Cultivating “Systemness” to Create Personalized, High-Reliability Health Care

Interview · May 22, 2018

Tina Freese Decker and Tom Lee

Thomas H. Lee, MD, interviews Tina Freese Decker, MHA, MS, ACHE, Executive Vice President and Chief Operating Officer for Spectrum Health.


Tom Lee:  This is Tom Lee from NEJM Catalyst, and we’re talking today with Christina Freese Decker — known to everyone who is in the know in health care as Tina Freese Decker — and she is the Executive Vice President and the Chief Operating Officer at Spectrum Health, the Michigan health care system.

Tina, when we first met a few years ago, you had different titles. You were in the midst of going from Chief Strategy Officer to President of the hospital group for Spectrum. I was interested at the time in how you’re trying to make Spectrum into something more than the sum of its parts, a real system. Those of us in management know that sounds good, but it’s the kind of work that involves making tough choices — choices like doing some things in some places and not doing them in others — and about standardizing things. They are hard choices. I wanted you to write and talk about that work then, but I remember you telling me, “It’s too soon. Give us some time to actually do something.”

It’s a few years later, and I have a chance to ask, how’s it going? How is Spectrum doing this work to become a real system? You should probably start by telling our audience a little bit about Spectrum, because not everyone out there will be familiar.

Tina Freese Decker:  Thanks, Tom. Spectrum Health is an integrated health system and, as you said, we are based in west Michigan. We have our health plan that has almost a million members. We have a medical group that has about 1600 employed providers, as well as a medical staff at our hospitals that totals another 1600. And then we have 12 hospitals that cover the west Michigan area. In total, we are about 26,000 employees and we are a $6 billion organization.

But most importantly, we are about and we are guided by our mission to improve the health of the communities we serve. We have a number of areas that we focus on to improve the health of our communities, and we are proud that a year ago we won the Foster G. McGaw Prize that focuses on community partnerships and what we’re doing to advance the health of all people in all our communities.

We are, like you said, a large, complex, matrix organization, and we are in the midst of this transformation that will frame our future as we go from what we’ve been doing today, destination health care, to more of a personalized approach, but ensuring that we are efficient and effective with all our resources and that we are doing this in a way that is more consumer centric.

Lee:  My memory is that you have one tertiary care hospital and 12 community hospitals that, correct me if I’m wrong, but I’ve read about the program that you call Nexus and how Spectrum’s been taking action to try to turn all these places into one high-reliability organization — and you talk about cultivating “systemness.” I know these terms get thrown around a lot, but I also know you, and you aren’t someone who’s about rhetoric. What do these phrases of “high-reliability organization” and “systemness” mean for Spectrum? What’s going to be different a few years from now compared to the way Spectrum was a few years ago?

Freese Decker:  High reliability is extremely important for us as we have a more consumer-centric [system], but also attention to quality, safety, and experience throughout all our facilities. The high-reliability term means that we are focused on doing the right thing all the time and making sure that our team members can do that consistently for every single person we serve. We strive for that high reliability; we all know it’s challenging to do so in a complex health system, but I believe it’s extremely important for us to achieve that high reliability.

One way we’re doing this is through an effort called “systemness.” It’s a cultural and structural integration that serves as the cornerstone for our high reliability. As you mentioned, we have a number of hospitals and facilities, and in previous times we operated differently. We had different standards for surgery, for rehab, for imaging. What we’re doing today is we’re bringing those together underneath the same leadership, with the same policies and procedures and processes, to make sure that as we are providing the care, we are doing it in a consistent and standard approach to promote quality, safety, and the best experience possible.

For example, Nexus was the implementation of our single electronic, clinical, and revenue cycle platform. But it was more than that. Nexus is more than just installing a new electronic health record. It was completely changing and transforming the care model so that we were consistent across the whole system to ensure that the experience and the outcomes were the best that they could be. Now that we’re through that implementation of the electronic medical record, we are continuing with those care outcomes to achieve success.

For example, by partnering with subject matter experts, we were able to reduce our order sets from over 1000 to around 300 across all our different sites. What this does is it allows us to be better at what we do every day, because we are giving clear objectives and standards for our team members to operate with.

Lee:  I have a sense of the sort of ladder one climbs, and aspirations, and I know that things get tougher as you go up. You have been working hard to become highly reliable around safety. You’ve been working hard to become highly reliable around being empathic and giving patients a good experience and being tuned in to what consumers want. You’ve been trying hard to standardize and reduce order sets in that way. But the hard part, the big step up the ladder and the reason I’ve been interested in your work for so long, is that you’ve been ready to take on regionalization, and all of this could be seen as a prelude to what’s necessary to take on regionalization. It’s hard to do that if you haven’t standardized, but you’ve been taking on regionalization in touchy areas like surgery. Can you tell our listeners something about that work?

Freese Decker:  We’ve learned a great deal through our Nexus journey, which is now in full engagement across our system. As you’ve said, we’ve experienced some challenges, but many wins, and it’s helped us improve our process as we go forward. The most important thing to remember is that we must keep the patient and the consumer experience as our priority while remaining strategic and flexible within the changing health care environment. This has been key to including our Patient-Family Advisor Counsels, to including discussion with our regional teams about how do we become and maintain our high-reliability practice, and that way we can hardwire some of these changes that we are putting in place through our Nexus initiative into everyday operations and ensure that consistency and standardization approach.

You’ve mentioned surgery. That’s one of the areas that we are working on now where we’re standardizing that process. We’re starting small but expect to do even more. One area that we have done more of is rehab; we’ve implemented our standardization for rehab care and creating a well-developed leadership structure over 10 sites. Over the past 18 months of implementation, we’ve been able to see productivity increase by 21%, growth increase by 28%, the experience for our patients improved by 7%, and our team engagement increased by 77%, and in all of this we’ve saved money of about 18%. When you take those outcomes for rehab, it helps people get excited about the potential and opportunity because this is aligning all our incentives together about what we need to do best for the people we serve every day.

As we take those rehab examples, we’re taking that now on to surgery or imaging or other services so that we can make sure that we’re making progress. What we’ve started first in is surgery is how do we focus on safety, all the safety areas such as retained foreign bodies or safety checklists that we can apply consistently across the organization so that we can ensure that we are meeting those high-reliability standards.

Lee:  When we first met — and I think you had just become President of the overall hospital group and we were talking about what that meant — one of the things that had me interested was that you understood the opportunity to improve quality and efficiency by not doing everything everywhere, and making those tough decisions to stop doing certain things in certain places. Has Spectrum been able to go there or made definite plans to make that kind of tough decision?

Freese Decker:  Those are the decisions that we are making right now. We needed to put our leadership structure in place, which is what I mentioned earlier with rehab and surgery. The next step becomes what types of surgeries are best for regional areas and local communities and what types of surgeries are best to be done — as you said, regionalized approaches so that we can optimize and perfect the skills and provide the best outcomes for the people we serve.

We found a lot of good information out by using our telemedicine approach to connect with specialists and consumers. We’re doing that from both an urban setting and a rural setting. That allows us to learn what’s best to provide in what key areas, and we’re also matching that with the data we have to know who’s willing to travel for services and who isn’t. We’re taking all that information, plus the “systemness” work, and aligning it from a leadership perspective to ensure that we know where we’re going to grow and what relationships we need to have in these key regions.

Lee:  Finishing up, I want to recall that famous Bill Gates line. Everyone quotes him as saying, “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next 10.” We should probably shoot for something in between. What are your hopes and expectations for what Spectrum will look like in 5 years?

Freese Decker:  First and foremost, I want Spectrum Health to be focused on health and wellness. In health care we are often treating those who are sick, and I want to make sure that we have attention on how we can keep people healthy and well. I also believe we must be focused on the consumer, whether it’s the patient, a member, a community member, an employee — overall, it’s the consumer, and we have to come up with innovative ways to partner with them to pursue better health in everyday manners. I believe virtual care will continue to grow significantly. We’ve already started our own Med Now program, but I see this growing, not only at Spectrum Health, but throughout the country in an effort to be more convenient and accessible for consumers. I also see us solving those last-mile problems for consumers, whether it’s the virtual care aspect or creating new ways to connect about their health and wellness activities, going forward.

Of course, all health systems will need to be focused on the table stakes, the high reliability of quality, safety, experience, and I’ll add in provider or caregiver fulfillment and joy at work. It’s absolutely essential that we take care of our own people and ensure that we can provide and deliver the care and coverage that our communities deserve and need.

What I’m most proud of for Spectrum Health is that we are an integrated health system. That differentiates us today because we can have — as you and I have talked previously about — care and coverage together, and we can put forward a good service and product that will help people be healthy and well, be fully engaged in their health going forward.

Lee:  Spectrum has done a lot of terrific stuff. NEJM Catalyst has run material from Seth Wolk and other colleagues on your physician incentive system, which I think is very forward looking and sophisticated. Clearly, you’re a system to watch and a group of leaders to watch in the years ahead, so you can expect that we will be checking in from time to time on your progress.

Freese Decker:  I look forward to it, Tom.

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