LEDI 87 | Financial Stability

 

In times of crisis, keeping financial stability and building resiliency are challenging tasks indeed. The healthcare industry faced these obstacles due to COVID-19, calling for huge structural adjustments. Dr. Chuck Peck and Ben Sawyer sit down with Carol Burrell, CEO and President of the Northeast Georgia Health System, to share how they survived the pandemic by implementing several strategic changes in their team. Carol breaks down her four-tiered notification system that addresses patient concerns even before lunchtime. She explains how this strategy proved useful in their success, all while keeping their operations aligned with the organization’s core values and overall vision.

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Achieving Financial Stability And Resilience With Carol Burrell

Ben, we had an enlightening conversation with Carol Burrell, the CEO and President of Northeast Georgia Health System. The thing that was so great about the conversation was that it was incredibly practical. It solidified for me what I’ve always believed leading through change was all about. No matter how difficult the situation is, if the vision and core values of the organization are solid and if they are not only practiced every day by leadership but passed down through the culture and accountability in the organization, then it makes success something that’s achievable.

The clarity that leadership has to provide around what the mission and the values of the organization are is so important when significant challenges come about. The example Carol used was being out of network with the largest payer in the State of Georgia for 97 days and getting through it, not only that but making all of her patients whole during that time.

Having been the CEO of a hospital 75 miles from Carol, I can tell you that it’s not pleasant having to go through something like that but when everybody is aligned around the common goal, and when you are focused on the patient and have some very practical things that you are going to talk about around how to get that done, it makes all the difference in the world. Being a servant leader, I guarantee you that if you look at the most successful healthcare organizations, most of them are being led and have been led by servant leaders. Carol is a perfect example of that. What do you think, Ben?

I totally agree. To our audience, you don’t want to miss this conversation. Carol gives you some very practical ways to apply what Chuck talked about, where they can do an escalation around their critical-status items and get the problem solved by 9:45 in the morning every day. They do a four-tier rapid cycle update. It is a part of her strategy execution system or what the Japanese would refer to as Hoshin Kanri. It’s super practical. I’m very impressed with what they are doing. She indicated that it has been foundational for them to be successful during challenging times. You will love what you are reading.

Welcome, everybody, to another episode brought to you by the Malcolm Baldrige Foundation and our strategic partner, ABOUT Healthcare. As always, I’m honored to be joined by Ben Sawyer, one of my good friends. Ben is an Executive at ABOUT Healthcare. He and I have been hosting this show now for several years. We have been talking about a lot of the changes that you have all been experiencing, particularly over the last couple of years with COVID. As we have moved out of COVID, we have been transitioning some of these conversations to how to lead through the dynamic changes that we are seeing in the healthcare world and environment as we move into the future.

I’m particularly happy to have a special guest and a good friend Carol Burrell, who’s the President and CEO of Northeast Georgia Health System. Carol and I have known each other for many years. We have served onboards together. She’s a very well-read and well-spoken CEO who doesn’t talk theory but who has made some incredible changes to the Northeast Georgia healthcare landscape. What we want to discuss with Carol are some practical, strategic, and operational things that she utilized as she helped move her organization through the change cycles that we are all going through.

Let me tell you a little bit more about Carol before we begin. Carol has served as the President and Chief Executive Officer of Northeast Georgia Health System since 2011, leading the health system through an era of unparalleled success and growth. One thing I want to highlight about Northeast Georgia and Carol is that she has managed, through her leadership, to maintain Northeast Georgia as an independent not-for-profit organization. As you all know, it’s very unusual to find large independent, medium-sized independent or freestanding healthcare organizations.

That fact alone should tell you a lot about Carol’s leadership. Through her leadership, Northeast Georgia has grown from a one-hospital system with a few employed physician practices and satellite outpatient locations to one of the largest and most well-respected healthcare organizations in the state, with an economic impact of more than $3.2 billion every year. Carol’s leadership is also one of the many reasons Northeast Georgia was named one of Metro Atlanta’s Top Workplaces for seven consecutive years by the Atlanta Journal-Constitution and 1 of Atlanta’s top 25 employers by the Atlanta Business Chronicle.

Carol has more than 30 years of experience in a variety of clinical operations in both profit and not-for-profit settings. One of the hallmarks of Carol’s tenure at Northeast Georgia has been a culture of continuous improvement called Quest for Excellence, which empowers everyone across the organization, from administrators to frontline staff, to identify and implement ways to improve care. Carol’s mantra is, “Be better tomorrow than you are today.” Carol, it’s great to have you here. Thanks for joining us.

Thank you, Chuck. I feel honored to be here.

I will start with this question. Ben will be very active in the conversation, as he always is. Carol, how have you managed to change over the past few years? How have you kept your teams engaged and focused? You have been working on that way before COVID hit but I know that leading through the change that has occurred has been particularly challenging.

We get a lot these days. I believe that healthcare leadership is primarily about change management, to be honest. To successfully manage change, you have to have a solid foundation. Here at Northeast Georgia, the foundation of every decision we make and everything we do is our mission and our core values, improving the health of the community in all that we do.

Our core values are a part of our daily mantra and conversation. On the other side of the coin, for every positive core value, there is an accidental core value. We have learned to call those out as well because those are the things that help you continue to progress and move forward. Over the past couple of years, everyone knows and has experienced certainly the challenges that we faced through COVID. As I have said multiple times, you don’t create core values in a time of crisis. It’s when those help you to survive through that.

Communication is one foot in front of the other but still trying to look up and out. We made some very strategic decisions during COVID with our expansion. That helped folks to have hope to see beyond. It was work that we had been working on for a number of years planning. To be able to still stand strong and have the courage said a lot. I contribute a lot of that to our board as well.

I could ask another question that’s a little bit more specific to use as an example of how you stick to your core values and your vision. When you and I were CEO colleagues and when I was a CEO in Athens, and you were 75 miles away up in Northeast Georgia, we both were up against what most in that part of Georgia would consider the Blue Cross Blue Shield monopoly and the difficulty that Anthem Blue Cross in that part of Georgia can provide healthcare providers, hospitals, and physicians.

We both went through similar issues. I know that when I went through it, sticking to our vision and value’s guns was a big help. I’m wondering. How did you get through that by sticking to your core values? The reason I’m asking it in this context is that we have had a lot of conversations in prior episodes about this problem. A lot of folks always fall back to their North Star even though the pressure is tremendous not to. I’m curious about what you think about that.

I have a lot of thoughts about that. I have even joked with some people when they ask about COVID and how you got through COVID. I said, “Six months before COVID, I was out of network with Anthem for 97 days and some other disruptions within the system.” You didn’t quite have all the support during the Anthem that you did through COVID but we went through a very challenging negotiation period with Anthem.

We certainly know that we are essential in our region. We stuck to that. When we looked at the terms that were in the contract, it wasn’t so much the financial piece. It was the language, the policies, and their rights, as you well know. As we looked at that and said, “If we sign this, it’s going to take the pressure off for the short-term,” but for what it would do to this organization long-term, I couldn’t do it. I had the backing of my board and the backing of our community too.

We met with the local employers. One of my now good friends who was the CEO at one organization said, “I can change insurance companies. I can’t change my hospital.” They stood by us. Some of them made changes. One decision that we made was to keep our patients who had Blue Cross or Anthem at the time whole, even during that period when we were out of network.

Those relationships in our community made a difference because those business owners reached out to Anthem and were able to get us both back to the table. We ended up with what was a fair contract on both sides. That was one of the toughest times in my career because I felt such pressure and burden for those people who were impacted but knowing that the right thing for this organization was to stand firm.

LEDI 87 | Financial Stability
Financial Stability: One of the toughest times in healthcare leadership is standing firm for what is right for your organization.

 

Ben, I know you have some questions.

There are a couple of related ones. Insurance companies have been increasingly aggressive with their contracting and even more so in their payvider activities, where they are acquiring providers and moving into what are typically catchment areas for health systems. How have you reacted to that? Are there some discussions going on yourselves to go the other way?

For example, we had the Banner Health Chief Strategy Officer and EVP on. They talked about how they went ahead and did a payvider journey. They did a contract with Aetna because they realized that in the evolving world, they needed to be able to be both the payer and the provider. I’m curious as to what your strategic thinking is in that regard and how you are responding to those overtures.

We have had our clinically integrated network or HP2, for a number of years. Years ago, we put a lot of resources and priorities toward advancing that under the premise of value-based care and preparing ourselves to be able to participate in risks. We have a number of value-based contracts. They are more focused on quality goals and outcomes but our vision is that down the road, we position ourselves so that we can share and risk arrangements.

We have payers who are interested in that, particularly around the Medicare Advantage, because that’s such a growing population here in this region. That’s how we are positioning ourselves. Some payers are more ready to do that than others. We are in negotiation with one of the larger payers, “How do you get business out with the policies that are changing constantly?” It’s going to be another tough battle because they are not ready to have a mutually aligned negotiation.

From the standpoint of network integrity with your HP2, as you’ve worked on that, have you found that the physicians have been very cooperative in terms of keeping their referrals within the network and strengthening your CIM? Is that a position of strength you are taking with these insurance contracts?

Northeast Georgia Health System has two employed physician entities. Our Northeast Georgia Physicians Group has over 600 physicians with a significant amount of primary care. We own the market share for primary care. We have our Georgia Heart Institute, which is our cardiac program. We have other independent providers, Longstreet Clinic being one of those, that are a part of the network.

The majority of that is Northeast Georgia Health System providers. We are all on Epic. Longstreet Clinic is now on Epic. Having the ease of being within the same system certainly makes a huge difference. We have PSAs or Professional Service Agreements with several of the other specialty groups and are looking to have them come in under the component that’s called Community Connect. It’s a part of Epic. The ease of making those referrals is what makes a huge difference.

Carol, what operational or strategic changes have you made to help transform Northeast Georgia and ready it for the future? If you look back over the last couple of years, what are some of the key strategies you’ve employed? What have you changed operationally to be so successful?

I would take that back to even before the past few years. We started on our lean journey. You made reference to it in the introduction. It’s our Quest for Excellence. That’s our umbrella for our patient experience safety and continuous improvement. We engaged and integrated all of our lean tools. We are a learning organization. I wondered how long it would be before I would say this, “Being better tomorrow than we are today in everything that we do.”

A part of that is creating standard work and understanding so that you know what it is that’s not working and how you improve that. One of the things that we implemented several years ago was our daily readiness huddles. We start at the frontline with tier 1 and go to the supervisor, tier 2, tier 3, and then ultimately to the C-Suite or tier 4. By 9:45 every morning, I know what the safety concerns and operational challenges are that we are going to be facing that day. I don’t know how we could have gotten through COVID without that.

The communication, agility, flexibility, and understanding across the entire organization of what the needs were did get us through. We find ourselves now on the other side of COVID or have learned how to manage and operate within that. We are refreshing ourselves around that. It got us through COVID but now what? What’s the next phase or the next evolution of improving the operations, having the frontline more engaged, and taking innovation to a different level? We are in the midst of doing that.

What have you done to recruit and retain talent?

That’s a big one. At the C-Suite and the management level, we have been successful in recruiting some very good talent. As you referenced, one of the facts that we are a large system but still remain independent is very attractive. Being the focused on the community is appealing to some talented executives. A culture fit is so vital.

LEDI 87 | Financial Stability
Financial Stability: Building a large system that can remain independent is an attractive goal.

 

We go through a leadership assessment by a third party for every individual. We didn’t settle with Anthem. I hired a chief human resources officer. I interviewed nineteen people before I made the final selection. We made the right one but that’s hard to do because you want to fill them and move on. It’s too painful when it doesn’t work out.

At the frontline level, it’s more challenging. We have had our turnover of frontline staff that are traveling, burned out, and tired. That’s my number one concern and priority. Our turnover is not that high. It’s below the national benchmark. We looked at that but we are expanding and growing significantly to meet the needs of this community.

We are struggling with capacity. As great as it is to be building a lot of new facilities, technologies, and all that, we’ve got to have the staff to be able to serve that. We are working with some local universities to do some accelerated programs. We have even started our patient care tech program and have that for a ladder. They go to LPN and then RN, which we are funding. Those are some of the things that we are doing.

Can I go back and ask you some questions? Your lean program, the Quest for Excellence, is fascinating. I’m a lean belt.

I could use you.

I worked with Chuck at Piedmont on a number of things. This is an interest area for me. From the standpoint of getting the staff to get their fingerprints on the change and own it, are they doing A3s? For the audience, it’s a rapid cycle one-pager. Is that a standard part of your practice?

Absolutely. Understand the whys and the whats before you jump to the solution.

Have you found that it has been particularly effective with silo-spanning processes or processes that cover more than individual departments? Where have you found that you focused those improvement efforts the most? Is it within departments? Is it typically across departments?

It’s certainly within departments but I don’t know if there are very many problems out there or challenges that are not across departments. It has been more valuable from a system perspective where you’ve got a process that touches many different areas. You have to come together to address it like that. It’s probably more so across the system.

Your four-tiered system of notifications up to 9:45 sounds to me like something that would be a practical takeaway for some of our readers that they could think about applying. Can you explain in a little bit more detail for those readers how you do that and how the organization is able to then distill the clarity around your strategic priorities, KPIs, and so forth within that process?

We have our strategic objectives and our goals from the board or organizational levels. We cascade those down through a catch-ball process. Our service delivery pillar is an example at the organizational level. That goal is then transitioned down to say, “What can a person or a unit do to help improve the quality rate?” It gets it down to be much more tactical. Each unit and division has a huddle board. That huddle board identifies, first of all, the daily issues. What are the methods, people’s issues, and supply issues? Safety issues are always first.

You go through each of those. Also on that huddle board are the pillars and their particular goals. Every morning, it starts at different times for different departments but most of them are starting before the first shift or probably at 6:30 in the morning. They gather around and say, “What are the challenges for the day?” Once a month, we will then say, “Where are we very metrics-driven on all of this about where we are and where we are trying to go? How does that process?”

Those at tier one or the first line, if there are issues that can’t be resolved within that unit, are elevated to tier two, which is with the supervisors and a broader unit. Tier three then goes to the executive director and vice president levels. Things continue to get escalated. Hopefully, they are being taken care of at the lowest level but for those things that are broader-system, they end up then being reported at tier four. Senior management is aware and then moves into how they can break down the barriers for that.

By doing this, you’ve set up an environment where problems that potentially could block your customer service with patients can be addressed the same day before lunch because of the alignment with your strategic priorities, KPIs, and the ability to escalate in the way that you described. Is that a correct assumption?

You said it perfectly.

For readers, this is Hoshin Kanri or what the Japanese did with the Toyota Production System, better known in the United States as strategy execution. In terms of your refreshment process on a strategic cycle, are you refreshing this, for example, in Q3 with your strategic planning cycle? How does this process get refreshed on an either annual or semi-annual basis?

We brought in a third party, Catalysis, from John Toussaint. I have had a relationship with him for a number of years. We had them come in and do an assessment of our senior leadership in some specific areas. We did a survey where we felt like we were and then what their observations were. Honestly, the gap wasn’t that far off.

We know that we slipped back during COVID and that we are not living it in a disciplined fashion because we were acting in the moment. We were doing what we had to do to get through the day. How do we get back into that discipline and consideration, not just rounding for the sake of supporting them that day, that’s important but rounding with an eye on improvement and accountability?

Here’s a quick question about that. We talked to a number of CEOs about it. Every one of them described that same thing where it was compelling to go into firefighting mode because it was the tyranny of the urgent. Did you find that you were better able to solve the crises through your disciplined process than interactions?

Absolutely. There is no doubt. I don’t know how we would’ve gotten through it from a communication standpoint, and understanding across the system had we not had that in place.

I would assume it’s also safe to say that without the process that you described, you would not have been able to maintain the margins that you have been so successful in maintaining and potentially not be able to maintain your independence in the way that you have. To summarize everything into one word that you’ve described, it’s clarity all the way down to the lowest level of the organization, having everybody on the same page and knowing what they are being measured against for accountability. The culture accountability piece is the most critical thing in your mind that’s kept the organization so successful. Is that too much of a statement? Is that what I hear you saying?

That’s very fair. It’s having that clarity, focus, and diligence of staying after that, even on the rounding on the part of leadership with an eye toward improvement, and holding people accountable for improving on the metrics and helping to break down the barriers. You can get comfortable with that and maybe take your eye off it a bit. It’s more of a social thing. That’s what I’m finding now that we have got to refresh and put that visibility and accountability around it.

The other thing that’s important where we still have some work to do is that our board is very much about lean. The way we got into lean was because two of my board members worked in manufacturing. This goes back to the mid-2000s. They have been with us on this journey. We want them to be more engaged and understanding about what it is. They have done, “Go and seize,” and that type of thing but at a higher governance level, they are holding it accountable. I won’t be here forever. Whoever comes in needs to want the culture to continue. The leadership behaviors, the focus, and the ability to continue are very important to our board leadership.

It’s interesting. The Baldrige is all about the notion of continuous improvement and making it a culture. With the program, we have worked on developing an organizational hierarchy of needs like an individual hierarchy of needs that reflects that and shows the board interactions and all that sort of thing. One other question that I have in that regard is this.

When you are doing something new like you are bringing in a technology or a process, is that process or technology screened or integrated into your improvement process to make sure that it’s not disruptive? How do you do that when you are doing innovations or new things that you are bringing into the organization? Can it be put in independently? Is it factored into this process?

We are launching into the venture capital world and looking at startup companies. Our focus is not just on finding companies to invest in but we want to look for innovation and new technologies that can come in and help us solve our problems. That’s the gatekeeper. You have to come in and be able to help us with capacity, throughput, and length of stay. If it meets that criteria, then we are willing to pilot it and where it may grow from there or not. That’s the gate that we utilize when we are evaluating technology.

An area we focus on extensively is the whole demand, capacity, and throughput continuum as a technology and best practices company. I understand. That makes perfect sense in terms of how you are tackling that.

Carol, we are out of time. Here’s one last question. This has been great. The reason it has been so good is because of all the things you offered in terms of practical ways to go about this. The clarity piece of this is so important. We have talked about it. I utilize the same techniques in Athens when the situation wasn’t so good there. It does work well. What’s the thing that keeps you up most at night?

It’s the staffing and the capacity. We are going to be expanding over the next couple of years. We are making some major investments, as you likely know. For the next couple of years, before the tower opens on the Gainesville campus, we are at capacity. Our ER is overflowing. You’ve got to logjam because we don’t have beds. Ultimately, that’s a strain on the staff. Those two things combined are what is my number one priority and greatest stressor at this point.

Can I ask an adjacent question to that, Chuck, if you don’t mind?

Sure.

Carol, as it relates to capacity, have you been looking at the post-acute care network then and the ability to get patients out more quickly so that you can help to accelerate the capacity on the front end?

That’s a major core tenet. We have our nursing homes. We have an inpatient rehab but we have approved and are starting the process. We are doing a standalone offsite inpatient rehab that will expand and free up beds here on the Gainesville campus but it also will have a total of 50 beds that will allow that. There are home health and all of those things to help get out. The problem is that there are not a lot of nursing home beds available.

Our number one challenge when it comes to the length of stay and getting patients out is that we have so many social admissions that don’t have a place to go for the appropriate care. The family doesn’t want them. They have substance abuse issues or Alzheimer’s. They are autistic. That creates a lot of safety issues because those can sometimes be very violent toward the staff as well. That’s a big challenge.

The number one challenge when it comes to the length of stay of patients in hospitals is having so many social admissions. They don't have a place to go for appropriate care. Click To Tweet

This conversation could go on for a while because this is fascinating. For example, the next question I would ask, which we don’t have time for, is this. Is the process then of managing the post-acute or discharge transition starting very far up in the admission process to be able to give you more runway and things like that?

When they are admitted, we are already implementing a discharge plan and putting a date on the board, “This is what we are striving for.” It works a lot of the time but in those long lengths of stay, not so much.

Carol, thanks so much for joining us. It has been great talking to you. It’s a breath of fresh air to hear from a leader who is able to clearly articulate some of the very specific things that you’ve done that have helped make the organization strong for a long time. Ben and I offer you our congratulations not only for getting through COVID so well but generally for the position that you and your team have put Northeast Georgia in and on the map. That’s great. We hope you have a great holiday. Thanks to our audience for being with us. This was a lively discussion. It offered a lot of clarity. Thank you to our audience for reading. Ben, I don’t know if you want to let our audience know what we will be discussing over the next month or so but please go ahead.

Carol, I want to echo what Chuck said. What you are doing is impressive. I live in your market and use your facilities. I can attest to the audience that it’s working well. Kudos to you. It’s fantastic. To the audience, what we have coming up next is on December 9th, 2022, we have a virtual executive roundtable.

The topic will be leveraging your technology, making sure you are getting the most out of it, which can often be a challenge for health systems because of the disparate nature of that, and making sure you are getting integrated data and real-time information that drives your KPIs and so forth. You will not want to miss that conversation. You can sign up on LeaderDialogue or you can always reach out to Baldridge Foundation’s Senior Event Coordinator, Erin. Her email address is Erin.Sellers@BaldrigeFoundation.org.

Thanks, Ben. Thanks again to everybody. Happy holidays, everyone.

 

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