E70: Achieving Systemness: Analyzing Gaps And Opportunities In Today’s Environment With Dr. Conrad Vial

Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. The Baldrige Foundation and the ABOUT Healthcare welcome you to LeaderDialogue Radio, where leaders glean valuable insights and practical takeaways to help navigate effectively through these challenging times. The show airs on the 1st and 3rd Tuesdays of every month at 1:00 pm (ET) on Business RadioX. Today’s guest is Dr. Conrad Vial, the Senior Vice President and Chief Clinical Officer at Sutter Health. In this episode, Dr. Vial talks about how the pandemic has revolutionized how doctors and healthcare providers approach patient care. He also shares his analysis of the gaps and opportunities in the healthcare system in today’s environment.

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Achieving Systemness: Analyzing Gaps And Opportunities In Today’s Environment With Dr. Conrad Vial

As always, I’m honored to be here with some friends of mine, Ben Sawyer and Darin Vercillo. Darin and Ben are executives at ABOUT Healthcare. It’s good to be back with you guys again, as always, and I’m excited about this show. The topic is Achieving Systemness: Analyzing Gaps and Opportunities in our environment. I’m particularly excited because of our special guests who I’ve gotten to know over the last few months very well. That’s Dr. Conrad Vial. Dr. Vial is Sutter Health’s Senior Vice President and Chief Clinical Officer. He’s a practicing cardiothoracic surgeon who has held various leadership roles in multi-specialty medical group practice and integrated healthcare delivery. Dr. Vial received his Bachelor’s Degree and Medical Doctorate from Stanford. He earned a Master of Philosophy at Cambridge University in England, while also completing a Postdoc Fellowship in Transplant Immunology. He conducted his General Surgical and Cardiothoracic Surgical training at Stanford University Medical Center. He’s board-certified in both General Surgery and Cardiothoracic Surgery. Conrad, it’s great to have you here. We appreciate you taking the time to talk with us. I appreciate being invited. It’s always good to be amongst friends and to discuss what we all agree are pretty important issues at this time or any time. Let me start off with a question, Conrad, and then we can see where this goes. As the nation’s health systems emerge from COVID, many gaps and opportunities for improving care are becoming evident. I have clients who are thinking that they’re just going to go back to the way it was before is the old normal. We also work with folks like yourself, who believe that the old normal is not going to cut it. We need to be looking at doing things differently and moving into a new normal. Sutter Health is a large health system in California that I’m sure everybody on the show is aware of. What are you doing to identify some of these opportunities? What gaps and opportunities in care have you already identified? Do you have examples of some new care models that you’re either thinking about or already implemented? You captured the moment in many ways in that question, Chuck. To take your questions in order, the first thing is adjusting our perceptions, projections, and attitudes around where we are in terms of that spectrum of old normal versus new normal that you just laid out. The pandemic has done a few things that perhaps are unique in terms of impacting or changing perceptions around healthcare. For the most part, it has been a catalyst. It’s been an accelerant. It’s been something that has forced us to take on board and start to implement ideas that existed for good reasons before the pandemic. From the perspective of integrated healthcare delivery systems, the themes that the pandemic has forced us to confront and that I hope will continue to confront and drive towards positive change around are themes like the difference between size and scale. What is the difference between assets defined in physical terms and human factors that underlie resilience and truly scalable compassion? What is the difference between where value is created in healthcare in the new normal versus the old normal? In many respects, we have looked at healthcare systems as delivering value primarily through their physical assets, infrastructure, venues of care delivery, tools, and technologies. Certainly, those continue to be important, I’m seeing a recontextualization of the importance of those factors. In many ways, those are secondary. For the good of patients and their caregiving teams, the new normal will be one in which we acknowledge our ability to make insight actionable and meaningful in the pursuit of sustaining well-being where people are well and restoring well-being where people are ill. It is the competitive differentiator and for good reason. Healthcare is a challenging and complex endeavor. We are unfolding our efforts to care for communities under a not-for-profit mission in a challenging environment. Click To Tweet We ought to celebrate that. It’s going to be a bumpy transition. It already has been. Getting away from this idea that your physical assets define your ability to generate value and talking more in terms of those physical assets. Frankly, intangible assets are merely tools in the ability to raise actionable insight that pertains to the well-being of either individuals or populations. That’s where we need to be going. That’s where the pandemic is pushing us. That is not something that we shouldn’t be not only cognizant of, but celebrating. Those are some great thoughts. It takes me to another question that I was thinking about as you were talking. All of us on the show here agree with your analysis of physical or tangible assets versus a lot of intangible assets that maybe we haven’t thought much about over the years, way prior to COVID. One of the things I was wondering about is an example of these different partnerships with physicians or vendors to enhance the effectiveness and efficiency of your care models. In other words, instead of using all the available capital you may have to build more buildings, whether you see much more value in things like partnerships. Maybe those are some things that we haven’t done before that we weren’t innovative enough in healthcare to think of before. These are things that are more intangible in that regard that bring much more value to people who are taking care of us, the doctors, nurses, etc., but also to the patients we’re caring for. That’s an important theme. To unpack it a little bit, it’s interesting to think about the journey of tech versus healthcare. I don’t mean to make the comparison be too strict or too close to one, because there are important differences. The journey of tech has been one of moving from products to systems to solutions to platforms. When you think about the journey of healthcare, industry development, the craft, as well as science and art, we’re still celebrating when we can put together “systems” instead of mere products. I don’t think the healthcare analogs necessarily to solutions and platforms have been built out, coordinated, or integrated in the way that they could have. That’s a real opportunity for us. It’s been an opportunity for a while, but it’s one we can’t turn our back on now because of what the pandemic has brought to us. We’ve been hearing a lot about it, certainly since 2011, about the transition or the pivot from so-called volume to value. I would like to suggest that we ought to reframe that much more along the lines of the pivot from the “analogs of production” to performance. Performance is a bigger category than production. It involves production setup against categories that are even more compelling, and ultimately more important for the end-user and the consumer of whatever we’re offering.

In that regard, we need to recognize the economics of healthcare. The fee for service is not going to go away anytime soon. The fee for risk will increasingly become important. That transition will continue to be a more protracted and messier one than any of us would like, but that’s reality. Talking about value as somehow only assignable or attributable to the fee for risk arrangements misunderstands the point. We are going to because of the economic realities that are currently with us and are going to continue to be with us, pandemic or no pandemic. We’re going to continue to need to recognize the value as something that we create irrespective of the avenue of revenue intake, irrespective of the particular book or sub-book of business that we look at, and irrespective of the clinical channels of care delivery. Without that, I don’t think we will make the transition as gracefully as we otherwise could. From our perspective, that means trying through population health care capabilities and related toolkits. Make it actionable, satisfying, and accessible to practicing clinicians to clinical decision-makers to practice with a value-driven mindset, irrespective of whether they happen to be taking care of patients in a fee-for-service arrangement or fee-for-risk arrangement. That means locating the sensitivity to performance factors, and not just production factors, as close to the practicing clinician as you possibly can. Every system and every culture will have a different set of guardrails from a regulatory perspective, an industry perspective, and a clinical strategic perspective around how to do that in their particular marketplaces and system. That general theme needs to be one that we’re all focused on. Darin, you probably have a lot of questions for Conrad. If one looked at ABOUT Healthcare and didn’t know anything about it, they would probably classify it as an IT company. You must have some thoughts about what Conrad talked about. It’s much more than that. Go ahead. This is my first time meeting Conrad on this show. It’s great to make your acquaintance. With ABOUT Healthcare, formerly Central Logic, we’ve had a history of working with Sutter for many years. 2011 is roughly when we started working with your transfer centers across the organization. Sutter is a broad and diverse system with its roots, mergers, and many different cultures brought together across the North of California there. It’s been wonderful to watch that ongoing transition through the years that we’ve done work there and see those cultures coming together. We’ve talked about this idea of systemness. Conrad, I wonder if you would comment as to the ongoing journey that Sutter has had to create systemness across those different cultures and organizations that were brought together. Maybe from the perspective of physician culture, as well as with your work and administration, how the different business aspects of Sutter come together and support each other, as opposed to working in silos. What’s the journey to creating that system? How was the pandemic also catalyzed that ongoing transition? The key elements in moving from old normal to new normal will be a more thoughtful reflection and a more vibrant conversation we can collectively have. Click To Tweet You point to a noble destination that I don’t want to speak for other systems around the country. It is one that we are still working our way towards. I can’t say that we’re there. We have to be honest and humble that healthcare is a difficult and complex endeavor. We are unfolding our efforts in trying to take care of communities and our not-for-profit mission in a pretty challenging environment. In Northern California, in our case, there are almost 3.5 million patients living in communities that are extremely diverse and complex in terms of their histories and ongoing dynamics. A singular system that is an open system from a physician’s perspective, and also from a patient perspective. We take care of more fee-for-service Medicare and Medi-Cal patients. Within that, you can think of the elderly and the indigent than any other system in Northern California. Yet we’re doing so in an environment that is replete with challenges from an economic and regulatory perspective. Cost pressures are intense everywhere. They are especially intense in the environment in which we’re doing business. It’s not a non-competitive area either. Northern Californians are blessed with lots of choices, extending from not-for-profit community care up to major academic missions that are also involved in healthcare delivery. From a Sutter perspective, you’re quite right to point out the fact that Sutter’s healthcare roots go back over 100 years in Northern California, but it’s 100 years in different places, in Sacramento, San Francisco, and lots of places in between. The Sutter that we know has been a Sutter that has been built over time through a series of not just economic and structural mergers, but noble attempts of cultural mergers. This is something that is important to bear in mind. Physicians are critical partners, but in many regards, I see them also as customers. Physicians have choices, whether they be in independent practice or in a foundational line group practice. They have choices as to what systems they can align with. The importance that Sutter needs to place on recognizing is that our product is something that we delivered through a medium. It’s a medium that is fundamentally based on human relationships. Those human relationships are between caregiving teams led by physicians, patients, their families, and the communities that come out.

We have to be mindful of what everybody’s role is so that we can harmonize those roles. If physicians are delivering care to patients through those relationships, then Sutter’s role is to help to enable those relationships to flourish and help that care to be delivered in a way that allows us to reach a level of scaled compassion, and satisfaction that is an improvement over what healthcare has been. I get back to the themes of looking for us to align around and create incentive alignment around performing together rather than merely producing together. What you’re pointing to is the core cultural challenge, at least for our system and in our part of the world. Here’s the good news on this, and my response to your question on this point. We could be worried or scratch our heads and be paralyzed by angst around the enormity of the challenge and the complexity of practicing in an environment which is what I described Northern California as. On the other hand, we could also see this as an immense opportunity for us to take on board caring for a population. Let’s call it 3.5 million, at least from a Sutter footprint perspective. Those 3.5 million people look and feel a lot like the rest of the United States populace. The level of complexity culturally and the level of disparities in income and access, the rural versus urban, choose any spectrum of healthcare demographics or healthcare clinical and business strategy. You will find that what Sutter is facing and what Sutter is taking on is something that has the potential to speak to some solution building for the rest of the national system. That’s how complex and diverse our environment is. Ben, I know you’re thinking about a lot of things. Please, go ahead. My question comes through the lens of performance improvement in Baldrige, Conrad. I was intrigued with human factor resilience, focusing on compassion, and the performance factors as close to the provider-patient interface as possible. That’s where the moment of truth is. What are the implications for systems when you start there and work backward? You’re looking at existing structures as assets. They need to be re-conformed essentially to fulfill the value that you’re delivering to customers across a much broader clinical structure than we were pre-COVID, which was largely acute care centric. The pandemic has opened up the hood and lets us look at what the real engine that drives satisfying and effective healthcare looks like. That engine is an engine that remains profoundly human. Click To Tweet There are three things that came to mind and I wonder if you could comment on those. One is the orientation of leaders to more of a servant leader mentality, almost an inverted pyramid where the patient and consumers are at the top. Those driving the moments of truth are the focus of attention, as opposed to driving mandates down from senior leaders. The second one is something that we’re hearing on the tech side, composable solutions. Instead of having rigid structural solutions, clinical documentation, and billing the technology has to adapt to become composable to what the organization is trying to accomplish. The third that comes to mind is this whole notion of access and orchestration. If patients are coming into Sutter from whatever portal, how do you make sure they get to the right place? If it’s a cardiac patient, do they need to be admitted? Could they see someone in their office or a service line CAP lab at a lower cost, higher quality, and better experience type of environment? How do you know what those assets are, and be able to orchestrate that to the best effect of the patient and consumer, including their follow-up on their pop health needs should they have social determinants of health issues? As you’re thinking through that human factor provider-consumer moment of truth thing, and starting with performance and working backward, what are your thoughts on those three things? The shift in leadership to servant leadership, the shift from highly structured IT to more composable solutions, and the notion of real-time access and orchestration of demand to capacity within the enterprise? There is a lot there. In the follow-up to whatever themes I invoke, I’m happy to go deeper as you all wish. Through this entire conversation, you’ve touched on some resonant themes. One of the legacies and blessings of the pandemic has been to open up the hood and let us look at what the real engine that drives satisfying effective healthcare looks like. That engine is an engine that remains profoundly human, despite the fact that there is an absolute opportunity, as well as the need for us to take digital tool development. That is so much a part of the cultural moment that we’ve been living through. I’m in Northern California. I come from the Bay Area. The Silicon Valley zeitgeist is not one that you can escape very easily. I don’t think you can escape it anywhere now. The point is, how do you utilize digital tool development and application to improve the humanization of healthcare service and delivery, rather than detract from it? We’re wrestling with this societally and culturally in a lot of other areas. Healthcare and education are the two that win my heart and soul every day. You invoked some principles around process improvement.

Whether you’re looking at the problems through the lens of lean methodologies, human-centric design, or the scientific method, there’s a convergence of viewpoints there coming from all of those perspectives. All of those perspectives are fundamentally focused on improving science and art. It is both. It is an improvement as a craft. All of those disciplines and sub-disciplines within each of those share in common a recognition. Whether you’re going to use the word gamba, invoke the use of the human agency that’s involved in any collective endeavor, or focus on it from the perspective of getting meaningful data and interpretations thereof, you’ve got to be out in the front line. You’ve got to be in the mess. You can’t be looking at it from either an ivory tower or a boardroom perspective. One of the key elements in how we move from old normal to new normal will be a more thoughtful reflection and a more vibrant conversation that we can collectively have around what is it about healthcare that needs to be run from a central perspective if we’re talking about systems. There is compelling value and accessible meaningful scale by running it that way. How does that need to interplay with what parts of healthcare need to be run on a more local and customized basis? The highest level of performance requires something that’s a bit more bespoke. For example, think about regionalization to drive more effective volume performance relationships in rarified tertiary and quaternary skillsets and sub-specialty or specialty care versus primary care. It is primary care in a much-disrupted form, that is still humanistic, local, and bespoke but team-based, and often multidisciplinary team-based. To recognize our physicians, we talk a lot about burnout. We talk a lot about the need to do things for burnout. On a parallel channel, we often talk about how we need to be patient-centric. The key here is that lots and lots of sources of credible data show that the two are so fundamentally and inextricably intertwined. We ought to be focusing on not just doctors and patients, but the relationship between the two. It’s this relationship-centricity that we need to call for. It’s not about me or you. It’s about the “us” principle in healthcare. The same is true for education. If you take something like digital tool development and application or you about IS or IT, that is the same conversation for me. We keep thinking about digital or IT from a clinical care delivery and a business perspective as off on their own island, as though we were all inhabitants of an island archipelago society. That’s just not true. IT and digital are not adjuncts to care. They are often the care. They’re certainly so close to the care that they need to be accessible and show up meaningfully for both caregivers and care receivers in the local environment. There are all kinds of aspects of the infrastructure management and innovation efforts that need to be run to scale and therefore have to map to a centrally driven vision and strategic set of formulations. It has to be less dichotomous than it is now. Healthcare is late to this conversation in many respects. I remember months ago reading an opinion piece put in by an IT leader in the tech business sector. He was being hyperbolic to make the point that we should abolish the IT department. I don’t think he meant we need to abolish the IT department. What he meant is that we need to have a more distributed model that exists or coexists in a central scale planning effort model. It looks a lot more like an ecosystem with niches being subserved in the way that they need to be, rather than a top-down approach. That lean mindset methodology-based techniques, human-centric design techniques, and scientific system, team health systems science approaches will all need to be harmonized in order to drive improvement in that direction. That’s the direction we’ve got to go. Conrad, this has been a fascinating conversation as I knew it would. We’ll be having more conversations around these themes. Hopefully, you’ll be able to potentially join us again. The central focus of humanism and thinking about why we’re doing all this work, how all these different pieces and parts integrate one to another to try to help patients get rid of suffering. All the things that you’ve been talking about are important topics. Thank you very much for joining us. It’s been a great conversation. Hopefully, we’ll get a chance to talk again soon. Thanks again, everybody, for reading and we look forward to seeing you again at the next episode.  

 Important Links

• ABOUT Healthcare
• Sutter Health
• Baldrige Foundation

About Dr. Conrad Vial

Adult cardiac surgery, Adult congenital surgery, Adult heart surgery, Aortic valve surgery, Ascending aortic aneurysm reconstruction, Bypass surgery – endoscopic vein harvesting, Bypass surgery – off pump/beating heart, Cardiac valve repair and replacement, Cardiac, thoracic and vascular surgery Complex aortic disease repair, Complex coronary revascularization, Coronary artery bypass surgery, Coronary bypass with endoscopic technology, Esophageal cancer, Heart disease, Heart failure services, Heart surgery for atrial fibrillation (MAZE), Lobectomy, Lung and airway surgery, Lung and esophageal cancers, Lung cancer surgery, Mediastinal tumors, Mediastinal, chest wall and diaphragmatic surgery, Minimally invasive aortic valve surgery, Minimally invasive cardiothoracic surgery, Minimally invasive surgery, Minimally invasive valve surgery, Mitral valve surgery, Multidisciplinary heart failure clinic, Off-pump coronary revascularization, Pacemaker services. Percutaneous valve implantation, Pericarditis, Pleural effusion, Re-operative coronary bypass surgery, Surgery for endocarditis, Surgical repair and replacement of the great vessels, Thoracic sympathectomy, Thoracoscopic lung surgery, Transcatheter aortic valve replacement (TAVR), Valve surgery – repair and replacement, Video-assisted thoracoscopic surgery (VATS)