Care Redesign

Immersion Day — Transforming Governance and Policy by Putting on Scrubs

Article · April 29, 2016

Interview with Dr. Ronald Paulus on a program at his health system for educating board members about care delivery.


The U.S. health care industry has long been beset by seemingly intractable problems: incomplete and unequal access to care; perverse payment incentives; fragmented, uncoordinated care that threatens patient safety and wastes money; and much more. These challenges are particularly vexing to the people who oversee or set policy for health care organizations. The disconnect between health care in its intimate, real-world setting and the distilled information delivered in the boardroom or policy discussions is a key barrier to responsive governance and policymaking. Sometimes seeing with new eyes can lead to transformational understanding.1 At Mission Health in Asheville, North Carolina, we’ve developed one potential solution: we ask board members, journalists, legislators, and regulators to put on scrubs, and we immerse them in our daily work.

Our board views its responsibilities soberly: we operate the region’s only tertiary and quaternary medical center (763 beds), five small community hospitals (each of which is the sole hospital in its community), and a post–acute care organization. We are the region’s safety-net provider, and 75% of our patients have governmental or no insurance. Our board focuses on governance and critical issues — quality, safety, community needs, physician relationships, behavioral health challenges, employee engagement, and organizational sustainability. Regionally, the buck stops with us: if we fail, nearly 900,000 western North Carolinians will be without a provider.

Yet until 2013, none of our lay board members had ever been afforded the opportunity to see the complexities of care delivery, except when they were patients, visited someone in the hospital, or watched a TV show like Grey’s Anatomy. Like most boards, we did our work in the boardroom. There, management and our four physician board members did our best to paint accurate pictures of our system’s complexity: the workflows and the choreography, the opportunities for error, the forces behind increasing costs, and the good derived from serving all patients regardless of ability to pay. We shared our struggles and successes using PowerPoint presentations, graphs, spreadsheets, and patient statements.

The educators, attorneys, manufacturers, investors, and bankers on our board are all passionate about improving our region’s health. They asked probing questions, striving to explore realities beyond reports and recommendations, and seeking the best tools for governing a $1.6 billion enterprise. They knew that health systems are immensely complex, but they wanted to understand our operations as deeply and fully as they could.

We realized that we could simply show them — an idea that seems obvious in retrospect. So we created “Immersion Day,” when board members and thought leaders could spend 9 to 12 hours in scrubs, behind the scenes, immersed in the nuances of care delivery.

One of us has led Immersion Days thus far. The typical program begins at 7:30 a.m.; participants arrive, undergo orientation, and finalize confidentiality agreements. Together, we move to preoperative care, listen to patients’ stories, and watch as the surgical team prepares a patient, puts him or her to sleep, conducts a time-out, and performs an operation. We talk with anesthesiologists, nurses, and surgeons and see the “surgical supply cost” come alive — as, for example, an artificial vascular bypass graft is sewn inside an aortic aneurysm.

Next, we join multidisciplinary rounds in the intensive care unit, observing critically ill patients who may have diabetes and obesity, be contending with poverty and drug abuse, be noncompliant with treatment, and more. Participants sit in a cramped break room and talk with staff members. The day is never scripted. Nurses relate their successes and fears, hospitalists type their notes, case managers describe their challenges.

We walk to a surgical area — on one Immersion Day, for instance, the open-heart-surgery suites, where board members peer into a chest and watch as a heart is placed on bypass and goes still. The cardiac surgeon relates the patient’s history: “62-year-old female smoker, recent bare-metal coronary-stent placement, couldn’t afford Plavix, stent now occluded.” The patient has no resources, no insurance, and only a sixth-grade education. Her bypass is successful; Mission Health absorbs the cost.

We make rounds with nephrologists, pulmonologists, trauma surgeons, and hospitalists. Our finance committee chair sees physicians struggling with a new electronic health record (EHR), drawing a more vivid link between documentation and revenue than we could ever describe in the boardroom. Bankers and investors watch a neonatologist insert an intravenous line into the scalp of a 500-g baby and are later taught — by a nurse and patient who’ve been friends for 20 years — how a dialysis machine works.

We conclude in the emergency department (ED). Patients lie on stretchers in the hallway because the ED, as usual, is overflowing with patients. Participants observe calm, controlled chaos — very different from a TV drama. There are random unforgettable moments: a patient who’s taken a drug overdose is intubated just as he stops breathing; a previously healthy 37-year-old mother is saved after 12 minutes of cardiopulmonary resuscitation by a physician whose hunch that she had a saddle pulmonary embolism led him to risk a 50-mg dose of tissue plasminogen activator; a patient with chronic obstructive pulmonary disease pleads for a cigarette.

Board members have called their Immersion Day “eye-opening and endlessly fascinating,” “unforgettable and humbling,” even “the best-spent day of my life.” One said, “I learned more about hospitals and health care from my 10 immersion hours than 6 years sitting on our board.” Our staff benefits, too: when a physician or nurse meets a board member in scrubs, the encounter builds trust and admiration in both directions. Word spreads. Caregivers express gratitude that the board is spending time seeing what they do; many had never previously met a board member. Physicians’ relationships with the board and management, though imperfect, are far better than they’ve been in years, despite ever-increasing challenges.

Immersion Day insights have produced real change at the board level. Several Friday nights spent by finance committee members in our hyper-busy ED demonstrated the strains produced by North Carolina’s distressed mental health care system, as well as challenges related to compliance and substance abuse. When a significantly larger ED was proposed for a new construction project, the board quickly approved it, understanding the need — and authorized substantial spending for behavioral health staffing and training. In addition, directors’ first-hand observations of the “hassle factors” and frequent interruptions that can cause burnout and patient-safety problems led to the approval of a “reNEW Mission” program, which allocates substantial resources for direct observation of caregivers and funds improvements in the EHR and workflows to enhance their experience and help restore joy to the practice of medicine.

Other types of participants are now sharing immersion experiences.2 Aiming to move beyond governance to engage and educate our community, we created a multiweek immersion program for a local journalist who subsequently authored a series of articles explaining concepts such as cost shifting and indigent care and illustrating why our state’s failure to expand Medicaid was so painful for our community.3

We then realized that an Immersion Day might also benefit state and federal policymakers — who, after all, fund the care of more than 70% of Mission Health patients. So we created a Policymaker Immersion Day. The first participant wrote an op-ed about his experience,4 and his work in the state capital is now informed by what he learned. Other participants have followed, and we now offer the experience to national policymakers as well.

Immersion is not a hospital tour. Through careful preparation, we’ve built a transformative experience that can guide our board. Deep immersion in the work of our health system has strengthened governance and engendered trust in our community, staff, and physicians, while elucidating health care for policymakers. After three years of Immersion Days, we cannot imagine being governed by a board that hasn’t seen so intimately how a health system works.


From Mission Health, Asheville, NC.

1. Shulkin DJ. Like night and day — shedding light on off-hours care. N Engl J Med 2008;358:2091-2093
2. Lee TH. An epidemic of empathy in healthcare. New York: McGraw-Hill, 2016
3. Ostendorff J. Special report: Mission Health at a crossroads. Citizen-Times, 2016 (
4. Turner B. Lessons from a challenging day at Mission. Citizen-Times, November 13, 2015 (

This Perspective article originally appeared in The New England Journal of Medicine.

New call for submissions

Now accepting submissions for NEJM Catalyst Innovations in Care Delivery, our new peer-reviewed journal


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Community Resource Referral Type

Assessing and Addressing Social Needs in Primary Care

Lincoln Community Health Center improved care quality by measuring and responding to upstream social and economic risk factors disproportionately affecting low-income households.

Time Driven Activity Based Costing for ECMO

Achieving Value in Highly Complex Acute Care: Lessons from the Delivery of Extra Corporeal Life Support

To improve both the value and outcomes of ECLS, Cedars-Sinai Medical Center created guidelines for ECLS delivery and explored opportunities for more efficient care.

ARISE and SFHN BHVS Collaboration

The “Behavioral Health Vital Signs” Initiative

A safety net system’s trauma-informed approach to integrating interpersonal violence into behavioral health programs in primary care.

OpenNotes Epic Patient Email Cascade Chart February 1, 2018 - August 14, 2018

Measuring Performance of OpenNotes Initiatives to Target Improvement Efforts

How a New York safety-net health system used data science to identify obstacles to OpenNotes use, address technical barriers, and develop strategies for improving clinical note sharing by providers and viewing by patients.

Mapping a Technology Strategy for Bundled Payment Care Using a Value-Driven Framework

Harnessing Emerging Information Technology for Bundled Payment Care Using a Value-Driven Framework

A four-part framework developed by physicians at Partners HealthCare provides a stepwise process for assessing and integrating technologies to effectively use data through a continuous patient experience.

UCLA Health CKD Risk Stratification and Management

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease and to modify care processes and personnel has led to improved health and reduced utilization.

Telehealth and remote monitoring are little used and ineffective for chronic disease care

Survey Snapshot: Treating Chronic Disease Proactively

Though survey respondents don’t indicate strong use of telehealth and remote monitoring, NEJM Catalyst Insights Council members discuss the ways they’re using these tools to monitor chronic disease, with good results.

Platforming Health Care Operations - Consumer-Driven Health Care - Business-Minded Optimizations

Platforming Health Care to Transform Care Delivery

Health care leaders need to focus less on ownership and control of the delivery process, and more on outcomes, cost efficiency, and customer experience.

Shah05_ integrated systems innovation pullquote

Build vs. Buy: What Should Health Systems Do?

The consolidation craze continues, but vertical integration has yet to demonstrate real progress toward the Triple Aim. Health care leaders would do well to consider innovative approaches that are working in other industries, including the tech-enabled full stack model.

Diagram Illustrating the COPD Care Pathway at Allegheny General Hospital

End-to-End Care for COPD Patients that Improves Outcomes and Lowers Costs

Allegheny General Hospital created a comprehensive solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved clinical outcomes, reduced hospital admissions and readmissions, and a resultant decrease in the total cost of care.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Coordinated Care

145 Articles

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease…

Care Integration

77 Articles

Platforming Health Care to Transform Care…

Health care leaders need to focus less on ownership and control of the delivery process,…

Assessing and Addressing Social Needs in…

Lincoln Community Health Center improved care quality by measuring and responding to upstream social and…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now