The recent pandemic exposed the many flaws in the current healthcare system. Now, how do we deal with these realizations post-COVID? Do we just go back to how things were? Or, do we re-design care for the better? Here to discuss this in depth is John Chessare, the President and CEO of Greater Baltimore HealthCare System and Health Corporation (GBMC). He joins Roger Spoelman together with co-hosts Ben Sawyer and Dr. Darin Vercillo to chat about the problems that arose during the pandemic and what GBMC did to mediate and do better amidst the adversity. Tune in to find out how they’re adapting patient-centered care post-pandemic and challenging the healthcare system to be more accessible.
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Learning From The Pandemic: How We Can Improve The Healthcare System Post-COVID With John Chessare
This episode is brought to you by the Baldrige Foundation. Our sponsor is ABOUT Healthcare. I’m joined by my friends, Ben Sawyer and Dr. Darin Vercillo, who are executives with ABOUT Healthcare. We always have a great conversation. How are you doing?
It’s great to be here.
It’s good to see you.
We are talking about the roundtable discussion that we had with some healthcare leaders from around the country, talking about some post-COVID practices, things that we have learned from COVID, and how we get back to normal. I’ve said this a few times, “I’ve come across two different kinds of healthcare leaders. There are those that have realized that this is different. Things have changed forever and some things for the better.” Given some of the things we have learned in COVID and dealing with COVID, we have learned some things that will help us help our communities.
There are some leaders, unfortunately, that I’ve run into that want to get back to 2019 as quickly as possible. That’s not going to help us. That’s not where we want to go. One of those leaders who have figured out that we need to do things differently and get back to basics is Dr. John Chessare. John was part of the roundtable conversation that we had in Atlanta. He encouraged and incentivized all of us to stay the course. John, thank you so much for agreeing to continue the conversation on this show.
Thanks for having me, Roger.
It’s so great to see you again, John. Dr. John Chessare is the President and CEO of Greater Baltimore HealthCare System and Health Corporation. GBMC is the actual title of your organization. John, you are a pediatrician by training. You are married to a physician. I remember your wife is a dermatologist. It’s a real medical family that you come from. You have been the esteemed leader of that organization for a number of years.
We are delighted that we were able to continue this conversation with you. To start things off, I want to talk a little bit about your involvement with the Baldrige Foundation. You have been a board member and recognized by Baldrige in many ways. You have been a great inspiration and leader there. I want to ask you to share with our audience how the Baldrige Criteria helped you continue to be successful and meet the needs of your community post-COVID.
The problem with doing advanced primary care is financial. Click To TweetFirst, I haven’t been a board member. I would look forward to that. We adopted the criteria at GBMC years ago because we recognized that using the criteria would help us accelerate our improvement. We were a pretty good hospital with good staff members and a good elder care company called Gilchrist but we wanted to become a true system that the patient and the community would experience as a system.
We wanted to hold ourselves accountable for helping people get to their best health with the best care experience. We also wanted to be part of the solution to reduce healthcare costs in the United States. The implementation of the Baldrige Criteria has helped us accelerate improvement and work towards those goals.
Roger, GBMC was the recipient of the National Baldrige Quality Award in 2022. There were quite a number of health systems and other organizations that received it because the Quest Conference had not been held for 2 or 3 years.
We were the recipients in 2020 but 2019, 2020, and 2021 recipients all received the award on stage in 2022.
John was also the recipient of the Dr. Harry Hertz Award for distinguished leadership by the Baldrige Foundation, which is a real honor. It represents someone who has very selflessly given to the profession and is forward-thinking and strategic about where healthcare and leadership are going. Congratulations on that, John.
Thank you, Ben. That was a fabulous honor. I was humbled by getting the Harry Hertz Award.
Al Faber is reading. If there ever were criteria for potential board membership, you’ve got it, John. We will see what happens. As we have talked with other leaders, we found that some people had to put things on hold because of the pandemic and all of the urgency around COVID. We didn’t know how long this was going to last or how involved this was going to be.
We had to find a point at which people said, “Let’s get back to what we were working on before because it was important. Our communities, leaders, and all of our associates and colleagues needed it.” That’s one helpful thing that the Baldrige Criteria did. It allowed you to focus on that. You earned the award or were recognized for the award in 2019. You didn’t say, “Let’s take a break.” I’m sure that you kept the momentum going.
We are very proud. We wanted to achieve the award, and we did but the real reason for implementing the criteria is to continually improve and move towards our vision of being the community-based system of care that could treat everyone the way we want our loved ones to be treated. During the pandemic, the how changed because we had to create all kinds of new processes to keep people safe but the why and the what didn’t change. We kept moving in the same direction.
Did you experience some of the same things that many of our colleagues did in terms of how there’s a lot of energy and focus around caregiving? We always say too, that we in healthcare are at our best in a crisis. All hands are on deck. We are shoulder to shoulder. Everybody works together, whether you are a physician, a tech, or a security guard. It doesn’t matter what your position is. Everybody is in this. That’s where healthcare shines but it has its limits because people get tired and sick. Their families have needs that they didn’t have before. Did you experience the turnover that many of your colleagues did? How did you handle that?
We have experienced quite a bit of turnover. Early on in the pandemic, we benefited from using the Baldrige Criteria because one of the questions in the criteria is, “What is your core competency?” We realized a few years ago that our core competency was redesigning care. We had gotten pretty good at testing and hard-wiring changes to move us faster towards our vision.
We were fortunate to have that competency as the pandemic started playing out because we could redesign systems fairly quickly and use people whose talents may have been, specifically in the operating room, for example, and move them into being patient safety officers for a while until we are safe to bring all the surgical volume back.
As far as the turnover goes, there are two issues. One is turnover, and the other one is supplying demand mismatch. We were at the beginning of a nursing shortage in the country as the pandemic was starting. We’ve got lulled into a state where we weren’t as focused on the nursing shortage because we didn’t need as many nurses because we shut down a lot of areas for delivering care.
When the patients started coming back, it underlined profoundly the burgeoning or growing nursing shortage, which, as you’ve pointed out, was made worse by the fact that a lot of nurses had to stay home to take care of their families. Some clearly got exhausted and decided to move away from the bedside. We have been working hard to keep the joy in the practice of nursing to recognize people. We had our annual Art of Nursing Celebration, where we gave out a number of awards. We do some celebrating and partying. Unfortunately, the supply and demand mismatch created a huge opportunity for companies that bring temporary nurses to the table.
They started attracting nurses who had no intention of leaving the bedside to these companies with the allure of significant increases to their hourly rate. The part that they didn’t tell the nurse was they were going to put another 30% on top of that for their profit. Healthcare leaders across the country are struggling with their budgets in part because of the supply and demand mismatch but then also because of the incredible increases in price, which is not sustainable.
Darin, have you seen that in your practice? I’m sure that you see people filtering in and out that are unfamiliar to you because of this.
We can either bemoan our lot in life or go out and try to design a better system. Click To TweetIn my hospital-based practice, there have been a lot of new faces. I’m sure every practicing physician in any healthcare venue has seen that. To John’s point, there have been many great nurses that have been lured away by the big dollars promised. The grass is always greener. The type of work they are doing and the sustainability of their work there isn’t always what they thought it was.
I find it also interesting that there have been nurses who have been lured right back to the same position that they were practicing before as an agency nurse as opposed to being employed there at triple the cost for the hospital to absorb. That’s a tough one. It’s one that we are going to need to reconcile, not only from the cost perspective but also from a pure numbers perspective. You hear projections of 5 to 10 years before we can overcome that shortage. To John’s point, that was already in motion before all this started.
Going back to the Baldrige Criteria, there’s a lot about culture. There’s so much about changing and redesigning the culture of an organization to achieve the criteria, which is great. We are not doing it to win an award. We are doing it to change the culture so that we can redesign care so that it’s safer and better for the patients and everyone.
You’ve got an unanticipated situation where, as you said, Darin, you’ve got nurses who used to work side by side. There’s a lot of transparency. We know how much everybody makes because of their pay letters and all that, “My colleague who’s working right next to me doing the same work is being paid twice or three times what I’m being paid.” I’m sure that is not helpful to the culture.
That leads me to a question I wanted to post to John. John, it was great meeting you at the CEO Innovation Council in Atlanta and hearing your career story and the things that you’ve done there as well in Baltimore. Here’s the question I wanted to pose to you. You talked a lot about your extensive use of advanced primary care and how your organization has rallied resources around doing what’s best for the patient. The additional effect has been the ability of your network to maintain contact with those patients.
Despite the fact that, granted, you are in Maryland, and it’s a little different than other states, these are issues that many system leaders and CEOs have been grappling with partially to provide that great care for the patients in their communities and be able to create a great business where their clients and patients stay within their networks and leverage everything from acute care to primary care and specialty care. What advice do you have to pass on to those leaders in other areas that might not benefit from the Maryland structure but do have those same goals within their geographic areas?
We are committed to being a system that the patient will experience as a system. Early on, we realized we needed an organizing function. Your typical smart human being who isn’t a scientist struggles to manage their health once they start getting sick. We embrace the concept of a patient-centered medical home where everybody has their primary provider. It’s generally a physician but it could also be a nurse practitioner. That person is aided by a whole team.
There’s a nurse care manager and a care coordinator. The easiest example is diabetes. We know that the country has a huge problem with obesity. That is triggering a huge problem with Type 2 diabetes. People get confused. They have a hard time making sure they are on the right diet, taking their medications correctly, and have the right plan for exercise. Without a team that’s trying to help them, it’s pretty hard for a lot of people.
Our teams are in action all the time. During the early days of the pandemic, we had a hard time because we were purposely trying to keep the patients away. We realized the conversations could happen beautifully without an office visit. We started getting better as we were redesigning things with virtual visits but you can’t get blood or test the hemoglobin A1C at a virtual visit. You’ve got to make contact with patients.
They will figure it out.
I’m looking forward to that day, Roger. We started falling behind in our hemoglobin A1C goals because we weren’t measuring, but now, that’s pretty much rectified. We have started to figure out how to do it safely. Now that most people are in our practices are immunized, and others have pretty strong levels of immunity, we are bringing people back. Those values are going up.
The problem with doing advanced primary care is financial. When you are in a fee-for-service environment, there isn’t anyone that pays adequately for that team-based care. If we all step up 10,000 feet and think about the cost of care, we can save a lot of money by avoiding diabetic ketoacidosis and overdosing people with insulin. We can avoid a lot of money from people getting so sick that they make it to the ICU.
If you are trying to keep them out of the ICU, the money has to stream differently but we all believe that the net, if we could change the payment model, would be a positive. We would spend less for better outcomes but not everyone is ready to move in that direction. My advice to leaders is to do the right thing and look for ways to work with payers, reduce waste in other areas, and fund advanced primary care.
There’s one thing I would piggyback on what you said, which is important. You’ve mentioned that many people will view this advanced primary care or multidisciplinary approach as a cost center. It’s true. On the macro level, it does benefit the whole community and does bring costs down. We have seen many organizations across the country that are looking for a greater degree of control within their organizations. They are a mix of fee-for-service, ACOs, and other value-based care models but they are always looking to be able to control that referral process of turning those patients back inward to take advantage of the services that they offer.
Honestly, I see this as a great method of controlling that process as long as they are taking care of their patients and looking after their needs. They have all these resources that they can leverage to bring to bear on those patients. They are going to get the same result they wanted to begin with and referrals to their primary care doctors and sub-specialists when they need to go to the hospital and get procedures done. They are going to be in control in a good way. That’s something they could take away.
Here’s a question, John. During the course of our CEO Innovation Council, you brought some key points to bear around why healthcare exists or why it should exist. Sometimes, the conflict exists in the market around that statement of purpose. You said in the course of our discussion that the pandemic impacted the how because the whys maybe weren’t clear. Your organization was able to realign to that how fairly quickly because the why was clear. Can you clarify that for the audience and why that distinction is important?
This is an opportunity to reflect and see if we can't get our act together to use systems thinking to design a better system. Click To TweetIt’s almost all not-for-profit healthcare organizations and, clearly, hospitals. The reason for having a mission statement is it states your purpose. If you read them, they all pretty much say the same thing, “We are here to serve the people in the community that need us to maximize their health.” We frequently fall into the trap for the reasons that we were discussing. We fall into the trap of providing more services that have an immediate margin.
The classic example is MRI scans for an outpatient. Most payers are paying well above the average cost of an MRI scan. For that reason, the number is we do 30 times as many MRI scans as they do in Germany per capita. What happens is we are starting to lose focus. Baltimore is not a huge city. It’s a good-sized city but a significant percentage of people in the city have no access to primary care. They are precisely the people that have the largest illness burden.
Darin referenced it. We are a little different in Maryland because of our waiver with the centers for Medicare and Medicaid innovation. We lose our way and start providing services without reflecting, “Is this meeting our mission?” At GBMC, when you use the Baldrige Criteria, the first step is to reflect on the why, “Why are you here? What are your goals? Where do you want to be? What is your vision of the future?” We have done that reflection. We had a four-paragraph vision statement. That’s how we’ve got to embrace the patient-centered medical home but in the absence of changes to the payment structure, it’s very difficult to have the resources to go into the neighborhoods that need it the most.
That’s an excellent representation of some of the crossroads that healthcare leaders are at. Given the fact that May is also Mental Health Awareness Month, what is your perspective on that? I have a son that has schizophrenia. I’ve had to deal with this as a parent and know how tough it can be to gain access that is cost-effective and readily available for people that struggle with this thing. Can you also provide insight into that venue around the same concept of, “Why do we exist? How do we do it? What do we do?”
Let me quickly turn back to the Baldrige Criteria. There’s this mnemonic in the Baldrige Criteria called ADLI. It’s Approach, Deployment, Learning, and Integration. I know marvelous human beings that are very well-trained and caring in our mental health system but if there was ever a system that needed to use ADLI, it is the mental health system. If you say to somebody, “What is our approach to taking care of Ben’s son and everybody else that needs mental health services?” you are going to get a wishy-washy dissertation on things that, if added up, would not meet the criteria for a system.
We don’t even get to how it is deployed because we are going to have to realize when we are trying to answer the question, “What is our approach?” that our how has got too many ifs, ands, and buts. It’s not right and fair to people who need help because only a tiny minority of the people that need the help to have anything to do with how they’ve got to where they are. I had a family member suffering from depression that essentially was triggered by finding a dear friend who had hung himself. This family member was able to get help because the family could afford to pay out of pocket.
There are many families that could not afford that. That’s not right. We can either bemoan our lot in life or go out and try to design a better system. The sad part is, and we know this, the money is already being spent. It’s just not being spent well because there is no systematic approach. One of the things that hospital executives have to deal with is, in most jurisdictions, if somebody calls 911 for a person with an acute mental health crisis, the ambulance comes and takes them to a general acute care hospital emergency department that has no capability to deal with that problem.
We can accept it if it’s a person with a new complaint but more often than not, there are people that are already well diagnosed but there is no systematic way to deal with them when their acuity level goes up. It starts with laws. There are regulations saying that group homes can’t administer medication. It’s silly if it’s the same medication they are giving on a chronic basis that they couldn’t give somebody a bolus of medication and instead send this person to an ED where they are probably going to live for 3 or 4 days. This is not an opportunity for John Chessare to rant and rave. This is an opportunity to reflect and see if we can’t get our act together to use systems thinking to design a better system.
It’s a big hole in what we commonly refer to as the healthcare system. All of us realize this. It’s even worse in our military. There are huge problems in how to deal with behavioral health in our military. To our readers and John, thank you so much. This has been fascinating.
The good news is we are going to continue this conversation at our next virtual roundtable. These episodes are intended to be the appetizer but the real meal is served at our virtual roundtables. We have one coming up. The topic is turning disruption and change into peak performance in the wake of the pandemic. We are going to have John Chessare on the roundtable along with David Burik, a previous guest. We are going to have a great conversation. You might want to make a note of this because we did have a change in the date. It is Tuesday, June 14, 2022, at noon Central.
We are delighted, John, that you’ve agreed to continue the conversation with us at that virtual roundtable. You will be with us, joined by David. David is the Director of the Center for Health Insights at Guidehouse. He’s a Guidehouse partner and also a very interesting guy. If you are interested, I will encourage you to read the previous episode. David Burik was our guest on that episode. That’s coming up. Ben, I want to toss it to you. You have some comments about the white paper that we are going to produce or make available.
For the readers, twice a year, we have a CEO Innovation Council that meets. We had the one we were talking about in April 2022 in Atlanta. We will have another one in the fall. It’s an opportunity for CEOs to come and reflect on their perspective of healthcare and what the opportunities are and to discuss with each other ideas and so forth. We are going to be using that in the context of the virtual roundtable.
There is a white paper that will be coming out that readers and the larger audience can refer to. You will find that very interesting. For example, there’s this whole question about the system approach to healthcare. “Are we meeting the needs of the community? Are we fulfilling our purpose and statement of purpose as a why? How do we effectively do that, particularly with the evolution of healthcare post-pandemic? What does that mean? How is that measured?” All of those kinds of things you can expect that we will have included in this roundtable.
Thank you, Ben. On behalf of Darin Vercillo, Ben Sawyer, and myself, John, thank you so much for taking some time with us. You are a wealth of information and experience. You are grounded in such solid principles in serving our communities and your entire team, employees, and medical staff. John, thanks. You are an inspiration. That’s what we are trying to do with this show.
We are trying to bring and introduce to you some amazing people in our healthcare industry who are inspirational and are leading the way. Thank you for joining us. We hope to have you back again next time. We are going to have another exciting and interesting discussion about how we can help you advance your leadership and the leadership of your organizations. That’s it for us for now. We will see you next time.
Important Links
- Baldrige Foundation
- ABOUT Healthcare
- Greater Baltimore HealthCare System and Health Corporation
- Baldrige Criteria Commentary
- Gilchrist
- Harry S. Hertz Leadership Award
- Art of Nursing Celebration
- David Burik – Previous episode on Spotify
- Guidehouse
