Mary Jane Kornacki, MS, interviews John B. Chessare, MD, MPH, President and Chief Executive Officer for Greater Baltimore Medical Center HealthCare, during the 2017 IHI National Forum.
Mary Jane Kornacki: I’m here today at the IHI National Forum on Quality Improvement in Health Care, and I’m visiting with Dr. John Chessare, President and CEO for GBMC HealthCare System. Dr. Chessare, tell me a little bit about your leadership journey or an example of something that you’ve learned along the way.
John Chessare: Well, Mary Jane, I think our leadership traits and characteristics, they sort of grow on us through all of our experiences.
I’d like to [talk about] an experience I had as a physician leader where we were investigating — this is quite some years ago — a patient who had a bad outcome, because the patient had been given the wrong blood. There was a need, a desire, a tendency for the leaders in that organization to find somebody culpable. A nurse was fired, and the nurse was devastated. And what we learned, those of us who were doing a deeper investigation, was that no nurse was following the procedure that was written in the policy manual and that the leaders knew it. I now know, because I’ve become a student in the just culture, how sad that is that the leaders did not do the right thing by starting with the vision of patient safety and inculcating the need and enrolling people in the need for standard work to keep people safe. But in the moment, “tough leaders” find somebody and prove how tough they are by removing them from their job, and that also was formative.
I’d like to turn from a negative learning that has shaped me as a leader to a very positive one: I had the incredible good fortune of being the national co-chair of a federal government initiative to increase organ donation back in the early 2000s. I fell into this role because I was the Chief Medical Officer at Boston Medical Center, which was a large donor hospital. I really knew nothing about organ donation other than that it was important, but I was surrounded by people who were marvelous at requesting that people give life, and I then became part of this faculty, this national faculty whose job it was to increase donations, using improvement techniques.
And I met a man by the name of Dennis Wagner. Dennis taught me a number of things. Probably the first thing Dennis taught me is, please do not be cynical about the government or people who work in the government — because Dennis is a lifelong federal government employee who has given his life for the betterment of others, and he is the best change agent I have ever met. Dennis taught me to be unconditionally positive. He [also] taught me a technique that I use to this day called “starting meetings with an effective question.”
I had come up through the academic physician ranks where everything is scrutiny, everything is “let me tell you why that won’t work,” and what I learned from Dennis is that is a huge waste of time. What Dennis taught me was that if you start a meeting with an effective question starting with the words “what” or “how,” you take off the table lamenting the status quo and you force people to get into the mindset of learning and testing change. I will be eternally grateful to Dennis Wagner for that.
Kornacki: Dr. Chessare, that’s a good lesson. What does that look like? Tell us how you would start a meeting today that’s different to how you might’ve done it in the past.
Chessare: Let me give you an example of how I did it in the past. I was the first Chief Medical Officer at Boston Medical Center, which was created in ’96 — I arrived in ’98 — and it had been the merger of Boston City Hospital and Boston University Medical Center Hospital. I remember one of my first days on the job, the director of medical records came to me and said, “You and I have a huge problem.” I said, “What is it?” And she said — and don’t quote me on the precise number — “We have 1,000 delinquent medical records.” And the rule was that the medical record needed to be completed within 30 days. Now, quite frankly, that’s interesting that if your mother was in the emergency department 2 weeks after discharge, the expectation was not that her record would be complete. But be that as it may, we had a very low bar, and we had a huge, very high defect rate.
So, we had created a meeting of all the physician leaders who obviously owned this problem, all the department chairs, and I started the meeting by asking people to talk about this problem and everybody was putting all their problems on the table. “Oh, our doctors have more important things to worry about.” “Oh, the problem is the medical record department. It doesn’t matter what we do, they can’t keep up.” And, “Oh, the dictation system doesn’t work.”
What I learned from Dennis, what I should’ve started with, was probably a brief story about how patients could be harmed and doctors could have their job much more difficult. If an ED doc was trying to figure out what had happened to Mrs. Jones who was discharged 2 weeks earlier and the discharge summary was not there, and I might’ve even said, “Imagine if Mrs. Jones was your mother and you were accompanying her to the ED, and think how your colleague is now going to scramble to figure out what happened.”
And then I would’ve said, “Our agenda for today is to answer this question: What can we do to reduce the number of delinquent records? What can we do? You each have a minute to think about that, and then we’re going to ask for three or four suggestions, and our goal for the meeting is to have an action plan where we’re going to test a change because our goal is to reduce it from 1,000 and eventually get to zero.” I’m so grateful to Dennis Wagner for that skill and a bunch of others.
I’d like to then finish by talking about another leadership moment that happened fairly recently in my career. I am a devotee of the Institute for Healthcare Improvement. I see myself as an improvement guy. I’ve spent my entire career trying to make things better. I had the good fortune of having Dr. Don Berwick as my research mentor in my fellowship back in the early ’80s. I believe that the way improvement happens is by leaders just giving people the tools and encouraging them and passionately telling stories, and all of those things are necessary but they’re dramatically insufficient.
I went to Greater Baltimore Medical Center HealthCare System in 2010, and we were making some progress on the Triple Aim in the first years I was there. We added the fourth Aim of “with more joy for those providing the care,” but things were not moving fast enough. We had this passion for change. We were making some good changes, but we weren’t improving things fast enough, and I knew I didn’t have a hundred years left in my career. I said to a consultant friend, Mike Holland, “Mike, what can we do to make this happen faster? He said to me, “You need to do Lean Daily Management in your health care system.” And I said, “Great, what is that?”
Lean Daily Management is a structured set of behaviors for leaders. It is a daily practice, and what it does is elevate improvement to the top of the daily agenda. What Mike Holland taught me [about Lean Daily Management] was that my people all wanted to improve, but they were too busy putting out fires. What we needed to do was create a space where they would let go of other things because they had no other choice, and they would generate improvement on a daily basis. I’m very lucky, and just so blessed, that my company has now been doing this every day, 365 days a year for 4 years, and we won the inaugural Patient Safety Award from the American Society for Healthcare Risk Management for the amount of change, of meaningful change, that we have triggered using this technique.
Kornacki: Bravo. That’s incredible. What I’m hearing and what you’ve just shared is that there is the passion that’s necessary, but it must be married to focus and discipline.
Chessare: Absolutely. The IHI, one of its learnings is that there are three things required for improvement: the will, and the passion and storytelling that generates the will; the ideas, and the ideas are out there, we have them in abundance; and the real problem is the execution.
What I learned from Mike Holland and from our practice of Lean Daily Management is that you cannot expect people to execute unless you create space and a requirement for execution. Once you do that, people get on board. We do Lean Daily Management every day at 9 a.m., and it takes one hour. We round on 35 different departments. We have an executive board that we present, and we do it according to a schedule. Every leader knows that we’re coming, and our goal is to foster improvement, say thank you, and remove barriers. Creating this space and this requirement for improvement was a marvelous bit of leadership advice that I’m very grateful for.
Kornacki: Thank you for sharing that. I think it’s very important that leaders at the top of an organization send the signal that improvement is absolutely critical. When you’re rounding, exactly what you’re doing is creating the signal and being the messenger for that very important priority. I want to thank you very much for your time.
Chessare: It’s been my pleasure, Mary Jane. Thank you.
This story was recorded at the Institute for Healthcare Improvement’s 29th Annual National Forum in Orlando, Florida, on December 10–13, 2017, by Mary Jane Kornacki on behalf of NEJM Catalyst. We wish to thank IHI for support of this project, especially Madge Kaplan for her technical advice and guidance. Click here for more Lessons in Leadership stories.