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LOOK IN THE MIRROR

Be honest with yourself about the state of your organization.

When you were in high school, did you ever walk into an exam thinking you had mastered a subject only to receive a grade that was surprisingly average or even subpar? It’s a humbling but also potentially energizing experience—and one that we at Intermountain know quite well.

In 2016, before I became the organization’s new CEO, I asked executives on my new leadership team to hire a consulting firm to thoroughly assess our culture and operations. One might have thought this unnecessary: in recent years, Forbes had named us in its list of best top employers, and Moody’s and Standard & Poor’s had given us the highest rating of any nonprofit healthcare system. A number of our hospitals received national recognition for their high quality. The Patient Safety Movement ranked us in the top 3 out of 400 institutions for our work in improving safety in our facilities.¹ Clearly, we were doing something right.

But I had been speaking to leaders and consultants about CEO transitions while also devouring everything I could read on the subject. A recurring theme emerged: for incoming CEOs, especially those entering from the outside, it’s important to obtain a clear initial picture of the organization—what it does well and not so well.

A top consulting firm, McKinsey & Company, assessed our organization for us. Some of the results were extremely strong. Intermountain Medical Center ranked at the very top of its peer group—in the ninety-ninth percentile nationally—when it came to the number of patients readmitted within 30 days (in other words, fewer of our patients had to return for unplanned care after leaving our facilities, which is a measure of quality). Our patient experience also ranked consistently above the national average and was tracking upward.²

And yet, other results were humbling. While Intermountain was known for delivering some of the highest quality care in the country and for pioneering the standardization of care, our review revealed that we actually scored at or below the median for quality in some areas. For instance, too many of our patients developed potentially serious central line infections. Although we performed better in this regard than Mayo Clinic and Cleveland Clinic, in 2015 we ranked at only about the thirty-fifth to fortieth percentile nationwide— nowhere near where we wanted to be.³ Also worth noting, we were paying millions each year in penalties under government programs that docked us for lower performance in specific areas.

McKinsey’s analysis uncovered other weaknesses in safety, stewardship, patients’ ability to access our services, financial performance, and more. Some of the problems seemed small but really weren’t. We learned that our 180 health clinics turned off their phones each day at noon so that staff could all have lunch together. That’s nice, but what about all the patients who were calling and trying to book appointments?

Reflecting on McKinsey’s findings, I concluded that past Intermountain leaders had laid a strong foundation in the form of a financially sound, integrated health system focused on improving quality and lowering costs. We had embarked years earlier on the path toward value-based care, digitization, and more customer focus— a tradition of innovation that had attracted me to Intermountain in the first place. But we also had the opportunity to build on our past accomplishments and innovate in these areas at much greater scale. Healthcare is always aspirational—we must constantly strive to improve and enhance what we do. McKinsey’s findings were a clarion call for us to become even better than we already were.

Many of our leaders and employees certainly thought this way. Learning of the findings, they yearned to get to work devising new solutions that would push us further and faster toward our broader strategic goals. But others found the results of our assessment unsettling. “I would say it was a somber and sobering moment for people,” says Dr. Shannon Connor Phillips, our chief medical officer for community-based care.⁴ My readiness to acknowledge Intermountain’s weak spots “challenged people,” our chief operating officer Rob Allen remembers. “It was hard, and people felt that the history and legacy of Intermountain were being attacked.”⁵ On my leadership team, even individuals who were receptive to the data felt anxious about it. As Intermountain veterans, they knew how tough it would be to improve on core quality and safety metrics.

The point of assessing ourselves, registering both our strengths and weaknesses, wasn’t to stigmatize ourselves or deflate our egos. It was to galvanize us behind a change agenda. And more specifically, it was to help us address a challenge that often stymies leaders at large, successful organizations. How do you inspire dedicated professionals who are already exceptional achievers to aim even higher? How do you take an accomplished, even iconic organization or team and energize people to advance its mission and live its values in new and exciting ways?

Our experience at Intermountain has taught me that it all starts with developing a common fact base. We must document the existence of problems that need fixing, challenging our people to look at our organization in the mirror and be brutally honest about what we see. We must encourage them to set aside any complacency they might feel and take a more realistic view, seeing the team or organization as outsiders might see it. While we’re at it, we must habituate ourselves as leaders to doing the very same thing on the individual level, embracing an ethic of rigorous, ongoing self-assessment and change.

NO MORE NAVEL-GAZING

Some large, successful organizations lose touch with reality when it comes to their performance. When organizational practices, processes, or norms work well already, well-meaning people within a system want to retain and replicate them. Why change what isn’t broken? People become invested in the status quo, building identities and careers around them. They feel less inclined to probe for flaws or shortcomings, and they often resist those who do. Over time, flaws can fade into the background and become hard to spot, entrenching the status quo even more.

Some of these dynamics were visible inside Intermountain, though ours was far from an intellectually sterile or stagnant culture. Because our employees cared so deeply about our mission of helping people live the healthiest lives possible, we had been working hard to improve safety, quality, and patient experience, to increase access in our communities, and to address the broader social determinants of health. Teams and groups within our organization were experimenting with innovations such as telehealth and the introduction of continuous improvement methodologies. We also were looking to the future, boldly investing almost $1 billion over the past five years on constructing new facilities.

Nevertheless, McKinsey’s analysis left me wondering if we could unleash dynamism, innovation, and an underlying introspection even more. In particular, I suspected that we could fire ourselves up to change by enhancing how we tracked our performance. Prior to my arrival, Intermountain had gained renown for its quality improvement initiatives, and our chief quality officer Brent James had emerged as a leading expert in the field. Applying industrial approaches to process management, we developed standard treatment regimens for medical procedures like delivering babies or caring for people with strokes, asking caregivers to track how well they did in quantitative terms and using that information to fine-tune and enhance the regimens over time. These initiatives were enormously successful, improving patient outcomes and driving down costs.⁶

Our approach also had some important limitations. Rather than comparing the quality of our care to that of other leading institutions (called “benchmarking”), we often tracked progress by comparing our numbers each year to how we performed in the past. We weren’t trying to evade accountability or prevent ourselves from changing. On the contrary, we reasoned that the industry in general wasn’t delivering strong quality, so we would do well to focus on bettering our own performance year-over-year. We also questioned the science behind some of the comparative quality measurements used in healthcare.

As valid as some of these concerns might have been, our reluctance to measure ourselves against others blinded us to some of our shortcomings. As Scott Anderson, chair emeritus of our board and president and CEO of Zions First National Bank, observed, “You need to compare where you are with the best in the industry. And if there’s a gap, you need to sit down then and have that hard conversation of what you need to do, not only to continue to improve but to step up the pace so that, in fact, on a comparative basis with the best in the industry, you are out there with them.”⁷

Benchmarking affords organizations tremendous opportunities. It spawns a discipline of improvement, one that, in the words of Dr. Shannon Connor Phillips, “becomes part of what you do every day.” Tracking how others are doing, you become curious “to learn who the high performers are and what worked,” and you constantly challenge yourself to be better.⁸ Since we weren’t benchmarking nationally, our improvement efforts in areas like quality and safety lacked some of the energy and insight that come when you compare yourself to high-performing peers. We needed to study the bigger picture, even if it wasn’t always flattering, and we had to open ourselves up more to best practices from others. An extra dose of humility and honesty would reignite our curiosity, lend a new intensity to what we did, and hopefully take us to a whole new level.

A NEW KIND OF INTROSPECTION

We’ve since introduced comparative measurements across Intermountain to underpin our change efforts. With our board’s strong support, our first step was to select specific industrywide measures to use in tracking progress and to select companies that would provide us with data about our peers. To help us monitor how well our hospitals were doing, we partnered with the healthcare consultancy Vizient, which collects information from the country’s biggest, most advanced hospitals. To help us improve patient experience and caregiver engagement, we partnered with Press Ganey, another organization that collects data from a peer group of organizations and from our own customers.

Not only could we use data from these partners to analyze how we worked; we also could learn the best practices of other institutions. In some cases, we could adopt these best practices, accelerating our progress. In other cases, we could deploy solutions generated by our own improvement efforts (more on that in Chapter 5). We didn’t need to arrive at all the answers ourselves. Instead, we needed to ask more questions and look for answers everywhere, not just within the confines of our organization.

With these partnerships in place, we met with teams at our hospitals and other facilities to introduce comparative assessments and discuss the gaps we were seeing in performance. These conversations weren’t always easy. Think of times when someone has challenged you to achieve even more in an area where you already excelled. It can come as quite a blow. We were asking our operations, medical, and nursing leaders to make themselves far more vulnerable by measuring themselves against our peers. When the data showed opportunities for improvement, we were asking our people to parse the data closely and identify the root causes of problems. We were also asking them to look to other organizations for possible solutions.

When leaders and caregivers pushed back, as they sometimes did, they weren’t necessarily wrong. Physicians, hospital operators, and finance professionals are all trained to view data skeptically, and some at Intermountain argued that national benchmarks were flawed— they used data that was old and out of date, they compared systems that differed in important respects, and so on. Still, as Dr. Mike Woodruff, emergency room physician and senior medical director for our Office of Patient Experience, notes, “No measure is perfect. No cohort that you compare yourself against will be exactly appropriate to your circumstances.”⁹ Even with its flaws, a comparative view allowed us to spot improvement opportunities we’d otherwise miss. Further, consumers were using publicly available benchmarks to evaluate us. We needed to pay attention to these measurements, too, taking any potential inaccuracies into account and improving the measurements going forward.

Our local teams persisted when faced with internal resistance, as did our Office of Patient Experience, which helped to implement quality, safety, and patient experience improvement initiatives, and our human resources team, which did the same with caregiver engagement. I pushed hard, too, stressing what was at stake for our patients and trying to humanize the conversation about abstract data as much as possible. I reminded caregivers that we were treating people and potentially hurting or killing them when we didn’t do it well. To drill home the point, I used human-like stick figures in my presentations instead of the usual bar charts. Making the point so directly got people’s attention. Since we were proceeding from a common fact base and referencing our shared desire to deliver even more completely on our mission, many of the skeptics eventually bought into the improvement initiatives we launched. The combination of approaching measurements comparatively and probing for root causes proved enormously effective, allowing us to uncover improvement opportunities that previously had gone unnoticed.

Consider mortality at Intermountain Medical Center, the largest hospital in our system. Like other health systems, we keep track of how many of our patients admitted for specific conditions end up dying. We compare those numbers to how many we expect will die based on data from our peers nationally. Unfortunately, analysis suggested that our performance lagged that of our peers. It seemed at first that we had a safety issue—more people were dying unexpectedly at our facility than at peer institutions. Although we spotted ways to improve safety and quality by standardizing best practices across our system, closer analysis uncovered a different root cause.

Our numbers ran high not only because of mistakes we were making in our care or inefficiencies in our system but because we were caring for these patients in our intensive care unit (ICU), using advanced technology to try to prolong their lives, rather than transferring them to hospice and focusing on relieving their pain and symptoms. Here’s an esoteric fact for you: When health systems provide end-of-life care in hospice, they don’t count these patients in their mortality figures; that data is meant to capture avoidable deaths. When systems care for these patients in the ICU, they do count, skewing the data unfavorably, even if these patients never had a chance of living. As Woodruff suggests, Intermountain had developed a blind spot in how it cared for people at the end of their lives. “We were geared toward providing the most care. We were rushing patients from the emergency department to the ICU. We put in breathing tubes, put in lines, gave them antibiotics, put them on a bypass machine, gave them all of our technology. We were geared to doing more and more and more for patients, rather than focusing as much as we might have on delivering the right care for them and their families.”¹⁰

More care versus the right care. Think about that for a moment. American culture often associates more with better, and health-care isn’t immune from that thinking. In fact, more care has long served as healthcare’s reigning business model, with facilities piling on the diagnostic tests, procedures, and pills to help patients get better. And yet, as we at Intermountain have long believed, more isn’t the answer. More care is how many systems boost their profits, often without benefiting patients. The right care is compassionate, of the highest possible quality, and often much more affordable for patients, employers, and the country at large.

The standard treatment regimens we developed prior to my arrival aimed to deliver the right care by codifying best practices for caregiving. But opportunities still existed to push this work even further. In this instance, a comparative view coupled with a root-cause analysis led us to be more curious and humbler—to think more expansively about end-of-life than we had before and to uncover important improvement opportunities we had been missing. Reviewing how our high-performing peers approached palliative and hospice care, we found that by adjusting what we did, we could provide end-of-life care more compassionately by keeping more patients out of the ICU. We could determine more quickly when a patient arrives if they are likely to never again leave the hospital alive. We could offer resources more rapidly to patients and their families to help them understand how best to ensure quality of life during their loved one’s final days and moments. These changes would reduce our costs (caring for patients in the ICU is expensive), but more important, they would allow us to give patients a more comfortable and meaningful death in hospice, surrounded by their loved ones.

These and similar changes across our system haven’t come easily to us. Just like exercising at the gym can make your muscles sore, challenging our caregivers to deliver care in new ways can lead to some sore feelings. And I might have pushed too hard at times as we introduced comparative measurements, perhaps leading some to believe that as an outsider, I felt I had all the answers. I wish I knew the precise amount of pressure to apply at any given time to promote change, but to be honest, I’m learning, too, and inspiring people who are already excellent to achieve even more is an extraordinarily delicate task. We leaders must do the best we can, understanding the sensitivities people feel and respecting them. And we must appeal to a higher calling that we believe in at our core.

Although I was an outsider, I knew that what matters most at Intermountain—what has always mattered most—is providing the best care possible for patients. Although they aren’t perfect, comparative measurements enhance our ability to do that. That’s the message I worked with other leaders on our team to convey, and it’s one that over time inspired us to take a more expansive look at our performance and how we could improve it.

HARD ON ISSUES, EASY ON PEOPLE

More honest and comprehensive introspection isn’t just good for organizations. We can also instill it at the team level to unleash our people. As we’ll see in Chapter 5, my leadership team and I have embedded introspection deeply into our culture by reimagining how we work. Central to our approach is a system of continuous improvement, where frontline team members surface operational issues and help leaders at all levels scrutinize performance more carefully.

Individual leaders can also take important steps on their own to build cultures of introspection and critical analysis within their teams. Here, they must strike an important balance. While they must set strong expectations that motivate people to do their best, and while they must hold people accountable for meeting those expectations, they must also help team members feel nurtured and respected, so that they are comfortable sharing frank, often difficult feedback.

To sustain this balance, I strive to take an approach I call “going hard on issues but easy on people.” I drive performance extremely hard on issues I care about. When results prove disappointing, I don’t hesitate to let people know. When we’re stuck creatively and having the same conversations on an issue we had three years ago, I’m very direct in observing it and exhorting my team to do better. But I also try to temper this message so that I’m easy on others around me. I don’t yell or swear at people. I don’t personally impugn individuals who aren’t delivering. I don’t play politics and speak behind people’s backs. I maintain cordial and even friendly relationships with everyone. I’m not perfect—there are times I wish I’d been easier on people. But in general, I try hard to treat people compassionately and with civility.

Let’s say I oversee a facility where patients are developing infections from their IV lines—a problem that shouldn’t happen. I could raise this issue by ranting and raving, saying, “What the hell is going on? How many times have we talked about this? Don’t we give a damn about patients? Who’s the leader there? Do they want to keep their job?” A softer, gentler approach might be to say, “Boy, this is disappointing. Have we performed a root-cause analysis? If so, what have we learned that we can share with others? What unit in our system is the best on this? Can we bring them in to share what they know and identify the flaw that’s leading to these infections?” If I take an aggressive approach, few people will feel safe raising issues, and they’ll go underground. A softer, gentler approach allows me to drill home the issue’s importance without antagonizing the very people we rely on to spot problems. Hard on results, easy on people.

Can we leaders treat others compassionately while also driving strong performance? I think so. Don’t listen to hard-liners who argue you must crack the whip to motivate your team. Taking a more humane approach reduces unproductive conflict and engenders an environment of civility. In our organization, such civility has persisted even when we’ve had to usher leaders out of the company. In one instance, a reorganization led to the departure of a leader whom many inside Intermountain regarded as a rock star. The departure led some within the organization to become angry with me. One of the people who wasn’t angry, however, was this leader himself. We stayed in touch and remained friends. I’ve maintained similar relationships with a number of people I’ve had to fire over the years, precisely because they feel that they’ve been treated compassionately.

We can take steps to treat people well and adopt standards of civility even as we push hard for the desired results. First, hold regular group conversations dedicated to honestly but compassionately discussing thorny operational issues. During the pandemic, Dr. Mark Briesacher, then our senior vice president and chief physician executive, began holding a huddle every two weeks for physicians across Intermountain. Relates Briesacher: “Everyone knows that we’ll discuss the most important questions on this call—issues like physician suicide, peer support, unprofessional behavior, and clinical mistakes that teams have made.” The point of these conversations is to create a culture in which it’s normal to hold a mirror up and honestly gauge our performance, but in a way that is respectful, productive, and never threatening. By leading such conversations, Briesacher also sets an example for the kind of civil but critical discourse he wants other leaders throughout the organization to follow.

We can foster civility by taking a second step: providing more opportunities for others on the team to become vulnerable with one another. When I worked at Cleveland Clinic, I once asked my team to go around the table and relate something their colleagues didn’t know about them. One leader described how two of his children were severely autistic. Caring for them had become extremely hard on his marriage, and the family had persevered because of its strong faith in God. The story moved everyone in the room. From then on, a new level of intimacy, friendship, and respect bound the team together. It became easier for everyone to show empathy and to engage with one another as human beings. Do you suppose people provided more frank feedback to one another? Do you think the team performed better as a result? Absolutely.

Third, we can explicitly engage team members to take responsibility for one another’s personal improvement efforts. When I first arrived at Intermountain, we engaged a professional coach to work with our leadership team. This coach interviewed each leader, looking deep into their histories and personalities and probing their individual strengths and weaknesses. We also performed intensive evaluations of one another, with each of us sharing the contents of the resulting reports.

This wasn’t an easy exercise. As Briesacher relates, the sharing of direct feedback hasn’t always been a dominant part of Intermountain’s culture. “Many people in the organization feel that when you’re direct with others, you’re being unkind.” By having members of our leadership team evaluate each other’s strengths and weaknesses, I wanted to challenge this cultural norm, building trust among our team members and achieving new levels of candor. I wanted team members to feel mutually accountable for their own growth and development, with each offering direct feedback to others and calling them out when they’ve failed to address it, and each listening to and acting on feedback from others in turn.

For Briesacher, the impact of this exercise and similar ones we’ve done since has been profound. “It has been gratifying to hear positive feedback,” he observes. “I also learned that I have a tendency to slow down and become more deliberate when I’m under stress. While some of that is good, you can’t slow down too much and become paralyzed.” Briesacher had long understood this tendency of his, but once he’d received data about it from his peers, he was able to focus on making behavior changes so that stress didn’t affect his performance. He was also able to rely on his peers to help him when, despite his best efforts, he was taking too much time making decisions. “We’re a team of individuals with strengths and weaknesses and different perspectives,” he says. “What we have now is a deep trust, knowing that we’ll be direct with one another out of a place of kindness and integrity and in a way that honors our relationship, while also allowing the organization to move forward.”

A fourth way we can go hard on issues but easy on people is to make ourselves vulnerable, too. I do this nearly every day. I solicit and receive very frank feedback from my team members about my performance, whether it’s how I handled a personnel matter, how I ran a meeting, or how well I presented myself during a media appearance. Likewise, when we created those detailed, critical assessments for members of my team, I had one created for me as well. Believe me, it probed deeply into what I did not do well, even as it alerted me to my strengths. I learned that my strengths actually cut both ways, becoming weaknesses at times. Some of my team members appreciated my tendency to speak candidly and call things exactly as I see them, while others found that intimidating and off-putting. My team members appreciated my quick mind—but not when I moved on during a conversation without giving others a chance to say their piece.

Was it easy to hear such feedback? Not so much. Was it helpful? Absolutely. We’re now able to talk openly about my difficult tendencies, which tend to pop up most when I’m under pressure. I can explain to others how my unhelpful reflexes—my “least good self,” as I call it—might have originated. My team members can understand me better and call me out when my least good self crops up. Meanwhile, I’m able to take steps to moderate my behavior so that I can have more impact as a leader. Over time, my least good self becomes a little bit better.

I have also made myself vulnerable by speaking frankly about my cancer diagnoses. When I was diagnosed with multiple myeloma, I told team members about what this illness meant for me—that it was incurable and that I would need to undergo a bone marrow transplant. I informed them that I would continue to work but I would need their help. I can’t be sure, but I suspect this honesty encouraged them to freely disclose their own challenges. The resulting communication made it easier for everyone to provide critical feedback about performance issues when they arose.

A fifth and final way of adopting standards of civility even as we push hard for results is to avoid triangulation. You see it all the time in teams: one person goes to the boss and complains about a colleague. The boss gets an ego boost by serving as the mediator, standing above the fray, and enjoying a kind of self-affirming intimacy with both parties. I don’t foster this dynamic, nor do I engage in the fruitless politicking that goes with it. When team members confront me with issues they have with colleagues, I nudge them to figure it out themselves. I ask if they’ve spoken with the others involved, and if not, I encourage them to do so. If they try and fail, I will agree to talk with both of them and help them to resolve the situation.

By encouraging people to have frank and sometimes uncomfortable conversations with one another, I nudge them to confront potentially difficult parts of themselves and in turn to improve their performance. These conversations foster open communication among team members, who over time come to accept one another much more deeply as complex and imperfect human beings who are, in effect, works in progress. Meanwhile, by avoiding the ego boost that one receives at the center of the triangle, I can remain more honest with myself and introspective about my own performance.

Beyond these five actions, I try to model my “hard on issues, easy on people” approach for other leaders in the organization so that they might adopt it. We’ve instilled elements of this approach across the organization through leadership training that focuses on psychological safety and the holding of difficult conversations. We routinely query our frontline caregivers about how safe they feel reporting issues to their supervisors, and we also rank teams in terms of how healthy and functional they are. When we find teams that are demoralized and disengaged and whose members don’t feel safe coming forward with constructive feedback, we provide coaches to the team leaders or, in extreme cases, replace these leaders.

“ARRIVING” IS JUST A FANCY WORD FOR STOPPING

Assessing how well you’re doing can leave you complacent and self-satisfied, or it can elicit the humility and curiosity you need to reach the next level. It all depends on how you go about it. At Intermountain, our willingness to observe ourselves in a more honest, uncompromising way has fueled a new intensity around improvement, one that persists to this day. We haven’t arrived at our ultimate destination, nor will we—self-analysis and improvement are a constant, never-ending process, and “arriving” as I see it is just a fancy word for stopping. But we have achieved massive performance gains that inspire us to keep going.

In 2016, only 2 of our 12 eligible hospitals earned top marks for quality in nationwide rankings. In 2021, 10 out of 12 did. Our Vizient metrics in mortality, safety, patient experience, effectiveness, and equity improved each year between 2019 and 2021. In 2019, we ranked as a system at the seventy-ninth percentile among our peers nationwide. By 2021, we ranked in the eighty-ninth percentile. As we’ve improved quality, we’ve also lowered costs: one analysis found that our pricing for a panel of key services ran 19 to 56 percent below market prices.¹¹

I’m proud to say that we’ve continued to scrutinize our performance and advance our improvement efforts during the pandemic. At times of crisis, it’s tempting for organizations and individuals to move into survival mode and give themselves a pass on self-improvement. Pulling together, we’ve managed to avoid that trap. As a result, we’re providing better care today at a lower cost than we were when the pandemic first struck. Although we still haven’t met our immediate goal, which is to reside in the top decile of health systems across the board, we’re getting much closer.

It’s important, I think, to acknowledge such accomplishments, but I find it equally important not to linger on them. If organizations are to continue improving, we leaders must maintain a constant, disciplined focus on imperfections and deficiencies. We must never stop taking stock of them, and we must continue to work as hard as we can to understand their root causes. It’s easy to look in the mirror for a time only to begin breathing our own exhaust again once we’ve achieved a measure of success. We must resist this tendency, staying grounded in reality and confronting the organization ever more fully with it as time passes. When it comes to unleashing and sustaining a revolution, complacency and self-deception get us nowhere. Introspection, inquisitiveness, and a burning determination to remedy our deficits win the day.