicians and Associates over the years with what I recognized as very poor performance in delivering kind, compassionate and highly-satisfying care to their patients, I often heard the response, “I am here to save lives, not make friends.” It is interesting to me, as I have been reflecting on our performance in patient satisfaction even more intensely in my transition period, that I came across an article that explains why those points are moot. “Patient Satisfaction is Here to Stay,” an article in the November 2010 edition of Emergency Physicians Monthly, also articulates in its closing paragraphs the need to combine our satisfaction focus with other areas we have included on our balanced scorecard to determine how “good” we really are.

It is clear that we are on this Journey to Excellence for the patients who turn over their most precious gift to us, their lives. We cannot violate this trust. We must be here to both “save lives” AND “make friends.”

Burning Questions, Part V

This week, I’ll be providing the final installment of my answers to the questions posed by leaders from across CHRISTUS Health at our recent leadership retreat.

Q. You mentioned that physician integration, seeing physicians as our partners and not customers or competitors, will be essential for our future success. Do we have strategies in place to make that happen?

A. Under the leadership of our Chief Medical Officer, and assisted by many team members, a myriad of physician integration strategies have been developed, and some are being implemented. Two important ones are the expansion of the employed physician model, now through our CHRISTUS Provider Network, and the development of evidenced-based clinical protocols which will be systematized.

Q. Should our growth be predominately out of the hurricane belt?

A. Although I believe we will explore every “call” that comes to us, our due diligence process will indicate that perhaps some of the best opportunities where we can expand our ministries will not be in locations prone to hurricanes. We have done that with our growth in San Antonio, both clinically and for our information systems, and in New Mexico.

Q. Do you believe there is a difference in a faith-based health system versus a non-faith based one?

A. Based on my experience in the three prior heath systems where I served, I am absolutely sure and have experienced a different ambiance in CHRISTUS Health. It has been much easier here to work with a balanced scorecard, making sure the decisions we have made were not driven primarily by a financial mindset. In addition the ability to routinely reflect and pray in preparations for meetings and events, as well as, with patients, sets us clearly apart. And finally, embracing the incarnational spirituality of our founding congregations gives us the ability to live out the golden rule every day, which should be the basis for all heath care quality and safety. In the end, if the care we render is not good enough for our Associates and their families, it is not good enough for anyone else who enters our doors! It is just that simple!

Q. Is there a role for young leaders in CHRISTUS Health?

A. Clearly the answer is a resounding YES! In the enhancement of our diversity program, we not only must be concerned about ethnic and gender diversity, but also talent and age diversity. The diversity of leadership has been a driver to determine participants in our coaching and mentoring programs, our leadership development classes, and our succession planning initiatives. Having younger and better prepared leaders coming behind you should be a goal for all of us as we continue our professional journey!

Q. What metrics did you use to plan a smooth and seamless transition?

A. To assure a smooth transition, the key is to plan as far in advance as possible. Abrupt changes in leadership are disruptive, even when they are done for appropriate reasons. Also, be totally transparent in explaining to all audiences the reasons for the transition. And finally, planning the transition when things are going well is most helpful, so your successor can assume the leadership responsibilities on a firm foundation, rather than meeting daily unknown surprises.

Burning Questions, Part IV

We continue again this week with my answers to the questions posed by leaders from across CHRISTUS Health at our recent leadership retreat.

Q. What is the direction you see for our international partnerships?

A. CHRISTUS Muguerza has many opportunities to grow in Mexico. And as capital in that country becomes more widely available, I am sure they will continue to explore and undertake opportunities to expand. We have become more culturally competent through this relationship, and CHRISTUS Muguerza is a much stronger ministry because we are partners in extending Jesus’ healing ministry. One of our sponsoring congregations, the Sisters of Charity of the Incarnate Word of San Antonio, is most interested in us investigating an expansion into Peru to work with their health care ministries there, which include clinics, visiting home nurses, a prenatal program, and inpatient and outpatient hospice programs. Our other sponsoring congregation, the Sisters of Charity of the Incarnate Word of Houston, recently asked for our assistance in the strategic planning process for their ministries in Guatemala. Through these opportunities, we are examining many possible future partnerships and directions.

Q. Can CHRISTUS Health develop successful ACOs?

A. The question is not “can we”, but “how” and “when will we.” Although we know the future will present challenges, we also know that we have all the pieces and are gaining the knowledge to put the puzzle together that will make us successful long into the future, regardless of heath care reform or not. Our abilities are undergirded by our 5 Strategic Directions and our 8 Strategic Enablers. We will do what we need to do to continue on the journey to put care within reach of all who need it.

Q. Has CHISTUS Muguerza fulfilled my expectation?

A. Clearly what had been accomplished in CHRISTUS Muguerza, expanding from 2 to 7 hospitals, multiple clinics, and ambulance service, a drug and addition center, a behavioral services facility, rehab facilities, and a network of clinics for the poor, has far exceed my expectations and vision for our international operations when we began that partnership in 2001. The team their embraced the CHRISTUS brand from day one, and quickly made the decision to join us on the Journey to Excellence.

Q. How do you move people out of silo thinking?

A. The ability to get every member of the CHRISTUS family thinking about how to horizontally integrate rather than to vertically report and think will be a critical success factor for our ministry. Clearly, we need to continue to explain the rationale of why this mode of operations is critical, and expand processes like matrix planning to force multiple constituencies to come together to plan a coordinated approach. And finally, integrated behaviors have to be incorporated into the performance planning processes, with clear expectation and identifiable rewards for accomplishing such.

A continued prayer for Haiti

I asked our communication teams around the CHRISTUS system to send the following message from me to all our Associates. Although we have not scheduled any future medical assistance trips to Haiti, we join with Associates, physicians, volunteers, patients, residents and friends around the CHRISTUS system to pray for support, comfort, and safety for our brothers and sisters in Haiti.

The chances are pretty good that tropical storm Tomas will strengthened and impact Haiti. Unfortunately, Haiti is slow in recovering from the earthquake, and the tent cities are much the same as when the CHRISTUS Team was there in February. In addition, a cholera epidemic is spreading, already having killed over 300 people. The relatives of the two girls from Haiti we are treating at CHRISTUS Santa Rosa Children’s Hospital are living within 4 poles covered by a blue tarp in one of these temporary housing compounds. If these flood, which is very likely, the results will be devastating to people have already suffered much and who we came to love while carrying out the healing ministry there. Sources on the ground indicate that the previous sources of international commitments are gone. I would ask each of you, on behalf of our original Haiti Task Force who planned our Mission, and the team that traveled their on your behalf, to keep all the Haitian people in your prayers as the storms pass over them. We, the CHRISTUS Family, know far better than most just what devastation these storms can cause. Hopefully, with our prayers, some sunshine will come forth from the clouds!

Burning Questions, Part III

We continue again this week with my answers to the questions posed by leaders from across CHRISTUS Health at our recent leadership retreat.

Q. How would you succinctly define quality care?

A. In concise terms, I think a quality outcome has four metrics:
1. Morbidity and mortality
2. Functional status
3. Patient satisfaction
4. Adherence to best practices and evidenced –based clinical protocols

Q. I know you said if you had it to do over, you would do it all over again. But is there one thing that you might change?

A. Yes.I would have been a pediatric specialist instead of a general surgeon. When I was training they did not have pediatric specialty residencies, and I did not think I would be challenged enough as a general pediatrician. As a general surgeon in the early years, before there were pediatric surgeons, I operated also on children. I love all patients, but have a special place in my heart for children.

Q. What is the one thing that can minimize the toxic side-effects of change you talk about?

A. Besides identifying the potential toxic sides effects, I would say there are two keys to implementing long-term change:
1. Providing clear rationale of why the change is necessary
2. Breaking the change down into doable chunks. Sudden and overwhelming change can, as we have experienced, trigger fundamental survival instincts and build strong resistance. Effective leaders recognize this and move quickly to help followers regain a sense of balance and equilibrium.

Q. You are saying on your recent visits to the regions and business units that if CHRISTUS Health is going to reach excellence, the leaders need to feel “called” and then be able to do transformational work. What is your definition of transformational leadership?

A. When describing transformational leadership, I use the 8 steps outlined in the January 2007 edition of the Harvard Business Review. They are:
l. Establish a sense of urgency
2. Form a powerful guiding coalition
3. Create a clear vision
4. Communicate the vision
5. Empowers others to act on the vision
6. Plan and create short-term wins
7. Consolidate the improvements, often creating more change
8. Institutionalize the new approaches

Q. What is the one major obstacle standing in the way of obtaining excellence?

A. Not dealing with the people who are satisfied with “good.”

Burning Questions, Part II

As I mentioned in my last post, we recently gathered leaders from across CHRISTUS Health for a leadership retreat. In my opening presentation to these leaders, I asked them to submit questions for me, one of which was, “If this was your last chance to meet with me, what burning questions would you like to ask?”

Our leaders submitted over 90 different inquiries, of which I answered about 50 at a later session. Here are some additional submitted questions along with my answers.

Q. You described the characteristics of a successful health system in your opening presentation. As we move forward, what do you think needs to stay constant in CHRISTUS Health, and what do you think can change in the future?

A. Certainly our brand needs to remain as constant as possible, with each component being enhanced and strengthened in the next decade. Also, our 5 Strategic Directions and our 8 Strategic Enablers must remain. In addition, I would list 5 other behaviors that must remain constant:
l. We must put our patients’, families’, and residents’ needs and interest first and foremost.
2. We must always give caring and responsive service.
3. We must treat each other with courtesy and respect to maintain the excellent team focus that a successful heath system must have.
4. We must be stewards of the resources that our communities and CHRISTUS have entrusted to us.
5. We must devote significant organizational and personal resources to not only replenish our knowledge base, but also to reflect in small groups and in one-to-one encounters on how we might further improve. Successful organizations grow both in individual and organizational wisdom.

With that said, I think everything else is malleable. However, I believe the prerequisite for each change--and we know many will be required in the future--must be a serious attempt to improve our ability to do our work in meeting the needs of our patients, residents, families, and customers, and well as to structure our education and research mission to ensure high quality and low cost services in our present, and to predict the future and change its magnetic north to better health.

Q. What energizes you when you are tired or facing tough challenges?

A. I always pause and reflect on the successes we have accomplished as a family or a ministry. You have heard me say many times that you must celebrate the incremental victories to get the energy to overcome the obstacles you see ahead. And I always remember Babe Ruth’s hitting history……..He struck out 1,330 times in between his 714 home runs.

Q. What do you pray for most often?

A. For peace…personally, professionally, and in the world.

Q. What in CHRISTUS do you love most, and what will you miss the most?

A. The answer to both parts of the questions is the same……..YOU!

Q. What is your biggest achievement?

A. Personally…having a family. Professionally….becoming a physician and helping to heal many people along the way.

Q. What is the most important lesson that every leader should learn?

A. You must always be humble!

Burning Questions, Part I

Last week, we gathered leaders from across CHRISTUS Health for a leadership retreat. In my opening presentation to these leaders, I asked them to submit questions for me, one of which was, “If this was your last chance to meet with me, what burning questions would you like to ask?”

Our leaders submitted over 90 different inquiries, of which I answered about 50 at a later session. Over the next few weeks, I will be answering many more via email with these leaders.

One question that was asked by many had to do with accountability, what it really means, how it is seen in action, and how it can be measured. Because this is such an important question and its answer is a critical success factor for the future of CHRISTUS, I shared with these leaders the 10 accountability items that I have looked for in my daily work for the last 44 years. They are:
l. Follow disciplined processes in getting work done
2. Feel ownership for the goals of the organization, region, business unit or program
3. Work to remove unnecessary bureaucracy
4. Drive out costs at every level
5. Eliminate redundancies
6. Meet commitments
7. Commit to quality and safety in all work activities
8. Accept responsibility for getting the work done
9. Provide and receive rewards, verbal as well as monetary, tied to meeting goals on time and within budget
10. Create and experience clear expectations for who has to do what to get the work done in an excellent manner

It is my hope that these 10 Accountability Items will be helpful for our leaders in reflecting on accountability and sharing their thoughts and expectations with their team members.

Five Ways Hospitals Will Change Over the Next 10 Years

I recently shared an article with our leaders from Becker’s Hospital Review entitled, ”5 Ways Hospitals will Change Over the Next 10 Years”.

I believe the information presented reaffirms what we have been saying, and supports the CHRISTUS vision, as well as our 5 Strategic Directions and 8 Enablers. In fact, I have blogged about all of the changes listed in this publication over the years. If you’d like to read more about how CHRISTUS is addressing these changes, I’ve provided links to these blog posts below.

5 Ways Hospitals will Change Over the Next 10 Years:

1. Hospitals will redesign their current processes rather than build new facilities. Blog post: Organizational Redesign

2. Physicians, RNs and physician extenders will do the work that fits their credentialing. Blog posts: Remembering the Human Touch and Health Care Reform: The Primary Care Crisis

3. Some hospitals will inevitably fail. Blog post: Competition and Collaboration

4. Hospitals will focus more energy on reducing readmissions. Blog posts: Catholic-Owned Health Care Systems Earn High Marks and CHRISTUS’ Changing Portfolio: 1/3 Non-Acute Care

5. Hospitals will have to focus more on disease prevention. Blog post: Health Care Reform: Wellness Programs and Prevention

Mental Health – An Important Part of Wellness

As we have now enhanced our focus on health and wellness as articulated in our current vision statement, it is imperative that our system, regional and business unit governance boards, in partnership with management, embrace, in a more focused way, the “Seven Determinants of Health.” These include:
• Primary outpatient locations that are convenient;
• Schools with quality teachers and educational processes;
• Preschool and after-school programs for working parents;
• Appropriate low cost housing;
• Appropriate nutrition;
• Appropriate psychological and psychiatric services;
• Right-sized hospitals with the appropriate acute care services.

Of all these services, those associated with psychological and psychiatric care have been significantly reduced over the last decade and are minimally available in most communities. This is highlighted in a recent article entitled, “The Forgotten Patients,” which appeared in the Sept. 13, 2010 edition of Forbes magazine. The article’s authors state that the “health industry ignores the 35,000 people a year who commit suicide.” This article also highlights the fluctuation of both mental health issues and suicide with age, gender and ethnicity, factors that we must take into account in our international ministry as the world continues to flatten. And finally, the article concludes by identifying some best practices, including proposed and ongoing research to address these challenges.

As the CHRISTUS Health family continues its Journey to Excellence, it will be necessary for us to develop processes to improve the mental health status of the communities we serve.

Medicine’s Next Frontier: The Brain

In discussions about the future of medicine, I often say that we will understand the brain in the next 25 years as well as we understand the heart today, the majority of knowledge about which we gained just in the last 25 years.

Supporting my assertion was information in a recent article in The Dallas Morning News about a new center for brain research associated with the University of Texas at Dallas that opened this week. I still believe that only one-third of what we do in acute hospitals today will need to be done there in 10- 15 years, and our major surgeries will be in and around the brain. We will discover new ways to treat cancer metastasis and new operative techniques for Parkinsonian and Alzheimer diseases, as well as chronic senile dementia.

CHRISTUS’ new vision statement speaks of being and innovator and partner in health and wellness initiatives, and keeping current on the treatment recommendations coming out of this and other brain study centers will be key as we continue our Journey to Excellence, making sure we are involved in the product lines that will add both quality and quantity of life to the people we serve in our sacred ministry.

A New Way of Thinking About Nonprofit Boards

As we regularly must make decisions about the future of CHRISTUS Health, we are familiar with the tension that some companies feel between “the board’s role” and “leadership’s role.” However, we have clearly defined these roles with a focus on “generative thinking” and have made it a part of our governance processes across the CHRISTUS system.

The greatest example of generative thinking in the CHRISTUS ministry is our future planning processes. Because we do that, it is much easier for leadership to follow through on implementation of plans without the need to return for more robust discussions with the board.

At CHRISTUS, we believe that with the SPA, our operational algorithm, and now our patient satisfaction algorithm, issues and challenges are clearly visible to all of us, including leadership and the board, which helps us to focus on the “generative questions”; for example, whether to stay in or exit a market. Clearly, this is not anything new to how excellent governance and leadership should interact, but it is a new way to express the need for robust, thoughtful and reflective discussions driven by a decision-making process.

Following are excerpts from a Website where one of the authors of the book “Governance as Leadership: Reframing the Work of Nonprofit Boards,” is interviewed:

Q: You introduce a mode of governance called "generative thinking." Can you give a brief overview of what this is, and why it is so essential to governance?

A: The most important work that takes place in an organization is when people first begin to identify and discern what the important challenges, problems, opportunities, and questions are. It's the way in which the intellectual agenda of the organization is constructed.

The generative work that we recommend encourages boards to be present at those times when the organization tries to make sense of circumstances, tries to make meaning of events.

The way in which we first make sense of circumstances is in fact what triggers or spawns strategies, policies, decisions, and actions. (We chose the word "generative" because its roots are in genesis.) Boards need to be there at the creation, when people say, "Okay—that's what we need to work on." Often, it's senior managers as leaders who come to a board and say, "We have looked at all the issues, here is the problem, here's what we plan to do. Does this solution sound right?" The question should be: "Do we have the problem right?"

When you think of a decision-making flow, all we are suggesting is that boards get at the headwaters. They need to get way upstream; they tend to wade in much too far downstream.

Generative thinking is getting to the question before the question. It's actually the fun part of governance. It's not about narrow technical expertise. Generative work is almost always about questions of values, beliefs, assumptions, and organizational cultures. That's what makes it interesting, but also what makes it important is to have people in those conversations who understand the institution, but have some degree of distance.

Catholic-Owned Health Care Systems Earn High Marks

I have repeatedly said since becoming the team leader for CHRISTUS Health that I feel this Catholic, faith-based health care system embodies my personal commitments to treating everyone who needs us with high quality, low cost health care in an accessible manner. Although I have worked in three other systems where I believe people were comfortable treating everyone who presented themselves, the well-documented principles in the Ethical and Religious Directives for Catholic Health Care Services (ERDs) and the resulting policies and procedures 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, 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.

To that end, I wanted to share with you a performance study of measures of quality, clinical efficiency and perception of care conducted by Thomson Reuters, one of the nation’s most well-known and highly-regarded providers of information and decision support tools. This study found that Catholic-owned health care systems as a group appear to have a significant head start on other ownership categories such as “other church” systems, secular not-for-profit systems and investor-owned systems.

The results of the study were published in the Aug. 9, 2010 edition of Modern Healthcare, and suggest that leadership at health systems owned by the Catholic Church may be the most active in setting and monitoring achievement of quality goals, as well as aligning the management of hospitals within a system in achieving what they see as a mission.

In addition, a changing role for health system governance and leadership is being seen, with leaders taking responsibility for executing well on clinical performance as well as the purely business and economic reasons that originally drove consolidation into systems. In the clinical and service quality areas, Catholic systems appear to be leading within an industry that is in transition, the Modern Healthcare article reports. And while the Catholic-owned systems tend to lead in this transition, the remainder of the industry is shifting, but not as rapidly.

In addition to using federally reported core quality measures, Thomson Reuters ranks hospital systems in its studies according to inpatient mortality and complications, an inpatient safety index, 30-day mortality and readmissions, average length of stay and patient perception of care. For the study of systems by ownership, a composite score across all the measures was computed for each system, and all 255 of those systems ranked in the report were stratified by ownership as defined by the American Hospital Association (AHA).

The mean performance rank for each category – lower is better – showed the 36 Catholic systems in front with an average rank of 84. Eleven “other church” systems combined for an average rank of 121, and the 176 secular not-for-profit systems combined for a rank of 129. The 26 identified investor-owned systems combined for a rank of 182. Six systems in the study had missing ownership information in the AHA reference guide.

This study seems to support my assertion that our Catholic culture and heritage ensure that the care rendered at CHRISTUS facilities is equal for all and of the highest standard possible.

Creating an ACO: An Ethical Issue?

I’ve blogged before about Accountable Care Organizations (ACO) and reform. ACOs were one of the few specific programs mentioned in the Patient Protection and Affordable Care Act, and have therefore received much attention from health care organizations around the country.

But perhaps more important than the “how” of ACOs is the “why” of ACOs. It is the hope of health care reform that by better integrating care for a person across the health care continuum, we will, as providers, be able to improve quality of care and patient safety while reducing costs. In a recent article appearing in the July/August 2010 edition of Healthcare Executive, this outcome was characterized as “The Ethical Basis for Creating ACOs.” The authors indicated that organizations, like CHRISTUS Health, “have a moral imperative to deliver cost-effective, high-quality and safe health care.”

The authors also wrote a small section on being stewards of health care resources, one of the important guidelines embedded within our values. Hence, it appears that with our strong commitment to becoming a high quality low cost provider, driven by our values and organizational ethics, that CHRISTUS Health can develop an ACO that is a trusted resource for health and wellness care, serving as both a national and international model.

Reaffirmation of CHRISTUS Health’s Balanced Scorecard

In December of 2006, three CHRISTUS Health Associates published an article in hfm, the journal of the Healthcare Financial Management Association (HFMA), entitled, “A search for the ‘Holy Grail’ of Healthcare: A Correlation Between Quality and Profitability.”

In the article, CHRISTUS sought to ascertain whether there is a favorable, statistically verifiable relationship between quality and financial performance. This effort echoes an industry-wide search for what might be labeled “the Holy Grail of health care”: statistical documentation that improvements in quality, patient safety and clinical vigilance are significantly correlated with profitability and measures of financial success. CHRISTUS Health sought validation that spending on quality care and patient safety constitute a genuine investment in improved profitability and viability.

Our results clearly showed the correlations between quality and financial performance. The findings thus gave hospitals strong evidence that well-executed clinical quality initiatives will contribute to improved financial performance. The article concluded that,” As an industry, we cannot claim to care for patients if we are unwilling to make an unwavering commitment to quality. But neither should we be expected to compromise our organizations’ financial well-being for the sake of clinical quality.”

Recently, a reaffirmation of our findings which support the use of a balanced scorecard to monitor our Journey to Excellence was published on HFMA’s Website with the headline, “Higher Hospital Margins Distinguished by Higher Patient Satisfaction.”

According to data from the Centers for Medicare & Medicaid Services (CMS), there is a distinct relationship between a hospital’s profitability and its level of patient satisfaction. CMS collects and reports measures of patient hospital experiences based on the Hospital Consumer Assessment of Healthcare Providers and Systems survey instrument. Data are collected for all patient types (i.e., not just Medicare patients). Currently, measures reflect patients’ responses to 10 questions regarding their experiences with an overnight hospital stay.

This analysis looked at patient responses regarding hospitals’ overall ratings and whether patients would recommend a facility. The percentages of patients answering “High” as to the overall rating (options were High, Medium and Low) and answering “Definitely” as to whether they would recommend the facility (options were Definitely, Probably and No) were calculated for each facility for the survey period ending March 31, 2009.

Hospital margins were then calculated for each reporting hospital from Medicare cost reports for periods ending in CY08. The results showed a clear relationship between higher margins and higher ratings. The median operating margins were positive only with higher satisfaction ratings. Using the same approach, the study found the same relationship between profitability in perceived quality in that higher profitability was seen in hospitals where a patient said they would recommend the hospital to others.

Because the Journey to Excellence, its four Directions and the results of the balanced scorecard have been an integral part of the CHRISTUS Health brand since we began in 1999, it is most reassuring from both of these studies to know our focus has been a key critical factor in our success.

What has changed in health care?

Lately, I’ve been looking back on my career thus far and considering how I may continue to serve patients and the health care industry in the future. Part of this process has included looking over and reorganizing articles I have written over the years, and it appears that we are still confronting issues that I was writing articles about 10 years ago.

In 1998, I wrote an article for Crossroads magazine called "The Courage to Change" about how physicians must transform their behavior so they could begin to think in terms of populations or preventions by becoming schooled in the economics of health care delivery, beginning to talk openly about outcomes with other physicians, accept input from patients and share clinical responsibilities with non-physicians. I made the case for change toward population-based medicine and care management strategies that view patients, disease and health through a wide-angle lens.

One could argue that health care reform aimed to end a compartmentalized approach to health care and align incentives so that providers are rewarded for providing better outcomes instead of more care. While I spoke of the necessity of these things in 1998, it is clear that improvement in this area is still a necessity today.

And while we as physicians and caregivers have come a long way in recognizing and adhering to practice guidelines, clinical pathways, practice profiles and outcome comparisons to generate evidenced-based improved clinical results, our work is far from over. We must continue to challenge ourselves—and one another—to measure up to the higher standards for outcomes, service and resource utilization that we know are possible.

As we predicted

The Wall Street Journal recently ran a story entitled, “Americans Cut Back on Visits to Doctor”. This story reflects our belief that health care usage in a weak economy would decline, particularly in acute care settings.

Instead, people are seeking alternative and complementary medicines and self-medication/treatments to address some of their medical conditions, and are certainly re-evaluating the need and timing for elective procedures. Understandably, we have seen a major shift occur, and I don’t believe care access patterns will EVER return to what they were before. (Please do not hold your breath hoping that “the good old days” will return, and do not keep looking for “another flu season”!)

This article clearly supports our position and thinking, and examines the eventual need for insurers to reduce their premiums to continue to capture the business. What does this mean for the CHRISTUS Health ministry?

1. We cannot rely on increases in volumes and increases in reimbursements to create better revenue streams for us. We have been saying for several years that revenue increases will only come from volumes created by organically-growing communities in markets where we are stealing market share, or where we can add new profitable service lines that the community values. Volume increases will not occur from our “same-store book of business.”

2. If people are going to doctors less, then less hospital admissions will be generated. Our CFO and I were on a call recently with the health care bond rating team from Standard & Poor’s, who we began bond rating sessions with in 1999. Their data again shows that inpatient volumes are down 7 percent across the U.S., and that outpatient volumes are starting to show declines as well.

3. With the reduction in revenue that physicians are seeing with their declining office visits, we can expect more doctors to approach us about an employment model. We must continue to tie these relationships to productivity and patient satisfaction structures that are justifiable and sustainable for the long term. We also need to continue to stress the need to partner with physicians in numerous other ways (like those identified trough our Physician Integrations task force) and come together to try and create win-win situations around high quality, low cost, and evidenced-based medical protocols and treatment plans.

4. We need to revitalize our focus on alternative/complementary medical services, which people will continue to seek once they discover and find them successful. Two of our Senior Vice Presidents are in charge of this activity, including the further identification of champion practitioners within our system. Fortunately, a good program has recently opened as part of the Sports Medicine and Wellness Center at CHRISTUS St. Vincent in Santa Fe, which can be used as a best practice to move forward in collaboration perhaps with our retail spa services or be created independently in our outpatient clinics.

5. We will need to continue to support other avenues to add additional funding to our revenues, which could include:
• The CHRISTUS Stehlin Foundation for Cancer Research
• Marketing some of our potential and already successful “adjacencies,” including TLRA, Revenue Cycle, Retail Services (including medical spas), convenient clinics, weekend and evening outpatient services on our acute care campuses, growth of our profitable non-acute services, etc.
• Garnering a clear understanding of how our international growth, which is less regulated, may provide more support for our U.S. ministries.

6. It is abundantly clear that the 5 strategic directions emanating from our intense Futures Task Force II work, driven by the overriding theme of having to become a high quality and low cost provider, are “right on” and position us well to respond to the changes and requirements brought about by health care reform.

It is important that we keep all of this information in mind as we continue to refine our system’s strategies in our acute, non-acute, and international divisions around our present and future thinking. Fortunately, the time we spend in future planning seems to be more and more valuable as we continue our Journey to Excellence.

It is reassuring to me, and I am hopeful to all of you, that we have much in place that, under Ernie Sadau’s future leadership, can be refined, intensified and accelerated to continue not only on our Journey to Excellence, but also to continue to strive to reach a goal that I put forth in my first speech in our first system leadership retreat in Houston in June of 1999: “To become one of the most excellent and most recognized health systems in the world.” Because of all of the efforts of the CHRISTUS family over the last 11 years, we are well on the way. The best is yet to come!

Health Care Reform and Medical School: A Disconnect?

In many previous posts, I’ve written about the need to increase the number of primary care providers if we are to increase access and create a medical home for as many people as possible.

The recent passage of health care reform which intends to provide health insurance for millions of previously uninsured Americans has only accelerated the need to rapidly increase the primary provider pool. And as the Massachusetts reform project proved, if we do not, our Emergency Departments, already over-crowded, will see a two-fold increase in their volumes.

In a recent newspaper article, the significance of this change was highlighted by a recent study ranking medical schools on their “social mission.” Under the study’s definition, each medical school was measured for its ability to turn out an “adequate number” of primary care doctors, including family practitioners and general pediatricians. The study also looked at the number of graduates who worked in underserved areas of the country, including rural clinics and inner-city hospitals. And finally, the study considered the percentage of graduates who were minorities, including African-American, Hispanic, or American Indian.

Using these factors, the 141 physician training medical schools were ranked and overall demonstrated that primary care graduates are not the focus of many of the schools at present. Unfortunately, some of the best medical schools ranked by U.S. News and World Reportannually rank in the 20 schools with the lowest social mission scores.

Hopefully, this study, which undoubtedly will result in some pushback, will stimulate a robust dialogue among the U.S. medical schools, resulting in strategies which will accelerate the number of graduates pursuing primary care careers.

Until this occurs, we will need to support or increase the training and use of nurse practitioners, physician assistants and midwives. Some physicians see these providers as “intruders” on their practices, but this is not the case. Hopefully the combination of more primary care physicians with the other primary care providers I mentioned will minimize the provider shortage that may result from health care reform, making the Massachusetts experience from becoming the national experience.

The Repetitious Cry: Don’t Wait for the Cavalry

Recently, I heard a local business owner who had been affected by the BP oil spill in the Gulf repeatedly state on a national TV interview that the government’s intervention to address this disaster has been minimal, disorganized and ineffective, often hampering the positive actions of the local inhabitants and volunteers. In essence, he was giving the same advice not only CHRISTUS Health, but others have given when facing disastrous events: Do not wait for the cavalry.

We first heard this cry when we visited New Orleans in 2007 on one of our learning journeys as part of Futures Task Force II. We heard over and over again from the leaders of a local hospital system that they got little helpful assistance in facing the significant negative results of the storm, including the large number of critically ill patients who needed to be evacuated. They, appropriately so, decided they needed to take control of the recovery plan and implement it themselves.

CHRISTUS Health had a similar experience in the Houston flood in 2004, Hurricane Rita in 2006 and Hurricanes Gustav and Ike in 2009. Our plans for evacuating patients, obtaining generators and garnering emergency supplies worked well because we had plans, teams and strategic relationships in place in the affected areas. Local systems that are efficient and effective appear to be easier for us to implement than the government, so we first and foremost rely on our resources and planning.

And unfortunately—but not unexpectedly—we experienced the same in Haiti. To overcome the lack of governmental plans, scores of volunteers have, and continue, to provide the most needed medical care and recovery efforts for those in need.

So what does this tell us as leaders in health care? First, it is imperative to have a well thought out and documented recovery plan in place. Second, these plans should be reviewed and drilled annually. Third, when disasters occur, get as much of the plan implemented as possible before the government intervenes. And fourth, don’t ever forget the leadership imperative: do not wait for the cavalry!

A Call for Help for those Affected by Hurricane Alex

Over the Fourth of July weekend, the remnants of Hurricane Alex struck Northern Mexico, dropping torrents of rain in what President Felipe Calderón called the worst storm “in recent memory” in the region. The storms left thousands of residents in the Monterrey area homeless and without water, electricity and in need of massive assistance.

Multiple CHRISTUS facilities, including hospitals and Adelaida Lafon clinics in the CHRISTUS Muguerza region, located in Northern Mexico, were directly in the storm’s path. Luckily, these facilities sustained no major damage, but CHRISTUS Associates there confirm the reports of destruction and the need for emergency supplies and recovery assistance for many who suffered losses in the region.

In addition to the destruction of homes, major highways were washed away and utility lines, bridges and most anything that stood in the flood’s path were destroyed. There are critical shortages of potable water, medical supplies and funds to meet the growing needs of those in the storm’s path.

While it is difficult for people of compassion to hear about the suffering of others, we know that many will be moved to act in the face of such great tragedy. That is why the CHRISTUS family is working directly with our colleagues in Monterrey to assess their relief and recovery needs, solicit financial support on their behalf and transfer supplies to them. Time is of the essence, because we are well into Hurricane season, and fear that if other weather systems continue to develop, the needs of our colleagues will increase.

If you would like to make a financial contribution to support our family and friends in Monterrey, you can contribute to the CHRISTUS Health Foundation (with the request to use your donation for CHRISTUS Mexican relief efforts) by sending a check to P.O. Box 840973, Dallas, Texas 75284-0973. Donations made by check to the CHRISTUS Health Foundation are tax deductible.

CHRISTUS Muguerza operates six Adelaida Lafón clinics in Mexico which are located in desperately poor and underserved areas. They provide high-quality medical care to those whose health is at risk due to social, cultural and economic conditions, and charge very small fees for their services.

There are more than 350 families (1,400 individuals, many of whom are children), who are served by our two Adelaida Lafón clinics in Monterrey in need of the most basic health and safety necessities. We have received reports that although it is hard to estimate structural damages because these families lived in tin and cardboard houses, they clearly lost everything but the clothes on their backs.

To assist them as quickly as possible, we are asking for donations of needed items to be gathered. The materials management department in each hospital/facility of CHRISTUS will be gathering the supply donations at sites designated at each facility and coordinating their shipments to Mexico. The items needed to help the families include:
o Folding beds, mattresses or camps mattresses
o Sheets
o Light blankets
o Pillows
o Towels
o Basic underwear – kids and adults, both sex
o Shoes, all sizes
o Basic toiletry – Personal Hygiene Products
o Toothpaste
o Toothbrushes
o Soap and shampoo
o Anti- bacterial gel
o Disposable cups, plates and plastic cutlery
o Bottle water
o Diapers (infant, child and adult)
o Non-perishable food items
o Canned goods
o Powdered milk
o Baby Formula or adult nutrition drinks (Ensure)

Thank you for considering how you might help those we serve in Mexico. For photos of our relief efforts, please visit our Facebook page, and please keep our colleagues and those affected by the storms in your thoughts and prayers.

What’s Next in Health Care Reform?

Although many articles have been written on the implications of the health care reform legislation, I thought a recent brief summary by Bill Jessee, the president and CEO of the Medical Group Management Association, in the May/June issue of MGMA Connexion journal was most informative. (To read the article, you must subscribe to the journal.)

A good deal of the value of Dr. Jessee’s commentary lies in the fact that it is based on a presentation at the MGMA’s fall board meeting by Lynn Nicholas, president and CEO of the Massachusetts Hospital Association and Alice Coombs, MD, president-elect of the Massachusetts Medical Society. Because the health care reform implemented in Massachusetts was often cited as a template for the federal plan, Dr. Jessee felt that examining what happened in Massachusetts after their 2006 reform bill passed could be instructive.

In the article, five key learning and potential implications of the national reform package were articulated. In summary, it appears that the following occurred thus far in Massachusetts:
1. Costs have not been controlled
2. The individual mandate worked
3. Cooperation between hospital leaders and physicians has been enhanced.
4. Consolidation and integration of practices is accelerating
5. Primary care entry access points were limited
6. Emergency Room visits increased

Hopefully, the Obama Administration will continue to observe and learn from the Massachusetts experience and incorporate these learnings into positive implementation strategies and tactics.

Perhaps the most important role of leaders

Although CEOs of organizations, including health care, have a myriad of important roles and responsibilities, none might be more important for the stability and growth of the company than succession.

With that in mind, I have been working with my senior leadership team and our board of directors to plan a smooth and effective transition process. This has been officially announced and will culminate for me after 12 years of service on June 30, 2011, one year from now.

The drivers for this decision and the timing of such are multiple. These include, first and foremost, the strength of the senior leadership team, none of whom are planning to transition with me. In addition, the CHRISTUS system is extremely stable, good progress has been made in all four directions to excellence, and the five key strategies for the next decade have been formulated. And finally, our office has had strong focus for the last eleven years on leadership training and succession planning, all of which has been successful.

With regard to the latter, and after a nine-month search process, the CHRISTUS Health Board of Directors recently named Ernie Sadau, the current senior vice president and chief operating officer for CHRISTUS, as my successor.

As I journey through my “final” and exciting year, I will be, with the support of my wife and family, exploring other career opportunities since I am extremely healthy and energetic. Regardless of what doors might open, when I leave I will be filled with much peace knowing CHRISTUS Health is in the best of hands. This is what every great leader should be able to say when the door closes.

Another Example of Overuse

I have harped on the overuse of medical equipment, procedures and tests as a major cause for the high cost of health care in the U.S. in numerous blog posts. In addition, I have occasionally spoken to the fact that this excessive use is leading to harm in many instances in the patients we treat.

Although we hope that the greater acceptance of evidence-based medical and surgical protocols will start the decline of overuse, we know that this will take significant time and never be totally successful as long as physicians and other providers have full or partial ownership of the imaging technologies. Some providers will unfortunately permit the misalignment of the increased revenue from unnecessary procedures to drive their ordering practices. So what else might help? Of course, a greater involvement of the patient in determining the need for a specific procedure.

I recently saw an AP story carried in both the Wall Street Journal and The Dallas Morning News supporting my position. Speaking to the overuse of radiation in America, the author clearly articulates the negative consequences of too much radiation for any individual over his or her lifetime. Some authorities predict that in the next 10 years, two to 10 percent of cancers in the U.S. will be caused by excessive radiation—a truly sad outcome if any or all of these cases become true.

The author of this article, aware of the misalignment of incentives described above, listed nine questions that Fred Mettler, a radiation-safety expert, suggests every patient asks before getting a scan or other radiologic tests. Because I agree totally with him, I list them here:
• Is it truly needed? How will it change my care?
• Have you or another doctor done this test on me before?
• Are there alternatives like ultrasound or MRI?
• How many scans will be done? Could one or two be enough?
• Will the dose be adjusted for my gender, age and size? Will lead shields be used to keep radiation away from places it can do harm?
• Do you have a financial stake in the machines that will be used?
• Can I have a copy of the image and information on the dose?

It is my hope that through the combination of the use of evidence-based medical practices, the education of the public through similar articles, and the patient/family questions like those listed above, the overuse of medical and surgical treatments will be eliminated, thereby achieving our goal—high quality, low cost health and wellness care for all!

Now it’s Recalls!

In last week’s blog post, I talked about my growing impatience with public apologies, connecting the dots to the importance of effective, honest, and transparent communication for excellence in leadership, including those of us on leadership teams in the health care industry!

Unfortunately, this week I have reached the same level of impatience with recalls, which are escalating in car companies as well as in the pharmaceutical industry and with other health care vendors.

We all know that as a whole, health care delivery sites in the U.S. and globally have not yet reached the highest quality and, therefore, zero occurrences of bad outcomes driven by strict adherence to safety guidelines. However, if the magnitude of violations of safety standards causing massive recalls in the industries listed above was occurring in U.S. hospitals, many would need to be closed.

In addition, if you would peruse the quality review processes in the car industry, I seriously question whether some members of their leadership teams are spending sufficient time debriefing and establishing a clear list of both lessons learned and what must be done to prevent the same bad outcomes from repeating themselves. How much into their quality improvement initiatives and how quickly are they being transparent and honest with their consumers?

What does all of this mean for us reaching for the best health and wellness practices for those we serve? I can think of at least seven implications:

1. Any recall/bad outcome is one TOO many!
2. We are taking care of human beings, not cars, and the sanctity of the trust our patients put in us cannot be violated.
3. Significant resources in ensuring our processes and procedures are correct must be placed up front rather than retrospectively!
4.Regardless of our prior success, we never can become complacent.
5.We must be as transparent as quickly as possible when we know we have made an error.
6.We must debrief on all misses and near-misses and make sure we have maximized our learnings.
7.We must turn our learnings into implemented corrective action plans to prevent the negative results from occurring again.

So the next time we hear about another recall, I would ask us to pause and make sure we review the seven implications for us outlined above. CHRISTUS Health is constantly striving for excellence because it is what we are called to do and what our patients deserve.

Sick of Apologies!

Are there others out there who are sick of hearing apologies? It seems recently that almost every day, some government or public leader, present or past, is apologizing for remarks he or she made. In addition, company CEOs are having to apologize for both their unfavorable actions’ outcomes as well as explanations they are giving initially to us—the consumers—to support these actions.

Has everyone forgotten the old adage, “Think before you speak?” We know one of the critical competencies for successful leadership is strong communication skills, both verbal and written.

Trusting relationships among leadership teams are dependent on consistent, open, honest, and transparent communication. Credibility of leaders depend on clearly-communicated rationale for the decisions, strategies, and vision the organization is taking.

We all know that to be successful in a leadership team, whether at the system, hospital, department, service line, project or task force level, one must embrace the following guidelines:
1. Articulate your position clearly, with consistency.
2. Be open to listening to other positions if they likewise are clearly communicated.
3. Be prepared to maintain your position or have it changed based on the communication of others in the meeting.
4. Be willing to support the consensus of the group, once it is reached, even if it is not your original position.

Clearly, we have somewhat of a void in strong and successful leadership in parts of our federal, state and local governments as well as in some for-profit and not-for-profit industries. Perhaps one of the drivers of this void is that too many leaders are speaking before they think it out. Excellent, successful outcomes will not be led by people who have to apologize for their verbal and written communications and their actions. To avoid such detrimental events, one must thoughtfully reflect on what comes out of their mouths.

In the end, we all know there is no substitute for intelligence that supports excellent communication skills. I would ask us to all ponder if leadership in all aspects of the public and private sectors would not be more successful if many leaders talked less and thought more!

There is a lot of gray in medicine

A significant saving in health care costs in the U.S. has been produced due to the increased incentives tied to the use of evidence based medicine-driven protocols. An article I read recently entitled “Rational Arguments – Evidence is Only one Part of the Story,” clearly highlights the challenges that evidence-based medicine and their outcomes will face.

For me, it was again a reminder that although we would like medicine to be black and white for both providers and patients, that in reality it clearly exists in a grey zone. It also is a stark reminder that technology-driven diagnostic tests are rarely a completely, 100 percent accurate diagnosis for a patient’s symptoms, and the final treatment plan must be devised by coupling the diagnostic study with the physical examination. Therefore, arriving at the best treatment plan—somewhere between the totally subjective and objective—must be done in the gray zone.

What does this mean? Should we walk away from the research studies that are described in the article? Should we forgo seeking the best clinical trials to guide us to the best treatment plan or drug? Because a large percentage of patients will not follow proposed treatment plans which they know will improve the quality of their life, should we decide that the effort of seeking the evidence is not worth it?

We all know the answers. We must continue to get providers to follow well-proven practices so that more consistency and predictability in the appropriate mix of studies, supplies and treatment plans will occur. This approach will result in a reduction of overuse, underuse and misuse of health care resources, which ultimately will lead to a higher quality, lower cost health and wellness outcome.

Secondly, we must continue to educate the patients with data on what would be in their best interest to keep them as healthy as possible and symptom-free. Recognizing that achieving 100 percent compliance is an issue, and will never be reached, we still need to always do what is right, and recognize that improving the health of a large population will always be done one patient at a time.

Clearly the article is correct—evidence is only part of the story. Pneumonia can mimic gall bladder diseases. “Heart symptoms” can be attributed to gastrointestinal disease, and a migraine can masquerade as a temporary stroke. This gray zone will always exist in medicine, but by collecting more and more evidence and sharing this information with both providers and patients, I firmly believe that the gray zone will be significantly narrowed, and higher quality/low cost health and wellness care will be the result!

The Future of Health Care

In April, I presented at the Four Corners MGMA Conference in Albuquerque about the future of health care in the next 10 years. I have long believed that future planning is a key to success, as the “correct future” must address the realities of the present. CHRISTUS is a very future-looking organization, and we have learned from our Futures Task Forces and future planning activities some things that I think will be helpful to blog readers as well.

I shared with the group what I consider short-term tactics to create success

Collectively
• Manage and reduce labor and non-labor costs (growing “revenue line” will be almost impossible, so must focus on expense line)
• Improve patient throughput
• Better integrate physician and hospital operational improvement plans
• Renegotiate financial contracts whenever possible
• Ensure best prices/discounts for equipment, supplies, and services
• Evaluate salaries and benefit costs
• Reduce risks and monitor compliance
• Be willing to make further changes, yet unknown

Individually
• Accept uncertainty and ambiguity
• Become a quick change artist when necessary
• Commit fully to your ministry
• Behave like you’re the only owner of the business
• Hold yourself accountable for your actions and outcomes
• See yourself as a service center
• Manage your own morale, passion and optimism
• Be a fixer, not a finger-pointer
• Speed up your improvement plans
• Elevate your expectations

CHRISTUS Health’s Futures Task Force II presented 26 future facts, 3 strategic drivers, 5 strategic directions and 8 strategic enablers for CHRISTUS Health. Together, these help us glimpse at a possible health care future:
• Some diseases will be “cured” (Alzheimer’s, Parkinson’s, Non-Hodgkin’s Lymphoma, Cystic Fibrosis, Osteoporosis, some behavioral diagnoses, some GI cancers)
• Trauma will become the leading cause of death in people 54 years of age and younger
• Some diseases will be best treated by alternative and complementary medicine, including migraine headache and tinnitus
• Illness related to global warming will evolve
• Home health and remote monitoring become a primary care delivery tool, resulting in retail, rather than payor-orientation
• Systems move to service line organization/orientation, managed at a system level rather than regional levels with huge organizational implications
• Fully-integrated EMR and sophisticated IT networks will drive patients, physicians and payors to work together
• Innovative partnerships with payors for disease management and wellness maintenance result in major cost savings and realigned industry incentives and payment strategies
• A more innovative physician employment model which enables a sophisticated communty-based care delivery strategy
• Innovative border strategy and medical tourism fully integrated into major system offering, increasing international service offerings and fully integrating into regional and system strategies

We hope that health care reform will make the future brighter by increasing the number of insured patients, enhancing information technology, placing emphasis on wellness and prevention and encouraging physician and health system integration.

As we navigate this new reality, I encouraged the leaders at the conference to work most of all to gain buy-in to their group’s organizational vision first. Then, they may position their organizations as value-based innovators with long-term staying power. They may also do as CHRISTUS has done, and use forward-looking data and market intelligence to inform actions of today and plans for tomorrow.

Are you Blind to the Truth?

Over the last eleven years, I have often said that if we are to develop action plans to mitigate the challenges on our Journey to Excellence, we must always seek the truth regarding the challenges we face.

Therefore, I believe that it is important not to be surrounded by a senior team that is loyal to a fault (i.e., people that want to tell you what you want to hear, and not what you need to hear), and why I think it is important to encourage “professional backtalking” among all our leadership groups. This is also why “the ability to have robust discussions” was identified as a critical success factor in creating outstanding teamwork in the teaming exercises completed by leaders in our regions and business units this fiscal year.

All of these messages came clearly in view recently as I read an article in the May/June 2010 edition of CEO Magazine. Entitled, “Are You Blind to the Truth?”, this article articulates “seven strategies for ferreting out critical feedback you’re not getting.” Although these strategies are not new, they are certainly worth a review and some reflection.

They remind us that, as leaders of regions and business units, we are seen as a base of power, and, “in the presence of power, even well meaning people edit themselves.” The article also stresses the importance of getting out of your office, which is clearly visible as we stress the critical nature of daily rounding to our leaders in order to bring about a multitude of operational successes.

There are some moments, while reflecting in my office, that I reaffirm that in CHRISTUS, where we have challenges, we either still do not have the right people in place, or we do not know the truth about the situation. It occurs to me that this could be the case we are facing with some of our current challenges in our patient satisfaction scores, a critical piece of our directions to excellence. Do our Associates feel safe in speaking up? Could our Associates identify their local leadership teams if they saw them? What do they see when they see these groups coming down the hall? Are our leadership teams “talking the talk,” or are they “walking the walk?”

I am confident that our answers to these questions as we lead this scared ministry are mostly positive. But to ensure that someday we will all reach the top of the mountain on our Journey to Excellence, these obvious strategies are worth reviewing, and the questions posed are worth asking periodically. Answering the call to serve in CHRISTUS Health is both an awesome responsibility and privilege, and I continue to be honored to serve as our ministry’s team leader.

Why we participate in social media

Many companies—including health care providers—have been reluctant to enter the social media sphere. But because of our commitment to transparency and serving as a national influencer, CHRISTUS has participated in social media for almost three years, utilizing a variety of sites to educate and engage our Associates and various publics.

In addition, CHRISTUS’ Futures Task Force II identified three critical drivers of the future: consumer empowerment, globalization and new advances in technology. Social media encompasses all three.

Social media includes any participatory online media where information, news, photos, videos, podcasts, groups and conversations are made public, and are often designed to encourage sharing and networking. It is important because it represents a fundamental shift in the way we communicate—organizations can no longer depend on one-way communication; consumers now expect to interact with brands and organizations in real-time, and can use the technology they already own (namely mobile devices like cell phones) and free tools to share their ideas and opinions with their social networks and the world. Consider:



Communities are being formed online in new ways, and are even being created for patients who share the same disease or chronic condition. Consumers are increasingly comfortable searching for health information online and sharing this with their health care providers. It is clear that we no longer search for the news; it finds us. Word of mouth has become world of mouth.

Therefore, it is imperative that CHRISTUS Health be engaged in building our brand and relationships online through new social media channels as well as traditional media. To this end, the CHRISTUS brand is represented extensively online, including:
• My blog
• Twitter
• YouTube
• Facebook
• LinkedIn
• CaringBridge – A program developed for patients to build their own free, secure websites for social networking.

To assist us as we move forward to harness the power of social media tools, we have also developed a proactive strategy for social media, which is designed to serve as a roadmap, directing our interactions online, aggregating our ideas and ensuring that all our efforts in this arena are guided by a measurable, larger strategy.

We also want to ensure that we help our Associates navigate the social media sphere, and have held numerous training and educational sessions and created two additional tools to direct social media efforts and provide guidelines for our Associates as they go about their activities online. The first is a policy that ensures that all communications are consistent and in keeping with our mission, vision and strategic communications plan, but a year ago was widened in scope to include social media sites. The directive clearly states that communication on these sites cannot be done on behalf of CHRISTUS or any CHRISTUS facility without approval of system or regional Marketing/Communication departments.

To assist CHRISTUS Associates who would like to speak about CHRISTUS online on their personal time, representing themselves solely as their personal representatives, Social Media Participation Guidelines were also created to help them understand how CHRISTUS policies apply to these newer technologies for communication so they can participate with confidence in all social media platforms.

CHRISTUS Health is a leader in utilizing these tools in the health care industry, all of which will help drive our five strategic directions.

Organizations Recognition Through Individual Awards

As another individual award was announced recently, and I was reminded again of the importance of two things: a key system initiative and the importance of teamwork.

Since CHRISTUS Health was formed over 11 years ago, one of our system initiatives has been to serve as an “influencer,” creating positive change in the health care delivery processes in both the U.S. and Mexico. The pathways for exerting these influences include writing and publishing papers; speaking at local, state, national and international conferences and receiving awards and recognitions. By achieving and sustaining influential status, we have become the “go to” organization for many members of the government, media and other colleagues and organizations in the field, who seek our knowledge and advice regarding the various components of the delivery process. Examples include future planning, revenue cycle, creating “systemness” and international development.

The other important thing to remember about an individual award is that it represents much hard work and success of a team of people in the CHRISTUS family. Each time an individual award is received, the awardee should pause and identify all the people who work with him or her who caused the recognition to occur. Today, with the complexities we face in this industry, it is hard to identify any success from which only one individual is responsible.

So, having recently been included in Becker's Hospital Review's annual list of 60 Physician Leaders of Hospitals and Health Systems, I stopped to write the same note as I always do on these occasions to the CHRISTUS Senior Leadership Team:
Thanks for all you do to make me look good! You make me proud! Always remember, it is what we do collectively that continues to move us forward on our Journey to Excellence!

Preparing for Biological Disasters

I have blogged before about the CHRISTUS Health experience with hurricanes multiple times. As many of our facilities are located on the Gulf Coast, we learned first-hand the importance of having a clear disaster response strategy in place.

This commitment to a disaster response strategy extends beyond just hurricanes, though. The world’s experience with H1N1 flu last year reminded all of us how important it is to be prepared to offer an immediate, well-coordinated response to pandemic and biological disasters as well.

At the end of March, the CHRISTUS Health Pandemic Committee conducted a system-wide drill after several months of development and revisions of its influenza/biological pandemic plan. The mock scenario was an outbreak of unusually severe illness; specifically, a particular strain of H1N1 influenza that had been identified by the Centers for Disease Control as Phase 6 (widespread) in many states including Texas, Missouri, Louisiana, Arkansas, Georgia and Utah – all regions in which CHRISTUS Health operates.

The exercise, was launched by the system Senior Leadership Team in the corporate command center in Dallas, and we immediately began assigning and prioritizing incident response activities.

Team members quickly solidified our roles and began responding to approximately 35 mock requests for assistance that were being phoned in or made via e-mail directly to the command center from across our regions and facilities. Regional emergency preparedness coordinators from the CHRISTUS Health Southeast Texas, Southwestern Louisiana, Central Louisiana and Ark-La-Tex regions, as well as CHRISTUS Spohn, CHRISTUS Medical Group, CHRISTUS St. Vincent, CHRISTUS Santa Rosa, CHRISTUS Health Utah, Infection Control and Risk Management were among those participating in the drill.

Through this exercise, we aimed to build system-wide competency and familiarization of the revised CHRISTUS Health influenza/biological pandemic plan; provide an opportunity to exercise system pandemic reporting applications (EMResource, CHRISTUS Health emergency Website resources) with participating CHRISTUS facilities and the corporate command center; and practice emergency communications protocols by relaying vital information between responding entities.

The exercise lasted approximately three hours, including a debriefing and “after-action” review to identify what went well, opportunities for improvement, gaps in our emergency preparedness planning, and policies that will be addressed. We’re also investigating how to build social media tools into our existing disaster response communication plans, realizing the need for additional communication tools in our arsenal that can be quickly updated and are easily accessible by displaced Associates via home computers or mobile devices.