A Physician CEO Reflects on What Looks Different Coming Into Senior Management

Tell me a bit about MarinHealth as an organization?

It’s a very strong community hospital, formerly named Marin General Hospital; it’s been in the area for 70-80 years. We’re the supporting hospital for Marin County, with an affiliation with UCSF [the University of California San Francisco Medical Center]. We’re the only trauma-designated facility in Marin. And we sought a strong affiliation with UCSF. We just recently opened up our replacement facility; it’s called the Oak Pavilion.

In my mind, there’s no substitute for clinical knowledge; I always default to quality and safety. It’s been a great opportunity to see healthcare from all aspects; and my ability to center patients directly derives from my clinical experience.

What have been the biggest learnings for you in the past eight-and-a-half months as CEO of the organization? Have there been any major surprises?

There are surprises every day. And coming into the pandemic required us to adapt quickly. But what hasn’t changed is that the people who work in healthcare are very dedicated people who care about the patients. I’ve found that our hospital staff and our medical staff are always willing to step up to do the right thing. Our workers will run to the fire to care for people. That’s never changed. The way we do things has changed. There’s rightfully so more of a push towards honoring lifestyle. Just like anything else, culture rules the day.

And I came out of a fee-for-service world when I was practicing. We still have our feet in two canoes. We’re moving more slowly into value-based care than I might have thought. But in the end, value is quality over cost. And also, higher quality actually costs less than lower quality. We’re having the same challenges everywhere; coming out of COVID, we’re all in a deep hole, so we have to make up for that. So we continue to change for the better; but I have yet to come across anyone unwilling to change, if you can explain to them why something is being asked of them.

How far along are you in beginning to shift into value-based contracting?

We have some bundled payment contracts, and some capitated contracts. So we have to be clinically and operationally efficient, and lower our length of stay, and be efficient.

What elements have been involved in your preparation to take on value-based contracts?

We’ve embarked on a clinical efficiency initiative program, to make sure that from the time we encounter the patient to discharge, that we’re doing things in an appropriate manner. We’re looking at cost containment and making sure that our supply costs are efficiently managed; so contracting is very important. We’re looking at all our clinical contracts. We’re making sure our service lines are well-managed, too. Are there service lines we don’t need to be involved in? But it’s all about quality and safety. For example, when a patient’s getting ready to be discharged, that’s not the time to do a CAT or MRI scan. And from the moment the patient enters the hospital, we need to begin planning their discharge.

A very typical early step often involves reforming surgical tools selection, which involves asking surgeons to collaborate in reducing the lengths of their “pick lists.” What have those kinds of processes been like for you and your fellow senior administrators at MarinHealth?

Being open and honest and transparent about the need for change, is important. And trying to understand why they would want one choice over the other. And a lot of times as a surgeon, you use things that you trained with. So just working with them to understand why they want to use particular items, is important. If there’s a true safety or quality issue, we won’t change that; but in most cases, there are options that are fairly equivalent. So working with them from a consensus standpoint. And one doctor may use one particular orthopedic joint, and another might use another; sometimes, facilitating peer-to-peer discussions, really helps. But I’ve really had pretty good success with the doctors.

Have you been able to significantly reduce the sizes of the preference lists?

We have, on both small and large items; and we have an ongoing initiative there. I think the doctors get it. I think they understand the current financial realities. So we show them the costs. Item A might be five or ten thousand dollars less than Item B, and we could shift people to Item A. I think when you discuss transparently.

And over time, in value-based contracts, you won’t be able to afford such divergences, correct?

Yes, that’s correct. I recall that in a past job, we looked at supply costs for hysterectomy; we told each individual doctor who they were, we tallied it up, and in some cases, there were ten, fifteen, twenty thousand dollar differences.

And the doctors who were outliers did move towards the center?

Yes, there was a bit of peer pressure, certainly, but Dr. K would go to Dr. A and say, how are you able to do this at such lower cost? It was a learning opportunity, and in that institution, we saw the doctors move forward into change.

We published an article about a recent survey conducted by the American Association of Critical-Care Nurses that found that critical care nurses are deeply stressed and physically exhausted right now. What has your organization’s experience of the pandemic been like?

I have to say that, early on in the pandemic, people were just running on adrenaline. And we know for a fact that there’s a much higher rate of anxiety and depression among all staff. We’ve focused a lot on resiliency. We held daily huddles. We’ve made sure people felt supported. Really strong focus on resiliency. Having the leadership team out and about was critical. Making sure the managers had not only the needed equipment, but the appropriate staffing. And folks who either got sick themselves or had to spend time with their families, was challenging at times. But focusing on mind, body, and spirit—we have several programs focused on the wellbeing of employees. So while it was challenging, people did well. And we just had a huge employee picnic last week, and it was great for everyone to be gathering outside. And also, we just recognized their bravery. And we had a huge outpouring support: almost every day, a business or community leader would deliver food and beverages. It was very isolating. And so that was important. Because caregivers give, give, and give. We were fairly fortunate in the Bay Area. We were never completely overwhelmed with patient volume. Every day was an unknown, but we were never completely overwhelmed with patients.

What do you see as the critical success factors for physicians, nurses, and other clinicians moving into senior management, as you’ve done?

It starts with compassion and focusing on the needs of the patient. There are plenty of senior officers who aren’t clinical. But in my case, it did help that I had been involved in patient care, and knowing the intricacies. But it’s being able to communicate, to drive culture, to be deliberate and focused and develop a long-term vision that people can follow. I don’t think the leadership skills are vastly different between clinicians and non-clinicians, but clinicians do bring that extra view of having been at the bedside. So that piece helps me the most. But all the other skills are important, too: surrounding oneself with great people, focusing on vision and mission, developing long-term plans. You need a strategic and financial sense. But it does come down to compassion, caring, and being a servant leader.

I couldn’t be more excited about my role. And I loved being a surgeon; but everything I’ve done since then has been richly rewarding for me. I really love my new organization.