As I have mentioned several times, health care is extremely complex. Therefore, it requires much time, effort, and focus on daily operations—particularly in light of the constant changes occurring in the regulatory environment.
However, an additional complexity of health care is that the trends we are seeing today are causing such radical changes in the delivery of care that if we don’t pause now to give sufficient time to envisioning the future, it is a very good possibility that when we reach the future, we will be inadequately prepared.
Consequently, since its inception in 1999, CHRISTUS Health has committed a significant amount of time and effort to monitoring health care trends and planning for the years ahead. After completing our first round of future planning (Futures Task Force I utilizing scenario planning) we recognized that the two major drivers of health care change for both CHRISTUS Health and all of U.S. health care would be:
1) the declining reimbursement under the control of both the federal and state governments, and
2) the rapid introduction of technology that would move a significant amount of health care from an inpatient setting to the non-acute arena. At CHRISTUS, we define non-acute care as “care and services that do not require an inpatient acute care hospital stay” (i.e., outpatient sites, clinics, continuing care retirement communities, long-term care, etc.).
In fact, when we began future planning, we believed—and have subsequently proven—that this introduction of non-invasive technology would be so rapid that it would be disruptive. In fact, it is so disruptive we could not respond rapidly enough to its introduction and were burdened with the question, “Should we purchase the first generation of the technology, or wait to purchase the second generation?” Technology is changing so rapidly that with limited financial resources, this question needs constantly to be asked, and then, as objectively as possible, be answered using data as rationale.
A living example of this dilemma which occurred in the last 10 years, was the introduction of lithotripsy. If you are as old as I am, you can recall that this technology was first introduced by requiring that patients be immersed in a water bath. It was clear to me as a practicing physician that this technology would not be long-lived, particularly because
1) If patients coded in the tub, how could they be revived without significant movement?
2) It would eliminate a large number of obese patients who were unable to be placed in the tank.
3) And it would eliminate a large number of patients who were afraid of water.
However, I was bombarded by requests from Urologists to purchase this technology as quickly as possible. Those of us who owned the first generation of lithotripsy devices soon realized when the second generation of dry lithotripsy was developed in response to all of the concerns outlined above, that we had indeed wasted $1.5 million and had to find another use for the small swimming pool we now owned.
With all of this learning, CHRISTUS Health has utilized these drivers to recognize that acute care will be significantly changing in the future, and that a much greater emphasis needs to be placed on the non-acute product lines. In addition, CHRISTUS is somewhat unique because of our strong international presence, predominately in Mexico.
Because of this, we have begun the transformation of our portfolio to one-third acute, one-third non-acute, and one-third international. I will cover each of these thirds in more detail in future blogs.
However, today, it would be appropriate to discuss two more drivers of this transformation, those being:
1) the senior aging process and
2) the large number of baby boomers who are reaching 65 years of age.
With regard to the former, it has been our observation while studying the seniors on our senior campuses (independent living, assisted living and long-term care), that these people—often with average ages between 85 and 90—are not aging like our parents. They are staying healthy for a prolonged period of time, have a strong desire to stay in the most independent living situation possible, and in their final weeks, are often facing an acute illness such as a heart attack or stroke, which cause them to request hospice care for a shorter period of time.
This is verified by our data that indicates that people stayed approximately three-and-a-half years in our long-term care facilities in 1999. Now, they spend less than 9 months on average there, instead spending most of their time in the independent living or assisted living locations.
It is important to note, also, the findings of an ongoing study in the United States of over 4,000 people who are over 100 years of age. These people have no common characteristics related to avoiding common health risks, i.e., obesity, smoking, alcoholism, etc. This population includes all of these health-risk factors. Instead, surprisingly, the four things they have in common are:
1) They are optimistic people; they always see the glass as half full.
2) They have learned to accept loss and move on. Most of these people have buried their spouses and all of their children.
3) They stay on a relatively routine schedule each day, meaning they get up at pretty much the same time each morning, eat their meals at the same time, and go to bed at the same time.
4) They all have an avocation. It may be as simple as meeting at Starbucks or the local diner for their morning coffee, or as complex as a daily golf round or a bridge session.
For me, this data indicates that if you live beyond 65 to 70 with a chronic illness, you have reached a stable relationship with that illness and will probably not die early because of it, or one of its major complications. For example, we do not find a large number diabetics in their 70s or 80s who develop gangrene or blindness, because they have learned to manage their disease. Consequently, when their final demise occurs, it is rather related to a short-lived acute episode as mentioned above. Therefore, this population of people—rather than requiring extensive inpatient stays and therefore new hospital beds—will want their care in non-acute settings accompanied with outpatient hospice support.
The baby boomers, on the other hand, are a population of people who want their care as rapidly as possible, as affordable as possible and with the highest quality possible. They are also being burdened with increasingly larger co-payments and therefore are much more focused on where, when and from whom they are going to get their care.
By doing a survey of this population, we have learned that they will much prefer to have their care in a patient-centered urgent center, mini-clinic, or other outpatient facility. They will only opt for inpatient beds which when absolutely necessary. And if it is necessary, they will want a room that is far different than our present hospital rooms. They will want them to be large enough to accommodate families at all times—much like we have in Mexico—and they will want full access to all the internet technologies so their communications, either from themselves or from their family members, will never be disrupted.
So our transformation has been driven by a clear understanding of the present complexities, the future vision and the major drivers of health care in the future. Transformation, we believe, is required if this future is going parallel with what patients and their families will desire and demand in the next 10 years.
Wednesday, August 15, 2007
Wednesday, August 8, 2007
Medical Tourism: The CHRISTUS Story
Because CHRISTUS is a Catholic, faith-based health care system, some of our potential strategies are driven by a “call”, meaning that other health care systems ask us whether we might be interested in partnering with them. Such was the case in early 2000, when we received a call from the Muguerza health system in Mexico. Because of the growing Hispanic population in the U.S., the increasing need for nurses from nursing schools in Mexico and the proximity of several of our markets to the U.S./Mexico border, we felt there were compelling reasons to enter into sincere conversations with the owners of the Muguerza hospitals to explore this opportunity.
As a result of our due diligence, which clearly demonstrated significantly high quality of both clinical and service delivery in their two facilities in Mexico, we consummated the partnership in April of 2001 and created what has now become the rapidly growing seven-hospital CHRISTUS Muguerza health system in Mexico, which also has a quickly expanding ambulatory component.
Our Journey to Excellence was rapidly embraced by the leaders in Mexico, who shared our strong commitment to prove the excellence in their health system by being transparent in well-defined metrics. That commitment to excellence was not only proven by their data, but was so significant that it generated a CHRISTUS Muguerza brand that is so strong that other facility leaders are now wanting to join our ranks.
As we reflected on CHRISTUS Muguerza’s high quality (as one example, we are the leading cardiac care center in all of South America), it became clear to us that we should not limit this quality to just people in Mexico, but should open our doors to people in other countries who were on long waiting lists for elective surgery or who did not have the financial wherewithal to have their procedures done at the costs that were being dictated in their home locations.
Consequently, we knew that we needed to develop a well-thought out and excellent medical travel program. This was also substantiated by our data, which indicates that many Americans from border states are already coming to our facilities in Mexico, and that the 4,000 Medicare-eligible patients are often paying for their care in our facilities. Why? Again, because the CHRISTUS brand is strong, denotes our Journey to Excellence, and produces measurable outcomes in both quality and service delivery.
In fact, we’ve received quite a bit of attention in the news media lately because of the high quality and convenient services provided at our CHRISTUS Muguerza facilities. One of those stories ran in the Dallas Morning News recently, and you can read it here. TV news coverage also ran recently on one of our CHRISTUS Muguerza hospitals, Alta Especialidad. You can view a TV broadcast about the hospital and our medical travel program via the website of a news station in San Antonio, Texas here.
Obviously, we are competing against medical travel programs in India and Asia that have been established longer, but we feel strongly that our services have an edge because of the close proximity of many of our facilities to the U.S./Mexico border, our Associates’ fluency in English and other languages, and our ability to provide appropriate recovery locations such as upscale hotels and retreat centers.
In addition, a medical travel program allows for more collaboration both ways across the border. For instance, if we have a pediatric patient at a CHRISTUS Muguerza facility in Monterrey, Mexico who needs specialty care, we have the ability to refer them to our CHRISTUS Santa Rosa Children’s Hospital in San Antonio, Texas.
I should also point out that although many other medical travel programs are driven by financial gain, our desire to create a medical tourism program was driven by our high quality and interest in community value. Obviously we are expecting to see financial benefits from this program, but our margins will be of great use as we continue to provide charity benefits to the communities we serve in the U.S. and in Mexico. We are the number one Catholic provider of community benefit, and see this function as central to our mission.
In fact, the CHRISTUS Muguerza system has opened five clinics so far in mainly rural areas to provide health care and other services to residents who would otherwise have little access to it. These clinics were opened in collaboration with local government leaders and health care providers, and 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. The services offered at the clinics varies by location, but includes basic health care services such as x-rays, ultrasounds, physical therapy, laboratory services, physician exams and chronic disease management – in addition to counseling and activities for older residents and mothers, and various community education programs.
Our answer to the growing popularity of medical tourism is to continue to leverage the expertise of our existing international facilities. I am very proud of all of our Associates, including those at our CHRISTUS Muguerza facilities throughout Mexico who provide excellent, high-quality care to their patients every day—patients who entrust their lives to us! What an awesome responsibility we, in health care, have!
As a result of our due diligence, which clearly demonstrated significantly high quality of both clinical and service delivery in their two facilities in Mexico, we consummated the partnership in April of 2001 and created what has now become the rapidly growing seven-hospital CHRISTUS Muguerza health system in Mexico, which also has a quickly expanding ambulatory component.
Our Journey to Excellence was rapidly embraced by the leaders in Mexico, who shared our strong commitment to prove the excellence in their health system by being transparent in well-defined metrics. That commitment to excellence was not only proven by their data, but was so significant that it generated a CHRISTUS Muguerza brand that is so strong that other facility leaders are now wanting to join our ranks.
As we reflected on CHRISTUS Muguerza’s high quality (as one example, we are the leading cardiac care center in all of South America), it became clear to us that we should not limit this quality to just people in Mexico, but should open our doors to people in other countries who were on long waiting lists for elective surgery or who did not have the financial wherewithal to have their procedures done at the costs that were being dictated in their home locations.
Consequently, we knew that we needed to develop a well-thought out and excellent medical travel program. This was also substantiated by our data, which indicates that many Americans from border states are already coming to our facilities in Mexico, and that the 4,000 Medicare-eligible patients are often paying for their care in our facilities. Why? Again, because the CHRISTUS brand is strong, denotes our Journey to Excellence, and produces measurable outcomes in both quality and service delivery.
In fact, we’ve received quite a bit of attention in the news media lately because of the high quality and convenient services provided at our CHRISTUS Muguerza facilities. One of those stories ran in the Dallas Morning News recently, and you can read it here. TV news coverage also ran recently on one of our CHRISTUS Muguerza hospitals, Alta Especialidad. You can view a TV broadcast about the hospital and our medical travel program via the website of a news station in San Antonio, Texas here.
Obviously, we are competing against medical travel programs in India and Asia that have been established longer, but we feel strongly that our services have an edge because of the close proximity of many of our facilities to the U.S./Mexico border, our Associates’ fluency in English and other languages, and our ability to provide appropriate recovery locations such as upscale hotels and retreat centers.
In addition, a medical travel program allows for more collaboration both ways across the border. For instance, if we have a pediatric patient at a CHRISTUS Muguerza facility in Monterrey, Mexico who needs specialty care, we have the ability to refer them to our CHRISTUS Santa Rosa Children’s Hospital in San Antonio, Texas.
I should also point out that although many other medical travel programs are driven by financial gain, our desire to create a medical tourism program was driven by our high quality and interest in community value. Obviously we are expecting to see financial benefits from this program, but our margins will be of great use as we continue to provide charity benefits to the communities we serve in the U.S. and in Mexico. We are the number one Catholic provider of community benefit, and see this function as central to our mission.
In fact, the CHRISTUS Muguerza system has opened five clinics so far in mainly rural areas to provide health care and other services to residents who would otherwise have little access to it. These clinics were opened in collaboration with local government leaders and health care providers, and 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. The services offered at the clinics varies by location, but includes basic health care services such as x-rays, ultrasounds, physical therapy, laboratory services, physician exams and chronic disease management – in addition to counseling and activities for older residents and mothers, and various community education programs.
Our answer to the growing popularity of medical tourism is to continue to leverage the expertise of our existing international facilities. I am very proud of all of our Associates, including those at our CHRISTUS Muguerza facilities throughout Mexico who provide excellent, high-quality care to their patients every day—patients who entrust their lives to us! What an awesome responsibility we, in health care, have!
Wednesday, August 1, 2007
The Importance of Transparency
Because people come into our facilities and programs each day, putting their health—and often their lives—in our hands, they deserve to know as much as possible about us. They want to receive health care services that are excellent and will result in the best outcome at the most affordable price.
We at CHRISTUS Health are committed to provide this information to our patients, residents and their families so they can make informed decisions about us. We are committed to total transparency in all we do.
This transparency ensures that our patients, their families and our Associates and physicians can hold each other accountable to the high standards of compassion and excellence that we have set for ourselves.
If we expect our patients to be loyal to us and trust us, we must return to them our measured outcomes so they are assured that we are committed to our Journey to Excellence and to carrying out the healing ministry of Jesus Christ.
Because of this commitment, CHRISTUS Health reports the following on its website:
Financials
We began posting our financial performance on our website in 2000. Since we are not a “public company”, we aren’t required to report this information online. However, because of our strong feelings about transparency and the increased scrutiny of public corporations’ financial health following the Enron scandal and passing of the Sarbanes-Oxley Act, the public reporting of this data has become even more important.
This section includes our audited financial numbers for the previous fiscal year. It begins with an overall financial summary and also includes downloadable files which report on our financial operating performance, balance sheet and cash flow statement for the previous fiscal year.
Community Benefit (our financial commitment to charity care)
We began reporting this in 2002, long before it was a hot-button issue. This section of our website includes our Community Benefit Annual Report, which reports the amounts we spent on charity care, community services, government-sponsored programs and total community benefit in the previous fiscal year. This section also includes information on our CHRISTUS Fund and its grant recipients as well as information on CHRISTUS’ dedication to community health. Recently, we have added region-specific community benefit information to the site.
Quality
This information debuted on our website in October of 2006, and is be updated quarterly. An FAQ section explains quality and how and why we measure it, and the site includes credentials and accreditation information, reports our performance on measures that we are required to provide to the Centers for Medicare and Medicaid Services (CMS) by system and facility, an explanation of each measure/treatment and why it is important and related information on prevention of disease.
Patient Satisfaction
This information also debuted on our website in October of 2006, and is also updated quarterly. Again, an FAQ section explains how we measure patient satisfaction and how we interpret it. We report our overall score and service measures (prompt care, concern for special needs, communication and courtesy and compassion) by system and facility. Also, we explain these measures in more depth, paying special attention to our service measures, which we feel define us as a Catholic, faith-based health system.
Pricing
This section debuted earlier this year. It includes links to the insurance carriers we work with, lists our pricing discount policies and displays estimated hospital charges for our most common procedures system-wide.
What other information about CHRISTUS would you like to see us post on our website?
We at CHRISTUS Health are committed to provide this information to our patients, residents and their families so they can make informed decisions about us. We are committed to total transparency in all we do.
This transparency ensures that our patients, their families and our Associates and physicians can hold each other accountable to the high standards of compassion and excellence that we have set for ourselves.
If we expect our patients to be loyal to us and trust us, we must return to them our measured outcomes so they are assured that we are committed to our Journey to Excellence and to carrying out the healing ministry of Jesus Christ.
Because of this commitment, CHRISTUS Health reports the following on its website:
Financials
We began posting our financial performance on our website in 2000. Since we are not a “public company”, we aren’t required to report this information online. However, because of our strong feelings about transparency and the increased scrutiny of public corporations’ financial health following the Enron scandal and passing of the Sarbanes-Oxley Act, the public reporting of this data has become even more important.
This section includes our audited financial numbers for the previous fiscal year. It begins with an overall financial summary and also includes downloadable files which report on our financial operating performance, balance sheet and cash flow statement for the previous fiscal year.
Community Benefit (our financial commitment to charity care)
We began reporting this in 2002, long before it was a hot-button issue. This section of our website includes our Community Benefit Annual Report, which reports the amounts we spent on charity care, community services, government-sponsored programs and total community benefit in the previous fiscal year. This section also includes information on our CHRISTUS Fund and its grant recipients as well as information on CHRISTUS’ dedication to community health. Recently, we have added region-specific community benefit information to the site.
Quality
This information debuted on our website in October of 2006, and is be updated quarterly. An FAQ section explains quality and how and why we measure it, and the site includes credentials and accreditation information, reports our performance on measures that we are required to provide to the Centers for Medicare and Medicaid Services (CMS) by system and facility, an explanation of each measure/treatment and why it is important and related information on prevention of disease.
Patient Satisfaction
This information also debuted on our website in October of 2006, and is also updated quarterly. Again, an FAQ section explains how we measure patient satisfaction and how we interpret it. We report our overall score and service measures (prompt care, concern for special needs, communication and courtesy and compassion) by system and facility. Also, we explain these measures in more depth, paying special attention to our service measures, which we feel define us as a Catholic, faith-based health system.
Pricing
This section debuted earlier this year. It includes links to the insurance carriers we work with, lists our pricing discount policies and displays estimated hospital charges for our most common procedures system-wide.
What other information about CHRISTUS would you like to see us post on our website?
Wednesday, July 25, 2007
The Toxic Side Effects of Change
It is obvious that significant change in the U.S. health care system will be required to correct the quality inefficiencies and simultaneous paralleling rising cost that we are observing today. This redesign also must be part of any successful presidential candidate’s plan, since the voices of change (government, business owners/employers and now patients and their families), are yelling their loudest in decades that both the quality of care and its related cost are unacceptable.
However, with change—whether it be in the clinical arena where treatments are being modified constantly, or in the administrative arena where processes and procedures must be updated to address these redesign needs—toxic side effects of change are inevitable. Therefore, it is prudent for us as health care leaders to predict these toxic side effects in advance so that when they occur, we will not have to face the ever-oppressing question, “Have we made a mistake?”
Such an example in the clinical arena would be the hair loss that occurs in a cancer patient when we are giving them what we hope will be curative chemotherapy. After two weeks of chemotherapy when we walk in to a patient’s room and find him or her bald, we do not say, “Oh no, what have we done?!” We rather say, “Oh, the treatment is working!” In this way, the toxic side effect of treatment proves to us that our ends are being achieved and the patient’s body is undergoing changes as a result.
We must apply the same logic in the administrative decision-making processes we undertake each day to facilitate the changes necessary for creating excellence. In this way, when we observe these side effects, we can say, “Yes, our strategies and initiatives are making a positive difference.”
One example of this would be CHRISTUS’ opening of many urgent care clinics (most are located in Mexico). Clearly, in advance of these openings, we predicted that a toxic side effect would be pushback from some physicians because they believe—inappropriately so—that we are providing poor quality of care and taking patients away from their practices.
Indeed, we have seen this pushback from the American Academy of Pediatrics and now the American Medical Association. The reality is that these clinics, staffed in Mexico by physicians and by nurse practitioners in the U.S., are providing patients with access to care for a limited number of illnesses which are carefully managed by evidence-based protocols that have been designed with strong physician input. Therefore, in no way has quality been decreased.
In fact, quality of care has been enhanced because patients can get access to care more quickly in the course of their illness and therefore more serious side effects can be prevented.
In addition, these clinics are open on evenings and weekends when most physician offices are closed. Physicians are always given the opportunity to work in our clinics, but they obviously must accept the salaries which make these clinics cost-effective. This payment level is readily acceptable and in fact is the standard for physician reimbursement in our international operations. It has been our experience that in America, physicians are not willing to do such.
In addition, we find very few physicians in America who are willing to open their offices in the evenings and on weekends. If they are willing to do so, we would be happy to partner with them to provide our urgent clinics in a joint venture methodology. We must always be willing to joint venture with physicians when they share our mission, vision, and values, and our goal is always to create win-win physician health system alignments. Working collaboratively with physicians has been and will always be a necessity for an excellent health care delivery system.
Another toxic side effect of these clinics is physicians’ fear of losing patients. In fact, the contrary is true in our clinics, where we generate primary care and specialty referrals for patients who do not meet the clinic criteria or do not improve with the therapies that are instituted and therefore require specialty consultation. So, in fact, we like to partner with both primary care and specialty physicians to provide a second level of care if it is necessary.
So as is often the case when changes are made, toxic side effects quickly make themselves known and in fact may turn out to have positive responses rather than negative effects. This of course does not mean that we overlook debriefing to decide what has worked and what has not, but identifying these toxic side effects beforehand will prevent Monday morning quarterbacking, feelings of “Oh my goodness, what have we done?”, etc. This is why before any significant change is made, considerable time and reflection should be spent determining the toxic side effects of a decision so that when they become apparent, there is no second guessing or scrambling to cater to opposing voices.
However, with change—whether it be in the clinical arena where treatments are being modified constantly, or in the administrative arena where processes and procedures must be updated to address these redesign needs—toxic side effects of change are inevitable. Therefore, it is prudent for us as health care leaders to predict these toxic side effects in advance so that when they occur, we will not have to face the ever-oppressing question, “Have we made a mistake?”
Such an example in the clinical arena would be the hair loss that occurs in a cancer patient when we are giving them what we hope will be curative chemotherapy. After two weeks of chemotherapy when we walk in to a patient’s room and find him or her bald, we do not say, “Oh no, what have we done?!” We rather say, “Oh, the treatment is working!” In this way, the toxic side effect of treatment proves to us that our ends are being achieved and the patient’s body is undergoing changes as a result.
We must apply the same logic in the administrative decision-making processes we undertake each day to facilitate the changes necessary for creating excellence. In this way, when we observe these side effects, we can say, “Yes, our strategies and initiatives are making a positive difference.”
One example of this would be CHRISTUS’ opening of many urgent care clinics (most are located in Mexico). Clearly, in advance of these openings, we predicted that a toxic side effect would be pushback from some physicians because they believe—inappropriately so—that we are providing poor quality of care and taking patients away from their practices.
Indeed, we have seen this pushback from the American Academy of Pediatrics and now the American Medical Association. The reality is that these clinics, staffed in Mexico by physicians and by nurse practitioners in the U.S., are providing patients with access to care for a limited number of illnesses which are carefully managed by evidence-based protocols that have been designed with strong physician input. Therefore, in no way has quality been decreased.
In fact, quality of care has been enhanced because patients can get access to care more quickly in the course of their illness and therefore more serious side effects can be prevented.
In addition, these clinics are open on evenings and weekends when most physician offices are closed. Physicians are always given the opportunity to work in our clinics, but they obviously must accept the salaries which make these clinics cost-effective. This payment level is readily acceptable and in fact is the standard for physician reimbursement in our international operations. It has been our experience that in America, physicians are not willing to do such.
In addition, we find very few physicians in America who are willing to open their offices in the evenings and on weekends. If they are willing to do so, we would be happy to partner with them to provide our urgent clinics in a joint venture methodology. We must always be willing to joint venture with physicians when they share our mission, vision, and values, and our goal is always to create win-win physician health system alignments. Working collaboratively with physicians has been and will always be a necessity for an excellent health care delivery system.
Another toxic side effect of these clinics is physicians’ fear of losing patients. In fact, the contrary is true in our clinics, where we generate primary care and specialty referrals for patients who do not meet the clinic criteria or do not improve with the therapies that are instituted and therefore require specialty consultation. So, in fact, we like to partner with both primary care and specialty physicians to provide a second level of care if it is necessary.
So as is often the case when changes are made, toxic side effects quickly make themselves known and in fact may turn out to have positive responses rather than negative effects. This of course does not mean that we overlook debriefing to decide what has worked and what has not, but identifying these toxic side effects beforehand will prevent Monday morning quarterbacking, feelings of “Oh my goodness, what have we done?”, etc. This is why before any significant change is made, considerable time and reflection should be spent determining the toxic side effects of a decision so that when they become apparent, there is no second guessing or scrambling to cater to opposing voices.
Wednesday, July 18, 2007
Health Care Reform – Who Should Come to the Table?
Health care reform is not a new topic; different groups have been talking about it for the last 20 years, but are now becoming louder and both more insistent and consistent.
The voices calling for change in health care have typically been the following:
1. The government: those who regulate and fund Medicare and Medicaid. Although governmental representatives should have a place at the table for this discussion, I believe that the most effective and logical solutions (those that work in practice and not just in theory) must be ultimately formed by experts who don’t have hidden political agendas and have worked in the health care field. These are the people who know best how to bring about the changes which are necessary.
2. Employers. When I worked at Henry Ford Health System, the cost to insure one employee at Ford Motor Company exceeded the cost for steel for one automobile. Insurance costs for employers continue to rise, and so they need a voice, especially as long as they are expected to foot the bill for much of the insured health care in America.
3. Patients and their families, long-term care residents, etc. Many of these are self-pay or must provide increasing insurance co-payments when receiving health care. Therefore, they are now stepping up to plate and saying, “I need to be heard.” As they are at the center of this discussion, it seems most important that they have the opportunity to participate.
As these groups gather around the table and embark on this ambitious journey, they should keep some additional things in mind.
First, do we have the resources to provide truly universal health coverage? Can we “cure” the health care system in America in one fell swoop, or does it make more sense to make changes incrementally? (I covered my opinions about this in last week’s post—obviously I believe that an incremental solution is best.)
Second, issues of quality remain paramount. We can’t afford to consider costs alone, but first and foremost must be able to ensure consistent and predictably high-quality outcomes. Providing consistently high quality health care must be at the top of our priority list.
Third, what is the incremental cost? When I worked at Henry Ford Health System, the number of Ford Motor Company retirees exceeded the number of people actively employed by the company. In many instances, start-up or up-front costs are more expensive, so we must be able to see a cost benefit over period of time, which is why we need to look at least 10 years into the future as far as actuarial costs are concerned. We must also be able to stabilize the system as we make the transition.
Fourth, since we are designing this system to last well into the future, what can we expect 10-15 years from now and beyond? We know that many baby boomers are expected to retire in the near future and that seniors today are aging very differently than our parents did. Today, the average length-of-stay in a long-term care nursing facility is less than 9 months. Yes, seniors today are entering nursing homes later and staying there less time than in the past, which is wonderful. Today, most seniors prefer to “age in place” and retain their independence as long as possible.
Fifth, funding, as opposed to quality, must be variable. I recently returned from a trip to Bogota, Colombia which gave me the opportunity to become familiar with the health and social systems there.
While I admit that Colombia is not perfect and of course cannot condone any human rights violations in the country, I found the social system to be an interesting one. In Bogota, there are 50 private agencies that provide programs of quality for their members that affect all three aspects of daily life: health, education and social. There are three levels of payment for services, based on one’s ability to pay:
1. If an individual can afford to pay, then they pay 100 percent of the cost (full sticker price).
2. If an individual earns four times the poverty level, then they are offered a 40 percent discount.
3. And finally, for those who are at or below the poverty level, the government provides a $400 a month subsidy.
In this way, everyone receives health care, education and social services at a price they can pay.
We must ensure that in whatever system is created, funding is variable but quality is not. Everyone must receive the same level of care regardless of their ability to pay. One life is just as important as the next, no matter what their economic stature may be.
In our facilities in Mexico, we are able to operate clinics for the indigenous communities, most often the poorest of the poor, by utilizing distant monitoring, an innovative and cost-saving approach. Generally, this population lives in rural areas, so distant monitoring allows professionals who are trained in data and evidence-based medicine to monitor these patients remotely.
As a whole, CHRISTUS spent over $286 million last year in community benefit. Every CHRISTUS region must have a plan for caring for the uninsured and underinsured. Our system has always been committed to caring for the poor, and is implementing “medical homes” for the uninsured so they can avoid needing to receive care in our expensive emergency rooms. However, the question is, “Can CHRISTUS Health or any health system sustain this level of charity care into the future?” With declining reimbursement, the answer is no.
Therefore, all the voices of change must come to the health care redesign table in order to ensure that all people receive high-quality health care that is cost-effective and innovative, regardless of their ability to pay.
It’s obvious to me that the plan in place in Massachusetts to require employers to spend 8 percent of their payroll on employee health insurance will not work in Texas. In Massachusetts, less than 10 percent of the population is uninsured. By contrast, over 24 percent of the population of Texas is uninsured. Therefore, those at the table may need to find another system for providing this additional coverage for the large numbers of uninsured and underinsured.
However, in deciding who comes to the table, I trust that those who are chosen to redeem health care are not as important as what is on the table. In the middle of the table should sit a picture of patient surrounded by his/her family so that all the groups can retain their focus on why we’re really here: to provide readily-accessible patient and family-centered care of the highest quality and lowest cost possible. We know it is possible because we already have models to study and incorporate into our redesign!
The voices calling for change in health care have typically been the following:
1. The government: those who regulate and fund Medicare and Medicaid. Although governmental representatives should have a place at the table for this discussion, I believe that the most effective and logical solutions (those that work in practice and not just in theory) must be ultimately formed by experts who don’t have hidden political agendas and have worked in the health care field. These are the people who know best how to bring about the changes which are necessary.
2. Employers. When I worked at Henry Ford Health System, the cost to insure one employee at Ford Motor Company exceeded the cost for steel for one automobile. Insurance costs for employers continue to rise, and so they need a voice, especially as long as they are expected to foot the bill for much of the insured health care in America.
3. Patients and their families, long-term care residents, etc. Many of these are self-pay or must provide increasing insurance co-payments when receiving health care. Therefore, they are now stepping up to plate and saying, “I need to be heard.” As they are at the center of this discussion, it seems most important that they have the opportunity to participate.
As these groups gather around the table and embark on this ambitious journey, they should keep some additional things in mind.
First, do we have the resources to provide truly universal health coverage? Can we “cure” the health care system in America in one fell swoop, or does it make more sense to make changes incrementally? (I covered my opinions about this in last week’s post—obviously I believe that an incremental solution is best.)
Second, issues of quality remain paramount. We can’t afford to consider costs alone, but first and foremost must be able to ensure consistent and predictably high-quality outcomes. Providing consistently high quality health care must be at the top of our priority list.
Third, what is the incremental cost? When I worked at Henry Ford Health System, the number of Ford Motor Company retirees exceeded the number of people actively employed by the company. In many instances, start-up or up-front costs are more expensive, so we must be able to see a cost benefit over period of time, which is why we need to look at least 10 years into the future as far as actuarial costs are concerned. We must also be able to stabilize the system as we make the transition.
Fourth, since we are designing this system to last well into the future, what can we expect 10-15 years from now and beyond? We know that many baby boomers are expected to retire in the near future and that seniors today are aging very differently than our parents did. Today, the average length-of-stay in a long-term care nursing facility is less than 9 months. Yes, seniors today are entering nursing homes later and staying there less time than in the past, which is wonderful. Today, most seniors prefer to “age in place” and retain their independence as long as possible.
Fifth, funding, as opposed to quality, must be variable. I recently returned from a trip to Bogota, Colombia which gave me the opportunity to become familiar with the health and social systems there.
While I admit that Colombia is not perfect and of course cannot condone any human rights violations in the country, I found the social system to be an interesting one. In Bogota, there are 50 private agencies that provide programs of quality for their members that affect all three aspects of daily life: health, education and social. There are three levels of payment for services, based on one’s ability to pay:
1. If an individual can afford to pay, then they pay 100 percent of the cost (full sticker price).
2. If an individual earns four times the poverty level, then they are offered a 40 percent discount.
3. And finally, for those who are at or below the poverty level, the government provides a $400 a month subsidy.
In this way, everyone receives health care, education and social services at a price they can pay.
We must ensure that in whatever system is created, funding is variable but quality is not. Everyone must receive the same level of care regardless of their ability to pay. One life is just as important as the next, no matter what their economic stature may be.
In our facilities in Mexico, we are able to operate clinics for the indigenous communities, most often the poorest of the poor, by utilizing distant monitoring, an innovative and cost-saving approach. Generally, this population lives in rural areas, so distant monitoring allows professionals who are trained in data and evidence-based medicine to monitor these patients remotely.
As a whole, CHRISTUS spent over $286 million last year in community benefit. Every CHRISTUS region must have a plan for caring for the uninsured and underinsured. Our system has always been committed to caring for the poor, and is implementing “medical homes” for the uninsured so they can avoid needing to receive care in our expensive emergency rooms. However, the question is, “Can CHRISTUS Health or any health system sustain this level of charity care into the future?” With declining reimbursement, the answer is no.
Therefore, all the voices of change must come to the health care redesign table in order to ensure that all people receive high-quality health care that is cost-effective and innovative, regardless of their ability to pay.
It’s obvious to me that the plan in place in Massachusetts to require employers to spend 8 percent of their payroll on employee health insurance will not work in Texas. In Massachusetts, less than 10 percent of the population is uninsured. By contrast, over 24 percent of the population of Texas is uninsured. Therefore, those at the table may need to find another system for providing this additional coverage for the large numbers of uninsured and underinsured.
However, in deciding who comes to the table, I trust that those who are chosen to redeem health care are not as important as what is on the table. In the middle of the table should sit a picture of patient surrounded by his/her family so that all the groups can retain their focus on why we’re really here: to provide readily-accessible patient and family-centered care of the highest quality and lowest cost possible. We know it is possible because we already have models to study and incorporate into our redesign!
Wednesday, July 11, 2007
Health Care Reform
Much has been said lately about the state of the health care system in the U.S. Every presidential candidate is talking about it, Michael Moore has made a movie about it, and terms like “single payer health system” and “universal health care” are becoming more and more popular.
I agree that the health care system in the U.S. is incredibly broken. In fact, I believe that the scope of the problem is equal to or may even exceed the problem of world hunger. But just as with world hunger, health care in the U.S. won’t be corrected instantly with one massive program or a “single payer system.” To fix health care in our country, I believe that a series of building blocks must first be put into place that will create a strong foundation on which further changes can occur.
Here’s what I believe those building blocks should be:
First, we need to move as much care as possible out of the hospital setting. Health care provided within an acute care hospital’s four walls is very expensive, so all care that can be moved and rendered in a cheaper setting should be. Here are some examples of how this can be accomplished:
1. Encouraging people who come to the emergency room for care but don’t need urgent care to find a medical home that they can afford. Too often, the poor or uninsured feel they have no other choice than to visit the emergency room for care when they are ill, even if they are not experiencing a medical emergency. They often can expect to receive care they can afford, but generally experience longer wait times and no follow-up care. Too often they don’t receive care soon enough and may have developed complications that would have been avoidable if they had been seen sooner. (CHRISTUS has piloted some innovative programs aimed at helping the uninsured find an affordable medical home. You can read about one of them, our community health worker program called Care Partners, on page 13 of our 2006 annual report.)
2. Strengthening our preventative medicine programs and aligning incentives so people have motivation to use them.
3. Stronger integration with education through avenues such as our school-based health programs, which educate people on disease prevention and appropriate health care utilization while they are teens. This will enable them to become healthier adults and also help educate the next generation of children about the importance of health care.
4. Supporting and developing collaborative programs for low-cost, affordable, suitable housing. If people do not have appropriate social environments and are not educated and at least literate, it will be more difficult for them to pursue preventive health care, let alone be able to follow medical instructions if they are acutely ill upon discharge.
5. Providing basic health insurance for all. This would allow the amount of charitable care to be more equitably shared by all health care providers in the country. It would also help us ensure that the 44 million uninsured people in the U.S. are able to receive the health care they need, particularly the uninsured children. These children are receiving little to no care at all, unless they are covered by a state-sponsored program (like a state-wide Children’s Health Insurance Program).
These are only the basics. After that, we will need to decide how to handle more sophisticated care and elective surgeries like cosmetic and bariatric procedures. Also, we must resolve how we will fund care for the elderly such as independent and assistant living programs. Those issues can be determined after the initial building blocks are put into place.
Also, as the government redesigns the health care system, they need to ensure that one basic tenet is changed: Medicare reimbursement must parallel the most fundamental building blocks in important the redesign. This means that if we really believe that the points I mentioned above will decrease the amount of care received in an acute setting (where the major cost is presently), then we need to make sure ASAP that reimbursement provides an incentive to provide care in a non-acute setting.
One of the reasons the health care system is in such a bad state is because incentives are not aligned to create the changes that need to occur. Acute care (which is often unnecessary) receives the highest reimbursement (funding), while social services, rehab services, home care, and long-term acute care are minimally funded. If we want health care to change, we should be paying as much for a person to go to a health club as we are paying to treat their diabetes (which might be avoidable by making healthy choices like exercising and eating properly).
Once again, I believe the changes must build upon one another. I am constantly reminding our Associates that we will only get where we want to be on our Journey to Excellence in 2016 because we did what was required in 2008 and then built upon that success. The health care system is the same: we fix the foundation and then build upon it.
We at CHRISTUS Health want to come to the health care redesign table and work with the leaders in Washington to design a system that works. We don’t have all the answers, but we do believe we have tried things that have given us some of the answers, and we would love to share our knowledge.
I agree that the health care system in the U.S. is incredibly broken. In fact, I believe that the scope of the problem is equal to or may even exceed the problem of world hunger. But just as with world hunger, health care in the U.S. won’t be corrected instantly with one massive program or a “single payer system.” To fix health care in our country, I believe that a series of building blocks must first be put into place that will create a strong foundation on which further changes can occur.
Here’s what I believe those building blocks should be:
First, we need to move as much care as possible out of the hospital setting. Health care provided within an acute care hospital’s four walls is very expensive, so all care that can be moved and rendered in a cheaper setting should be. Here are some examples of how this can be accomplished:
1. Encouraging people who come to the emergency room for care but don’t need urgent care to find a medical home that they can afford. Too often, the poor or uninsured feel they have no other choice than to visit the emergency room for care when they are ill, even if they are not experiencing a medical emergency. They often can expect to receive care they can afford, but generally experience longer wait times and no follow-up care. Too often they don’t receive care soon enough and may have developed complications that would have been avoidable if they had been seen sooner. (CHRISTUS has piloted some innovative programs aimed at helping the uninsured find an affordable medical home. You can read about one of them, our community health worker program called Care Partners, on page 13 of our 2006 annual report.)
2. Strengthening our preventative medicine programs and aligning incentives so people have motivation to use them.
3. Stronger integration with education through avenues such as our school-based health programs, which educate people on disease prevention and appropriate health care utilization while they are teens. This will enable them to become healthier adults and also help educate the next generation of children about the importance of health care.
4. Supporting and developing collaborative programs for low-cost, affordable, suitable housing. If people do not have appropriate social environments and are not educated and at least literate, it will be more difficult for them to pursue preventive health care, let alone be able to follow medical instructions if they are acutely ill upon discharge.
5. Providing basic health insurance for all. This would allow the amount of charitable care to be more equitably shared by all health care providers in the country. It would also help us ensure that the 44 million uninsured people in the U.S. are able to receive the health care they need, particularly the uninsured children. These children are receiving little to no care at all, unless they are covered by a state-sponsored program (like a state-wide Children’s Health Insurance Program).
These are only the basics. After that, we will need to decide how to handle more sophisticated care and elective surgeries like cosmetic and bariatric procedures. Also, we must resolve how we will fund care for the elderly such as independent and assistant living programs. Those issues can be determined after the initial building blocks are put into place.
Also, as the government redesigns the health care system, they need to ensure that one basic tenet is changed: Medicare reimbursement must parallel the most fundamental building blocks in important the redesign. This means that if we really believe that the points I mentioned above will decrease the amount of care received in an acute setting (where the major cost is presently), then we need to make sure ASAP that reimbursement provides an incentive to provide care in a non-acute setting.
One of the reasons the health care system is in such a bad state is because incentives are not aligned to create the changes that need to occur. Acute care (which is often unnecessary) receives the highest reimbursement (funding), while social services, rehab services, home care, and long-term acute care are minimally funded. If we want health care to change, we should be paying as much for a person to go to a health club as we are paying to treat their diabetes (which might be avoidable by making healthy choices like exercising and eating properly).
Once again, I believe the changes must build upon one another. I am constantly reminding our Associates that we will only get where we want to be on our Journey to Excellence in 2016 because we did what was required in 2008 and then built upon that success. The health care system is the same: we fix the foundation and then build upon it.
We at CHRISTUS Health want to come to the health care redesign table and work with the leaders in Washington to design a system that works. We don’t have all the answers, but we do believe we have tried things that have given us some of the answers, and we would love to share our knowledge.
Wednesday, July 4, 2007
Health Care Leadership – My Journey
I thought that as a way of introducing myself, I would spend some time letting you know more about me and how I got where I am today.
As early as I can remember, I always wanted to be a physician. I think that was because I had an aunt who was a director of nursing in a hospital, and my father, who was the manager of a line plant, was responsible for first aid in his job. My father was actually blinded in one eye, and I learned about eye and line burns on the job from him.
Whether those early experiences played any part of my choice to practice medicine or not, I always felt that it would be a profession that I would enjoy and have the skills for, and that it would allow me to feel good about serving others. As a teen, I found myself participating in community projects that served others, and I found great rewards in being a volunteer. I ultimately felt that some of that volunteerism was part of being in the medical profession.
As I grew older and knew more specifically what medicine would require, I made sure that I was academically prepared, and was very focused on my grades in high school and college. My first day of medical school, I went to a lecture and anatomy class and knew I had made the right decision.
I still feel that the best work I’ve ever done in health care has been my clinical work. I have always said—even as I moved into leadership roles—that I am a physician leader and not an administrative leader. I also recognized very early that just as in clinical medicine, you need to function within a strong team to provide excellent health care.
Consequently, I realized that as a physician, I could bring a strong clinical perspective to the table, but also needed to work with other people who could bring strong business skills to the table as well as expertise in other necessary services such as human resources, legal, etc.
I didn’t set out to become a “physician leader”, but I soon realized that I would be able to maintain at least some clinical focus throughout my career, even if I was not actively participating in clinical care. I began that career first as a general surgeon, then worked as a trauma physician in the Emergency Department, and then moved on to Chair of an Emergency Medicine Department. I founded and directed an emergency medicine residency program associated with the ER and developed a poison control center and a hyperbaric medicine program.
As I held my various positions and accepted new leadership roles, I realized that I always needed to be strongest in my clinical expertise. An excellent health care organization has to be driven by what is best for patients and their families, residents of their long term care facilities, etc., and I knew that should be my focus as a physician as well as a leader.
Now I do what I can to stay clinically attuned. I read as much clinical information as I can, and I periodically go to work in one of our three clinics. I have decided that my future clinical work will be predominately done in clinics for poor.
Clearly, as I look back in my career, I began as an informal leader. Even in high school, college and medical school, when I would see things that weren’t working, I would try to get involved with the group of people who could impact or change those things, make them work better. I think that as people see you doing that, they decide that maybe you should be put in a formal leadership role. So I was president of my high school class, Chief Medical Resident in my surgical program, president of the resident’s association in my training program, and then moved on to Chair of The Emergency department, Assistant Medical Director, Senior Vice President for Medical Affairs and then COO and CEO of several smaller groups. It was a progression, but it occurred because I was an informal leader and was always willing to do more than what was expected, more than what was in my job description, because my goal was always to achieve excellence wherever I was. It’s just inherent in my makeup, so that’s what I did. I didn’t start my career with the idea of becoming a CEO; in fact, that would have been furthest from my mind.
I feel strongly that good clinical physicians can be good health care leaders. But they have to be comfortable in understanding that they have to broaden their knowledge base, and they also can’t be overwhelmed with the authority and become arrogant. Many physicians make a mistake and create poor leadership because they know that in order to be a good doctor, you need to be clinically egotistical. What I mean by that is that when patient comes into a physician’s office, that physician must approach the patient with the mindset of, “I’m going to save your life. If I don’t know something, I will seek help. If you die, it will be not because of what I didn’t know, but because there was nothing else that could be done.”
Many physicians get into difficulty in leadership positions when they let that clinical egotism go to their heads and they become arrogant. Arrogance drives dictatorial behavior and the “I” mentality. Health care leadership has to be a consensus and a “we” mentality. Unfortunately, we need more physician leaders, but because of the inability of many physicians to understand the difference between clinical egotism and arrogance, they can’t make the transition.
I am a strong proponent of professional back-talking, which I think is one of the hallmarks of good leadership. This means that leaders need to listen to what they need to hear, not demand what they want to hear. I would hope that discussions with CHRISTUS leaders would be a robust exchange about things that others are hearing that they might agree with, include the sharing of knowledge and the presentation of good rationale behind what they might disagree with. I believe that we as leaders must be open, have strong listening skills and must be prepared to change our positions at times.
The responsibility of leadership and authority are not nearly as important to me as the accountability of leadership, which means that you must produce improvement and positive outcomes to be considered an effective leader.
As I have said before, I am hopeful that my years of experience might be helpful to others who work in health care field or are interested in it. I have had to create a sort of science as far as the art of leadership is concerned, and am frequently asked about what is required for a “journey to excellence” or to create excellent health care leadership. What do you think?
As early as I can remember, I always wanted to be a physician. I think that was because I had an aunt who was a director of nursing in a hospital, and my father, who was the manager of a line plant, was responsible for first aid in his job. My father was actually blinded in one eye, and I learned about eye and line burns on the job from him.
Whether those early experiences played any part of my choice to practice medicine or not, I always felt that it would be a profession that I would enjoy and have the skills for, and that it would allow me to feel good about serving others. As a teen, I found myself participating in community projects that served others, and I found great rewards in being a volunteer. I ultimately felt that some of that volunteerism was part of being in the medical profession.
As I grew older and knew more specifically what medicine would require, I made sure that I was academically prepared, and was very focused on my grades in high school and college. My first day of medical school, I went to a lecture and anatomy class and knew I had made the right decision.
I still feel that the best work I’ve ever done in health care has been my clinical work. I have always said—even as I moved into leadership roles—that I am a physician leader and not an administrative leader. I also recognized very early that just as in clinical medicine, you need to function within a strong team to provide excellent health care.
Consequently, I realized that as a physician, I could bring a strong clinical perspective to the table, but also needed to work with other people who could bring strong business skills to the table as well as expertise in other necessary services such as human resources, legal, etc.
I didn’t set out to become a “physician leader”, but I soon realized that I would be able to maintain at least some clinical focus throughout my career, even if I was not actively participating in clinical care. I began that career first as a general surgeon, then worked as a trauma physician in the Emergency Department, and then moved on to Chair of an Emergency Medicine Department. I founded and directed an emergency medicine residency program associated with the ER and developed a poison control center and a hyperbaric medicine program.
As I held my various positions and accepted new leadership roles, I realized that I always needed to be strongest in my clinical expertise. An excellent health care organization has to be driven by what is best for patients and their families, residents of their long term care facilities, etc., and I knew that should be my focus as a physician as well as a leader.
Now I do what I can to stay clinically attuned. I read as much clinical information as I can, and I periodically go to work in one of our three clinics. I have decided that my future clinical work will be predominately done in clinics for poor.
Clearly, as I look back in my career, I began as an informal leader. Even in high school, college and medical school, when I would see things that weren’t working, I would try to get involved with the group of people who could impact or change those things, make them work better. I think that as people see you doing that, they decide that maybe you should be put in a formal leadership role. So I was president of my high school class, Chief Medical Resident in my surgical program, president of the resident’s association in my training program, and then moved on to Chair of The Emergency department, Assistant Medical Director, Senior Vice President for Medical Affairs and then COO and CEO of several smaller groups. It was a progression, but it occurred because I was an informal leader and was always willing to do more than what was expected, more than what was in my job description, because my goal was always to achieve excellence wherever I was. It’s just inherent in my makeup, so that’s what I did. I didn’t start my career with the idea of becoming a CEO; in fact, that would have been furthest from my mind.
I feel strongly that good clinical physicians can be good health care leaders. But they have to be comfortable in understanding that they have to broaden their knowledge base, and they also can’t be overwhelmed with the authority and become arrogant. Many physicians make a mistake and create poor leadership because they know that in order to be a good doctor, you need to be clinically egotistical. What I mean by that is that when patient comes into a physician’s office, that physician must approach the patient with the mindset of, “I’m going to save your life. If I don’t know something, I will seek help. If you die, it will be not because of what I didn’t know, but because there was nothing else that could be done.”
Many physicians get into difficulty in leadership positions when they let that clinical egotism go to their heads and they become arrogant. Arrogance drives dictatorial behavior and the “I” mentality. Health care leadership has to be a consensus and a “we” mentality. Unfortunately, we need more physician leaders, but because of the inability of many physicians to understand the difference between clinical egotism and arrogance, they can’t make the transition.
I am a strong proponent of professional back-talking, which I think is one of the hallmarks of good leadership. This means that leaders need to listen to what they need to hear, not demand what they want to hear. I would hope that discussions with CHRISTUS leaders would be a robust exchange about things that others are hearing that they might agree with, include the sharing of knowledge and the presentation of good rationale behind what they might disagree with. I believe that we as leaders must be open, have strong listening skills and must be prepared to change our positions at times.
The responsibility of leadership and authority are not nearly as important to me as the accountability of leadership, which means that you must produce improvement and positive outcomes to be considered an effective leader.
As I have said before, I am hopeful that my years of experience might be helpful to others who work in health care field or are interested in it. I have had to create a sort of science as far as the art of leadership is concerned, and am frequently asked about what is required for a “journey to excellence” or to create excellent health care leadership. What do you think?
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