The Exec: 'Leadership Needs to Listen'

Establishing effective communication is crucial in leading a large health system, the chief medical officer of AdventHealth says.

At large health systems, it is essential to bridge the gap between the corporate leadership and the frontline, says Brent Box, MD, senior vice president and CMO at AdventHealth.

Box has been SVP and CMO of the Altamonte Springs, Florida–based health system since February 2018. His prior leadership experience includes serving as the health system's senior medical director and chief of hospital medicine.

HealthLeaders recently talked with Box about a range of issues, including the challenges of serving as CMO of a large health system, care transformation initiatives, and the keys to success in hospital medicine. The following transcript of that conversation has been edited for clarity and brevity.

HealthLeaders: AdventHealth is a large health system with more than 1,200 care sites, including 51 hospitals in nine states. What are the primary challenges of serving as CMO of such a large health system?

Brent Box: The biggest challenge is we are large and have significant diversity in the size and scope of the services we provide to the different communities we serve. For example, in Orlando, Florida, we have more than 1,000 beds in a group of facilities, but we also have rural hospitals with less than 70 beds. So, there is a difference in the work that we do in different communities.

What we have done at AdventHealth is we are highly focused on safety and quality. So, despite the diversity, you must have common goals. We have common goals for our acute care facilities. Particularly with the Centers for Medicare & Medicaid Services (CMS) star ratings, we want every hospital to be four or five stars. We want all of our facilities to earn an "A" from Leapfrog, and we want all of our facilities to be in the top quartile for mortality. We want to meet external measures and pay continuous attention to the data and information you must have for our leadership teams to make decisions and achieve improvements.

There are other challenges.

First, communication is a challenge. We are a large organization geographically. There is a lot of space between leadership and the frontline, particularly leadership at the corporate level and the frontline. So, we need to make sure that communication avenues are open bi-directionally and effectively. Leadership needs to listen. We need to make sure we know who the operators are in terms of the folks who are taking care of patients in the markets, and we need to listen to their expertise as we make decisions.

Second, we need to be intentional about not working in siloes. It is easy to have siloes in a large organization. We work hard at building partnerships—such as partnerships between the markets, partnerships between the clinical staff and supply chain, and partnerships between the clinical staff and marketing. We are always working hard to be on the same page.

HL: Since coming to AdventHealth, are there initiatives or programs that you are particularly proud of?

Box: When I first came to AdventHealth, my job was in hospital medicine. We have a large number of hospitals across the footprint of AdventHealth, and organizing hospitalists and working toward common clinical improvement goals is something I am very proud of.

We started a clinical excellence program, which is our effort to achieve improvement in CMS stars ratings and mortality.

I am very proud of the work we did in COVID-19 care. This is a large organization, and we came together in ways that we had never come together before. We achieved some great clinical results treating a disease that we knew nothing about initially.

Finally, we have been rolling out a high reliability program for about four years. We call it HRO-Unit Culture. The program gives voice to our teams at the frontline to improve care and achieve reliability in the care that we provide. It is about the culture you need to have at the unit level to achieve high reliability.

HL: Give examples of care transformation initiatives that you have worked on.

Box: We have a sepsis initiative. Sepsis is one of the highest volume diagnoses, particularly when it comes to mortality and cost of care. We are working on a systemwide effort to reduce morbidity and mortality by improving early recognition of sepsis and early intervention. As a health system, we are already top quartile in sepsis mortality, but we believe this is an area we can focus on to save lives. All of our facilities are working on a sepsis plan, order set usage, and achieving compliance with the SEP-1 bundle.

We are also working on length of stay for two reasons. First, it is about the clinical care that you provide as well as the effectiveness and efficiency of the care. Second, it is also a marker of value. The length of stay initiative involves boosting teamwork; working with our care managers, nursing teams, and physicians; and providing interdisciplinary care that is more effective and efficient.

Brent Box, MD, senior vice president and CMO at AdventHealth. Photo courtesy of AdventHealth.

HL: What are the keys to success in hospital medicine?

Box: Hospital medicine is a particular interest for me because I spent several years as a hospitalist as part of my clinical career. We have more than 800 hospitalists across our system, and they take care of 80% of our hospital patients. There are four keys to hospital medicine:

1. We must have a common "why" across our system. When I started working at the corporate level in 2016, the "why" became that we wanted every patient attended to by our hospitalists to receive the best clinical care, we wanted patients to have great communication and coordination of healthcare services, and we wanted it all done with uncommon compassion.

2.  We also focused on the fact that every patient deserves a "captain of the ship." We lifted up our hospitalists as the captain of the ship for their patients.

3.  We have spent a lot of time over the past five or six years developing hospital medicine leaders. We have a yearlong hospital medicine leadership program to develop leaders to align with our system goals.

4. We have common measurements for success. Across AdventHealth, all of our hospitalists and hospital medicine leaders know what the measurements are, they know what they are after, and they synchronize with our clinical agenda.

HL: What are the primary elements of achieving high clinical quality at AdventHealth?

Box: We have had a consistent strategy for achieving high clinical quality. We have a recognition that good healthcare is the continuum of care. It is not just what happens in the four walls of the hospital—it also involves the primary care clinics, the ambulatory care arena, the emergency departments, and post-acute facilities.

To achieve excellence, we feel we need four other things—three of them are pillars and the fourth is an undergirding process:

1. A good infrastructure. For example, we need to have a systemwide electronic medical record. (Editor’s note: Box explained AdventHealth is about 85% of the way through rolling out Epic as an organization.)
    
2.  Good data. We have been focused on data and analytics as well as understanding that we need to communicate data and help leaders across the health system use data to achieve improvement.
    

3.  Clear systemwide goals for mortality and trying to be the safest healthcare organization in America. So, we want to reduce measurable harm and reduce unnecessary variation.

Undergirding those three structural elements in our strategy, we want to recognize that clinical culture is extremely important in achieving high reliability. That's our HRO-Unit Culture program.

One more thing is you must have committed leadership at every level to achieve high clinical quality, and we have that here.

HL: You have a clinical background in internal medicine. How has this clinical background helped you serve in physician leadership roles such as CMO?

Box: I spent more than 20 years in direct patient care before I came to AdventHealth—some of that was in private practice and hospital medicine. That experience grounded me in what it takes to provide good care to patients. When you spend time taking care of patients, you learn that often the work is long, the work is hard, and the work is exceptionally rewarding. That experience is key to leading clinical care teams because it is hard to lead unless you have been there and done it. 

HL: You have served in medical education roles. What are the qualities of a good medical educator?

Box: You must know your subject; and more than that, you must be willing to spend time preparing to teach. You must [also] have a passion for teaching. Not everybody has a passion for teaching, and the best teachers are passionate. They are passionate about cultivating curiosity.

Finally, a good medical educator must be patient and must start with the belief that you are building the caregivers of the future … so you must constantly both educate and build up students to be great clinicians.

Related: The Exec: Transparent Leadership Crucial Element in Physician Engagement