Building Resilient Healthcare Organizations | Quality Time with Dr. Schaal

On this episode of Quality Time, Dr. Tom Lee, chief medical officer at Press Ganey, practicing physician at Brigham and Women’s Hospital, and editor-in-chief of NEJM Catalyst,  discusses how healthcare organizations can build resilient systems in a world defined by uncertainty. Dr. Lee emphasizes that success requires becoming comfortable operating in environments that are constantly changing. To illustrate this complexity, Dr. Lee introduces the concept of BANI, a framework that captures the realities healthcare organizations face:

• Brittle systems that can break
• Widespread anxiety among staff and patients
• Nonlinear disruptions, from policy shifts to crises
• An increasingly incomprehensible world of constant change

He emphasizes that organizations with a strong culture and earned social capital are better equipped to build resilient systems to withstand BANI and navigate through challenges and change.

Notable topics covered:

·      Press Ganey

·      NEJM CatalystJournal

·      BANI framework of uncertainty

·      Social capital and organizational culture

Transcript

DR. SHLOMIT SCHAAL: 0:01

Welcome to Quality Time, a Houston Methodist leading medicine podcast. I'm your host, Dr. Shlomit Schaal, a clinician scientist and a retina specialist, and I serve as the Chief Physician Executive of Houston Methodist. Join us each month as my guests and I discuss the many ways that quality impacts care delivery. Today, I am delighted to welcome Dr. Tom Lee. He is the Chief Medical Officer for Press Ganey. He's also an internist, a cardiologist, and he practices primary care at Brigham and Women's Hospital in Boston. And he's on the faculty at Harvard Medical School and the Harvard T.H. Chan School of Public Health. He is also the Editor-in-Chief for the New England Journal of Medicine Catalyst. Welcome, Dr. Lee.

DR. THOMAS LEE: 1:04

Thanks so much. I'm really happy to be here.

DR. SCHAAL: 1:07

So, Dr. Lee, tell us a little bit about your background. How did you become to be the famous Tom Lee?

DR. LEE: 1:15

Well, I do a bunch of things, but they all do fit together. And I would say what they converge on is I wanna take good care of my patients, I want my institution to do well, and I want the healthcare system to do well also. And that means providing excellent care with access to everyone. So, that means we have to make care efficient as well. So, all those things, value-based care, institutional vitality, excellence for individual patients who are right in front of me, it's all the same work. We have to figure out how to do them together. I know you try to do them all as well. And I can't think of better work to do. So, I've been working at all of those streams throughout my adult life. DR. SCHAAL: This is wonderful. Tell us a little bit about your role as the Editor-in-Chief of the New England Journal of Medicine Catalyst. What do you do there, and how do you propagate the knowledge that you gain from all these insights all over the country in your role in Press Ganey? Does this collaborate, that this, you know, is part of the pieces of the puzzle? You know, and I think it's an interesting story, and I'll tell it in a little more length than I might otherwise because I won't be a bit surprised if you follow a path like this down the road, where, you know, if I go back to, you know, like 15 years ago, I was working very hard in the senior executive role for Mass General Brigham. We called it Partners Healthcare then. I was the CEO for the network. And I fell into a working partnership with an academic, Michael Porter, from Harvard Business School. And I knew I had things to learn from him for thinking about strategy. And he valued working with someone who really knew patient care and healthcare delivery. And so we started writing things together about, you know, a strategic framework for how to actually improve healthcare. And the articles were long. They were way too long for the New England Journal of Medicine, where I was an associate editor at the time. But, you know, we felt like there was value. Like, we wrote this one article that was 11,000 words long instead of 2,500, which is the word limit of New England Journal. Harvard Business Review published that. We felt that there had -- Harvard Business Review said,"We will never again publish anything that long."[Laughing] You can't -- For complex topics, it does take a lot of time and a lot of space. So we thought we needed a place to publish things that would help healthcare move down the road toward being higher value. And so we talked to the New England Journal, and they agreed that they would create something new, an online publication. And it's really different from traditional academics. In the traditional New England Journal, which I love and I've worked on a great deal over the last 20 years, you know, the New England Journal never wants to be wrong. They want to be sure everything in there has been gone over so carefully, it must be true. Catalyst, we realized, we want to accelerate progress, which is something different than never being wrong. You know, we want to say,"If Houston Methodist is doing something called JIMI, you know, it's not a randomized trial of JIMI versus no JIMI, but everyone should know about JIMI. And we're going to put it out there. We are not going to torture Shlomit before we publish it. And we're going to get it out there so other people feel jealous and feel like,'Why aren't we doing this?'" So we have a different frame of mind from the traditional New England Journal. The whole NEJM group loves the fact that we have a diversified portfolio. So it's all about accelerating progress and trying to spread -- to accelerate the dissemination of innovation. It feels like fun work and good work.

DR. SCHAAL: 5:21

This is fantastic because this is exactly, you know, I think, the struggle that we have as physician leaders. You know, we're kind of trained the way the New England Journal of Medicine wants to do stuff. We're trained to never be wrong, you know, follow the guidelines. And yet we find ourselves as physician leaders in an environment that keeps progressing, where you have to try things, new things, and you have to be wrong. So I know you held a webinar about uncertainty recently in your role as the editor of the New England Journal of Medicine Catalyst. Tell me what you learned there. What are the thoughts? It's just this, I would say, tension between a physician that needs to be right and a physician leader that needs to be comfortable in operating in an environment that is continuously changing.

DR. LEE: 6:23

Well, you know, it was such a fun discussion. And I think it highlighted how interesting our times are. And I will say, without -- it'll sound like a joke, but it really is true. We actually started talking about what does it mean to be cool? You know, what is it? And what it meant to be cool in the era when I finished medical school and I was starting my career in the last century, you know, at that time, you wanted to have an encyclopedic fund of knowledge. That was the phrase. You wanted to be the person who knew everything. And you read the New England Journal every week so you could stay up to date, and you would never look like you didn't know something important. What we were talking about yesterday was now there is so much to know for clinicians, no one can know everything. Anyone who is like they know everything, that was cool 40 years ago, but that is not cool today. What is cool today is to know how to go looking for information, know how to deal with uncertainty. And that means having a network of colleagues that you can talk to about cases where you don't know what's going on, and having -- knowing how to use AI, how to turn to open evidence and ask for help when you don't know what's going on. So that was the really fun discussion, how in this day and age today, being cool means knowing how to deal with the uncertainty that is so common when we see patients. And it is very common in our management roles and our leadership roles as well. So we need a combination of confidence and humility. And that is the ideal. And I know you have that completely. You know, you're strong, but you're completely ready to say when you don't know something. You're completely ready to ask for help from people who know more. Trying to help our colleagues get there culturally and trying to give them the tools, both in the IT tools and the cultural tools, being in an environment where you've got people that you can talk to, that's part of my work. That's part of your work.

DR. SCHAAL: 8:55

So, you know, I think that my comfort level with uncertainty and unknown comes from my being a scientist. So everything in science is an experiment. You do not actually know. You know the background, you know things that people published before you, but actually you do not know what your experiments are going to lead you to, what kind of conclusion. We talked a little bit about different, kind of, abbreviations around uncertainty. Do you want to educate us a little bit about these?

DR. LEE: 9:30

Well, no, you know, in our talk beforehand, with your military background, you brought up VUCA. And what I said is that recently I've been hearing many people say there's a new definition, a new abbreviation to replace it called BANI. But first, you describe VUCA. You have the military background. You get that one. DR. SCHAAL: Right. So VUCA is an environment of uncertainty. So it stands for volatility, uncertainty, and then continuous change. That's, you know, that's what VUCA is. The A stands for ambiguity and the C for complexity. So it's volatile, it's uncertain, it's complex, it's ambiguous. And this is exactly the environment that we are leading in, in healthcare. Now you taught me about BANI. What is BANI? Okay. So BANI is B-A-N-I. It stands for brittle, meaning things could break. Yeah, in our system, you know. Anxiety."A" is anxiety, like people are scared. Patients are scared. Everyone is -- everyone really has fear."N" is nonlinear. That means something could happen next year, like, you know, the Big Beautiful Bill, and then funding could suddenly drop off dramatically. Or there could be another pandemic, you know, that just completely changes everything. And then "I" stands for incomprehensible. You know, no one can really understand all the things that are going on. And therefore that's also very unnerving. So, to a certain extent, it's the same sort of pressure for leadership that VUCA implies, but it's sort of like VUCA with, you know, taking LSD and like -- DR. SCHAAL: Steroids. Anabolic steroids and adrenaline. Now, the reason BANI is, you know, comes up is that, you know, many thoughtful people I know are talking about in a BANI environment, and we are living in a world that is really tumultuous, what should leaders do? And, you know, and I think that and I see you and your colleagues, I think I'm very impressed with them. You know, like I'm, you know, one of the things one of my colleagues said, you know, in this environment, you get credibility not because you know what's going to happen next, you get credibility because you're honest. And, you know, when everything is unstable everyone has to know that what is stable are your values. And, you know, you have to communicate, you know, communicate well, you know, humanity is really important. So these are things that, you know, I know, I've watched Houston Methodist and I -- how you adopted high reliability culture. And this was before you got to Houston Methodist, but I know that you fit right in with this. I know how the high reliability culture helped Houston Methodist through the pandemic, through hurricanes and all sorts of climate things, you know, and, you know, it enabled you to do things that other organizations had great difficulty doing that there's a reason you were the first to mandate COVID boosters, and it didn't precipitate a riot that you were able to do that. So I think that there is -- I know how strongly Mark Boom and you and, you know, Roberta Schwartz feel about culture, but in a BANI environment, which we are living in, culture really, really matters, you know, so honesty, values, communication, and so on.

DR. SCHAAL: 13:44

Yes, I love that because here, you know, I think I told you the story when I interviewed for my job here at Houston Methodist, I was interviewed by 60 different people, and every one of them was talking about values. So I think that's really an important thing. You know, as you said, you may not make the right decision, but this decision is anchored to our values. And I learned this from Dr. Boom. You know, every decision that we make, he's asking,"Does this decision -- is this decision in line with our ICARE values?" This is a question that he asks, and I learned from him and really value that. You talk a lot about social capital. Remind us what it is and how it connects to culture and values.

DR. LEE: 14:39

Yeah, and it really is a strategic and sociologic way of looking at the things that come instinctively to us. But then because it's strategic and it's of social importance, the implication is it's about being disciplined about pursuing things that we're all for. So, you know, capital is anything that gives you an advantage, anything that makes you better, better than you are now, better than your competitors. So financial capital is the money that enables Houston Methodist to build buildings it couldn't otherwise build. Human capital are hiring the people with the expertise that will enable you to do things you couldn't otherwise do. Social capital is how those people work together, how they relate to each other, how they relate to their infrastructure, how they relate to patients, that enables you to do things you couldn't otherwise do. So instinctively, we all love teamwork. We all love our experiences being on a really good team. But it's one thing to be grateful when we have it, and it's another thing to build it relentlessly and in a disciplined way. And, you know, the way Houston Methodist built HRO culture over not one year, over like 15 years, that took real work and it took real discipline. You know, everyone actually talks about values, but to actually turn them into norms and have an enforcement mechanism where, if you don't adhere to the norm, something happens, you know, you get feedback, that is something that many organizations' leaders don't have the courage to do. Or it's not that they don't have the courage, they don't understand how important it is.

DR. SCHAAL: 16:41

So what do you mean by norm? What is a norm, and what is this enforcement mechanism that you're talking about? What is that?

DR. LEE: 16:49

You know, a norm is where we're all going to do this. You know, we're all going to pursue zero harm. That one is now very straightforward in many organizations. But you hardwire it by like, you know, "We're all going to have huddles, and you are including you. And when you come to the huddle, you've got to speak up. And if you don't speak up when you saw something that was an opportunity to improve things, that's not what we do here." You know, and you hear about it from your colleagues. And so the enforcement mechanism is not financial. It's not in your job description, but it comes from peer pressure. So, you know, the example I like is one that stunned me. At Mayo Clinic, I learned that everyone answers their beeper when it's a clinical page. It comes across as a priority page. You answer immediately. That's one that I'll answer later.[Laughter] But that was a page for me, but it's not a clinical thing. I'll answer it later. But at Mayo --

DR. SCHAAL: 18:07

It was timed perfectly, by the way.[Laughter] You were talking about pinging, and then it came. It's great.

DR. LEE: 18:14

Well, you know, this is actually part of one of the really interesting themes in some of the discussions I've been having. You know, I don't know if you watch the TV show <i>The Pitt</i>.

DR. SCHAAL: 18:28

Yes!

DR. LEE: 18:30

So, you know, one of the things that's so accurate about <i>The Pitt </i>-- I mean, virtually everything is accurate -- but what is -- when you're being interrupted all the time as you go through. Like, how do you keep your sights on -- how do you deal with uncertainty when you're being interrupted? How do you keep focus on your values and look straight ahead? This is part of our environment. And the interruptions actually, it makes life kind of fun, you know, stimulating. But you've gotta focus on performance while you're being interrupted all the time.

DR. SCHAAL: 19:08

So, I have to tell you something before you tell the story, is that I started wearing a regular watch, not an Apple Watch or a smartwatch anymore. And I do not bring my phones to meetings anymore for that exact reason. I wanna focus on you. I wanna focus on what you're telling me. And I do not want to be interrupted. And I know that if something horrible happens, my assistant will come into the room and interrupt us. But other than that, I focus on you. So, you know, I think I'm trying to model it for my team as well because, as you said, we are interrupted all the time.

DR. LEE: 19:49

Well, you know, I'll tell you -- well, first I'll finish the Mayo thing, but then I'll say something else about phones because this is so much fun talking with you. I hope it's fun for our listeners.

DR. SCHAAL: 19:58

Oh, it's fun. And the people here in the room are smiling all around, so everybody's enjoying it. DR. LEE: Okay. Well, at Mayo, you answer your beeper clinical page immediately. Like, you don't finish driving where you're going. You pull off the road. And when I've asked people at Mayo, "What happens if you don't answer your page right away?" You know, the first doctor said,"The earth would open up and swallow you." And the second one said,"You'll be put out in the winter in the cold and you will die." You know, it will be like being in Houston and being put out in the heat in August. In a hurricane.[Laughter]

DR. LEE: 20:32

Yeah, yeah. But so it is social, you know, that people feel they don't wanna -- they're tied to their colleagues, they're interacting with them, and there's also clear,"I would disappoint my colleagues if I did not answer my beeper right away." Now on the telephone thing, you know, I think Frances Frei from Harvard Business School, she also has made it very clear that if there's one thing you want to do to earn trust in people, is put away your phones. Put them out of sight. Don't let them be seen. And so your instincts about attention is precious are very important for building a real relationship. And it is a big symbolic thing that your phone is not there. But the little thing that I think you'll love in that -- all right, so I have, you know, I think you know, I have a famous cousin. She's a psychologist, Angela Duckworth. Who writes about -- DR. SCHAAL: The author of <i>Grit</i>. Yes! Yeah, yeah, yeah, yeah. And she has a new book coming out in September. And one thing in the new book, because, you know, I get to read it early, she did this project with students. And she asked them,"Where do you put your phone while you work?" And, you know, level one was,"It's next to me and it's facing upward and the sound is on." Level two was,"It's next to me, but it's turned over and it's put on silent." Level three, "It's near me within arm's reach, but it's out of sight. Like, I put it behind the computer." Level four is,"It's in the room, but it's not within my reach." And level five is,"It's in another room." And so she asked each student where their phone was. And at the end of the year, she looked at their grades, and the grade point average correlated with the distance that the telephone was from them.[Laughter] So the best students had the phone out of the room, and the students who did the worst were the ones who had it right next to them.

DR. SCHAAL: 22:45

Yeah. You know, the interruptions are real and the attention is real. You talked about financial capital. You talked about human capital. You talked about social capital. For capital, there is also currency. And I truly believe that the currency of leadership is attention. And so if I can give my attention, it requires energy. So I try to keep my attention on the things that really matter most and the people matter most to me. So that's why I keep my phone in a different room. That's why I'm not wearing any smartwatch. Just keeping my attention on the people.

DR. LEE: 23:27

Well, you know, so I think that's very important. But I will say, Shlomit, that that's just step one. Because step two is, you know, you have to have real relationships with the network of people, and they have to have relationships with each other. They have to feel like a team. And then you have to spread the right -- you have to have clarity of what the norms are. And you have to build structure into the interaction so that we are all going to show up for the huddles, and we're all going to make sure that the tiered huddle system works. So that if something -- Do you have a tiered huddle system at Houston Methodist? DR. SCHAAL: Yes. I am -- I'd be shocked if you didn't.

DR. SCHAAL: 24:10

Yes, we did -- We actually implemented it relatively recently, in the past maybe year and a half. And now all our physician organizations, we have huddles everywhere in our clinics all over Houston, with tiers, right, that things can escalate. But this is relatively new for us. Only recent. A year and a half.

DR. LEE: 24:31

It's relatively new for everyone. But I will say that, you know, in NEJM Catalyst, we have been disseminating this. I mean, the first place to do it was like Intermountain, and this is like 2018. And Cleveland Clinic started doing it. And now --

DR. SCHAAL: 24:48

And UMass, UMass. I brought this idea from UMass. Eric Dickson, the leader, that's how they do things over there at UMass Memorial Health.

DR. LEE: 24:57

Yeah, well, so the fantastic thing about tiered huddles, when you really think about it, is that it hardwires a system where people know, if I've got an issue, people are going to hear about it and there's going to be a response. And, you know, as you know, one of my colleagues, Chrissy Daniels, said it actually creates an environment where people walk around saying,"I had a problem, and we fixed it." And if you can't fix it at your level, it goes up. It goes up so that on the same day, Mark Boom will hear about it. And, you know, in Prisma in South Carolina, they actually have a goal that 95% of problems that come up should be addressed the same day.

DR. SCHAAL: 25:45

That's incredible.

DR. LEE: 25:47

And they actually track it, and they're running 96, 97%. So that confidence that someone is going to respond, that is, you know, as Deirdre Mylod, my colleague, said, "It is the opposite of learned helplessness." It is actually hardwiring group efficacy. So this is social capital, and it is really different. If this is what it -- You know, it means individuals have to give up some of their individual autonomy so that the group can be flexible enough to deal with the BANI world, where things are just completely unpredictable. This is, I think, what Houston Methodist taught me and many other people, is that the high reliability, HRO stuff, helps you deal with crisis and uncertainty. This, by extension, social capital, helps you deal with the BANI world.

DR. SCHAAL: 26:50

And social capital, you said the norms and the enforcement. What is the role of the leader? You talked about the peers enforcing this culture, if you will, or these norms, but what's the role of a leader in that environment?

DR. LEE: 27:06

Well, you know, I think the leader has to be good in all the ways that we know. You know, they have to articulate the right values. They have to be trustworthy. And I actually feel that Frances Frei's simple framework for trust is simple and useful. For the listeners, that's F-R-E-I. And it's a simple framework. You've got to be authentic, you've got to have empathy, and then you've got to have a plan. You've got to be capable. And she calls it logic. But then you not only have to be those things, you have to be transparent so they know that. You know, you need all three of those things. Like, if you're empathetic and you're authentic but you don't have a plan, people aren't going to trust you. And if you're empathetic but no one knows you're empathetic, they're not going to trust you. But I feel that, all right, so the leader is very important. But where the real action is, is do the managers, all the way down to front line managers, do they get it? Do they get -- What I've been saying is they should be like the CFO for social capital and have the same intensity and discipline as the CFO does for money, for building teamwork and respect and connections, enforcing the norms in their groups at the front line.

DR. SCHAAL: 28:32

And I heard you say that when I was listening to your talks. And I wanted to ask, how do we make sure -- because the manager level in the organization is pretty far away from senior leaders -- but how do we make sure that managers get it, that managers do it? Because I completely agree with you. These are the people that have the widest influence in numbers and in contact with our team members, our front line team members. So how do we make sure that the managers get it?

DR. LEE: 29:04

Yeah, well, I think it's work. And I can tell you there are many systems with terrific leaders in the C-suite. And they have a good team in the C-suite. They're very close with each other. And the next layer down is very much in tune with them. But then after that, it's the Wild West. And it's the bar scene in <i>Star Wars</i>, where everyone is completely different and so on. And in those organizations, you will often see the front line people admire the senior leaders, but they don't feel that good about the person that they're reporting to, and so on. There are other syndromes where people feel relatively good about their managers, but they do not trust the senior leaders. I think the way you do it is you measure. You look at data. This isn't a Press Ganey sales pitch. This is common sense, I think. And there is -- every organization should be looking at their social fabric and seeing where they're weaker. Because everyone's got a fabric. Houston Methodist has multiple sites. It's not going to be strong everywhere, in every site. And that is -- So looking for where trust is vulnerable, teamwork, safety culture, you know like, the ability of people to speak up. I feel very good about your impact at Houston Methodist from what I've seen from afar. Physicians were not as engaged in the organization's culture as the rest of the employees. And even though it wasn't terrible, my take from afar is that you were part of -- bringing you in and the work you've led has -- the fabric was not as strong for physicians. Now it's very strong. DR. SCHAAL: Yes. And I love that fabric kind of metaphor, that there are things that interact with each other, and we cannot be strong everywhere. But we need to know the weakest points, or where we are vulnerable, or where the fabric -- maybe there's a hole forming in the fabric. And why don't we identify it and then get to it? You know, Dr. Lee, it's wonderful to talk to you. You're so smart and inspiring. And I do want to ask you the last question that I ask all my guests here in this podcast, which is, what does quality mean to you? Oh, well, I will say that if I'm doing things which impress my three daughters and my wife, that means I'm on the right track. And I can tell you that when my oldest daughter became an intern at the Brigham, where I see my patients, and my wife is a doctor at the Brigham too, one night after she'd seen some of my patients as a walk-in, she emailed my wife and said,"Mommy, Daddy's notes are kind of short." And after that, oh, my God, the quality of my notes instantly got better. And then I started saying, the goal isn't to treat everyone like they're a member of your family, the goal is to treat everyone as if a member of your family was watching you. So that was my cute little joke related to my daughter coming in. But I do think it is related to social capital. If you really have good relationships with your colleagues and you don't want to disappoint them, that will -- you're going to be on the right track. I saw patients this morning, and I really feel I try to do a good job. But to tell you the truth, I feel like I am performing for the people on the team who are there, you know, the medical assistants, the clerk out front. Because if I'm doing a good job, they're going to think I'm wonderful. If I'm not doing a good job, they will feel it. They will know it. And so I, to a certain extent, if my colleagues feel like care is good, we're on the right track.

DR. SCHAAL: 33:42

Fantastic. And I absolutely love the fact that every time I ask the question, everyone answers in a different way. You have three daughters. I have four daughters, so even more pressure to you know, perform and impress. But this idea that somebody is watching -- and that's why, by the way, I love academic medicine, because a lot of times we are not alone in the room with a patient. There's somebody, usually younger, representing the next generation and the future of medicine, watching us. And that encourages us to become better. So I love that. Thank you, Dr. Lee. You've been a fantastic, fascinating conversation.

DR. LEE: 34:26

Thank you. I look forward to much, much more for many years to come.

DR. SCHAAL: 34:32

And thank you for listening. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. I appreciate your support. Thank you. And until next time, I am always listening.