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EMBRACE AN OUTSIDER’S PERSPECTIVE

Committing to change means immersing yourself in different cultures and embracing an outsider’s perspective.

Why in the world would a Jewish guy from Pittsburgh want to move to the United Arab Emirates to run a hospital? I’m sure some people wondered that in 2011, when I became CEO of Cleveland Clinic’s large multispecialty facility in Abu Dhabi. Four other CEOs had come and gone over the previous five years. As I like to joke, I got offered the job because there were no other leaders at the Clinic left to ask.

And yet, having recently overcome bladder cancer, I wanted a challenge, and this was a big one. When I first arrived in Abu Dhabi, the massive, three-million-square-foot facility was in the early stages of construction. The administrative offices had only just been moved out of a trailer and into something more permanent. Over the next several years, we’d have to complete the building, hire 3,500 people, construct the hospital’s systems, purchase all the necessary equipment, and implement processes that would render our medical operations safe and effective.

Critically, I’d have to lead all of this while operating as an outsider. I’d never been to Abu Dhabi before, and the language, culture, religion, and politics of the region were new to me. This posed an incredible challenge. Because I didn’t know the social etiquette in this culture, I constantly worried about saying something awkward or offensive to my local colleagues and partners. Outside of work, I struggled with simple tasks like buying groceries or ordering in restaurants, as so many of the foods were unfamiliar. Lacking a social network, I was lonely, especially for the first few months until my family arrived. I also felt overwhelmed and isolated. The accommodations I’d been given were perfectly comfortable, but they were located in a hotel across the street from our project. Every window looked out on the construction site— an unsubtle reminder of the enormous task before me.

Despite my initial trepidation, I stayed in the job for five years, overcoming numerous crises and occasional sleepless nights. At one point about a year in, I became so frustrated with the organizational politics that I nearly quit. I can’t convey how hard it was for our team to finish this mammoth project on time and on budget—with the Arab Spring going on, no less—and how challenging it was for me to lead our team while also living eight time zones away from home. And yet, as I became acclimated, I found living and working in Abu Dhabi to be an incredible experience. Despite my many mistakes and stumbles, my Emirati colleagues treated me well, and we developed strong working relationships. My outsider status proved to be a benefit, allowing me to bring a unique perspective to my work and lead the organization in ways that might have been more difficult for insiders.

It’s fashionable today—and absolutely necessary—to call for more diversity in organizations and to understand its business benefits. But when it comes to supercharging an organization’s potential for innovation and growth, that conversation is incomplete. To unleash an organization and its people to drive change, leaders must embrace outsider perspectives more broadly. In addition to pushing diversity and inclusion as one of their top business priorities, leaders should accept that it’s OK for them and other leaders at every level not to belong. They should physically put themselves in the outsider’s role, as I did by accepting the Abu Dhabi assignment and later by coming in from Cleveland Clinic to lead Intermountain. And they should bring outsider perspectives—and actual outsiders—into their ranks with the deliberate purpose of shaking things up.

Let’s be clear: it’s critically important to recognize the invaluable contributions of strong leaders from within the organization and to draw upon the strengths of these individuals. In many cases, insiders can themselves serve as powerful change agents within organizations if given the chance. But leaders have much to gain from drawing on outsider perspectives to help drive progress. The point of promoting outsider viewpoints isn’t to displace insiders. Rather, it’s to unleash all of us—including the organization’s existing leaders—as a powerful force for innovation by helping us to see with fresh eyes.

GIFTS OF THE OUTSIDER

In 2017, we at Intermountain brought in a consummate outsider, making a hire that raised eyebrows and sparked curiosity within Intermountain and in the healthcare industry. We appointed Kevan Mabbutt, formerly global head of consumer insight at Disney, as our chief consumer officer with a mandate to revolutionize our consumer experience. To my knowledge, nobody in healthcare had thought to hire an executive from a big consumer brand to run their marketing function. But I believed Mabbutt was exactly the kind of leader we needed to innovate Intermountain’s already strong offerings, accelerate our evolution into a platform company, and instill a more intense consumer focus and discipline across our organization.

In addition to working at the world’s preeminent consumer-focused company, Mabbutt’s personal profile didn’t fit that of the typical Intermountain leader: he had been born in the United Kingdom, was raised in Zambia, had worked at the BBC and Discovery Channel, and was a fan of safaris and Formula 1 racing.¹ These outsider attributes, I thought, coupled with his inherent creativity and empathy for consumers, would help us break from the status quo and drive aggressive change.

Mabbutt was hardly the only external hire we’ve brought into the C-suite to help accelerate change. Besides myself, our leadership team includes our chief operating officer Rob Allen, who worked at Intermountain early in his career and subsequently occupied posts in Wyoming, New Jersey, and Massachusetts; chief nursing officer Sue Robel, who built a successful 34-year career at Geisinger Health prior to joining us; and Marti Lolli, CEO of our SelectHealth insurance plan, who grew up in rural Montana and had built her career at an organization in Michigan.² We also count outsiders in clinical and management roles throughout the organization. We absolutely treasure the excellent leaders in Intermountain who have grown up in the local area and built their careers inside the organization. At the same time, we’ve found that individuals from other geographies and industries and from diverse backgrounds can enrich our collective thinking, furthering our efforts to drive change. The ability to fit into an organization and grow with it over a period of years or decades is tremendously valuable, but not belonging has its benefits, too. Organizations need both perspectives.

Outsiders tend to fuel progress in four primary ways. First, they are uniquely alert to an organization’s blind spots. Outsiders can cut through some of the rigid bureaucratic rules that impede change, precisely because they spot dysfunctional or subpar features of the organization that insiders may not perceive as clearly. When Kevan Mabbutt joined us, we were all set for a deal with a company that would help us create a digital front door. This firm had developed a digital platform, and we were planning to buy their services. I was impatient to get started with this work, and when Kevan arrived I made it clear: I wanted to get this deal done. To my surprise, he advised that we blow up the deal. The services we were contracting for lacked consumer relevance and were too expensive in his view, and he also harbored concerns that the company wouldn’t be able to deliver everything they were promising. Although we had scrutinized this deal backward and forward, he hadn’t been part of this years-long process, and so could look at it with fresh eyes and spot flaws we couldn’t see and that I in particular hadn’t recognized. I listened to him, and good thing: the company has since failed and had to reinvent itself under new leadership.

Kevan’s bold action leads me to a second benefit: outsiders often take more risks on behalf of change than insiders do, in part because they’re not as invested in the status quo. Insiders may shrink from change, attempting to safeguard “how we’ve always done it.” Outsiders may not know about traditional practices or policies, and if they do know, they might not feel the same need to conserve them. Outsiders may also harbor more of a growth mindset that inclines them to take risks, trying out new ideas or arrangements and potentially failing in hopes of learning and developing. Insiders often perceive and resist any change as “too risky,” while outsiders more often see equal or greater risk in adhering to the status quo.

Consider again my experience in Abu Dhabi. In the Emirates, as in other places I’ve lived, long-running family alliances and disagreements influence professional and business relationships. Colleagues belonging to families with centuries-old histories of enmity can’t easily forge relationships with one another. Simply trying to do so could prove risky. But as an outsider, I didn’t hold any family allegiances. Instead, I came in respecting this diversity and worked to bridge these kinds of divides, bring people together, and make progress happen. By the end of my four-and-a-half-year tenure, we had our 3,500 people from 70 countries working seamlessly together to make people in the region healthier, transcending gender, ethnicity, and religion. My experience confirmed what I’ve long known: that our shared humanity transcends any differences that separate us.

A third reason outsiders help to drive change is that they introduce new knowledge and best practices. People inside large organizations can sometimes navel-gaze, precisely because they’ve already achieved some measure of success. Drinking their own Kool-Aid, they can lose sight of the outside world and think that their processes and norms are automatically better than anyone else’s. The general specialization of professional and academic life only fuels such narrow thinking. Quoting an “internationally renowned scientist,” the journalist David Epstein writes that, “increasing specialization has created a ‘system of parallel trenches’ in the quest for innovation. Everyone is digging deeper into their own trench and rarely standing up to look in the next trench over, even though the solution to their problem happens to reside there.”³ The presence of outsiders challenges such navel-gazing, introducing new ideas, assumptions, and practices.

In helping us to construct My Health+, our digital front door, Kevan didn’t limit himself to technologies or formats already present in the organization. Instead, he very deliberately looked outside rather than inside healthcare and found inspiration from other industries. My Health+ offers digital functionality in three key areas: finding the right care, managing care, and paying for care. To develop capabilities in each of these areas, Kevan used his expertise to identify best practice leaders. In the case of finding and booking appointments, he and his team looked to the airline industry and their proficiency in scheduling flights. For managing care, he and his team looked to Disney and other hospitality brands adept at helping consumers navigate complex experiences. And when it came to creating a simple, relatively pain-free path for processing payments online, they looked to Amazon.⁴

In addition to introducing new best practices, outsiders can help organizations ramp up accountability by introducing new standards for assessment. One reason my team succeeded in Abu Dhabi is that we didn’t hold our facility to local operational standards, comparing us to other hospitals in Abu Dhabi. We had determined that we wanted to build a facility to deliver quality, safety, and patient experience that was every bit as good as what patients can access at Cleveland Clinic’s main campus. Having those external standards and holding people accountable for achieving them made a big difference in our success. As I’ll recount in the next chapter, we have done something similar at Intermountain. Recognizing that we had been assessing our performance by focusing on our own internal metrics, we introduced external benchmarking, a move that allowed us to spot hidden weak areas and improve them.

A fourth reason outsiders help fuel change inside organizations is that they have a catalyzing effect, inspiring and emboldening insiders to change as well. You don’t even have to hire outsiders per se to see this effect in action—just inviting them in for a visit can do the trick. Later in this book, I’ll describe how we reinvented our primary care model, paying providers salaries and tasking them with keeping people well, as part of a value-based care model that includes a fixed amount of prepaid revenue per covered member. A pioneer in this area was Dr. Rushika Fernandopulle, cofounder and CEO of a venture-backed company called Iora Health. Fernandopulle and his team had operationalized the model at a small scale, achieving great success keeping people well.

In 2017, we invited Fernandopulle to speak with Intermountain’s community-based care group, which oversaw primary care. We dangled the possibility of bringing him in to disrupt our primary care model. We wanted Fernandopulle to visit and for people to know that he was there. If they did, we thought they might feel a little anxious—enough to take change more seriously.

Our gambit worked. Following Fernandopulle’s visit, a group of very talented Intermountain leaders approached me to express enthusiasm for reimagining primary care. They wanted to build a new primary care model themselves. They rose to the occasion in impressive fashion. Today, between Intermountain and Castell (a company we launched), we care for more than 500,000 patients under the prepaid model, with exceptional gains in quality, customer experience, and caregiver satisfaction. Exposure to an outsider was just the boost this group of leaders needed. As this story demonstrates, insiders who open their hearts and minds to an outsider perspective can drive change, too.

These four mechanisms allow outsiders to serve as change agents inside organizations, not necessarily opposing the status quo at every turn, but questioning it and breaking with it when necessary or helpful. They allow the rest of us to operate at our very best and to envision new possibilities. Kevan is a case in point. Not only has he spearheaded a range of consumer innovations inside Intermountain; he also injected a respect for and interest in consumers into the organization from an entirely new perspective. He helped us develop a modernized social media strategy. He helped us rethink our approach to marketing, enabling us to evaluate in terms of the economic and reputational value we create, not just the number of impressions we make through our advertising efforts. He took marketing from a reactive service function to a strategic driver of our mission and business objectives by focusing relentlessly on consumer relevance and influence. And the list goes on and on.

MAKING GOOD TROUBLE

In remarks delivered in 2020, civil rights icon and political leader John Lewis exhorted listeners to, “Get in good trouble, necessary trouble, and help redeem the soul of America.”⁵ Driving change in any kind of business organization ultimately boils down to the creation of “good trouble.” It requires a willingness to question the status quo, not in the spirit of egotism or belligerence, but out of a genuine desire to spur progress. Because outsiders are more inclined to reveal blind spots, take risks on behalf of change, introduce novel practices, and galvanize others, they are often well positioned to create “good trouble,” unleashing others inside an organization to join them as well.

But of course, good trouble is still trouble. It sparks conflict, unsettling people accustomed to the status quo and prompting them to push back against change. Outsiders introduce ideas that might alter how decisions are made, how responsibilities are divided, how the organization will invest its time and energy, and much more. If they are to succeed, they must minimize and manage the resistance their very presence naturally provokes.

When I arrived in Abu Dhabi, a project manager who felt threatened by my presence did his best to scuttle my efforts, subjecting me over the course of months to what I can only describe as hazing. He did everything he could to cause problems for me, raising the same bureaucratic roadblocks he’d used to impede the previous CEOs. I never encountered anything of this sort at Intermountain, but I know that my arrival and the subsequent moves I made rattled some people in the organization who pined for “the way we’ve always done things.” Eventually, some relented, while others left the organization. And some continue to harbor misgivings, perceiving me as an outsider taking Intermountain astray. I deeply respect these individuals and know they want what’s best for the organization. I hope that with time they’ll come to view me and my decisions differently.

If we’re going to adopt the outsider role ourselves or bring in others to do so, we must expect resistance and become comfortable with it. I’ve been rattling cages since childhood, much to the horror of my more conventionally minded mother, so I’m about as used to it as anyone can be. In elementary school, my teachers constantly sent me to the principal’s office—the bench outside it basically had my name on it. In high school, if there was a student protest going on, I was involved. I got suspended from Sunday school for advocating for Palestinian civil rights. (My line was: “How can an oppressed people like the Jews systematically oppress others?”) I suppose that setting off a smoke bomb under my Sunday school teacher’s car didn’t help my cause. In short, I’ve been pushing against the status quo in one way or another ever since I can remember. I’ve grown a tough shell and have learned not to take it personally when people push back. I’ve also realized that an outsider perspective doesn’t mean I always get it right. It simply widens my gaze and opens my ears.

This last insight leads me to a broader point about making good trouble as an outsider: you can’t simply thumb your nose at insiders and hope to succeed. Part of the challenge you face isn’t just to withstand resistance but to actively and genuinely engage with insiders who might harbor different ideas than you do. Insiders are often correct in their judgments, and their perspective is equally critical in helping an organization to drive meaningful progress. Further, insiders can help outsiders themselves learn and grow—something I’ve experienced firsthand at Intermountain. If you enter with an I-knowbest mentality, you’ll miss out, and the organization will, too. It’s far better to hear out what insiders have to say, acknowledging that their intentions are likely very good, even if you don’t agree on how to achieve the desired results. It’s far better, in other words, to practice the kind of intense empathy described in Chapter 1, giving way where you can and staying strong where you must.

Kevan Mabbutt’s arrival and our decisive movement toward a more consumer-centric orientation sparked intense resistance among some inside Intermountain. Many caregivers expressed disapproval, arguing we were damaging the sacred doctor-patient relationship by even referring to patients as customers or consumers. Patients aren’t customers, some caregivers told us. They’re patients. And healthcare isn’t just another business. It’s a sacred calling. If we start thinking about patients as customers, we risked compromising the intimacy and integrity of our relationship with them, thinking about them strictly in economic terms.

These were legitimate concerns. As a physician, I deeply care about the integrity of the doctor-patient relationship. And I also believe that thinking of patients as customers doesn’t compromise that integrity; on the contrary, it enhances it. Traditionally, our organization and healthcare companies generally were designed around providers and their needs—not patients. Patients bore the brunt, suffering needless waits, scheduling difficulties, and other inconveniences. Putting patients and their needs first for a change—treating them as customers—was fully in keeping with an elevated, servant-oriented mindset. It also was a practical necessity. Times had changed, and consumers wanted better treatment. If we didn’t offer them healthcare to fit their needs, others would. To prepare for the future and avoid disruption of our business, we would fundamentally change our operating model to put patients first and implement digital technologies.

I and other like-minded leaders in the organization made these points over and over again in the course of socializing a consumer orientation inside Intermountain. We also did our best (although not always successfully) to forge common ground with those who felt differently, noting that life thrusts all of us eventually into the role of healthcare consumer, even if we’re providers. To evoke the need for change, I told stories from my own life that I thought were relatable. There was the time, for instance, when my kids came home for Thanksgiving and one of them needed a haircut. He went online and booked an appointment. A couple of hours later, I asked him when he was going in, and he said, “Oh, I don’t know. They’ll text me when they’re ready.” This caught my attention. Rather than have customers wait around for an hour reading boring magazines, as hair salons used to do, this one had devised a technology-based system that minimized waits for customers. Why, I asked our leaders, weren’t healthcare systems like us doing that, especially considering that twenty-somethings like my son were poised to become our single largest group of patients?

I also recounted a time when I had a sore neck from running a triathlon and desperately needed a chiropractor to help sort it out. I went to a local chain of chiropractors and arranged for a session. When I handed them my credit card to pay for the appointment, they asked me if I wanted to prepay for the next 10 appointments. They also handed me a little tag with a code on it. The next time I came in, all I had to do was swipe my tag and my patient information would come up. Their system would immediately register me for my appointment and charge my credit card. Now consider healthcare. When you want to see a dermatologist, for example, you may have to wait for five months. When you get there, you have to fill out a paper form and most likely fill one out again each successive visit. You also have to physically hand over a credit card each time. Will you receive a small discount for paying in advance? I don’t think so.

Caregivers inside Intermountain could understand these stories because they also booked appointments with professionals outside of healthcare and appreciated how innovations in those contexts made life easier. They could understand intuitively that such innovations might make life easier for our patients, too. It took a couple of years, but the sheer repetition of such stories allowed our organization to assimilate this seemingly outsider philosophy and embrace it as our own. Eventually, most people came to take these ideas for granted. And as they did, our shift toward behaving like a more customer-centric organization gained traction.

As outsiders or advocates of outsider positions, we can’t expect others to “get in line” and accept us. We must set our egos aside and do the hard work of bringing others along. Orit Gadiesh, a widely respected businessperson and the chairwoman of the consultancy Bain & Company, recalls the challenges she experienced earlier in her career working with clients in male-dominated industries. Often, as the only woman in a meeting, she faced the challenge of winning over male CEOs who were her clients. Microaggressions, and even bigger ones, were a regular occurrence. “I never took it personally,” she says. “I never thought I needed to change the world. If I had a CEO who I could see was uncomfortable with women, I thought it was my job to make him comfortable with me.”⁶

Gadiesh used humor to build rapport and looked for opportunities to connect around common interests. She also wasn’t afraid to get creative when she needed to. On one occasion, she had an assistant contact her counterparts in the offices of 10 male leaders who were set to participate in a meeting with her team, asking these assistants to inform their bosses in advance that a woman would be attending on the Bain side. That way, Gadiesh would avoid any awkwardness that might ensue if her presence proved surprising. It was a small gesture, but as Gadiesh understood, it would help her to build rapport.

Bringing others along often means not just making a special effort in the moment but doing our homework. We must frame our outsider perspectives skillfully in ways that speak to the concerns and mindsets of insiders. We must take the time to get to know the insiders and what they care about so we can hold productive, respectful conversations. As Gail Miller, a highly respected Utah businessperson and former chair of Intermountain’s board, notes, “Change is good if it’s done correctly. And to do it correctly, you have to study it. You have to understand the lay of the land.” This is a task, she suggests, that’s even more vital if you’re coming in as an outsider, with little or no baseline understanding of the landscape.⁷

Dr. Kathleen E. McKee agrees. A neurologist with Intermountain Neurosciences Institute at Intermountain Medical Center, she is a relative newcomer to Intermountain, having arrived in 2019. She is also an outsider, having done her internship, residency, and fellowship at Massachusetts General Hospital in Boston. Soon after her arrival, she emerged as a change agent, working hard and passionately to further diversity, equity, and inclusion (DEI). The murder of George Floyd and the subsequent burst of national interest and activity related to DEI left her wondering about Intermountain’s activities in this area. Observing what she regarded as “radio silence” compared with how other organizations were responding, and discovering that we lacked a chief equity officer, she wrote me a letter in 2020, urging that we adopt equity as one of our fundamentals of extraordinary care, alongside safety, quality, a personalized and caring patient experience, a strong consumer focus, partnership with the community, and engaged caregivers. Afterward, McKee participated in meetings and other activities, sharing what she knew about the history of equity in healthcare and urging more leadership in this area. She also coauthored a paper about our organization’s experiences embarking on an ongoing journey toward more equity (described in Chapter 1).⁸

McKee is unsparing—and rightfully so—in her assessment of all the equity-related work that remains to be done at Intermountain. Crucially, though, she has been effective at driving change because she has imbued her advocacy with a genuine respect for insiders and their perspectives. She spent a great deal of time consulting extensively with mentors and colleagues to understand insiders and uncover strategies for engaging with them productively. These conversations led her to realize, among other things, that many of her colleagues admired the late business expert Clayton Christensen. To help her ideas seem less foreign, she has often connected them to Christensen’s work, a move she believes has helped to foster dialogue. “You’ve got to find some common ground first,” she says, if you want to engage with people around change. “You’ve got to find out what matters most and also what’s bothering people the most,” recognizing that the answers to these questions might not be what you would think at first glance.⁹ It’s important for all outsiders to realize that teaching and learning goes both ways—insiders and outsiders must help one another do both.

Aside from doing this groundwork, outsiders seeking to make good trouble must shine light on themselves and their own motivations. Insiders sometimes resist change proposed by outsiders because they suspect that ego and opportunism are driving it rather than a genuine desire to improve the organization. In many cases, of course, they’re right. Outsiders operate with a whole range of motivations. Further, some might be only dimly aware of their deepest intentions. Outsiders should ask themselves: Are they truly trying to drive change in an area they care about for the organization’s benefit? Or are they doing so to gain some kind of advantage for themselves? You can fool an organization at first if you lack the strength of your convictions, but people will sniff out artifice eventually. Conversely, an outsider deeply dedicated to the welfare of the organization, its customers, and the wider world will usually gain credibility as time passes and enlist insiders to their cause.

Outsiders must also take steps to convey their genuine commitment and make it palpable. In 2021, we named Dr. Paul Krakovitz as the region president of Intermountain Healthcare in Nevada. Krakovitz was responsible for overseeing our integration of a large physician group (about 340 physicians and 55 clinics) that we acquired in that state.¹⁰ Krakovitz faced a challenging task. Although this physician group was well-practiced in value-based care, it had focused on caring for a single demographic: patients over the age of 65. As an integrated system, Intermountain cared for patients at every stage of life, and we needed our doctors in Nevada to do that, too. As an outsider coming in from Intermountain’s headquarters, Krakovitz had to convince the doctors to follow him in making an array of difficult operational changes. Further, he had to navigate an existing culture in Nevada that was different in some respects from that prevailing in Intermountain’s traditional service areas of Utah and Idaho. Since two other organizations had owned this physician group in recent years, Krakovitz also had to contend with skepticism about whether or not he and Intermountain were in Nevada to stay, as well as fear that Intermountain, a much larger organization, would dictatorially assert its will and change everything about the Nevada physician group.

In this environment, Krakovitz worked to win adherents among insiders in Nevada by listening intently to their concerns rather than dictating solutions. “I knew I was doing well,” he says, “when I would be in a meeting, and I was telling them what the output felt like, and someone would say, ‘I’m doing all the talking, I’m sorry. Next time we meet, I’d like to learn more about you.’”¹¹ The act of listening proved to insiders in Nevada that he wasn’t going to take an aggressive, dictatorial approach. By allowing insiders to express themselves, Krakovitz allowed them to feel confident that their ideas and approaches had merit, even as he was able to soak up knowledge about the organization.

In addition to listening, Krakovitz took other steps to make his commitment to the Nevada organization come alive. First, he relocated to the local area, demonstrating that he was personally all-in as a leader. (I did the same when I accepted the post at Abu Dhabi, and it made a difference.) Second, although the pandemic was still raging, he held as many meetings as possible in person rather than via Zoom—he wanted people to feel his presence and really get to know him. Third, he brought down senior leaders from Intermountain’s corporate center to Las Vegas to meet with members of the organization there. He wanted people in Las Vegas to know Intermountain’s leaders personally and to understand that these leaders were willing to spend considerable time forging long-term relationships built on trust and mutual respect. He also wanted the physician practice in Nevada to understand that he as a leader was committed to connecting the Nevada operations to Intermountain, ensuring the two organizations would fully integrate with one another.

Krakovitz is already seeing signs that insiders in Nevada are beginning to accept him and feel more comfortable with Intermountain. Building trust will take time, and future challenges will certainly arise, but Krakovitz is optimistic that the integration will succeed. Openly affirming his commitment to the Nevada organization as an outsider allowed him to get a running start and unleash people to pursue change.

INTEGRATING OUTSIDER PERSPECTIVES

To activate the power of outsider perspectives in your organization, take a balanced approach. Don’t suddenly throw outsiders or advocates of outsider positions into every key role and ask them to make trouble. We’ve sometimes gone too far in embracing outsiders, and on these occasions, we’ve paid the price. In 2017, we sought to enhance how we handled the task of transferring patients from the outside into Intermountain facilities to receive care. We experimented with outsourcing this function, hoping that doing so would allow us to operate more efficiently. It didn’t work. We had assumed that the process of transferring patients was straightforward and easily codified, allowing outsiders to step in and perform it well. As we learned, this function relies on quite a bit of insider knowledge; outsiders can’t do it as effectively. We reversed course, building from scratch a new internal center for transferring patients that now performs exceptionally well.

I’ll say it again: insiders are critically important too in legacy organizations seeking to stay fresh and vibrant. If everyone were a change agent coming from the outside, chaos would ensue. We need cadres of people who understand the organization’s history, purpose, and founding principles and can connect novelty and change to this heritage. We need people who understand what already works so the organization can retain these elements, build upon them, and adapt them.

Although we’ve introduced outsiders like Kevan, Rob, Sue, Marti, Kathleen, and Paul into the mix, our leadership team at Intermountain remains a solid mix of organization veterans and newcomers. The combination allows for a productive tension between old and new to flourish, allowing us to make progress and do so in a way that minimizes unnecessary conflict and disruption to the organization. It also allows our team to model the productive collaborations between insiders and outsiders that we want to see take root across the entire organization.

One practice of ours is to bring in outsiders only after trying and failing to find someone internally who is more qualified and able to drive a desired change. When we were searching for a chief marketing officer, I spent months scanning the entire healthcare industry, and I couldn’t find the kind of consumer-centric leader I felt we needed. Only then did I entertain the possibility of bringing in a marketing executive from a leading consumer company. Likewise, we brought an outsider in as our chief nursing officer for the enterprise after I had exhausted possibilities internally. Our previous chief nursing offi-cer was a wonderful spokesperson for the organization and a polished thought leader on safety and quality. She was also a long-time Intermountain employee who was beloved inside the organization. I would have been happy to retain her on our team. Only when it became clear that I couldn’t and that nobody else in our organization could fill her shoes did we start to look to hire an outsider.

In addition to bringing in outsiders, seize opportunities to become one yourself. Open yourself to career moves that might put you in an unfamiliar geography or business area. The loneliness and uncertainty that comes with stepping into a new environment is real, but don’t fear it—lean into it and learn from it. If you can’t step into an unfamiliar environment or hire an outsider, then at least try to seek guidance from people with diverse backgrounds who can push you in new and perhaps uncomfortable directions. In many cases, you can expose yourself to fresh perspectives simply by sitting down with customers and listening to them describe their experiences, needs, and desires.

Functioning as an outsider or inviting them into your midst is by no means the easiest path. But it’s a vital way of unleashing change in yourself and others. For organizations as well as people, change only comes at times when you challenge yourself. Athletes don’t build new muscle by performing the same familiar movements in a relaxing way. They do it by gritting their teeth and putting their muscles under strain so that they work up a sweat. We can all become change athletes, drawing on outsiders to reveal weakness in the status quo, push us into our discomfort zones, and help us to grow and improve.