Four health system CEOs from different parts of the country weigh in on the most important thing they do, the biggest challenges they've faced in the past year, the complexities of healthcare technology and what in healthcare is most in need of change.
Participants
Steven Altschuler, MD, CEO of Children's Hospital of Philadelphia
Steven Safyer, MD, president and CEO of Montefiore in New York City
Warner Thomas, president and CEO of New Orleans-based Ochsner Health System
Dan Wolterman, president and CEO of Houston-based Memorial Hermann
Question: What is the most important thing a hospital or health system CEO can do today?
Dr. Steven Altschuler: When people talk about what makes a leader great — and I think this is especially true when they are referring to CEOs — they talk about the leader's ability to simultaneously manage the present, selectively forget the past and create the future. We know there is change on the horizon. The change is probably not moving as quickly as we once thought it would, based on the [Patient Protection and] Affordable Care Act and other forces, but there's definitely a need to focus on the work underway today while at the same time understanding what the future might hold for the organization. 
Dr. Steven Safyer: At Montefiore, our most important focus is the patients and their families, and the patient experience is our first priority. This means tending to [patients'] medical needs as well as their mental health and social needs, treating the whole person. Montefiore physicians, nurses and others on the care team have always responded to our patients' needs in innovative ways. We incorporate that emphasis on the patient experience at our Centers of Excellence in cardiovascular services, oncology, transplantation and pediatrics, offering multidisciplinary expertise and well-coordinated care. We foster and vigilantly work to support a culture and environment in which all Montefiore associates can succeed in providing an optimal patient experience.
Warner Thomas: The most important thing a hospital or health system CEO can do is create a clear strategic direction for their organization and make sure it's properly communicated to the board, management and employees — and that it is fully understood throughout the organization. As CEO, my job is to lead the team.
The CEO also has to set the tone for the culture of the organization and the expectations within the organization. At Ochsner, we always talk about patients first in everything we do. We started our Power of One communications initiative to remind every employee that each one of us makes a difference and that each one of us plays an important role, no matter what your job title, in how we take care of our patients.
Dan Wolterman: The most critical thing an executive leader can do is set a clear and compelling vision with easy-to-understand strategic initiatives. All constituencies, including employees, physicians, boards and the community, should clearly understand where our system is going and how it will get there — that's the most critical thing.
Q: What has been the biggest challenge for you or your organization in the past year? How are you overcoming it?
SA: The biggest challenge for CHOP is keeping up with the demand for our services. One of the things that sets us apart is that we are much more than a hospital – we are an integrated pediatric healthcare delivery system that attracts patients from throughout our region, across the country and around the world. We offer very high-end, specialized quaternary pediatric healthcare services, and there is great demand for those services — especially for things like in utero surgeries and unique cancer therapies. Keeping up with this demand has been our greatest challenge, but it has also kept us operationally and financially healthy.
We're in the midst of a very large construction program, with about $2.5 billion invested over the next seven years. The ability to manage that type of construction and development and pace of growth is a challenge. CHOP has invested more than $1 billion in construction on our main campus — hundreds of millions in facilities in our Care Network, investments in IT and other infrastructure.
Our Care Network is an important part of our growth strategy, and one way we build the network is by forming relationships with providers in our region. Right now we're evaluating six new relationships with other community providers that we could potentially include in our network.
SS: Opportunities arise out of challenges; once you understand that, you can embrace them as vehicles of change. Our most recent challenge has been the expansion of our health system. The addition of two new hospitals, a freestanding emergency department, a nursing home and range of ambulatory services has created a broader geographic reach, transforming our entire system.
In addition, a redefined relationship with our academic partner, the Albert Einstein College of Medicine, is enhancing our ability to respond to changing healthcare and medical education landscapes. Over the past several years, the partnership has enabled us to recruit the nation's leading clinicians, scientists and researchers, so that we may offer the most advanced bench to bedside treatment for our patients. The new relationship, in which we will play a more active role in daily operations, ultimately strengthens each institution.
Our continuing growth is certain to bring new challenges. We must support our strategic expansion and maintain our successful model while integrating best practices that exist in the new institutions.
WT: Like everyone in our industry, we are managing a significant amount of change as we aggressively transform from volume to value. Managing this change, such as the impact health exchanges, innovation and technology will have on the industry, can be challenging for both the management team and for the employee base. We have to make sure we understand the change and can communicate how we intend to address it.
That's why it's important to have the right people in our organization…and the right people in the right positions. Our leaders need to be good at managing change and being master communicators. If not, you have to make the appropriate adjustments to ensure success.
DW: We're blessed at Memorial Hermann to be in the wonderful market of Houston. We are in a strong, vibrant economy with the population growing by more than 1 million people every eight years. Our biggest challenge is capital allocation among many worthy strategic initiatives. We have to grow our system since most of our hospitals are full every day. How do we continue to provide needed services to the community and grow with the community during these changing times?
This is a unique characteristic of the Houston market; the hottest economy in the U.S. for the last five years. Is that a long-term phenomenon? Probably not, but Houston has a population of about 6.5 million people, soon to be 7 million. So when I say resource allocation, it includes both capital and people. How do we attract and retain the best people, particularly clinical personnel, when there is such a shortage of them?
Q: What are some unique circumstances facing your organization? Are any especially helpful or thwarting?
SA: We do have a good payer mix for a children's hospital, but we serve patients in southeastern Pennsylvania and from at least two states that border our Main Campus — New Jersey and Delaware. All have different Medicaid plans and different Medicaid managed care players, and some of these plans are difficult to maintain relationships with. I think that's definitely a challenge.
SS: As the national healthcare system shifts, we are in a unique situation to support our way of providing care. Montefiore was an accountable care organization before ACOs existed to manage our patients' chronic conditions and keep them out of the hospital. This has been Montefiore's model and we know from experience, including having the best performance of 32 Pioneer ACOs in the first year of the program, that the model works. We embrace the opportunity to be accountable for the quality of our care, our patient outcomes and the cost of our care.
WT: In Louisiana, we have a fairly large indigent population and a significant amount of chronic disease such as diabetes, stroke and heart disease. As the largest nonprofit healthcare provider in the state, it's extremely important to us that we play a major role in improving the health of the communities we serve as well as helping the state address the health challenges of the overall population.
Additionally, one of the unique things about Ochsner is that we play an important role in each of the Southeast Louisiana communities where we are located, and at the same time, we are a regional and national referral center taking care of people from across the country. Managing the process of serving our local areas with the highest quality care while also ensuring access to the same for patients who come to us from out of state can be a unique situation.
We are fortunate, however, to have so many people who count on us and significant demand for our services — as well as playing an important role in our communities.
DW: Something we've been dealing with for 15 years is the poor payer mix. Texas, for years, has led the country in the amount of uninsured individuals. Houston is about 34 percent uninsured. The uninsured problem is compounded by the state of Texas' decision not to expand Medicaid and the PPACA prohibition of selling insurance to undocumented individuals. Houston is estimated to have 16 to 18 percent of its population as uninsured, undocumented individuals. Even if the state of Texas expanded Medicaid, and the PPACA worked wonderfully well, we would still have to deal with 16 to 18 percent of the patient population having no ability to pay. This demographic creates a unique challenge for our system's vision of population health; specifically, how do we keep all these people healthy and well when they have no access to healthcare? We don't see this challenge going away. It's something we grapple with every day.
Q: What in healthcare remains difficult despite new advances in technology? What challenges will likely persist even while technology continues to progress?
SA: Technology can really be very, very helpful in healthcare. Certainly technology can lead to improvements in patient safety and quality and enhance communications with patients and between different providers within the care team. The implementation of technology, though, always involves changing the way you do the work.
I'm a physician by training. When I was training, we'd sit with the patient, do the history, make eye contact and record notes while talking with the patient. Today, if you have an EMR in the hospital, most history is done on the computer. Physicians look at the computer screen instead of at the patient. That is something that has struck me — a very simple thing. Although technology is critically important, it does change relationships between healthcare providers and patients. We have to consider that as we think about how we design exam rooms, how we make rounds and how we communicate with patients.
SS: Montefiore was an early adopter of EHRs to link our broad network of hospitals and ambulatory centers throughout the community and provide the best possible healthcare to a wide and diverse population. We embarked on a multiyear adoption of Epic this year after careful analysis of our current systems and our future trajectory in order to drive optimum patient outcomes. Our challenge is to successfully support a massive IT restructuring while maintaining a high level of care delivery throughout our system. Technology is a great enabler. We use technology to identify those most at risk to manage their chronic conditions and therefore coordinate and ensure the safest possible care.
WT: I think the key is figuring out how to use technology to optimize interaction with our patients. We try to engage and build relationships with patients not just when they're in our clinics and hospitals, but when they're not being seen, as well. Epic, our electronic health record, is a great example of using technology to enable patients to take a more active role in their healthcare, whether through online appointments and prescription refills, interfacing with physicians easier or accessing clinical notes. We also have a strong telemedicine network throughout our state to allow patients to access high-quality care no matter where they are.
I think we can learn from other industries how to use technology to build stronger relationships with our patients, too. If you look at Amazon, for example, they are constantly trying to build a relationship with their customers, whether they are buying or not. They send suggestions to them, they put potential items in front of them based on their history. There is a lot to be learned from that success.
We do still find it challenging to know everything that's happening with a patient because some still seek services with other systems. It is critically important for our providers to understand the complete picture of a patient's health so that we can deliver the highest quality care and a great patient experience.
DW: The first thing that strikes me is how do we pay for all this emerging new technology? It's wonderful, it is making lives easier, but there is a significant cost to it at the time when we are trying to bring the cost of healthcare down. We really have to challenge efficacy of technology. Does it reduce cost or improve health? A big challenge is how do we afford technology going forward in the current configuration of the healthcare system? I'm not optimistic about that.
Where is technology underutilized? To me it's prevention, wellness and early detection — where you have biggest potential savings. Yes, we've made progress, but there is so much more we could do. When people have genetic predispositions, how do we intervene and keep it from materializing? We also haven't done enough to eradicate infectious disease. Every time we seem to get on top of it, some new infectious disease pops up.
Q: When was the last time you found yourself really, genuinely excited about something? Why was this moment particularly thrilling?
SA: Diseases caused by genetic abnormalities are very common in pediatrics and impact a large portion of our patients. Over the last 15 to 20 years, we've been working on gene therapy technology that uses viral vector to replace a defective gene in a certain part of the body and restore function. One particularly exciting area of this work has focused on a congenital form of blindness. You use an attenuated virus and basically engineer this virus to carry the corrective gene. You place the vector with the corrective gene in the retina and restore the patient's sight. That's pretty exciting in its own right.
SS: Montefiore is a special place and I've been lucky enough to spend my professional career here. Every day brings something new and exciting. I'm particularly looking forward to the upcoming opening of our new ambulatory center, the Hutch Metro Center. This "hospital without beds" is certain to be a model for the future delivery of care. "The Hutch" will have a beautiful, patient-centered space featuring multidisciplinary approaches to primary, specialty and sub-specialty care.
WT: I was genuinely excited just last week at Ochsner's Power of One Employee Experience meeting. The Power of One is Ochsner's communications platform and our Employee Experiences bring together hundreds of employees from across our system together in one place. In one day, I got to spend time with 2,000 fantastic employees, educating them on developments in the healthcare industry and also energizing them for the future. It's so exciting to see how committed they are to our patients. It is really uplifting and exhilarating to have the opportunity to lead such a great team. It gives me great energy.
DW: The last excitement was probably just a month ago when we concluded our fiscal year, and it wasn't that we hit an all-time record financial performance, but that six of our hospitals went a whole year without a serious safety event.
We set out in 2006 to become the country's first high reliability [healthcare] organization. We wanted to emulate other industries where we caused no harm to our customers. We studied other industries that are highly reliable, like commercial aviation and nuclear energy. Instead of trying to reinvent what we do, we adopted many practices from those industries and applied them to healthcare. When you look at our performance on hospital-acquired conditions, serious safety events — whatever you want to pick — we're clearly in the top 5 percent if not 1 percent across the board. We want to be the first health system to achieve zeroes across the board on all hospital acquired conditions and serious safety events.
Q: What should we in healthcare spend more time solving, discussing or investigating? What is most in need of innovation?
SA: If you look at where healthcare is going, everyone talks about value-based healthcare: the notion of high-quality care at an appropriate cost. But when you really take a close look at it, I think the industry has been focused solely on cost, with quality really being an afterthought. The big move among insurance companies now is the creation of narrow networks, which is in effect saying, "We'll offer you a less expensive insurance product if you sign up for a much narrower scope of providers." This issue is critical to pediatric healthcare. You may have heard that in Seattle, there were a number of health insurance exchange products offered in the state — and all excluded Seattle Children's Hospital. Seattle Children's is now suing the state health commissioner.
Are we really moving toward value-based healthcare, or are we just moving to a system that will have cost as its only criterion and will try to exclude providers of care and providers of very specialized care that are important in communities? You can imagine that when you have high-tech children's hospitals, the cost of care will be higher. But for certain types of care, those high-tech hospitals are where you'll have the best outcomes. A value-based system has to take into consideration both the cost and the quality of the care provided. If it is only focused on cost, then you are not developing a true value-based system.
SS: Leaders across disciplines need to focus on chronic disease, socioeconomic determinants of health and workforce development. It might sound like these issues aren't related, but they are intricately tied to the future success of our country. We are tackling these issues head on because we see them day in and day out in our community. We have community outreach and population health resources dedicated to moving the needle on chronic disease through wellness initiatives, antismoking campaigns, and screening and treatment events. We provide access to healthcare to those who need it through a network of more than 170 locations across the region, including the largest school health program in the nation and a home health program.
We understand the relationship of poverty and health and work to ameliorate the challenges of housing, homelessness and transportation that our patients experience. As the largest employer in the Bronx, we take meaningful responsibility to support education and job training programs that will fuel the future healthcare workforce. Our efforts cannot stand alone and need to be magnified on a broader scale. We work with our partners in academia, private, nonprofit and government sectors to create a space for this to happen, but more work is needed in these areas.
WT: We need to focus on reinforcing people's personal commitments to leading healthy lifestyles and giving them the information and assistance needed to keep them engaged. We need to make sure delivery systems and payment mechanisms are modified to provide the right payment and incentives to ensure providers are working with their patients to help them live healthier lifestyles. Currently, many payment mechanisms are not structured to provide innovation in the way we take care of patients to help them stay healthy.
We will continue to have challenges in healthcare until we have a broader portion of the population actively leading a healthy lifestyle.
DW: I do not see any real progress in truly reforming the healthcare system in this country. The PPACA goes after health insurance reform. That was a necessary step, but we are not reforming the delivery of healthcare and changing the incentives in the system so we can bring costs down and make it more affordable to all people, including patients, governments and employers. What we need to focus on is changing our delivery system and how we finance it so we are more incentivized to keep people healthy and treat chronic disease more aggressively instead of waiting until they get acutely ill.
As a country, we have to bring our costs per capita down to where the rest of the industrialized countries are; not spend double what every other country spends. There are pockets of success on an experimental basis, but as a country we seem to have no appetite for significantly reforming the financing and delivery of healthcare.