Health System CEO: You Can't Lead from Behind the Curtain

Regional Health's CEO discovered he couldn't just pull levers and push buttons to get clinicians to change practice patterns aimed at reducing sepsis mortality. Instead, he had to get out and lead that change.

This article first appeared in the December 2014 issue of HealthLeaders magazine.

As president and CEO of Regional Health for the past 10 years, Charles Hart, MD, thought he had a good relationship with physicians at the rural South Dakota health system, which has five adult hospitals, two specialty hospitals, and 24 clinics. He's one of them, after all, and that is a good thing when you're trying to get them to change practice patterns. You speak their language. Hart is something of an institution himself, having led the system for the first decade of its existence after having been associated with the system and its flagship, 329-bed Rapid City Regional Hospital, for the past 31 years. But all that goodwill and familiarity still wasn't enough.

But when the leadership set about trying to address the organization's greatest cause of mortality—sepsis—Hart found that meetings, evidence, and cajoling didn't work very well. After all, sepsis wasn't a problem that could be traced to one person or even one department.

"It doesn't live in one place within the organization like coronary artery disease or orthopedics or total joints," Hart says. "It's just everywhere." Sepsis is a problem in most inpatient organizations where patients must remain attached to IVs, catheters, ventilators, or other places deadly germs can lurk.

Which can mean that it's everyone's problem, and also no one's.

Hart and his leadership team decided to attack the problem through the practice patterns and care protocols of Regional Health's nurses and physicians. But they found they had trouble convincing staff that changes could make a difference in mortality and hospital stays. Clinicians didn't really know what they were doing suboptimally, says Hart. Without faith that any changes would be helpful, getting buy-in became the fulcrum on whether the system would be able to improve on this important metric, which increases mortality, unnecessarily extends hospital stays, and contributes to patient misery and even mortality.

And that's where Hart recognized a problem with the way he, as a leader of the organization, was approaching the issue. Running a large organization is sometimes like being the Wizard of Oz, he says. Others in the organization can't necessarily see all the levers he's pulling and buttons he's pushing. So he made sepsis an organization-wide target, and took on the problem personally by visiting sites of care frequently and asking questions about problems with the guidelines or their implementation.

"Our highest cause of mortality and our highest cost per patient was sepsis," he says. "But as CEO, you find out that you can't hide behind the curtain."

Instead, leaders have to get out there and deliver the message about why it's so important and how to drop incidence of sepsis.

A key is to find an improvement tool that you feel comfortable with and "live" that tool, he says. For Regional Health, that tool is Lean, borrowed from auto manufacturing giant Toyota Motor Company but since used successfully by many healthcare organizations to cut down on waste, duplication, and mistakes.

The hard part: engaging physicians

"The hardest group for us to bring on board were the physicians," Hart says. "But once we got them involved in some of these initiatives and they began to see the differences they could make, it really helped spark some confidence."

Strict adherence to evidence-based care protocols has made a huge difference. "We cut the cost of care probably 30%, and we cut our mortality 10%," he says.

Getting physicians and nurses to believe the changes would make a difference was the key to obtaining good results, says Hart. He says earlier successes with Lean process management set the groundwork for physician buy-in with sepsis protocols.

"The cultural change was when the physicians saw the differences we made [in other areas with Lean]. That was what got them engaged."

"They said, 'Hey, we can do this [with sepsis],' and that created the cultural change," says Hart, who will retire in January 2015. "I'm looking out from behind that curtain now, and seeing that they are going down the yellow brick road and they're doing the work."

For Hart, the success with sepsis was also a reminder that leadership decisions can't be made and executed in a vacuum. Leaders have to get to those who are doing the work and solve issues that crop up quickly. That is, the CEO has to be there in person. Not at every moment, but staff has to know he or she is there to help solve problems that inevitably interfere with implementation.

"What has made a difference for me personally is getting to the floors and bedsides to observe the processes and interacting with the doctors, nurses, and ancillary staff," he says. "Do they understand these new processes and protocols? Are there barriers we could remove? What works and what doesn't work? These interactions have been invaluable to great buy-in."

And as importantly, invaluable in teaching the CEO a lesson of his own.