Anne Ponder knows complexity. As chancellor of the University of North Carolina at Asheville for nearly a decade, she led the intricate enterprise of a modern university, with its diverse stakeholders, revenues and goals.
Yet she remembers her first meeting on the Mission Health board of directors with acute clarity. The terminology, benchmarks, trends, strategies and challenges of the $1.6 billion, nonprofit, six-hospital system were foreign to her. And the gravity of the health system’s mission struck her immediately — it’s the only tertiary care system in 18 counties, with 1 million people relying on it despite shrinking reimbursements and an aging population. Ponder recalls: "I realized immediately I needed to become a student of health care in order to be an effective board member. And there was so much to learn."
Scott Hickman, another Mission board member, has deep experience with technology and complex systems. The Stanford-trained engineer’s first job was selling uranium on global markets. After two years at Harvard Business School, he ran a major tech firm’s operations across Eastern Europe, and then became CEO of a manufacturing firm.
Hickman feels a need to fully understand any important task that’s given to him, he says, but the complexities facing Mission every day were hard to comprehend. “In manufacturing, you cannot understand the business without first spending time on the production floor," Hickman explains. "Otherwise, you can't grasp the associated challenges and opportunities."
Show the board
Mission’s CEO, Ronald Paulus M.D., has been recognized for strengthening Mission's financial health despite a daunting payer mix, and for earning Mission a spot on the Truven 15 Top Health Systems list four years in a row, beginning in 2012. Nevertheless, he had trouble explaining some of Mission’s challenges to the board in spring 2013, such as the difficulty in moving emergency department patients from triage to admitted beds in less than 6.5 hours and in starting 30-plus operating rooms on time each morning. Even plans for surviving $400 million in new government payer cuts announced that year are hard to understand for those who don’t live it daily. After Paulus’ presentation, one board member said, “Why can’t you just leverage your software, optimize your algorithms, use Lean production techniques and maximize your throughput?”
As a vascular surgeon and longtime board member, I tried to help Paulus explain that it just wasn’t that simple. But we struggled to describe why. Then, in an epiphany that seems obvious in retrospect, we realized that we could simply show our board. We could take them deep into the hospital and let them see for themselves why Peter Drucker (the father of modern management) called it “the most complex human organization ever devised.”
After all, our board members were some of the most insightful and experienced leaders in our region. But they came from other fields: banking, law, manufacturing, education, philanthropy. And their exposure to health care derived from meetings, PowerPoint slides, spreadsheets, and — in the vacuum left by the absence of direct observation — perhaps even Hollywood.
First Immersion Day
Two weeks later, Hickman agreed to become our experimental subject in what we soon named "Immersion Day.” We began at 7 a.m. in Mission’s 770-bed flagship hospital, signed documents assuring HIPAA compliance and changed into scrubs. We walked together to pre-op, where Hickman met a patient being prepared for major aortic bypass surgery. He followed into the operating room, where he saw the “safety timeout" he'd heard about at board meetings: Before the incision, the entire surgical team stopped to confirm that they were performing the right procedure, on the right patient, and with the right preparation, positioning, and patient-specific planning and precautions. He watched nurses, doctors, anesthetists, lab and radiology techs, support staff and managers do their parts in practiced choreography as the surgery proceeded.
We moved next to cardiac surgery, where Hickman stood 2 feet away as surgeons stopped a man’s heart and placed it on bypass. He saw da Vinci robots help urologists preserve nerves while excising cancer, and he saw his finance committee’s spreadsheet entry for supplies come alive in the central core as he strolled along aisle after aisle of implants destined to replace aortas, spines, hips, knees, heart valves, corneas, bladders, hernias and skin.
Next, we walked to the intensive care units, where Hickman saw how poverty, substance abuse and just bad luck can leave anyone fighting for life. He learned why care can be so expensive and caregiving so draining. He watched as a trauma surgeon struggled with the electronic health record as alarm chimes, pages and urgent phone calls peppered him. And he listened along with palliative care doctors as the family of an elderly woman made the sad but loving decision to withdraw now-futile care.
We stopped at the Remote Patient Observer Center, Mission’s futuristic and high-tech innovation that seeks to prevent falls among patients at risk. Next, Hickman talked with a man while he underwent dialysis, surrounded by awesome technology and receiving intensive care from a highly trained team of nurses. Hickman remarked that witnessing this scene helped to explain why kidney failure now consumes 10 percent of Medicare’s entire budget. Then, on another floor, he watched interventional neuroradiologists guide wires, catheters and coils into the brain of a woman with a cerebral aneurysm.
As Asheville’s rush hour gave way to Friday night, we entered the ED through its public entrance doors. From the triage desk to the major trauma resuscitation room, the team showed Hickman how wildly inaccurate the TV dramas are. Mission’s staff tamed chaos with calm and professionalism as they intubated an overdosing teenager, broke the news of advanced cancer to an elderly man in the next bay, and then soothingly and painlessly set the leg fracture of a child with congenitally brittle bones.
Immersion Day today
Ponder's Immersion Day was just months ago. The program had grown to include deep exposure to our behavioral health program and the societal challenges it bears. Ponder saw firsthand how mental illness, substance abuse, homelessness and shrinking resources combine to place huge stresses on patients and on our ED and inpatient resources.
"I found my Immersion Day both informative and moving," she relates. "At every turn, I saw boardroom concepts come to life: quality of care for patients, quality of life for physicians, futile care. Our patients were older, sicker and poorer in aggregate than I'd imagined, and Mission's tenuous stream of resources seemed fragile. The experience deepened my understanding and commitment to board service."
The program also has expanded beyond board members: Paulus and Senior Vice President Rowena Buffett Timms designed an Immersion Day for a Gannett newspaper journalist, who spent weeks inside the health system and produced a landmark,17-article series that explained Mission’s challenges and mission better than any paid public relations campaign ever could. Key policymakers have spent Immersion Days with us, too, including state senators, representatives and a cabinet secretary.
Insight and collaboration
Now that almost every board member has completed the program, what changes has it brought to Mission’s board? Although it’s naturally difficult to quantify, executives and board members agree that their experience put a face on Mission’s need for facility expansion and was an instrumental factor in the board’s decision to approve construction of the $404 million Mission Hospital for Advanced Medicine, a main campus replacement tower. Paralleling the addition of behavioral health to the Immersion Day experience, the board is also moving toward funding and building a separate psychiatric hospital. And board members’ close-up exposure to caregivers in the trenches brought the empathy to support Paulus’ novel burnout-fighting program, Mission: reNew.
One effect that Mission’s executive leaders don’t see is any desire on the part of board members to become more involved in operations rather than governance and strategy. Perhaps counterintuitively, it seems that once board members understand how complicated the delivery of care is today, they come to appreciate even more the skill and expertise of management — and to leave operations to the management team.
The benefit of immersion for boards seems to be the focus it brings to strategic planning, the experience and authority it gives to board members when they advocate for the system, and the bonding that forms between board and management as both face the stress and rapid change of modern care delivery.
Health system boards have been slow to incorporate the best practices exhibited by large, publicly traded companies. Home Depot, General Electric and many others require that board members spend several days each year embedded in operations. Given the fact that even medium-sized health systems like Mission are now large, financially complex enterprises, it’s become essential that they catch up with modern governance strategies.
The Mission website explains that its board of directors “bears the ultimate authority and accountability for everything Mission Health does.” That’s an awesome responsibility. Now, with the Immersion Day program, board members like Ponder and Hickman more fully appreciate the challenges faced by management, and they feel energized and confident in contributing to their community as members of a high-functioning board.
Their CEO agrees: "Immersion Day brings a life-changing experience that grows trust between the community, staff and physicians, while offering policymakers a new way to better understand health care," says Paulus. "The results are transformative."
There are a number of concerns commonly raised about health care system board immersion. Here are some of them and some responses:
Finding the time: In three years, we’ve never had a board member be too busy to schedule an Immersion Day. Even lawmakers make room for full days with us. They realize it’s a once-in-a-lifetime opportunity.
Anticipating something bad: Our board already hears about the really bad stuff. Board meetings can make a trustee forget about the good care delivered in our hospitals every day and, if an untoward event occurs, our board members invariably take it in stride.
Encounters with ”problem doctors”: Every hospital has a few challenging physicians, but they are already known to management and the board. Over dozens of immersions, we haven’t had a single problem with inappropriate “grandstanding.”
Wanting to get into operations: When our board members see how health care is really delivered, they appreciate its complexity more than they ever could through spreadsheets and PowerPoints. They report far less desire to become involved in operations after their immersion experiences.
Interfering with doctors: In our experience, doctors and staff have been uniformly generous with their time and with explaining what they do as they do it. They enjoy the interaction. We’ve even observed an unexpected side benefit to staff morale: Most caregivers have never met a board member. When one shows up in scrubs on a Friday afternoon, it sends a powerful message that our board cares about what we do. Word spreads.
Violating privacy regulations: Board members are an integral part of our health system, and there’s no HIPAA barrier to a well-planned and executed immersion program. Even journalists and policymakers have been properly incorporated into Immersion Days.
Executive Corner: Immersion Day Best Practices
Here are some of the best practices followed by Richard Bock, M.D., of Immersion Advisors in Asheville, N.C., when he conducts an Immersion Day program:
- Meets with health system leadership to understand their goals.
- Drafts immersion plans tailored to the institution.
- Meets with the system's chief medical officer to refine the plans.
- Individualizes standard HIPAA releases and other agreements as needed.
- Communicates directly with medical staff and nursing leadership ahead of time.
- On Immersion Day, prepares, orients and accompanies participants in all hospital areas.
- Conducts debriefings afterward.
- Optionally arranges end-of-day discussions with the CEO and other key leaders — particularly valuable for policymaker immersions.