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.