295: Patient First, System Second: Rethinking Healthcare Leadership in a Complex World with Douglas Slakey, MD

What if healthcare systems have been optimizing the wrong thing?

In this episode of The Human Side of Leadership in Healthcare, Dr. Pelè sits down with internationally recognized transplant surgeon, healthcare executive, and author Douglas Slakey to explore why great healthcare outcomes require more than clinical excellence and standardized systems.

Drawing from more than 30 years in transplant surgery and healthcare leadership, Dr. Slakey explains why overly rigid processes often fail real people, and why healthcare leaders must begin designing systems that adapt to the realities of individual patients rather than forcing patients to adapt to the system.

Together, they discuss:

• why healthcare breaks down under pressure despite intelligent leadership
 • the hidden limitations of standardization and process rigidity
 • how social, economic, spiritual, and environmental realities shape patient outcomes
 • why healthcare systems struggle with fragmentation and incentives misalignment
 • the role of leadership flexibility in high-reliability organizations
 • how AI and technology could enable truly personalized healthcare experiences
 • the future of patient-centered healthcare through Dr. Slakey’s new venture, LifePath
 • why the ultimate measure of success is not operational efficiency, but whether people can truly live better lives

The episode closes with a powerful story from a transplant patient whose life was transformed 25 years after surgery, reminding us that the human side of healthcare leadership is ultimately about helping people live fully beyond the walls of the hospital.

Connect with Dr. Douglas Slakey on LinkedIn: https://www.linkedin.com/in/douglas-slakey-md/

Transcript

Welcome And Today’s Big Question

Dr. Pelè 0:05

All right. Welcome to the human side of leadership and healthcare podcast. I'm Dr. Pillay. On this podcast, we explore how leadership shows up in real moments and how those moments shape trust, culture, and patient results. And today we're talking about healthcare as a complex system and why improving outcomes requires more than clinical expertise alone. I'm so excited, and it's my pleasure to welcome Dr. Douglas Slakey. Doug, how are you doing today?

Douglas Slakey 0:41

Oh, great. And Dr. Pele, so uh excited to be with you and your audience and have this conversation.

Dr. Pelè 0:48

All right. Well, I should say that Dr. Slakey is an internationally recognized transplant surgeon, healthcare executive, author, speaker, and expert in complex systems and process optimization. He's also the author of a book that I just love, of taking a look at it, The Process Manifesto. And Doug, you're going to tell us all about your new and uh venture, life path. So let's go ahead and jump straight into it, Doug. How are you doing today specifically? And where are you?

Douglas Slakey 1:20

Well, great. Sitting here in Nashville. Okay. Um a year and a half ago, I came to Belmont University to help open the new Frisk College of Medicine. And I have the honor of chairing Health System Science. Um, I've been chair of surgery at a couple different institutions. So this was definitely a bit of a career shift, but really, in so many ways, the culmination of my experience and my interaction with patients and teams, not just in the United States, but around the world. And the most exciting thing for me is this gives me an opportunity to really be engaged with the amazing innovations that are coming our way. And to also think how can we help the next generation of healthcare leaders be prepared? That's so important.

When Perfect Surgery Still Fails

Dr. Pelè 2:17

Yeah. Yeah. You know, Doug, you've got a 30-plus year history of just excellence in transplant surgery. Uh, just as a healthcare leader, when you look back at your story, how you got here, when did you first realize that great healthcare outcomes were not just about the clinical side, but also about the human side, which is where some of your focus is these days, right now.

Douglas Slakey 2:43

Right. Well, there were a couple of key pivotal moments. There were um a couple of patients in particular where I had done um surgery, liver, kidney pancreas, whatever the transplant was, and everything went perfectly in our four walls of our operating room, in the post-op recovery. But then there were elements of their long-term recovery once they were discharged that I realized we didn't fully appreciate the context in which they were receiving health. Everything from environment, socioeconomics, family, spirituality. We knew we thought we knew a lot about our patients, but what we captured in the electronic health record, I realized was just a snapshot of their actual lived existence. And so that really got me thinking that to optimize outcomes, we had to appreciate each individual's long-term health journey. And most importantly, we had to really start to think what was most important health-wise to the person, the patient, the person, as opposed to what did we as the providers think is most important? They may be the same, but in many instances they're not identical. And we emphasize the system and having people conform to the system. And I got to realize that maybe we should be thinking the opposite way. How can the system better conform to the realities of the person? And so that led me on this um journey of some introspection, but also thinking strategically about how we could take high reliability lessons, complex system theory, and apply it in a way that really empowered both sides of the front lines of care, the provider side and the patient or the consumer of healthcare side. We have to recognize both as being essential and important.

Dr. Pelè 5:10

You know, I I love the high ideals of what you're sharing. And frankly, I couldn't agree with you more. I'm just wondering how a system that has put compensation on the side of the provider and a lot of the incentives for success are around patient experience scores and things like that. Um, how do we shift that to be a patient first approach versus you know the system first approach? How do you do that?

Standard Pathways Versus Real Life

Douglas Slakey 5:39

Yeah, well, uh that's whoever finally achieves that, that's Nobel Prize material. But I do have a couple of ideas that we're working on and exploring. And I think first and foremost, we have to think about outcomes and value from the consumer side. And that's that's just so important. Um, I can think of times, for example, where I've been to large meetings touting amazing innovations in cancer treatment. But then at the end of the day, you look at improvement, and here we're thinking, let's say, stage four cancer. And you look at improvements in survival, and sometimes while statistically they seem to be great improvements, often people are left quite disabled. Maybe they can't live at home anymore, they're spending a lot of time in the hospital, and that's where we have to rethink the patient. What does patient-centric really mean? And how do we learn to have those conversations? And how do we aggregate information that helps drive that? The other thing, uh, a starting point, I think, and this is one of the key hypotheses I argue in my book, is that for 20 or 30 years we've had the belief that if we reduced patient care to a highly defined standard pathway, we would achieve better results. But we know with a few exceptions, that hasn't happened. And we have to ask ourselves why. And the reason is, although this sounds cynical, but human beings are not like a car on an assembly line. We're all individual, we all have individual realities, and those realities are sometimes so complex there are unknown unknowns and there are unintended consequences. So what I advocate for is we must have, while we must have guardrails, we have to understand that overly standardized approaches to individuals is not effective. And as a consequence, we have to avoid the tendency of blaming the patient, the consumer of healthcare, and think about how we can change our delivery to optimize behavior and adherence. It's just really important. I'll give you uh one one simple example that I use sometimes. So uh I've done over the years quite a bit of work looking at um social determinants of health. The area deprivation index from CMS is a great resource. It can show you overall education levels in a community, average income, house prices. So what if I told you I had three patients that looked identical on paper, same education, same household income. But what if I told you one lived in a small town in Appalachia, one lived on the south side of Chicago, and one lived on a Native American reservation in New Mexico? They might look the same on paper, but we know as human beings, we know those are very different people. They're not going to see our care in exactly the same way. And we shouldn't expect them to. So my point is that one of the ways of transitioning is to empower the consumer. And I'll give you my third one just very quickly. Uh one of the things that I think is very exciting and honestly necessary is to begin to develop a personal portable healthcare record where we, and it's not just abstracting from the electronic health record, but think in terms of curating everything about your health journey that is important to you as the consumer. That's a very different approach. That's truly patient or person-centric, not system-centric. And I believe that when we can start to do that, we will empower the consumer of healthcare and ultimately give them more discretionary choice. And that will lead to a cascade of meaningful change.

Dr. Pelè 10:33

You know, in your book, uh, The Process Manifesto, and actually I want to ask you a word, a question about the word process, by the way. Um, you know, you you talk about this patient-centered approach. And, you know, I'm just wondering with in an in an environment where process is a lot anyway, um, what is it that intelligent healthcare organizations and leaders are why are they still struggling with fragmentation or inefficiencies and preventable breakdowns when process is so central to what they do already? What does your book, The Process Manifesto, uh propose that's different when it comes to process?

Douglas Slakey 11:14

Well, I think I'll I'll encapsulate it in in one message, which I think is really the most important take-home, is that we while there are areas where a very hierarchical structure makes sense. So supply chain, um, staffing, we have to avoid the tendency to overcentralize decision making at the point of care delivery. And so to manage complexity, you have to do a couple of things. One is you have to acknowledge that there must be discretionary choice at the point of care delivery that relates to situational awareness at the given time. What is the reality today, which might be different from the reality of last week? You know, I saw this all the time with transplant surgery, where we would get an organ offer in the middle of the night. The operating room was completely booked with block time, and then we would come in and say, Oh, we need to start the surgery at you know, seven or eight in the morning. And you know what happens? That creates all sorts of friction. So you actually tend to start them at five in the morning because then by the time the 7 a.m. block time people arrive, we're already in the operating room. So that's why a lot of transplants start at five in the morning because we we don't have those adaptive capacities that are consistent and built in to reflect the reality of complexity. And and the beauty of pushing some of the discretionary choice down to the front lines is it allows people to work at top of license. Now, the one huge challenge for leaders is to appreciate the importance of education and and meaningful education uh in terms of how do we make sure individuals are at the top of license and how do we make sure teams are working together with the greatest degree of operational efficiency? And and for any group of people, you know, you think about a sports team, it it takes time, it takes commitment, it takes uh a willingness to uh pay for that. You know, you yeah, and do we really do that all the time in healthcare? Do we really take the time for teams to actually train when they're not constantly looking at their page or their cell phone because they have a million other things to do? And and they have to train together. Um it's so, so important.

Dr. Pelè 14:34

Yeah. You mentioned earlier that um, and I love the way you said this, overly standardized approaches um are not effective. And I think when I hear you say that um, you know, you're proposing uh being more more of a personalization approach. Like let's get to the individual and really understand their story beyond what's happening today, like the big picture, the maybe a more holistic picture. Why why do healthcare systems struggle with with you know uh getting away from uh everybody is uh basically the same? Let's just treat everybody the same and that's it. How do we get away from that and be more uh less rigid, I think is what you're proposing.

Decentralizing Decisions At The Front Line

Douglas Slakey 15:15

Well, let's start with why are we in the space we're in today? I I think I think some of the reason, and I discuss this in my book a little to a degree, we have wanted to have standards of documentation and compliance that meet the expectations of our billing and payment model. And I do think that's really a fundamental issue. You brought it up earlier, how do we change that? And sometimes that even induces um misaligned incentives um where we're looking at, well, think about in terms of this um hernia surgery, great example. So if I'm writing a contract as a manager for a surgical team, I'm gonna base most of that contract today on work RVUs. So I'm gonna expect people to generate a certain amount of work RVUs. We know that there are many hernias, there have been famous studies, like a VA study called Watchful Waiting. Not every hernia needs surgery. But if my contract is predicated on performing surgeries, generating work RVUs, and I get a referral for a patient who was told, oh, you have a hernia, you need to see a surgeon. The whole system's expectation is triggered to just go ahead and do that surgery. It's easier, it's less time, um, arguably, there's less follow-up, but we all know there are potential complications. Not every hernia surgery is the same. Is the same. Not everyone is without complications or infection and chronic pain. And there's a lot of things. I've done a lot of hernias in my career, repaired a lot. So I know there are some that definitely need to be repaired, but on the other hand, there's others that don't. So that's a good example of how we have this standardized process. If X, do Y. And if you don't do Y, we can go back and say, why didn't you generate more work RVUs? Why didn't you operate on all those people you were referred to? Or why did you send them out of our system? You know, that's that that's the incentives that we've developed that don't really acknowledge that. The other thing that's so important, Dr. Pele, is that until now we really haven't had the technology that allows us to aggregate these very diverse data sets in a way that starts to paint a picture of the whole. We've looked at data sets in isolation, and that's created a system where the fragmentation naturally evolves. I mean, we even know, even if if you or I had three doctors, different hospitals or different clinics, even if each one was on the same software like Epic, the portals are probably different. There is Epic everywhere, but we don't always know if everything is aggregated. Um and there are sometimes incentives not to aggregate all the data, not to share it all. So those are some of the I think key transition points we have to acknowledge and we have to recognize the opportunity today.

Dr. Pelè 19:24

Yeah. Now, so at the middle of everything, of course, is the humans, the leaders, the people who make decisions that trickle down into patient outcomes. One of the themes that we explore in our podcast is that leadership often breaks down under pressure. And you know, it's not because people don't know what to do, it's just that when they're under pressure, they do what they have habitually done. You know, and so I'm wondering what your perspective is on how we can build leadership over time to be, as you are proposing, less rigid uh with their habits, more flexible with the specific patient in front of them. How do we get leaders developed in this new world that you're describing?

RVUs, Incentives, And Fragmented Data

Douglas Slakey 20:07

Yeah. Um that's really where we have to start, isn't it? And and I think there's um a couple of key elements. And when I used to um give initially started thinking about high reliability and taking lessons from other industries and bringing them over, I realized a couple of things. A, you do have to have standards like the airline industry, the control towers and the pilots, they speak English around the world, right? That's a common language. So that's an existing standard. But we all know if we've been fortunate enough to travel overseas, that there are cultural differences in the way that the gates and the waiting rooms are organized. Um, I can even think of trips I've taken to Japan where the crew on the on the tarmac actually bows respectfully to the pilots and the passengers as the plane's departing, you know? Yeah, I I think if that happened in Nashville, you would think it was strange, but it's normal there. And and so my point is that at the at leadership, you have to have an overarching vision. But then as you start to disseminate out to those actual points of patient care, of consumer interaction, you the the most senior most leaders have to have trust in those local and regional leaders to execute and carry out. So how do you do that? One critical just Talent or technique that's inseparable from success is effective communication. Not 30,000-word, you know, policy binders that nobody reads, but clear communication about why are we doing what we're doing, how are we measuring outcomes, and how are we adapting to those inevitable challenges that we'll see and face. So communication. The other is taking the time to really empower leaders to be able to execute at the local level. Um, and that's hard. It's hard to relinquish control sometimes, but it's such an important skill. And I think with modern technology, AI, quantum computing, all coming, relinquishing rigid control is going to be more important than ever. You still have to have the vision, you still have to have the guardrails, but you have to be able to adapt at the local and regional level.

Dr. Pelè 23:18

Absolutely. And you mentioned technology. I'm excited to learn more about your new venture, LifePath. Um, in a world of AI and systems just moving so fast. What is LifePath? Tell us about that.

Leadership Under Pressure Needs Trust

Douglas Slakey 23:33

So I've had this idea. It actually began when I was really writing my book and contemplating um what you know, what was I trying to say and how was I going to say it effectively? And, you know, I started thinking in depth that we needed strategies to really help people understand the health information that was important to them. How do you prioritize it? How do you better help people understand the consequences of their own decisions to give them more empowerment? Not everyone's gonna be ideal. None of us are, even at a high level, right? Some of us sit too much and we know we should be up walking. And, you know, we order Uber Eats and probably not always the best, you know. Nothing against Uber Eats, but you you know, what we're getting aren't always our fresh fruits and vegetables, are they? No, they're not. Um, and so so I started thinking about this, and actually it's really been a fascinating journey because it's just recently, Dr. Pele, that the technology is catching up with this vision I had. So imagine the ability as an individual, you or I or family members, to be able to aggregate all the information that we see as important in our health. Not to do a frontal assault against the health system. I mean, I spent 35 years of my career doing incredibly complex surgeries, right? So we still need that. But as the individual, our genetic, our physical, our mental, our spiritual, community, family, financial, those elements all blend together to create what we perceive as our health, our realities of our health. So what we really did was we looked at how can we take technology, put all that together, and then incorporate elements that allow people to ask healthcare questions, the answers to which incorporate the knowledge that you're accumulating about yourself. You know, so if you're living in a rural farming community in Middle Tennessee, as opposed to somebody living in downtown Chicago, the answer to some of your questions, how do you access care? How do you think through the resources available to you is going to be different?

Dr. Pelè 26:29

Absolutely.

LifePath And The Portable Health Record

Douglas Slakey 26:30

So that's where breaking down that idea that everyone's the same and everyone has to be the same. Even, you know, you think about diet. Like we tell people eat a Mediterranean diet. Well, what does that mean to a first generation immigrant from Mexico or somebody who grew up in Okinawa, Japan, and comes to this country, they're probably saying, well, Okinawa is a blue zone. Why should I eat, you know? And but that's what we do, right? Currently, we give everyone the same advice. And so we want to curate that. And then the I'll finish with this. The other really exciting element is that we have a vision of facilitating bilateral communication with the healthcare team in a way that helps the healthcare team understand what's most important at the time to you. So curating the information. So the information that goes to your primary care would probably could be different than information that went to, let's say, your cardiologist or even went to your financial advisor when they're thinking about how does your healthcare reality impact financial decisions that you need to make today? And we know that's a reality, right? You can't it's a fallacy to think you can separate economics at the individual level from healthcare decisions. How many people do we know don't take their medicine every day because they can't afford it? So they take it every other day or every third. That's a reality. And should we blame the patient for that, or should we look for solutions to help change that dynamic? A less expensive medication, a different source of medication, different healthcare strategy, which might reduce the dependency on prescriptive medicine. So, anyway, that's what I'm so excited about is changing that dynamic and really helping people with their what we call well-being journey.

Dr. Pelè 28:49

Ah, I love that. And you know what I really uh appreciate about your life path concept and the strategies behind it is this idea that one size does not fit all. Yeah. Right? This idea that, you know, sure, we can start from standards, but let's really give space for the individualization and the personalization of our patients because that will increase care. Um, you know, I I would love to ask you for four leaders, any leader that might be listening today, healthcare leaders, um, what is one process-related mindset shift uh that you would suggest that they could begin working on today to move forward?

Douglas Slakey 29:28

Yeah, I think I think one is to avoid the tendency to work backwards and think that you can, with a high degree of precision, identify a failure point. That in in in um the engineering world, that's called failure mode analysis. But that presumes that everything is highly predictable. So the one thing I would encourage leaders to do is to think in terms of how do we optimize our processes so that they have a degree of flexibility built into them, a way to accommodate and and to avoid that strict adherence to a rigid linear process as the only solution. And that's I I that's actually very hard to do as a leader or a manager is to have that ability to accommodate. It doesn't mean that you don't have standards, it doesn't mean that you don't have a continuous quality improvement. In fact, understanding the ultimate outcome as opposed to intermediary process measures is the key take-home message for leaders. You have to start with what do you want your customer to experience? What do you want the customer to remember about the experience? And then start to make your processes flexible enough to be able to accommodate those realities. That's the key. If you just say, I'll give you one quick example. So, you know, if you just say, for example, I want operating room turnover time to be 18 minutes. Yeah.

Dr. Pelè 31:41

That's a standard.

Douglas Slakey 31:42

Yeah, that's like some standard. But you know, if I have a 30-year-old who's getting their knee scoped because they played basketball and twisted it last weekend, yeah, maybe I can do that in 18 or even 16 minutes. But if I have um an 85-year-old who's got a lot of comorbidities and getting a surgery, should I really rush them through in that same 18 minutes?

Dr. Pelè 32:16

Yeah.

Flexible Process Thinking For Leaders

Douglas Slakey 32:16

No, and that's where you have to have that degree of accommodation, otherwise, quality, the ultimate measure of outcome, suffers absolutely because we're too rigidly focused on intra process measures. Now, I uh one other thing for leaders, and I I know why people gravitate towards those intra-process measures. It's easy to collect the data. Yeah, it's much harder to collect that ultimate experiential data and understand it, because some of it is going to be subjective, as opposed to being completely objective. 18 minutes room turnover, that's objective. I can measure that. I can tell you if you're one standard deviation away. But if you or a family member or one of my family members is going through a complex health system, understanding whether they truly believe they had a good outcome. And even when we talk about patient satisfaction, what do we measure? Was it easy to park? Were you seen within 20 minutes of your appointment time? Did the doctor or nurse listen to you? Well, maybe they did. I don't know. But is my health any better when I got home? Who really asked that? Was I able to go on a three-mile hike because my breathing is better and I feel better and my energy levels better? Nobody asked that.

Dr. Pelè 34:05

Yeah.

Douglas Slakey 34:06

But that uh was I able to see my grandchildren and actually kick the soccer ball or throw a baseball with them. That's for most people what really matters. Yeah.

Dr. Pelè 34:20

Absolutely. You know, absolutely. You know, um, as we as we close, I want to give you the last word. You know, you after everything you've experienced as a surgeon, a leader, an author, what does the human side of healthcare leadership mean to you personally?

A 25-Year Reminder Of Purpose

Douglas Slakey 34:36

Yeah, you know, uh I I'll tell you, I'll give you one example that really resonated with me from two months ago. I got a call in the office, a voicemail, and it was a person saying, This is so-and-so from Lafayette, Louisiana. Is this the Dr. Slakey who used to be in New Orleans? So I called the person back, and it turns out that he called me the first of March. It turns out that on March 7th, 2001, I did a kidney pancreas transplant on him. He was in his mid-20s, juvenile onset diabetic, legally blind, had already had a partial foot amputation, probably only had three or four years expect life expectancy at that point. So I did a kidney pancreas transplant on him, and he told me, he said, Dr. Slakey, this is the 25th anniversary of my transplant. My creatinine is between 1.4 and 1.5. Wow. My hemoglobin A1C is 5.1. And you know what he told me? He said, you won't remember this, but when you came to discharge me, I told him, I said, look, I did the best job I could do in the operating room. Now you have to take care of those organs. And that is, I think, such a great example of that human element. What's really, really important is for us to appreciate what we're doing isn't about us, it's about somebody else living their life and enjoying their family and their community and contributing. So that's the human element that I'd love to just leave everyone with.

Dr. Pelè 36:36

And and Dr. Slakey, I can tell you the goosebumps, the in fact, almost tears that are in my eyes as I listen to you. What a gift. And I know that you are also feeling very heavily about what you just shared. Thank you for being a guest here. Your heart is so obvious, obviously full of empathy and connection with the patient and not just the system. And I want to thank you sincerely for what you said.

Douglas Slakey 37:04

Well, thank you so much. And uh thank you for all you do. This is really my pleasure. All right.