LEDI 90 | Managing Change

 

Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. The solutions they come up with will serve them not only in the current environment but also in the future. For John Raffoul, the President of Adventist Health White Memorial, managing through the changes is all about understanding the value of the organization’s mission. In this episode, he shares with us how their mission and values helped them overcome the adversities brought by COVID. A Malcolm Baldrige Award Winner, John then talks about the Baldrige framework that allowed them to formulate their strategy, processes, and growth. Join him in this conversation as he dives deep into leadership, employee retention, patient satisfaction, and more!

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Managing Through Change With John Raffoul

We had a wonderful conversation on Leader Dialogue with the CEO of White Memorial Hospital, which is part of the Adventist Network in Los Angeles, California. The CEO’s name is John Raffoul. He has a very interesting organization. It’s a 350-bed or so hospital in one of the poorer areas around Los Angeles and mostly serves the Hispanic population.

When I was talking to him, we started off by asking about some of the challenges that he’s had leading through adversity, particularly over the last couple of years. The first thing that he went to talk about in terms of his leadership was around the mission of the organization, and how everybody in the organization understands and can articulate what the mission is. Also, how important it was, particularly over the last couple of years, for everybody to be focused on that mission because it made it much easier for everybody in that organization to know what to do, when to do it, and what to focus on.

While John agrees that no margin and no mission are important, he also firmly believes that if you focus on the right thing, which is the patient that’s right in front of you, you can be successful. John’s organization certainly has been successful. They are Malcolm Baldrige award winner. He also had a lot to say about going through the Baldrige process, which they went through for twenty years. I also found that to be pretty amazing.

What he said that it did for them was give them the discipline and the knowledge of processes that were needed to get them through the COVID crisis in a much better way than many other organizations. It gave them a process. He specifically mentioned that he and his colleagues were speaking to people in the Far East before COVID even came to the shores of the United States. That gave them a headstart on getting themselves prepared.

He also stated that Baldrige helped them to know exactly what to do when the crisis hit. He gave examples of knowing what to do about PPE, knowing how to handle vaccines, knowing what to do about isolation and capacity in the operating room, and also communication. He was very bullish on the methodology and the quality improvement processes that he learned from Baldrige. He feels like he’s very well prepared with his organization to meet any challenges that come in the future.

I would strongly encourage you to tune in to this episode. It reminds us all about why we got into healthcare in the first place. It also shows that if you stay focused on your mission and your values, that will lead you to the correct strategy. Most importantly, it will allow you to execute that strategy. Thanks again for tuning in to this episode. I hope that you get as much out of it as I did.

Welcome everybody to another episode of Leader Dialogue and Happy New Year. Leader Dialogue is brought to you by the Malcolm Baldrige Foundation and our strategic partner in healthcare. I’m Dr. Chuck Peck, one of your co-hosts. For those of you who tune in regularly, you know that we’ve been focused on leadership and change management topics over the past several episodes.

We plan on continuing our discussions over the next few months, talking about some of the leadership challenges that you all have been facing. We’ll have additional CEOs and other healthcare leaders who have led their organizations through the very challenging times that we’ve seen over the past several years.

We’ll be expanding on the theme of the Leadership Challenge. Specifically, we’ll be discussing the challenges of leading through adversity with our special guest, Mr. John Raffoul. John is the President of Adventist Health White Memorial, a 353-bed not-for-profit, faith-based teaching hospital that provides a full range of inpatient, outpatient, emergency, and diagnostic services to the communities in and near downtown Los Angeles.

White Memorial has been serving more than 245,000 patients a year since 1913. John assumed the role of AHWM’s president in March of 2015, while Adventist Health was starting to come together as a system, serving more than 80 communities on the West Coast and Hawaii. With John’s longstanding steadfast tenure at White Memorial, the Medical Center has been able to take its performance to the next level in terms of clinical quality, patient experience, associates, physician engagement, and operations.

John has been dedicated to working with White Memorial associates, physicians, patients, and community partners to build strong working relationships that support a helpful work environment to better serve the needs of the community. Under John’s leadership, Adventist Health White Memorial has built a solid financial framework to help face future challenges in healthcare. Over the last several years, the hospital and health system have received multiple distinguished awards and accolades, including Healthgrades’ 100 Best Hospital Award.

In 2018, White Memorial was the only hospital in California to receive the highest gold-level CAPE Eureka Award for Outstanding Commitment to Sustainable Performance Excellence Through Innovation, Continuous Improvement, and Visionary Leadership. In 2019, White Memorial was the recipient of the highest presidential honor, the Malcolm Baldrige National Quality Award. For those of you who are also Baldrige winners, you know how difficult receiving that award is. We’re pleased to have John with us as our guest. Welcome, John. It’s great to have you on.

Thank you very much.

Let me start off with this question. How did you lead White Memorial through the adversity of the past several years with COVID, all of the reimbursement and payment challenges? What are some of the things that you had your team focus on during that period of time?

Thank you, Dr. Peck. I appreciate it. Thanks for the opportunity to participate in this show, and thanks to the audience who also took the time to spend with us. The last few years were very trying years. It started in 2020 with the pandemic. It’s something we’ve never experienced before in our lifetime. It was very much unknown to us. We thought it was over and it hit us again in 2021 and hit us again in January 2022.

It’s an unrelenting pressure on us. There’s no time that we were called for leadership like the time we were called in the last few years. The one thing that we have to always center ourselves on is our mission. If you know your mission, what you’re here to do, what you’re about, and what the organization is about, that’s what will center us. That kept us going steadily throughout those years.

If you know your mission, you know what you're here to do, what you're about, and what the organization is about. Click To Tweet

Our mission here at White Memorial is to live God’s love by inspiring health, wholeness and hope. We are here to take care of our patients, not just physically but mentally and spiritually. We take the whole person. When adversity hits, all we had to do is lean back on our mission to say, “This is what matters.” The obstacles don’t matter. The money doesn’t matter. Capacity doesn’t matter. We have a patient right in front of us that needs help. They are in need and this is where our focus went.

To be honest with you, we didn’t worry about reimbursement. We didn’t worry about where the money is coming from. We worried about taking care of our community and the patients that came to our hospital. That’s what kept us centered throughout the whole time. Nobody was prepared for something like this. I can go for hours talking about what we had to do to be prepared and to take good care of our patients. I’ll pause here and see if you have other questions.

It’s interesting that you started with this. I’m going to use a little bit of a crazy example but it’s a nearby example for you and one that I’ve experienced. That’s Disney, believe it or not. I’ve had the opportunity to spend time at the Disney Institute and to be at the Disney Institute. One of the first things I asked when I got there was, “What is your mission?” They’re very strong believers in a very simple but impactful mission and vision statement like the one that you articulated. It’s quite simple. It’s three words, “We create happiness,” but that’s not the point of my comment.

The point of my comment is that no matter who I asked in the entire organization during the time that I was there, it didn’t matter if it was the person sweeping the street, selling the ice cream, running the rides, whoever it was. Every single one of those people that worked at Disney was able to articulate those three words. I’m going to assume that if I had come to White Memorial during this period of time and asked what the mission was, your employees would be able to tell me what the mission is.

Our employees are very much versed in our mission. Honestly speaking, we intentionally picked the word living God’s love. Living means you’re not pretending. It’s not something that you put on the wall and you forget about. It’s something that you live in your own life. Our employees go with us to Africa, to the Philippines, to Mexico, and all over the world, delivering free care to the needy. That’s one way of living our mission. They know that we mean what we say. We put our money where our mouth is and we live our mission to the fullest extent.

Do you think that being part of a much larger organization like the Adventist system makes it easier to not be as concerned about some of the other things that so many people have been concerned about that you mentioned? The finances and some of the hardcore things that everybody seems to be talking about now.

You go onto websites like LinkedIn and you talk to leaders, and so many of them talk about retention and recruitment. The bottom line is some of their main concerns. Do you think it makes it easier that you’re part of a larger organization? Even if you were still an independent or freestanding hospital near Los Angeles, do you think that you would still be saying what you’re saying now?

Practicing your mission and doing what you’re supposed to do has nothing to do with whether you’re part of a bigger system or not. It’s a frame of mind whether you have money or not have money. I have employees that donate bags for kids in schools from their own funds. They donate backpacks. They fill it with supplies and take it to the local school.

We have donors that give money. Our executives all go out and feed the homeless. That doesn’t cost any money. We do it out of our own funds. It’s a frame of mind to be connected with your community and with your mission. Whether you have money or not and whether you’re part of the system or not, you have to have that mentality to the frame of mind and you’d be able to do it.

Having said so, you mentioned retention, finances and cashflow. It makes a big difference being part of a 24-hospital system because when you need help, you have credit lines to back you up. You have bond financing that could back you up. You don’t run out of cash as readily. However, you still have to be cautious about your bottom line and your profitability. As people say, “If there’s no money, there’s no mission.” We cannot keep that mission going unless we are profitable and we’re producing enough money to support that mission. We take that very seriously.

LEDI 90 | Managing Change
Managing Change: We cannot keep that mission going unless we are profitable and producing enough money to support that mission.

 

Could you tell us a little bit about your strategy even going backstage before COVID? Maybe to 2015, 2016, 2017 or whatever. Are there any things that you’ve changed strategically as you’ve moved White Memorial forward?

Honestly speaking, we’ve been on the Malcolm Baldrige Charity for 22 years. That was our strategy that consumed our organization because we knew every time we applied for a Malcolm Baldrige Award, we improved and we got better. Every time we put the application in and got the feedback, we knew we had to do things differently and we did better every time. That progression of improvement over the years is what kept the drive going.

Honestly, at the end of the day, you’re not going for the award. You’re just going for the improvement because that’s your why. That becomes the way you are living your life. That becomes the way you’re running your organization. You all know what the pillars of the Malcolm Baldrige framework are. That formulates our strategy for pharma leadership, the results piece of it, the process, human resources, and growth. It formulated our own strategy from those pillars that were given to us by Malcolm Baldrige.

There are a lot of different programs or methodologies that hospitals and health systems can follow now. Maybe expand a little bit about Baldrige. What is it specifically about the Baldrige framework that attracted the organization? You said you were on this course for many years. This isn’t a one-and-done thing and you had to obviously decide to go through something like this because as our readers who are Baldrige Award winners know or have gone through the program, this is no easy thing. This is something you have to commit the entire organization to. What is it that attracted you so much to Baldrige as opposed to some of these other programs?

I could sum it up in one word. It’s discipline. Leadership takes discipline. The leadership takes a framework. It can’t be a willy-nilly process in that you do what you want when you want it. The Malcolm Baldrige gave us the framework and the discipline to do things right. Also, what transformed our organization is a process.

LEDI 90 | Managing Change
Managing Change: Leadership takes discipline. The leadership takes a framework.

 

For instance, when COVID hit. We didn’t have to scramble. A lot of hospitals scrambled to find out what they were going to do. We were very organized because we had the process down. We learned the process from Malcolm Baldrige over 22 years. We knew what we needed to do. We formed committees. We had a committee on PPEs, vaccinations, isolation, capacity, OR, and also the communication piece.

We had a committee that did nothing but communicate with our doctors daily. Every morning at 8:00, we had a call with our doctors to bring them in. We established a command center immediately to communicate with our board and our employees. It’s the process and the discipline that you learned from Malcolm Baldrige. For us, we went to action. We were like an orchestra. We knew what instrument to play. We knew what to do. We looked so organized and so much on the ball because of the Malcolm Baldrige discipline that we had.

What you’re saying is that you feel like the organization over the past years, not just through COVID but I’m sure other challenges that you’ve faced, have prepared you for almost any eventuality that could come your way.

Absolutely, and the learning piece of it too. You learn in Malcolm Baldrige to be open-minded and to do things differently. We reached out to hospitals in South Korea and China before anybody knew what to do. These folks had already gone through the SARS fifteen years earlier. We had two-hour or three-hour meetings with these hospitals to learn what they did fifteen years ago. We implemented these things before anybody implemented them here in the United States. It opens your mind to learning.

What do you anticipate your biggest challenges might be over the next 1 to 3 years? What are your plans to face those challenges?

We learned a lot over the last few years. I would love to tell you we were perfect, but we were not perfect. There are a lot of things that happened that we wish didn’t happen. We have an independent medical staff at large and we also have residency programs. We found out during the pandemic that we overburdened our residents to a great extent.

Our independent physicians a lot of times worked in the community, so they were not always here when we needed them. We established a hospice program now to say, “We are going to rely on the hospice, so if something happens in the future, we have our own dedicated doctors that are being paid to be here.” That’s one thing that we did differently. We also started a PPE management program. Even though we had PPEs, some of them were expired PPEs.

We now make sure that we have an active PPE program to make sure that we’re ready if something hits in the future. We connected with our community. We started a program called the Blue Zones Program that says, “Your community has to be healthy as well.” Even though we’ve done a lot of work in our community before, this time around we said, “We’re going to roll out a program to measure how healthy our community is and be proactive in managing their health even if they don’t come to the hospital to do that.” We’re expanding our market reach. We’re connecting with markets next to us and coordinating with them. We did a lot of that type of work to be ready for the future. Hopefully, if this happens again, we’d do things a little bit differently and a little bit better.

If you had a magic do-over button or if that was available to you as a leader, knowing what you know now, would you have led differently or would you have spent your time and attention on other things? What did you learn in terms of your own leadership as you went through all the last several years with COVID, etc.?

We’re struggling now with employee turnover. People are tired and exhausted. The marketplace also. You had the registry. They were paying certain rates that are double and triple what nurses are making in hospitals. When people are very tired and exhausted and you dangle three times earnings in front of them, guess what? No matter how dedicated they are, a lot of times, things fall apart. This happened to us.

Our staff was fatigued or tired. We had a high turnover. That’s a concern. Also during COVID, we lost the focus that we had on patient outcomes and safety even though we’re doing very well, but we were priding ourselves on being in the 90th percentile in that. That needed some more work and attention now because our focus shifted to taking care of immediate emergencies of COVID.

If I had to do things again, I would put more emphasis and maybe have a separate structure because people that were doing this work got diverted into other things. Have a separate structure to take care of employees’ well-being, as well as patient outcomes, and keep the focus there during that times of adversity. That’s something I learned the hard way. You have to have a dual focus. You can’t just shift all your attention to the crisis. You got to keep everything going.

LEDI 90 | Managing Change
Managing Change: Have a separate structure to take care of employees’ well-being and as well as patient outcomes and keep the focus there during that time of adversity.

 

One of the topics that we discussed a lot over last summer, in fact, it consumed a number of our shows, was this whole issue around retention. I wonder if you could share with the audience some of the things that you’ve implemented specifically around retention so that in the future if something like this happens again, you may be in a different place in terms of dealing with that. Do you have any ideas on your own on what healthcare can generally do to impact this issue of retaining good people? That seems to be the number one issue on most C-suite leaders’ minds now.

That’s a very tough question and a very tough issue to address because retention has so many things and so many variables that impact it. I do think that you have to pay your employees fair wages and we do that. We started what we call specialty bonuses for the ICU, LND, emergency room, and ORs. We’ve never done this before. We establish what we call specialty differentials.

That’s something that they appreciated very much. We made sure that we adjust salaries to the market rates where they feel are being paid fairly. We started the magnet journey for the nurses so they could be proud of the work they’re doing. We’re on a magnet journey now. Shared governance was a big deal, so they feel they contribute to the decision-making over here at the hospital. From a health standpoint, we started a farmer’s market every Thursday, so they could eat healthy and go out there in the sun and shop and take the food home with them. I can go on and on about different programs that we have done to make them feel valued.

There’s only one thing that makes all the difference. Money helps, health helps, and paying attention to the employees helps. One thing that helps the most is the relationship that employee has with their boss and supervisor. With all the money in the world, people don’t leave organizations. People leave their bosses. The biggest effort that we are trying to do is to educate our leaders on compassion and how to be compassionate with their employees. If you have that compassion and that connection, that’s what matters.

With all the money in the world, people don't leave organizations. People leave their bosses. Click To Tweet

I’m also curious about your patient experience scores. Did they take a big hit during this pandemic? What are you doing to focus on the patient experience as well? I’m a big believer as a former CEO like you that if employees feel valued, motivated, and satisfied in their journey with their organization, they’re going to do a much better job focusing on what your mission is, which is that patient right in front of you. What do you do to maintain high scores with your patient satisfaction? How have your employees focused on that?

Our patient experience during COVID took a big hit. The reason it took a big hit is when you have a patient with COVID, they’re struggling. Some of them passed away and you tell their family you can’t go and visit your loved one. Our community is largely Hispanic community. It’s big on families. Families come to the hospital. Normally, when a patient comes in, they have an entourage of families that comes with them. Having to tell the families, “Sorry, you can’t go into a hospital. You cannot visit the patient.” We went into restrictions. You can only have one visitor come at a time. That kept going on for a few years.

Our patient satisfaction took a big hit because people didn’t understand. “Why can I not go in and see my mother? Why can I not go in and see my father? Why are you restricting me or any of my family to go and see them?” Now we have to rebuild. We are rebuilding and re-educating. Our visitations are relaxed now because we had excellent patient satisfaction scores before. Not only that but we are also retaining or hiring a full-time person to focus on that aspect of patient satisfaction.

We’re addressing all the other things that we always focus on like the quietness at nighttime and the responding to the call lights. We’re looking at every aspect of patient satisfaction. As a CEO, when I do my rounds in the hospital, I walk into a patient room and ask them, “How are we taking care of you? Are you happy? Is there anything that you need? Are we meeting your expectations?” It takes commitment from every executive, every nurse, and every physician to make sure patients are happy here.

We’re coming close to the end of our discussion. I wanted to ask you a little bit about innovation and how you’ve innovated at White Memorial. To start with a couple of questions, what do you think the ingredients are to be an effective innovator? What does successful innovation look like to you and your organization?

The most successful ingredient for innovation is for the CEO to get out of the way. If people are intimidated, don’t want to do anything unless they check with you. If you have to approve everything, finance everything, and validate everything, people will never come forward with any innovation. I get out of the way and people go to work.

I can’t tell you how many great innovations we’ve had in this hospital from artificial intelligence in the ED to our patient tracking system in our OR that came to fruition from the ground up. People took the risk because they knew they can take the risk. They knew they didn’t have to go through loops to get things approved. They took the risk and we have some of the most successful innovations here at the hospital as a result of that.

I was going to ask you how you can both innovate and effectively manage change at the same time. It sounds like the key to your success has been to have the right people in the right positions. Empowering them to go do their jobs, make the decisions that you hired them for, and that you have confidence that they can make, and then get out of their way and provide them with the resources that they need in order to get their jobs done.

I could not have said it better.

Also, since the mission piece of your organization is so strong, they’re going to be able to successfully do that because they themselves can go back to know what the mission is and make sure that whatever it is that they’re deciding to do is consistent with that mission.

Yes, that’s true. They trust you and you have a trusted relationship with them so they know what’s right or what’s wrong. They will never go outside that parameter. They always do the right thing.

That’s great, John. Thank you so much. The thing that I took away from this that’s been the most impactful for me in talking with you is how sometimes we get all bogged down in a lot of things that at the end of the day may or may not matter. We both agree that without any money, it’s hard to have a mission. However, in order to have money, you have to have a mission. It has to be a mission that’s consistent with your community. This is what I’m hearing from you. It has to be a mission and a vision that all of your employees, staff, and physicians embrace, understand and can live each day.

At the end of the day, when things get rough and tough, you also have to have a methodology and a structure that you know you can lean on and depend upon no matter what the challenge is and no matter what the crisis is. It sounds like at least for your organization, the Malcolm Baldrige Award and looking to try to work on that over many years, not looking for some silver bullet, was critical in your ability to manage through all these crises over the last few years, to manage successfully before that, to be at the top of your game, and receiving some of these very prestigious quality awards.

It sounds like you also have a very solid plan for the future so that even if things change again in a month, 6 months or 6 years, you and your organization and all of the people working with you are ready for those challenges. Thank you so much for joining us. Thank you for sharing some of the things that have made you successful with our audience.

Thank you to our audience. As I mentioned at the beginning of the episode, we’ll continue to be talking to leaders like John over the past several months to try to share with you some of the things that they’ve done with their organizations to weather the storm over the past several years, and be ready for whatever storm is coming down the path over the next 3 to 5 years. Thank you again and we hope that we’ll see and hear you again sometime over the next few months as we continue our Leader Dialogue. Have a great year.

 

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About John Raffoul

LEDI 90 | Managing ChangeAdventist Health White Memorial is the recipient of the 2019 Malcolm Baldridge National Quality Award. It was rated by Healthgrades, a national healthcare rating agency, as one of the top 100 hospitals in the nation in 2016 and 2017. Recipient of the 2017 California Gold CAPE award ranking it #1 in the State. CAPE stands for “California Award for Performance Excellence”. As President I am focused on reaching new heights and delivering the best care possible to our patients. Our employee engagement, patient experience, physician satisfaction and community partnership is at the heart of everything we do. Our mission is “Living God’s love by inspiring health, wholeness and hope”.