INTRODUCTION
In 2009, I was diagnosed with bladder cancer. I was preparing for my seventh Ironman triathlon—I participated in my first triathlon in 1982 and had been doing at least one a year ever since. But this time around, the training wasn’t going so well, and during the race itself, I began to urinate blood. That’s when I knew something was seriously wrong.
I received aggressive surgical treatment, which thankfully did its job. A month after the procedure, my surgical pathology showed that I was cancer-free. And yet, I knew the battle had just begun. My prognosis wasn’t particularly reassuring: only 40 percent of patients survived for five years. That and the physical pain I experienced because of my treatment left me with a deeper empathy for patients and a new awareness that life is short and our fortunes unpredictable. I had always wanted to have a positive impact on the world—that’s why I’d become a doctor and more recently a physician leader. Now, I realized, with greater urgency, time was ticking. I had to take bold steps right now to make my organization and the broader healthcare system much better than it currently was.1
TACKLING THE SEEMINGLY IMPOSSIBLE
I was working at Cleveland Clinic at the time, and my determination to drive far-reaching change led me in 2011 to accept a role overseeing the construction and launch of Cleveland Clinic Abu Dhabi, a world-class hospital that was the first of its kind in the Arabian Gulf. Over a five-year period, and despite the tremendous challenges of operating in a cultural context that was very different from my own, my team and I made what was initially just a bunch of steel planks jutting out of the ground into a gleaming, state-of-the-art facility with patients from more than 70 countries and 3,500 staff.2 When it was complete, the hospital revolutionized medical care across the region, providing residents with access to cutting-edge treatments.
In 2016, I accepted an opportunity to become CEO at Intermountain, Utah’s largest health system with $6.1 billion in revenues, 22 hospitals, and some 1,400 physicians and advanced practice clinicians.3 I knew this organization well: decades earlier I had completed a pediatric residency and pediatric critical care fellowship there. I believed strongly in the organization’s mandate to serve as a model healthcare system for the country, as well as in its mission of “helping people live the healthiest lives possible.”4 Now I would have a chance to lead a daunting evolution of this famed healthcare system.
I say daunting because Intermountain had a sterling reputation nationally for delivering excellent care and also for delivering that care to everyone, even those who couldn’t afford it. Given that the organization also had a strong culture and was in great shape financially, some inside Intermountain assumed that leadership’s greatest priority should be to sustain established practices and ways of operating, not develop new ones. Interestingly, this thinking belied what was actually quite a long history of innovation at Intermountain. The organization had been one of the first health systems in America to establish an insurance company, to create a medical group, and to move toward electronic medical records. Nevertheless, a belief had taken hold in parts of the organization that fundamentally transforming Intermountain at this point in our evolution would be misguided, even dangerous.
I saw it differently, as did Intermountain’s board of trustees and its previous leadership. As much as Intermountain had already accomplished, an opportunity existed for the organization to do even more, ratcheting up its innovation and in the process leading much-needed change across the entire healthcare sector. Despite decades of talk about reforming healthcare, our industry was still mired in an outdated, inefficient, and less compassionate fee-forservice model. It was a familiar system that the industry couldn’t seem to escape. Under this model, key metrics such as patient experience, quality, and safety lagged, and caregivers focused on taking care of people once they got sick, not on preventing them from getting sick to begin with.
Newer, value-based care models rewarded healthcare systems for delivering better quality care, not just a larger quantity of it. One of these models, population health management, went further and compensated healthcare systems for taking care of patients on a per capita basis for a period of time rather than only for providing discrete “episodes” of care. Using this approach, we would essentially share the risk of taking care of patients. Insurers would pay us a certain amount per patient to provide for their care. If we could provide care for sick patients at lower cost, and if we could keep patients healthier to begin with and minimize their need for expensive healthcare interventions when they got sick, both patients and the healthcare system would benefit. Instead of receiving payment based on the specific services we provide, we would receive compensation based on health outcomes we deliver for a given population of patients. Such arrangements would incentivize us to keep people well, not just care for them once they became sick.
These newer models are the future of healthcare, poised to displace the older fee-for-service models. The latter models were bankrupting America even as they compromised the health of its citizens. Since healthcare providers under fee-for-service got paid based on volume, they benefitted financially by seeing more patients and performing more procedures, not by improving what they did. They had little incentive to innovate in ways that would allow them to operate more efficiently, improve the quality and safety of the care they provided, make care more pleasant and convenient for patients, or help keep patients well and out of hospitals.
Given how unsustainable the existing model was, Intermountain prior to my arrival had already begun a bold transition toward value-based care and population health. Since 2011, movement toward these models had been a C-suite priority and board-level goal. We had established an entire department and team dedicated to the transition and to pushing the deeper changes it entailed inside the organization. These efforts had borne fruit. By the time I arrived, 20 percent of our revenue derived from outcome-based payments under the population health model—far more than at most other leading health systems, and a testament to our efforts in this area.
And yet, we needed to do far more. As members of our board and others at Intermountain saw it, government policy would increasingly depart from the fee-for-service paradigm, putting pressure on big healthcare systems to adapt. New players in healthcare were also beginning to nibble away at the business of healthcare systems, finding new and better ways to deliver specific services. Observing the appearance of nimble startups, it seemed clear to us that most healthcare providers operating under fee-for-service, including Intermountain, were like Kodak, BlackBerry, or Blockbuster Video—big lumbering incumbents that would become easy prey in the years to come. The choice was ours: Adapt now, or consign ourselves to an early death. Disrupt ourselves, or wait to be disrupted.
My cancer diagnosis left me with an even greater sense of urgency. After what I’d been through, waiting was not an option. Although some leaders at Intermountain were already bought in and excited to innovate, I perceived that as an enterprise we had only begun to transform our operations, offerings, and payment arrangements so that they supported value-based care and population health. I wanted us to accelerate decisively and proactively toward these newer models. Over the long term, we would stay on the strongest possible financial footing by becoming the “Tesla of healthcare,” seeking out value- and population management–based payment arrangements and deploying new technologies, approaches, and initiatives that would allow us to thrive.
Reinventing ourselves as an innovation machine, we could deliver higher-quality and more proactive care, and do so more compassionately, at lower cost, and at scale. Some healthcare organizations had experimented with population health management and had invested in promising areas such as genomics, prescription drug reform, and at-home care or telehealth, but they hadn’t unrolled these innovations to large populations. We wanted to go all in. By fully embracing value-based care and population management, we’d effect a revolution inside Intermountain and inspire change across the industry.
Guided by this vision and drawing on the collective efforts of our 42,000 employees, we’ve kicked off an ongoing, far-reaching transformation at Intermountain. Our work commenced in 2017 with a reorganization that formed an internally competitive health system into One Intermountain. We also adopted an operating model that, by underpinning a culture of continuous improvement across the organization, mobilized our entire workforce to help drive change.
That was just the beginning. We reorganized and revamped our medical group to become more integrated, allowing us to standardize care and coordinate it more effectively and, in the process, improve quality and reduce cost. We unveiled a host of clinical initiatives and ventures, including Civica Rx, a company that provides patients with more affordable generic drugs; HerediGene, the world’s largest population genomics study; an array of new telehealth services and capabilities, including an entire virtual hospital; and much more. We launched numerous pilot programs related to the social determinants of health, such as a behavioral health project that increases access to care for vulnerable populations. We created an impact investing function that bets on ventures poised to contribute to better health in the communities we serve. And the list goes on.
Underlying and facilitating all of this change has been a wide-ranging cultural shift across the organization and in our leadership team. We’ve learned to move quickly to execute on our strategies. To more honestly assess our shortcomings so we can begin to fix them. To partner with outside organizations rather than thinking we can do it all ourselves. To listen to one another and work through tough issues together. To monitor our ongoing performance and hold ourselves more accountable. And, of course, to embrace loftier, industry-shaking goals.
Over the past five years, we’ve become one of the first major health systems to make the shift to population or value-based health—it now accounts for half of our revenue, up from 20 percent in 2016. As part of that shift, we’ve delivered on our social mission, dramatically improving quality, safety, and patient experience, which were already strong. We’ve expanded on Intermountain’s longstanding commitment to increase access to care and improve the health of the diverse populations we serve. We’ve worked to lower the suicide rate in Utah, reduced the number of opioid pills our caregivers prescribed by 40 percent, provided more than $1.1 billion in free care for low-income patients from 2016 to 2020 for medically necessary services, and earmarked $120 million for impact investing. At the same time, our financial fortunes are better than ever. Not only have we grown rapidly, but we’ve doubled our revenues and expanded our operations to Idaho and Nevada in addition to Utah. We’ve also done so in a fiscally sustainable way, achieving the top bond ratings of any US healthcare system.
This work has been immensely rewarding. Leaders sometimes presume that organizations can’t deliver better for consumers and achieve social objectives while also growing and delivering strong financial results. We’ve proved they can.
OVERCOMING THE CONFLICT CULTURE
As you might expect, unleashing this kind of change is immensely challenging. Many of our actions sparked a passionate response among employees fearful for their jobs, as well as a political backlash in the community. But Intermountain’s leadership was determined not to let the divisiveness beyond our walls infect our culture. From the front lines to our executive team, we’ve persevered, attempting to stay true to our organization’s founding charge of serving as a model healthcare system and attempting to work creatively to find common ground with many skeptics. Instead of just mustering the usual determination and focus that strong leaders show, we’ve sought to lean into deep-seated tensions and conflicts, both within the organization and beyond. Rather than avoiding conflict or seeking to ram through it, we’ve accepted it as a fact of life and attempted to manage it adroitly and compassionately on behalf of progress.
Navigating conflict to ignite change is, I’ve come to see, a leadership discipline of its own, one that requires special intensity, attentiveness, and skill. On the one hand, and perhaps most notably, leaders must work to avoid the unnecessary and excessive conflict that, in our harshly polarized society, all too often prevents change. It only adds friction, slowing much-needed progress. Departing from a command-and-control mentality and deploying empathy, curiosity, and other “soft” skills, leaders must bring people and organizations together to drive change, creating new and productive collaborations with business partners, customers, employees, community members, and even competitors.
But leaders seeking to unleash their organizations on behalf of progress must also be willing at key moments to incite conflict to productive ends. Mindful of their ethical purpose and the organization’s mission, they must take meaningful stands on behalf of their beliefs and in the service of progress. On an ongoing basis, they must prod people to embrace change even when they don’t necessarily want to. Of course, there’s a balance to be struck. At all times, leaders must take care not to go too far but to behave compassionately, empathetically, and respectfully toward others with differing perspectives.
To date, we’ve succeeded because we’ve worked creatively to find common ground with many skeptics. One of our community health program managers, a liberal, Harvard-trained healthcare leader, partnered with a leading gun rights advocate in one of America’s most conservative states to make progress on firearm-assisted suicides. Likewise, we addressed the problems of high prices and drug shortages by working with competitors to found a nonprofit generic drug company.
Communities struggle with poverty, crime, and other seemingly nonmedical issues. That’s not normally seen as a healthcare crisis, but Intermountain views it through that lens because we’re following the evidence upstream. So we’re investing millions to address these issues, recognizing that they in turn profoundly affect people’s health.
It’s not just Intermountain that has grown and evolved. I have, too, as have my relationships with caregivers and leaders in the community. Early critics have become good friends, while a good number of skeptical employees are buying into the radical and ongoing changes we’ve undertaken. I should emphasize that I’ve learned valuable lessons from them. I’ve seen leaders and caregivers deploy ideas and strategies on the front lines that I never would have imagined. And I’ve marveled at how teams of people have unleashed themselves to make a difference of their own, pushing me to be a better leader, a better listener, and a better human being.
My urgent need to drive change hasn’t wavered. On the contrary, it has only intensified. If cancer doesn’t fire you up to try to do the seemingly impossible, I don’t know what will. Unfortunately, there’s more to that story. In 2018, I received a second tough diagnosis, this time of multiple myeloma, a blood cancer. Educating myself about this condition, I kept running up against the word “incurable,” and it haunted me. New treatments were allowing more patients to live with the disease and manage it as a chronic illness, and I was determined to be one of them. More than ever, I couldn’t take anything for granted. If I wanted to make an impact with the possibly limited time I had left, I knew I had to push myself and our organization even harder.
In 2019, a key treatment I underwent—a bone marrow transplant—failed, and my condition quickly deteriorated. It seemed that my time really was running out. We scrambled, and I underwent a novel immunotherapy called CAR T-cell therapy.5 My body’s killer T cells were removed, souped up using genetic engineering to better fight the cancerous cells, and then returned to my body. The treatment works for about 70 percent of patients, and so far, I’ve been one of them.
I don’t know how long this treatment and others I might try will contain my disease, so I’m not wasting a minute. Every day, I wake up more committed than ever to pursue the path we’ve been on and push change forward, regardless of the challenges. Despite what we’ve accomplished, we’re nowhere near ready to declare victory. As I’ve found, life and business are always evolving, a work in relentless forward progress. We’re determined to keep going, continuing to unleash possibility inside our organization and improve the quality, safety, and cost of the care we provide.
ABOUT THIS BOOK
I’ve written Possibility Unleashed to share what we’ve learned by driving change at Intermountain. I want you to take your organization and industry to new heights by unleashing your people’s power to innovate. To that end, the book introduces you to a new and perhaps iconoclastic perspective on leadership, one that I find to be not merely innovative but pragmatic, results oriented, collaborative, and healing.
My argument is simple: leaders can have a far greater impact on society than we realize while also building strong, economically healthy organizations where people love to work. The key is to focus not on scoring political points or even behaving “sustainably,” as many leaders today strive to do, but on taking personal and organizational responsibility for solving broader social problems and working together to make it happen. Leaders must muster courage on multiple levels. They must recognize the limits of their own authority and seek solutions from frontline employees and external partners. They must set aside political and cultural differences and find common ground. And they must not merely tolerate diversity but draw on it to power breakthrough innovation.
I’ve written Possibility Unleashed in hopes of exposing executives, managers, students, and entrepreneurs to the insights, mindsets, and practical tools that we’ve mobilized to disrupt a troubled industry and heal ailing communities. In the chapters that follow, I’ll elaborate on a set of principles related to the challenge of leading change in fractious times. In the first two chapters, I lay foundational principles— empathy and the welcoming of outsiders—and then cover themes related to organizational transformation (Chapters 3–5), strategy (Chapters 6–9), and stakeholder communications (Chapters 10–11). In each chapter, I’ll push into the complexity, exploring the inevitable tensions leaders must surmount and the balancing acts they must sustain to solve big problems. You won’t hear just from me. Having had the honor of knowing or working with distinguished leaders in healthcare and beyond, I’ve woven in stories and lessons of theirs that have helped me to learn and grow as a leader.
As you read this book, I invite you to hold up a mirror to your own leadership and reflect on what it will really take in the coming years to bring meaningful change and stay ahead of disruption. The chapters ahead will cover challenging topics such as the importance of talking to your “enemies”; walking in the shoes of the underserved; navigating the land mines of identity politics while acknowledging and leveraging cultural differences; pushing others in your organization into a healthy state of discomfort; and breaking out of your habitual domains to solve problems.
I’ll also invite you to ponder what growth in an organization is really all about; whether you have the right business model and offerings to allow for true innovation; whether you’re willing to be hated (we must be if we want to do anything truly disruptive and meaningful); and whether you’ve been honest with yourself about the state of your organization. I hope to approach these themes not with abstractions or platitudes but with heartfelt meditations rooted in real experience. As I’ll reveal, a dedication to the difficult and ongoing process of collaborative problem-solving at Intermountain has saved lives, transformed communities, and built a thriving, industry-leading organization.
Many leaders are scouring the horizon for new ways of operating, not least because customers, employees, and investors are clamoring for leadership that is focused on driving progress rather than making a political point. Yet all too often, leaders fail to take bold action and to galvanize others to do the same. We’re beset not just by inertia, but by a conflict culture that makes any bold move seem perilous and even impossible. By reflecting on experimentation and change-making, I hope this book will inspire you to set aside conventional thinking, seek out unlikely partnerships, pursue them in productive ways, and get the job done.
The time has come to get serious about change. We all know this. We also know that the polarization and divisiveness in our society has gotten out of hand. So let’s stop the grandstanding and the bickering. Let’s step up, take responsibility, and work with and through our differences to make change happen. We must become not just innovators in our domains or evangelists for our ideals but pragmatic healers and problem solvers for all of society. Let’s unleash possibility in ourselves and our organizations, so that we might move together toward a healthier, more prosperous future.