Leadership Lessons for Pharmacy, Nursing, and Hospital...

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Leadership Lessons for Pharmacy, Nursing, and Hospital Leaders

August 25, 2009 Webinar Transcript

Charles Denham: Hello. We would like to welcome all of the attendees for the NQF Safe Practices for Better Healthcare 2009 Update Webinar. Our subject matter is Leadership Lessons for Pharmacy, Nursing, and Hospital Leaders. We're very blessed to have business giant Bill George, former CEO of Medtronic, now a professor of leadership at Harvard Business School and author of a book that is just coming out that he'll be addressing. I'm Charles Denham. I am chairman of TMIT and the co-chair of the NQF Safe Practices Maintenance Committee and as such will be addressing at the very high level the Safe Practice No. 1, Leadership Structures and Systems. We have Jennifer Dingman, who is a wonderful patient advocate. She is the co-founder of PULSE, an organization focused on patient safety, has been a co-author with me and others with the Journal of Patient Safety, and is a contributor to many national programs in patient safety including with the federal government, with the HRSA, the Healthcare Resources and Services Administration, who are doing a terrific job in patient safety and medication management. We have Hayley Burgess, who we're very honored to have speaking on this webinar. She is one of the unsung heroes behind the scenes who’s involved in the National Quality Forum safe practices. She and I and Mike Cohen from ISMP and others worked on the Safe Practice for Better Healthcare focused on pharmacy leaders, a composite practice that incorporated prior Safe Practices. Hayley is the director of Performance improvement at TMIT. As I said, she was our staff team lead on our 2009 update and the 2010 update now. She is, has a PharmD and has undertaken a residency in hospitals and was formerly in the quality department in one of the leads for HCA. We also have, and I'll skip over Bill George because we'll be coming back to him as we introduce him, Peter Angood. Peter is the senior advisor for patient safety and really leading a number of the patient safety initiatives for the National Quality Forum. and Peter is a trauma surgeon with an esteemed academic background and most recently was the vice president and chief patient safety officer for The Joint Commission. And Peter will be providing leadership national comments regarding programs that are in place and actually also be reacting to the content that Bill George will be addressing. The major focus of this webinar is really to apply the seven lessons for leading in crisis, which are embodied in Bill George's new book which has just been released. I'd like to turn the mike over to Jennifer Dingman. And as we always try to do with these webinars and our national programs is make sure we remember who is most important, and those are the patients whom we serve. It's that sacred trust of our patients that's the most valuable thing that we have. And we'd like to begin the webinar with just a comment from Jennifer and then Jennifer will also give us our last word. Jennifer? Jennifer Dingman: Good morning, everybody. I just want you to know how excited I am about today's webinar and I'm so happy to have Bill George here with us and his wisdom and knowledge about what to do. And I also want to thank everybody on this call for caring enough to take the time to be here today on behalf of all the patients and families whom we represent at PULSE and other organizations. Thank you. Charles Denham: Thank you, Jenny. The Slide No. 7 is just an introductory slide that we use with one of the videos that you'll be able to download or watch from safetyleaders.org addressing this really critical issue with many headlines regarding leaders and the key issues. My goal for the next few minutes is just to remind those who are coming on who may have been attracted to hear Bill George speak and not be familiar with the 2009 Safe Practices for Better Healthcare that were released in March. There are 34 Practices. These are the most harmonized practices that have ever been created and we are very, very pleased to announce that January 1, with the wonderful leadership of the NQF by Janet Corrigan, Dr. Peter Angood and his superb staff, will move up the release of the 2010 Practices. They will embody practices that target the criteria that you see below on this slide, Slide No. 8. And I'll just move quickly through these slides in order to give more time to Bill George.


But just a reminder that the 2003 practices were loosely a bound set of practices without great standards. You can see on the top of the stack of the book on Slide 9, very thin type of practices, they were not standardized. The 2006 update were the first harmonized set of Practices, much more bulky, had a unified and a standardized framework and were carefully referenced and carefully evidence-based with a lot of assets and implementation guides. The 2009 Practices, although four Practices were added and some were retired, to bring the total to 34. You can see the bulk of the document is just under 500 pages. And namely the, the update to the 2009 Practice, and you can see on Slide 10, which I will not read to you. This is an asset we provide to you just so that you can see how much of a forklift upgrade there was to the 2006 Practices. Format was preserved, a lot of added information, and we're very blessed to be adding now to the 2010 update in January a glossary, more hyperlinks. The practice number will remain the same; however, there will be additional opportunities for implementation information and the latest assets that will be available. So this is the 2009 set. This slide is a slide we used in 2006, this is Slide 12 just for those of you who are tracking along, of six major organizations harmonized right down to the data spec level, and we're really privileged and pleased to say that the 2009 is much more harmonized now including CDC, the Infectious Disease Society of America, SHEA, APIC, the leaders of infection control, and a number of organizations. So as we look at harmonization, we're talking right down to the specification level, and we're pleased that the 2010 Practices will also be organized in that manner. The practices are organized in functional categories that you see on Slide No. 14, in functional chapters, and Slide No. 15 is an eye chart but it does – when you review them later you'll see what practices were updated for 2009 and those that did not have material changes and those that were new. Again I won't, won't go through them in detail. This brings me to the Leadership Structures and Systems Practice, Practice No. 1. And if we had to capture everything on one slide, I believe it would be Slide 16. Basically the committee was very careful about linking information, power, knowledge, and accountability to the governance leaders through administration, the independent medical leaders as well as those who are part of the organization, with focus on four areas, which I'll get to in a moment. But the first four practices, Leadership Structures and Systems, was carefully integrated with culture measurement, teamwork and training, and of application on projects as well as identification and mitigation of risk and hazards, which really lays a blueprint out for the C-Suite, if one were to really undergo the transformational change or build a new hospital system. Safe Practice 1, Leadership Structures and Systems, is organized by the four As of awareness, accountability, ability, and action. And the Leadership Structures and Systems have to be established to ensure there is awareness of patient safety gaps, accountability for those leaders to close the gaps, adequate information and the ability and skills, knowledge that drive abilities, and then the actions. The awareness section really ties together the awareness of gaps to the other four, the other three practices and actually links leaders across the rest. I’m on Slide 18. Slide 19, again, I won't read the slide, but great care was undertaken to tie accountability of leaders to close gaps and as Bill shares with us the challenges of leading in crisis, we believe it will really be important that we have accountability. And the structures of accountability are absolutely critical for implementation and so you see in the blue bullet points on Slide 19 there is detail – these are just slides that address the headers. But each one has details that actually lay out a blueprint. The committee was very careful in 2006 to write the Practice as a blueprint that could be followed. And it had no material, minimal, minimum material changes in '06 or '09, and there will be minimal changes – although considerable updates in terms of references. When we move to ability, these are the capacity resources and competencies that are absolutely critical and we know that, that budgets and funding, dark green dollars, for people systems, quality systems, and technology systems are key; and we knew that you're going to be aware of the gap, you're going to be accountable to close the gap but if you're unable to close it, you can't act. Which takes me to Slide 21, which has more detail on the slide, and again I won't read the slide but this is for future reference to go back to how these structures and systems need to be integrated to allow direct action, to close known gaps, to identify unknown gaps and then really to complement awareness, accountability, and ability. And the specifics of what governance leaders need to do, there are direct actions for governance leaders, for administrative leaders that are specific and yet,


yet structured so that a six-bed hospital in Idaho could implement them as well as a 2,000-bed hospital in Orlando, again with detail right down to the independent medical leaders. That is a quick drive-by review. I recommend that you read the chapter and read the specifications very carefully written and trust in the fact that [there are] no real material changes other than just updates to references in the practices or in the activities for the 2010 update. We just finished having a terrific committee meeting this last week co-led by Dr. Peter Angood who may comment on them. But I'm going to turn over the mike to Hayley Burgess, as she was very instrumental working with the pharmacy leaders across the country and with us to help develop and shape the Pharmacy Leadership Structures, Practice No. 18. Hayley? Hayley Burgess: Thank you, Dr. Denham. It's a pleasure to discuss with our audience today the leadership practice for pharmacists. For my brief presentation I'll begin by discussing the importance of safe medication use followed by national attention through standards and measures on medication management, then briefly overview the pharmacist leadership Safe Practice and conclude with some actionable items for pharmacist leaders to begin transformation today. Adverse drug events occur across our health systems and often in the transitions of care. And you can see in Slide 23 a discussion of admission, hospitalization, and discharge adverse events. We know that, upon admission, 50 percent of patients experience one or more unintended medication discrepancies, and nearly 40 percent of these have potential for moderate to severe harm. This study certainly points out the need of accurate medication histories, which will assist us in our medication reconciliation process. During the actual hospitalization, Dr. Bates found that 1 in 10 inpatients experienced an adverse drug event. I don't know about you, but these numbers are incredibly staggering and frightening to me. Furthermore, adverse drug events occurred in 66 percent of the 400 patients studied in a general medical service day. Adverse drug events were the most common cause of injury to patients during this discharge period, and many were preventable and the result of poor discharge planning and a lack of communication. Medication management systems are clearly complex, and they affect patients across the continuity of care. So why focus a safe practice on pharmacist leadership? Well, the previous slide certainly focused on the urgency to prevent harm to our patients, and over the next several slides we're going to discuss the growing number of national standards and measures that are focused on medication use. These measures affect our reimbursement and pay-for-performance initiatives to our organization, so that's going to be incredibly important to us as well as our senior leadership, our brand competition with other organizations, and even consumers and purchasers as they're reviewing our data. And as this data is publicly reported and even shared internally within our own systems, this gives an opportunity for pharmacists to lead quality improvement efforts in regard to medication us, and this time is no more apparent than now. So, let's briefly discuss the national attention to medication used. I'd like to mention that while I'm discussing the role of pharmacists primarily in medication management, we clearly know that safe medication utilization involves all clinicians, information technology and solutions staff, and the support of senior leadership. As it takes a village to raise a child, it takes a whole organization to create safe medication usage for each patient every time. This table displays some of the major harmonization partners for the Safe Practices, as well as the regulating and standard-setting organizations for our country. Each of these organizations has multiple areas of focus that are specific to medications. The web links are embedded here within the table so you can take at look at those individually. I'm going to discuss briefly just a few of these. This slide talks specifically about the NQF Safe Practices that are related to the medication use process, and I would say conservatively that 15 out of the 34 Practices are specific to medication use. If we look at the Centers for Medicare & Medicaid Services, their core quality measures, they're heavily focused on medication use; and approximately 66 out of the almost 100 measures are associated with medication utilization or counseling. When we look at CMS, the patient perspective survey, if we look at questions around pain management, communication about medication, and discharge information, all of these


things are going to tie back to medications. So I hope that what I'm doing is creating the case for you that pharmacist leadership has never been more important than it is now. Pharmacists were recognized in 2008 by CMS to document, in the patient medical record, contraindications to medications. Previously this level of documentation was restricted only to prescribers. The National Priority Partnership is focusing on six areas of healthcare for improvement. Pharmacists had an incredible opportunity here in all six of these areas to lead quality improvement initiatives. And ASHP has done a great deal of work to pool resources that can assist pharmacists' involvement in these priority areas, and that web link is back in the table on Slide 26, if you'd like to review that. So, let's move on to Safe Practice 18. Now that we've shared the importance of medication and harm to patients and families across our healthcare system, there is certainly a growing body of evidence around national standards and measures that are focusing on medications. We know medication systems are incredibly complex. They affect practically every process, technology, every patient in our organization. So where do we start? Well, here's the good news. Safe Practice 18 was created as your roadmap. It focuses on pharmacist leadership to develop and implement, streamline medication systems, and a comprehensive medication safety program. We're now on Slide 33. The objective of this practice is to establish the pharmacist leader as the core of the medication safety program. Of course we want to ensure that there is a multidisciplinary team focus, but we want to streamline the operational approach to achieve organizational, safe medication use. The Safe Practice Statement identifies the pharmacist leader as a crucial member, a critical member of the administrative leadership team, which has the authority and the accountability for medication systems process improvement and performance. This statement could appear intimidating to those pharmacy leaders who are comfortable with the status quo. However, for those of you who are ready to end preventable harm to patients around medications, this is your roadmap for success. This Practice begins with one of the most important keys to success, which is regular and direct communications with your administrative leaders and your board of directors regarding medication management systems. For a sustainable change, pharmacist leaders must have the support and communication with the senior leaders and their organizations. I think we would all agree to that statement. Please notice that you're seeing some of the same wording that Dr. Denham used previously when discussing Safe Practice 1, Leadership Structures and Systems. The Pharmacist Leadership Practice has the same framework. We know that when we're aware of our gaps, we have direct accountability for them with the ability – meaning finances, knowledge, staff – then action can be taken and harm is mitigated. Certainly our culture of safety and the teamwork of our staff are integral to the success as well. Pharmacists are so well-trained in medical evidence and evaluation that we're truly experts at streamlining the evidence-based formulary and individual regimen for patients. This is a great place for us to tighten our finances and to cut out wasteful, inappropriate use of medications. A medication safety committee is really important for the evaluation of medication errors and potential harms to patients with accountability for a performance improvement plan to prevent future errors. I was on a webinar for Dr. Denham probably two years ago before I began working for him, and he asked me a question around medication management of what kept me up at night. And my response at that time, and it still remains true today, is that we know oftentimes about our close calls, our near-misses, our medication errors, our problems with our systems. We know this information but we don't always share it. And there's lots of reasons for that. I would love to see a time when our culture is such, around medication safety, that we are freely sharing within our organization where our issues are, so that we can quickly mitigate those. The additional specifications of this Practice are further broken down into standard, functional, and operational sections, and we're familiar with this, right? This is how IOM and The Joint Commission, pharmacotherapy textbooks are broken down, so this makes a lot of sense to pharmacists. What you find within the additional specs is really a starter kit, if you will. It's not going to be all-encompassing and it will be updated and refined over time.


The opportunities for patient and family involvement section, this is new to all the Practices this year. I hope you'll take a really close look at this. We can learn so much from our patients and families, especially regarding medications, because our words that we use in healthcare certainly don't compute oftentimes with patients and families, and this is a great way to find out more from our families so we can communicate clearly. So what for pharmacists? I always like to ask this question when I'm working on projects, the “so what” question. Well, the majority of quality standards and measures currently are focusing on medication management. It's easy to measure medications because we have them and databases, so we have data, so of course they're going to focus on us. Pharmacists can make a major difference aligning our initiatives and our services with the current pay-for-performance and public reporting programs. Pay-for-improvement is coming and pharmacists really have a great opportunity here if we don't miss the bus. Opportunities for pharmacists today – begin to collect and analyze your data. There has never been a greater time for us to step up and assume our role as medication safety experts and organizational leaders. If we truly embrace these hard times with innovative solutions and performance improvement, then we're going to see a new season of safe medication for each patient, every dose. And I just want to remind everyone, like Dr. Denham mentioned, that we're going to continue the leadership collaborative focusing on medication management in the next several webinars. More details will follow. I do want to thank ASHP for partnering with TMIT on this collaborative. And at this time I'll turn it back over to you, Chuck. Thank you. Charles Denham: Thank you, Hayley. And, so now as I introduce Bill George, what I wanted to do was just emphasize that we've also invited nursing leaders to be participants in this and we've added them to the collaborative effort that we'll be undertaking. There is a nursing-specific Safe Practice that we did not have time to go through in detail, and I recommend that you go to the full body of the practices and read them and look at them and you'll find one thing that we emphasize, that nursing leaders need to be part of the, the C-Suite chain and they need to be elevated to an opportunity where they can describe the performance gaps, provide accountability, provide information and power flow back to the C-Suite; and in the Safe Practices 1 through 4 that address leadership and culture, you'll find a number of places where we took nursing leaders and pharmacy leaders and gave them an opportunity to have direct impact on sharing of information and the feedback loops that are so very important. Because if we were to think of a healthcare system, the last three feet of our healthcare delivery system are delivered by caregivers and by nurses assisted by pharmacists. Pretty much like we look at the IT system and say the final mile of our information highway is that cable to the house. And until we have robots delivering care it is a social system and leadership is so critical. It's a real honor to introduce Bill George. I had the wonderful opportunity of getting to know him in four different ways, in one case when he was the leader of Medtronic. And in each of these four cases, he led through the values. The values were part of all of his conversations, leading through values. And you'll find in his three terrific books that he is unwaveringly focused on those. I was involved with Bill as he negotiated with major hospital groups to sell products with Medtronic, when he was a speaker at the World Economic Forum, and again, values-driven approach. We've had the honor of getting to know Bill now as the chairman, one of the chairs of the Harvard Advanced Leadership Initiative at Harvard University. And now we have the opportunity of having him share with us some of the insights that are terrific in his new book. He's the professor of management practice at Harvard Business School where he's taught since 2004. He is the author of three bestselling books: True North; Finding Your True North; Authentic Leadership; and now, just being released, 7 Lessons for Leading in Crisis. It'll be published in September and we've provided a way for you to access the book. This is a terrific book, I've read it. It has direct application for those of us leading organizations, not only from the top but at the midlevel and even at the front line. He's the former chairman and CEO of Medtronic. He was the leader of Medtronic as it grew from $1.1 billion to $61 billion in revenues, a 35 percent year-over-year growth over ten years. This speaks volumes to businesspeople to be leading through values and have such extraordinary financial performance. He received his BSIE with high honors from Georgia Tech, his MBA with high


distinction from Harvard University. He was a Baker Scholar. He has honorary PhDs from Georgia Tech and Bryant University, and he was professor of IMD International in Switzerland, and an executive in residence at Yale School of Management. And we've asked him to share with us terrific insight from his new book, 7 Lessons for Leading in Crisis. And if we can hand the ball to Bill George. Bill George: Thank you, Chuck. It's really a privilege to be here. I want to thank you for taking the leadership on these seminars and all the things you're doing, and Hayley, I particularly appreciate your comments. The whole area of safety is just so critical and quality in healthcare. And I am particularly pleased to see nursing as an integral part of this program because I think in many ways nursing leadership holds the key to the future of healthcare and I think it's been widely overlooked in the national dialogue as far its importance. I think all of us will acknowledge that healthcare is in crisis in the United States. It has been for a long time. But crises left unaddressed are like malignancies that spread in the body – they don't get better, they only get worse. And I've written a couple of articles recently you can find on my new web site, billgeorge.org. I encourage you to go there. You'll see one in Business Week called “The 2009 Healthcare Reform Debacle,” and another one on “Sound and Fury of the Healthcare Town Hall Forums.” I'm extremely concerned about the way the national debate is going. I had great hopes a year ago the way it was going go in this discussion, and frankly, this reform is going to go in a very, very different way. I think we've devolved down to health insurance reform. We're not talking reforming healthcare, we're talking about reforming health insurance. Now that's an important thing to do, I'm not diminishing that at all, but in many ways healthcare is like the blind man and the elephant, and we just, each one of us looks at our own aspect and no one's looking at the whole elephant. And on the whole of healthcare, I don't think one can address this crisis without looking at quality, without – we are looking at access, and to the president's credit and the Congress's credit, they're focusing on access. I really feel very strongly we have to provide in some way access for all Americans, but I don't think we can just provide full-up access free so that everyone can have full healthcare, as much as I’d like to see it, because there's not the money there and literally we'll bankrupt the Medicare system. I think the focus has got to be on quality, cost, and particularly on patient empowerment, as well as access. Those four elements make up the basis of what I think a good healthcare system is going to be made up of. So, in today's agenda I'm going to give you an overview of some of my thoughts on how we focus on leading in crisis, I’ll address Lessons 1 to 4, and then turn it back to Chuck for a Q&A. And then Lessons 5 to 7, and then we'll have a longer Q&A and Peter Angood will be involved with us in that as well, and then a very brief conclusion. You may be interested in the book Chuck referred to, which has a lot of healthcare examples, 7 Lessons for Leading in Crisis, which again you can order directly through the web site billgeorge.org and that takes you to Barnes & Noble or Amazon. So why is this so important? Let me just say I feel that there are basic lessons which we can learn about crises, which are really eternal. And I've seen – the reason I wrote the book is I'm shocked at how many leaders fail to observe these basic lessons. I think it is the true ultimate test for any leader to how you lead in a crisis. I have led through growth situations. I thought we were doing great when that, I can tell you that growth covers up a lot of sins when things are growing. And I've led in stable situations. That really requires more managerial skills. But I think crisis is the ultimate test for any leader. And it's really a place to be developing leaders. And I think one of the real gaps we have in healthcare is not developing a sufficient number of leaders at all levels of our healthcare system. I think all too often we look to the top leaders, often we bring them in from consulting firms or accounting firms to take over top jobs and they really haven't had the leadership experience in the clinical setting, in the hospital, in the clinic, in the in-home study and in other complimentary care providers. And I think this leadership is needed at all levels. I think we've vastly underestimated the importance of developing leaders. We don't have enough physician leaders, enough nursing leaders, and enough healthcare leaders of all kinds. I think the reason leading in crisis is so important is this is really the test of whether you're going to follow your true north. Now I defined in my book True North, true north is your most deeply-held beliefs, values, and the leadership principles by which you lead. I think we all know what our true north is. I think the real test is when we're under pressure. Are we going to move away from it, are we going to cut corners as


we've seen many people do? Are we going to be seduced by rewards and opportunities – opportunities for promotions or bonuses or getting ahead? And really are we going to tell the whole truth? I used to say to people at Medtronic, “Integrity is not the absence of lying, it's telling the whole truth.” We can't solve any problem in medicine or healthcare without looking at the whole problem, otherwise we're going to be solving symptoms instead of the real problem. I think to follow your true north you have to have a deep level of self-awareness. What is your life story? What are the crucibles you've gone through? Where do you come from? Who are you at the deepest level? You have to have the confidence that I can step up and lead 'cuz I know my area, I can get this done. I don't have to be a director, a vice president, or a CEO. I can get it done. And third, a growing need is for resilience. How do I have the resilience to go through any crisis and just keep going? It's not a question of hours worked, it's a question of having the confidence and the awareness of myself to know that I can bounce back from the most difficult circumstances and I can lead people through them. As an old English proverb said, a smooth sea never made a skilled mariner, and I think in this crisis we're really finding out who are the skilled mariners of our healthcare system. I'm not going to spend a lot of time on the global economic crisis, but I think we are experiencing the fallout from that. As Fortune magazine said in a review of my book, this is not a result of subprime mortgages, this is a result of subprime leadership. And I think we have leaders who failed who ignored risk, and the same is true in healthcare. We aren't really looking at the risk we face, and we often look at the short term – can we make the budget this quarter, this month, this year – rather than looking at what are we building in our hospital? What are we building in our clinic? What are we building in our institution? What are we building in our pharmacy? Are we building for the long-term health of the people we serve? At Medtronic we had a mission to restore people to full life and health. I think that's a mission that applies to every aspect of healthcare. Are we pursuing that long-term mission every single day? Do we always put the patients' needs, the customers', the consumers' needs first? Do we ever put the needs of our own system ahead? Are we, do we have other influences? And so, I think that's absolutely critical that we do that to be successful. So this is a list of the seven lessons. I'm not going to go through each of these but I want to dive right into Lesson No. 1, which is face reality starting with yourself. In many ways until you do this, until you face the reality of the crisis, you cannot overcome the problems. And in healthcare, if we only think we have an access problem and we don't realize we do have a safety crisis, we do have a cost crisis, we do have a quality crisis, and we have, I think, perhaps the largest crisis of all is that of patient empowerment. And in my Business Week article I tried to address how important that is. We can't solve the problem unless patients are engaged in their own health and take responsibility for their health – and this may be heretical but I'll say [it] – and have an economic stake in their health like they do in everything else in life. But oftentimes leaders go into denial, and this is a real tragedy. I say here, denial's not a river in Egypt. One of the, the greatest pharmaceutical companies in my life growing up, even though I served on the board of Novartis for 12 years, has been Merck. Merck did so much, from treating river blindness to so many drugs they've created. But Merck – at a certain point in time its inventions slowed down and it pushed the drug Vioxx. And the tragedy is not that they had problems with cardiovascular disease, patients with cardiovascular disease with Vioxx; the problem is that they went into organizational denial about that data and it delayed and delayed facing the reality when they were getting the feedback from major insurers, major hospital groups that there was indeed a problem. Vioxx was an excellent drug, but in the end the CEO, Ray Gilmartin, had to suspend the sale of the drug worldwide and the drug was lost to all those patients who need it because of the problems of cardiovascular disease. I think this is a classic case of organizational denial that caused problems. But why is this hard to face reality? Well, here's, in this instant case here's a company that needed the revenue growth, and I think that's a tragedy; because in the end it caused a great problem. Now they've shown yeoman-like efforts in pulling out, and they're bringing out a lot of new drugs now and they've solved their legal problems, so to their credit they're back on, on track. But an interesting compare-and-contrast to that is Amgen, which faced a very similar problem with its drug Aranesp, which is an anemia drug. And Aranesp had some problems about


label use. They were coming out with studies that Amgen and their co-partner Johnson and Johnson did show these problems, and the FDA started raising serious concerns. And at first, as Kevin Sharer, the CEO of Amgen, relates the story, his people were very, very angry towards the FDA administrator who was arguing against the drug. Finally Kevin pulled back and he said, “You know, if you were that administrator in the FDA, how would this look to you? Would you want to make a change? Would you want to do something differently? If it's your family on this drug, would you be concerned about it being given this way?” And they finally recognized that they did. So he tasked them with solving the problem. Well, weeks, months went by and nothing was happening. And finally he said, “You know, I've gotta look at myself in the mirror and say what is my role in this? Did I push too hard for growth? What mistakes did I make in pushing this drug?” And so that's why I call this “face reality starting with yourself.” Kevin started with himself. He looked himself in the mirror and he made a long list, he said he made a list of the things he'd done wrong and he said, “You know, it was a long list.” He sat down with his top executives and he said, “Let me explain the mistakes I've made here,” and they were shocked that a CEO would admit his errors. But once he did, it freed it everyone else up to face theirs and they went about solving the problem. It cost them a billion dollars in revenues, Amgen's revenues fell by $1 billion, but you know, they saved the remaining 75 percent of the application of Aranesp. It's a good drug and continuing to grow on the market. So I think, you know, it is hard to admit your mistakes until you acknowledge your role in the problems. And that's what Kevin Sharer did and I think that's why he was very successful. And when you deny reality, honestly it only makes things worse. So that's the lesson I take away from Lesson No. 1, that you can't deny the reality of a crisis any more than you can deny the reality of someone's health. The second lesson is, “don't be Atlas, get the world off your shoulders.” I can't tell you how many times as CEO of Medtronic I felt like I was carrying the weight of the world on my shoulders, that [with] one screw-up in our design or development or our software coding, we could hurt tens of thousands of patients. And I was extremely concerned about that. But, you know, the real danger here is leaders who turn inward when that happens, that they disappear, they go into their office, they think they can solve the problem. The pressures are mounting and they become more isolated. I found – of course when I came into the business I didn't really come into healthcare until 1989, 20 years ago, I was involved prior to that time in high-tech business. I knew a lot about high-tech business, very little about healthcare. So I relied very, very heavily on the people who reported to me who were medical doctors, were scientists, and were engineers. They had a far greater knowledge of medicine that I will ever have, and I relied very, very heavily on them for help. There was no one who wasn't willing to step up and, and really help out. And I think when you're facing a crisis, it's so important that you build your team around you very closely and you ask everyone, and you really genuinely listen to people. There were times at Medtronic that we had products and we weren't sure we could go to market, there are others on which we had some data that was a little questionable and we looked at it very closely and said no, this product's ready to go and it's going to do far more good than it could ever do harm. And those judgments are very, very close calls and you're never perfect. You know, in medicine we never have a circumstance where everything goes exactly our way. But I think that it becomes very, very critical that you build a team around you and listen hard to what people have to say. And sometimes you may have to make a lonely decision to go your own direction, but at least you have listened to the advice. At the same time I think we need help outside our organizations. I think we need what I call an external team around us. What do I mean by that? Well, I think it starts with having one person in your life who you can tell everything to, all your greatest fears, and in my case it's my wife, Penny, who's been the greatest supporter, confidante, advisor, and also critic that any person could ever have. So I ask you, do you have someone like that in your life to whom you can turn – your spouse, your partner, your best friend, your mentor? I think all of the above can be very helpful. I've been blessed with some outstanding mentors at different stages in my career who helped me tremendously. And I think in addition to that I've been really blessed by having a group of people with whom I – actually I have two groups. I have a men's group that meets every Wednesday morning, and I've been out of town a lot lately, but we meet every Wednesday morning from 7:15 to 8:30 and talk about important issues of life. And I know a number of years ago when my wife was diagnosed with breast cancer and I had gone into denial myself that this could actually be a terminal disease, I'd tell her no, you'll get well. They pointed out to me because of cancer of my mother and the death that came from cancer, and my mother and fiancée 30 years,


20 years before, that I was in denial. And had I not had that group of people around me really helping me, a group of men… And we also have a couples group. And when Penny had her mastectomy, I remember, it was at Abbott Northwestern Hospital in Minneapolis; and seven of us, Penny was upstairs in the surgery room and we were fortunate enough to be able to find a room directly below her surgical suite and we're praying and, and hoping and kind of just supporting each other for her recovery, and fortunately she's done very, very well the last 13 years and she's blessed with very good health today. You know, I think this all takes a willingness to be vulnerable. And this is hard to do, to say, you know I made mistakes, I'm scared, I don't know how we're gonna get through this. But when you show your vulnerabilities as a leader, that's not a sign of weakness, that's a sign of strength. And in healthcare there's always uncertainty and we just need to pull together through difficult times. I think it also has to do with building your resilience. And this is – at the Institute for Health and Healing, we supported Abbott Northwestern Hospital in Minneapolis – Dr. Henry Hammond has the resilience training. And that focuses on, first on all the employees, on the nurses and the healthcare workers, even on physicians. And this resilience training has been enormously valuable and they're now offering it for outpatients and some inpatients, but the resilience training has been tremendously helpful. You know, if we as healthcare workers can't feel healthy, how can we possibly have the right kind of influence on the patients we serve? If we don't have all the aspects of our life, our stress under control, our diet, our nutrition, our exercise, if we aren't doing all those things, the proper healthy weight, a positive mental attitude, the kind of support we need – we all need to have the tools to build our resilience because the bottom line here is, you're much more effective when you ask for help. We go on to Lesson 3, which is “dig deep for the root cause.” How many times in medicine have we treated symptoms and not the root cause of the disease? I'm a strong believer in the military phrase of “trust but verify.” We have to verify, we have to trust the people we work with but we have to verify the data. A lot of times that means bringing your team together to really get into the root cause because you may not know yourself. And that's why I think a cross-section of not relying on one person to figure out the problem but to bring a team together of knowledgeable people and the best experts you can get to find out what is this patient's problems? What's the systematic quality problem we have in our institution? How do you know when you're there? I think you have to just keep testing to verify that you in truth have found a solution and you haven't created two more problems with it. But I think one of the problems, the reason people often have fears of digging deeper is they're afraid that things may be much worse than they thought. So I think it's very important to dig in and really get in depth and get to the root cause. Lesson 4 is “get ready for the long haul.” You know crises, like the healthcare crisis, are not going to go away overnight. This one's been many, many decades in the making. We're not going to change it overnight. And I think there's always a problem with national healthcare reform efforts. They try to do everything from the top down. To me healthcare is a local business built from the local, from the nurses, doctors, physicians, healthcare workers who form great hospitals, great institutions, great health providers and all the complementary providers. But I think we all have to recognize that things may get worse before they get better. That's what's been happening in healthcare now. But we also need to display, or respond to the early warning signals in the systems out there, because the crises like we're seeing in healthcare have very long roots. But to correct those problems you cannot take modest action, we need to take decisive action, and I think that's what we’ve really failed to do in many cases. In this case I think one of the great overlooked areas of healthcare is the whole area of patient empowerment and patient involvement. All too often, healthcare policy and Medicare look at patients as people who are lacking in any kind of empowerment, any kind of knowledge and we don't help them, we don't get them involved in the healing process. There's no better healing tool that's ever been created, there's no better drug or surgery than the human body itself and its capacity to heal when people have a positive mental outlook. And we're learning more and more about the link between the mind and the body and the spirit and how important to have all three of aspects of human beings working in the same direction. So you can't underestimate the severity of the crisis; but at the same time I think we need to be ready to address the problem in rather dramatic ways.


So I'm going to stop there, Chuck, and if we could turn things back to you and maybe we can get the questions going, and I think you are telling people about how they can submit their questions as well. Charles Denham: Fantastic, Bill. Thank you so much. We really thank both you and Hayley for keeping your comments right to the mark, they've been great. Bill, as we look at pharmacy and nursing leadership, we have a situation where we may be 15 or 20 years behind other industries, and the concept of learned helplessness is really at play where many of our leaders of pharmacy, leaders of nursing are managers of current processes and budgets, but not really leading, not taking chances, not owning their own problems and pursuing the common good. And it's more often that they are having a pity party over their learned helplessness. They are feeling that they don't have power from above and access to the C-Suite and they forget that they are leading people. Can you just give us a little confidence in the fact that those leaders who are on the phone can take the chance of Lesson 1 and owning it and then publicly owning the problems and the mistakes and that kind of thing? We are way behind other industries with a name-blame-shame cycle, and breaking that cycle really can only be done by our leaders. Can you just address, give us a little confidence that taking that chance that the sky is not going to fall in? Bill George: Well, Chuck, I think the first thing we got to do is distinguish between management and leadership. You know, managing budgets, giving performance reviews, these are all important skills of management. But that's not leadership. Leadership is stepping up, seeing a problem, stepping up, bringing the people together to go fix the problem. And I think all too often we buck these problems up to top management, top leadership, and then we wonder why they don't act, like they've got dozens if not hundreds of things on their plate. And I think the only way a really healthy organization – let's take the Mayo Clinic, a really healthy healthcare organization. You know, they have leadership at all levels. And I know Denny Cortez, the CEO, you know, he doesn't presume to solve all the problems himself, he gets leaders at all levels, and I think the great healthcare organizations need that kind of leadership. And I think too often we've observed a pecking order, let's be blunt, in healthcare and where doctors are on top of the pecking order and nurses and technicians and pharmacy workers are somewhere down in the hierarchy. I think this is wrong. I think we have to lead each in our own way that we have knowledge. The nursing committee is often far better – and I have a son who's a, a surgeon and a daughter-in-law who is an OB-GYN, so I'm not criticizing my family members. But I can tell you, all too often nurses have to defer to the doctors and nurses are often far better with patients, far more humane, and give the patient that sense of wellbeing, yes we can get through this, we are going to heal. And so I think we underestimate the importance of leadership, Chuck, at all levels. And I don't even like to talk levels – in all aspects. But I think, you know, don't worry about shooting the messenger. I mean we just gotta have people who step up and lead and put the problem on the table and say here, we need to solve this problem right now, let's get on top of it and go do it, and that kind of can-do people. I think can't-do people – at Medtronic I frankly didn't have a lot of for can't-do people. We need people who don't say, I can't do it, I don't have the budget. What an excuse that is. You know, let's just go get things done, we'll worry about the budget later. I'm not talking about big spending, I'm talking about solving the problem. A problem that's not solved because of budgetary reasons in the end will cost you a lot more money. And so I just, I think we need empowered leadership throughout our healthcare organizations, including our pharmacies where people feel, I'm not just filling a script, I have the responsibility here to say, what's the right thing for this patient? Can we use a generic drug? Do we, you know, is it necessary to use the prescription this doctor wrote out for the, the branded, formerly-patented drug, or can we give him the alternative? Why not? I think that kind of leadership is needed at all levels. Charles Denham: Bill, you led many, many people in structures that are not completely dissimilar from what we have in hospitals. Can you just frame for us, underscore for us what you've said in your books, call on the others' core values and use the core values of the organization as the language that can be used to build collaboration when you have more soft power than hard power. We had the blessing of having a seminar with you at Harvard on leadership with Joe Nye and using soft power and hard power. Many of our nursing leaders and pharmacy leaders really know where the problems are but there's a conspiracy of silence and a belief that we're, we're going to cover up these problems. But can you just underscore for us any suggestions regarding using the core values and stated core values of the organization, the language that you use when you're bringing problems upstairs?


Bill George: At Medtronic everything was built around the mission of restoring people to full life and health and the values incorporated in the Medtronic mission statement. I probably spent, I know I spent more time on that talking about the mission with people, doing mission programs and ceremonies and asking people, are we fulfilling a mission than anything else I did, far more than I did chasing numbers. 'Cuz you know, you really can't impact the numbers much, it's the people that impact the numbers. But if they're passionate, if you have that alignment around mission and values, your organization will be successful. Well, this idea of a mission-driven organization, isn't that what we're in, aren't we all in the business of restoring people to full life and health and ensuring wellness and prevention of further disease? I mean, we all share a common mission, and the values have to be the same throughout the organization. And I think we as leaders need to be the representative of that mission, we need to reflect those values in our everyday life. There's no excuse for us to try to say we're here to empower patients and then be cranky and critical of other people and act like the boss in a top-down kind of leadership. The great organizations of the world, Chuck, are organizations like Genentech, the Biologic company, Google, which are all bottom-up organizations. That's what we tried to create at Medtronic, a bottom-up organization, not a hierarchy. A hierarchy setting rules, that doesn't get you anywhere. You can never write enough rules to govern all situations. We just need to see an empowered organization where you get alignment. And I even resist strongly the word, this being the soft side of leadership, I think it's the hard side of leadership. The soft side? Managing the budget. We all know how to do it, just lay off 20 percent of your workforce, cut everyone else's salaries 10 percent, you'll get, you'll bring the cost down. But you know what? That's not hard. But that doesn't solve the problem, that's going to come back to bite you later on when you cut out things that are really important, like your research plans, your leadership training, your quality efforts. Those are the first things to go and that's the worst thing to go. I think we all as leaders need to get behind the alignment of people around mission and values. Charles Denham: Bill, Julie Jenkins is one of our participants and addresses something we see all the time, that there are nursing leaders put in nursing leadership positions with no guidance, no leadership training. They're not really equipped to be leaders and then when they fail, you know, it's no great surprise. Any tips to those senior leaders who are on the, on the call regarding developing the skills of leaders and, and that they don't just happen, there are skills and knowledge and know how to really build succession in leadership. Any recommendations there? Bill George: Well, you know, Chuck, I had an opportunity to lead an organization first at 27. Now, this was a small organization, about 200 people, and over the next two years we built it to around 2,000. But I'll tell you, I learned how to lead that way, and certainly not perfectly, but there's no better time to lead than early in your career. And I think we need to develop leaders, find out who are the natural leaders in your organization and give 'em the opportunity. They're not going to sink the organization. Give 'em a chance to lead, to make mistakes, to learn from their mistakes, to show what they can do to be creative, to be innovative, and I for one would like to see, and frankly am very much inclined to put together, a leadership development program for nurses because I think there's just such potential out there for nursing leaders, that I would like to see young women coming right out of nursing school get in there. In fact I'd like to see it happen in school, but if it's not going to happen in school I'd like to see 'em get involved, young men who are nurses, get involved in leadership development programs very early on and have those opportunities. There's no better development program though for leadership, Chuck, than on-the-job experience. We can send people out to seminars and get all kinds of continuing education credits, but there's no better opportunity than doing it on the job and having to deal with those crises yourself. So I'm a big advocate of developing leaders in pharmacies and nurses and healthcare providers and workers, as well as physician leaders. Charles Denham: Bill, we've got two more questions. The first one is regarding – and this may be your call to action to our senior leaders that are on this call – I know you've been tracking the number of CEOs and COOs and folks who wanted to hear you today. We've got a major problem in U.S. healthcare. We have nurses and pharmacists who are criminally indicted when they're involved in harming a patient that really was led to or set up by system failure. They might have made a human factors error, a predictable mistake, absolutely predictable. We know from training in aviation and manufacturing that a certain number of human factors issues are at play, and if we don't have the systems in place to protect and prevent that, they're going to happen. And yet, we have nurses and pharmacists who are criminally


indicted, and many of the hospitals turn their backs on these individuals and let them take the fall because of shame, because of reputation and, and let them be the Oswald, and focus on them rather than the systems. Any reaction to, or any advice to our senior leaders to step up and, and really take responsibility for the systems that predispose them to that; and any reaction to this terrible phenomenon of the criminal indictment of caregivers who commit predictable human factors errors when systems allow that to happen? Bill George: Boy, I can tell you I lived in, in mortal fear of the criminal indictment or, every day I was at Medtronic. I used to wake up at 3:00 in the morning, to be totally honest, thinking oh my gosh, you know, could this be the time when I get a call from the head of my pacemaker division and we've just got a product out there, 100,000 products and they could systemically harm all people and, you know, somehow or maybe we had something done in the system that I didn't know about or someone said this product's terrible and it never got to me and then I was partly responsible for that when it was perceived by the government to be a cover-up. I think the only way to deal with this, Chuck, is first of all I don't believe in this, I mean to be blunt. I don't think our legal system is the way to solve these problems. One of the points in my plan, my seven-point plan for healthcare reform, not health insurance reform, is tort reform. I think our whole legal system of going after the people who are actually helping – and I, I know my daughter-in-law who is an OB-GYN doesn't feel she can practice in private practice because she'll have a 20-year tail and she's probably going to move with my son when they complete the residency process and he completes his residency. She completed hers a couple years ago – you know, this is terrible. Why should we be constrained about going where we want to go because of carrying this huge medical malpractice? And frankly, people say, “Well, it's not a big part of the cost” – nonsense. It's a huge part of the cost. It's not, it's not just, Chuck, the cost of the lawsuits, it's the cost of all the unnecessary tests. And let's be honest, we all know we give a lot of unnecessary tests to protect ourselves legally and partly for the kind of indictment you're talking about, because someone can always say, “Well if they didn't, if you'd given that one MRI, don't you think it's possible that you might have uncovered this problem?” Well, look, anything is possible in healthcare. But I think we need to acknowledge that mistakes are made. Now, I think the only way to deal with that, with the mistakes, is systems, good quality systems. There's no way to get on top of quality on a one-off basis and just trying to fix problems after the fact. We've got to get out front by having very tight systems. And we need, we need a culture of candors, I write about in my book. We need to have a culture of candor, that if I bring forth this problem that this patient died and I had a responsibility for it that I'm not going to get shot, I'm not going to get fired for it, I'm not going to get hung out to dry. I think we need to have a culture of candor where we honor people who acknowledge mistakes and then ask people to be part of the solution and ask them to fix those. And I think it used to scare, scare the dickens out of me that we would have a cover-up of a problem and no one told me about it and I used to say to people at Medtronic you'll never lose your job for making a mistake. You – and I can honestly say that people did not lose their jobs for making – but you will lose your job very quickly for covering one up because we're not so clairvoyant. And I would say that to the CEOs and COOs on the phone – you're not so clairvoyant you can know all the problems going on. If people are not bringing 'em to you, as Jamie Dimon, the CEO of J.P. Morgan and Chase said on a panel I was chairing in Davos, he said, “You know, some woman said to me you need at least one truth teller on your team. Look,” he said, ”if you got one truth teller you’ve got a real problem; you need ten truth tellers. Everyone needs to tell you the truth at all levels.” And I think that's what a culture of candor is all about. We bring these problems forward, we never shoot messengers, we honor people who acknowledge problems, and then we go to work in getting the best people to solve the problem. That's the only way I know how to do it, Chuck. But medical quality systems are essential and we can, there is so much room for improvement, and I think we need to work on that basis. And, you know, at Medtronic we could never solve the problems of quality until we had a very systemic reporting process where all the major hospitals reported into us all of their problems. We actually sent people out, monitors to find the problems and we always reported immediately to the FDA because until you can do that, to have that culture of openness and transparency, you're never going to get there from here and you're never going to have a system that's going to really work for you. But there has to be a sense that you will not punish people for bringing forward mistakes or even making mistakes.


Charles Denham: Bill, thank you so much. It is very, very difficult to speak truth to power, and I think we're behind in healthcare. This was a great answer. I'm so glad that we recorded this, and Slide No. 53 is your article from Business Week, the August 15 article, and we've got it up so that people will have a chance to go and review that. I'd like to turn things back over to you, Bill, to take the balance of the lessons, and we want to thank Kelly Martin for that question regarding the punitive environment, one of our participants. I'd like to hand the ball over to Bill and have him continue on and take us through the next section of lessons. Bill George: Thanks, Chuck, and this particular article can also be found at BillGeorge.org, so that's not hard to find. Well, let's go on to Lesson 5, “never waste a good crisis.” It sounds like cliché and a lot of people are claiming credit for this. Actually, this came from Machiavelli, and I'm not a great fan of Machiavelli, but this is one of the better statements he had. Like, when things are going well in an organization, how hard is it to get changes? People say we don't have any quality problems here. We don't have any safety problems. Actually, we do, but in a crisis, that's the best opportunity to make fundamental changes in your organization. If you don't do that, you'll really regret it. So take advantage of these opportunities to get to make fundamental changes in your organization 'cause crisis is the best opportunity. Don't hunker down until the storm passes. You know, what if a storm you think is going to pass in a few hours, you're out at sea? What if it goes on for weeks or months? And storms and, and crises in healthcare can go on a long time. I think you also need to anticipate what lies ahead, and sometimes even create a crisis to say, you know, we could have major quality problems here, so we're going to get on top of this right now. If you go back to Jack Welch's tenure at GE, he actually created a crisis of global competition 'cause he saw what was coming 10, 15, 20 years ahead of anyone else, where his competitors like Siemens and Phillips and Mitsubishi and Westinghouse never saw this, and he took the lead in getting these problems solved. Al Mullaley at Ford saw the problems coming in automobiles, and he went and borrowed $24 billion to protect his company, whereas General Motors went happily along. I think it's so critical that we are in a crisis, and we take advantage of this right now to solve the problem and get to the root cause of the problem, and also use it to reinvent our organization. Is your organization too top-down? Does it need to be bottom-up? The great organizations of the future are not going to be top-down organizations; they're going to be bottom-up organizations where there's alignment around mission and value, and they're a very solid system that everyone adheres to and where all the data is transparent. You know, if the chief of cardiac surgery in your department has a bad surgery, is everyone able to talk about it openly? Can we say that it's a big mistake? Are we allowed to talk? Do we have the data, the transparency? I think that's absolutely critical. Lesson 6 is “you're in the spotlight, follow your true north.” How often are we in healthcare put in the spotlight these days? Pick up any newspaper, and you'll find it's all over the papers, and any mistake we make, it's out there. Somebody gets harmed in one of our facilities, it's on the web, and there is no hiding. You can't cover it up. Today, I believe that internal and external communications have morphed into one. The only way to be credible is to be fully transparent. The idea that we can keep this problem inside our own four walls, forget it. You're going to have problems, and that's when you have difficulties, that's when you get lawsuits, that's when you get media reporters coming after you. I think the best way to be credible is to say we made a mistake. To even know what's going on, particularly if you're in a position of leadership, you need a culture of candor. Who's going to tell you the truth? Now, are there times when you had a problem and you don't know the root cause of the problem? Yes, and it takes you time to find that out, and so you often find yourself dealing with a position where you're trying to express public confidence, but you have private doubts. How should you handle that? I think you should handle it by being articulate and being open and saying, you know, we don't know the full answers. We're trying to find out why Mrs. Jones died, but we're going to get to the root cause, and we're going to come back and tell you what really happened here and engender that public confidence, even if you need to buy some time. But I think that means taking public responsibility for the problems. You may remember a number of years ago when consumers reported that there was lead in children's toys, and Mattel had to recall about 12 billion toys because of lead in them, and the CEO of Mattel went to Congress, and he said, “This is all a problem with the Chinese


manufacturers, and, therefore, it's not Mattel's problem,” and no one reminded him that his name was on the product. He was supposed to conduct the safety surveys. He was supposed to conduct, and he blamed it all on his suppliers – by the way, 100 percent of his suppliers were in China, so he had no other choices, and he created a huge xenophobia, anti-Chinese movement. Contrast that with Jim Burke, the famous case where Jim Burke actually had no responsibility, like Mattel did, for Tylenol being laced with cyanide in the capsule. Some terrorist in Chicago did that and another one in L.A., but Jim Burke stepped up to that one. He didn't know what it was, but he said, “You know, we're going to get to the bottom of this. I can tell you Johnson & Johnson will act responsibly.” The head of the FBI, William Webster, advised against recalling the Tylenol capsules, said, “You're gonna create a problem.” The head of the FDA advised against it. Burke said, “No, we are going to recall every single Tylenol product. We are not going to take any risk that our products could harm people, even if we didn't do it.” And then, as a result, Tylenol's still the leading painkiller on the market today because of his integrity in dealing with that and because he followed every one of these, transparency, credibility, culture of candor, public confidence, while he had personal doubts about what was going on and whether it was somebody who was out to get the company. And, most importantly of all, taking public responsibility for the problems, in his case, he wasn't even doing, and I think he got in front of that crisis by being open. So, that's the bottom line I draw. When you're in the spotlight, you need to follow your true north, and that's the real test. Can you stay true to who you really are and what you believe? The final lesson is Lesson 7. You know, I think all too often in a crisis we think that it's just about getting through it, and if we could just survive this crisis. You know, it's really not about that. It's about going on offense and focus on winning now. To succeed in a crisis, you don't need to just play good defense. You need to play good offense, and organizations that win do that. Steve Jobs, when he went back to Apple, it was in a total crisis. They were losing the computer battle with IBM and Dell. What'd he do? Well, he got his computer line shaped up, but he also brought out the iPod, iTunes, and now he's taking over the telephony business with iPhone. Why? Extremely creative, and if you look at those products, they all use the same capabilities, totally different than what IBM and Dell offer. They offer great human factors and great information on a mobile basis to consumers. So, he played offense. Indra Nooyi, the CEO of PepsiCo, when she took over three years ago, she recognized that the bulk of her profits are coming from high-fat foods and sugar-based drinks. She said, “You know, we're going to shift to healthy drinks and healthy foods by 2010, which isn't very far away. Fifty percent of her revenues will come from healthy foods and healthy drinks,” and she actively is campaigning against obesity, to her credit. A lot of people won't even use the word for fear of being politically incorrect. She's actively putting money into doing that and personally campaigning against it and trying to help solve the world's water problem 'cause they know how important water is for the kind of water-based drinks they have. So does Dr. Dan Vasella, CEO of Novartis. I served on that board for 12 years, watched him build a great pharmaceutical business, take on the global problem. I just got a CEO five minutes ago from the head of research at Novartis in Zambia trying to solve the healthcare problems there and literally giving drugs away that Novartis has made, and designing drugs like Coartem for malaria for people in developing countries where they have diseases that there's no profit to be made there. This is a company of integrity, but Vasella also recognized it and brought the vaccines, and he took over a failing vaccine company and recognized that the buyer of the vaccine had never had the right vaccine 'cause it kept mutating, and so he created this cell production instead of egg-based production in his vaccine business. And today, with the swine flu business coming along – just this morning I heard on the Today Show tremendous warnings about the swine flu and how many people could be killed, a lot of people, children, could be affected. They've got a solution to the H1N1 virus. They'll probably have it to market and available for use this fall before anyone else, so just some examples. I think one other example, Chuck, of people going on offense and focusing on winning now are the people who have been the pioneers of integrative medicine. This is an area where my wife and I have been very involved. And you see an organization like Scripps, like Harvard, Harvard Medical School, like Duke, like at the Institute of Health and Healing at Abbott Northwestern, University of Minnesota – have been real pioneers in the whole integrative medicine movement, bringing together the best of proven western medicine with the best of proven complementary medicines. I'm not a great believer in alternative – but bringing these things together so we'd look at the whole patient. How else can people heal unless they heal in mind, body and spirit and have the opportunity to see when is the appropriate time to use an herbal medication?


When is the appropriate time to use acupuncture, massage, chiropractic? Are these things part of your healthcare practice? I think they have to be. When is the humanity of a nurse in interacting with a patient the key to that patient's healing, to knowing they can get through the most difficult times? And I think organizations – and I hope your organizations are doing this by focusing how are we going to have our organization have the best patient care in our community? And we're going to teach patients to be empowered, to take responsibility for their health, and we're going to focus on prevention and wellness. Everyone says. “Oh, we can't do that. There's no money in it.” Look, I'll tell you, that's where the future is, prevention and wellness, and if we as a nation don't get on top of prevention and wellness, then we as hospitals, as clinics, as healthcare organizations, as pharmacies, if we don't get on top of prevention and wellness, there's not enough money in the United States to solve the problems of end of life and of chronic disease. So, we, just today, The New York Times, on Page A10, had an excellent article out looking at 59 percent of the problems basically come from obesity, people describe themselves as unhealthy and older people. And I think we need to focus on those areas with excellent quality health, safety in our systems that can save so much money, and getting people to look at patient empowerment to take care of our health. So, that's Lessons 5 to 7, Chuck, and I think I'll turn it back over to you for questions while we still have some time. Well, the next chart, 57, let me just say, has seven steps to focus on what you have to do to win and how do you, how do you work through these, and so we'll leave that chart with you that you can use, but Step No. 7, rigorous execution plans, I'd emphasize that until you have solid systems rigorously enforced, full transparency of the data, I don't think you can get there from here. Charles Denham: Well, Bill, thank you. Thank you so much, and one of our questions was going to be about integrative care, mind, body, spirit. Can you share with us that – you, you actually put a lot of this to work at Medtronic in terms of healthy food, in terms of a number of the approaches that you took to your own employees. You've been on the board of Target, you're on the board of Goldman Sachs, you're on the board of Exxon. Can you share with us what dialogue hospital leaders need to have with employers about what they can do, practical things that they can do to bring down healthcare costs that are just spiraling upward? Then we'll return to the pharmacy and leadership and nursing leadership. But you have a rare vantage in that you are a philanthropist who funds mind, body, spirit work knowing that it drops the cost, and then you're also on the board of these very large employers. Can you share with us your perspective on what leaders can do about their employees and even, you know, we've got CEOs with 11,000 to 18,000 employees that work for them? Bill George: Chuck, how long do I have? You just hit on all my hot buttons, you know. I mean, shouldn't the employees in your organization be the healthiest? I just am shocked at the food that's served in hospitals, in hospital cafeterias for the hospital workers, that's served in the rooms that looks like something out of the 1950s, and it's not healthy at all for our people. A lot of times our healthcare workers are far from being specimens of health. I think that's where we ought to start. At Northwestern, we put in a big fitness center that's largely used by employees, and we give particular reduction to the insurance. Same at Medtronic. The people that go to the fitness center to keep their body mass index in line, that eat nutritional foods at Medtronic in the cafeteria – you can't get unhealthy foods. They're not sold there, you know? And I think that's so critical. We pay, Medtronic pays people a $50.00, gives them a $50.00-a-month reduction on their healthcare premiums in order to take a health-risk questionnaire and then have a counselor, and if they're in a low-risk category, they mail and they get e-mails, but if they're in the high-risk categories, they're going to have regular visits with a health coach. In the medium category, they're going to have regular telephone calls. Shouldn't we be doing this for our patients all over? Shouldn't we be doing it for our own employees? I keep referring to Abbott because they have 25,000 employees. That's a huge number of people. I'll give you, but I think far too long, employers have underestimated this and have abdicated their responsibility to the health plans, to the insurance companies. And you know most large employers are self-insured. Let's take Target. Target has 380,000 American employees, almost 400,000, and the previous CEO paid little attention to this. He just worried about the cost without looking at what the underlying factors were. The new CEO, Gregg Steinhafel, and his staff, you know what they found?


They found when they have employees who are engaged in their health, that their same store sales go up, and their customer satisfaction sales, ratings go up. How about your customer satisfaction? Do you see a correlation in your organization between the health of your employees and the engagement of your own employees in the health and the satisfaction of your patients? I bet you do. I bet if you look at it, you would find a high level of engagement. So why shouldn't we put emphasis on this? It is also hospitals’, one of their biggest costs. And so I think the emphasis has got to be on prevention and wellness, as we did at Medtronic. Frankly, we had a program at Medtronic where we gave people money for prevention and wellness, and then they went into a high-deductible plan, and we always covered their catastrophic costs. Why? Because we felt like people have to take responsibility for their health, and I think that's so critical, and it is, as you taught, Chuck, looking at an integrative approach and looking at the whole person. My wife has taken the lead on this, but we've been very, very devoted – are very devoted to that because we think, you know, right now there's no money in it. We think we've got to put it there, and maybe someday the various systems will recognize that this is the key to long-term health and prevention and wellness – is looking at the whole person, that we allow the human body to heal or give it the encouragement. Chuck, you've done a lot of work in your team in the whole area of pain management. Why shouldn't we use acupuncture? Why shouldn't we use meditation, massage, healing, healing touch? I've got a massage this afternoon in a few hours. Why shouldn't we use energy medicine and other forms of ways helping people avoid intensive pain medications without side effects. There's no side effects for meditation, which I've done for the last 30 years, so I can assure you there are many other ways to look at this. So, I think if we can come together around these kinds of approaches to look at what are the person's needs, both the patient and the person who is not yet a patient. How do we allow them to empower themselves to stay healthy and give them the tools to work with as healthcare providers? Charles Denham: Bill, you touched on – you and I must be just tracking mentally – because I wanted to go into this example of the pain management effort. You know, we run thousands, actually thousands of people on these phone calls, and as we embark on this mind-body-spirit integrative care piece, many of our conventional pharmacy leaders and nurses kind of say, “Well, that's outpatient,” or “That doesn't apply to us because we're conventional practitioners.” What you've established at Abbott is really working within the system and complementing conventional pain management with evidence-based best practices and in really complementary care have been able to – what it appears and as more study will find out – to have dropped costs, increased patient satisfaction, improved referring physician satisfaction and, at the same time, reduced overall utilization. So this is really being done within the hospital system with good leadership who have recognized these opportunities, that this really isn't alternative care. This is really the best evidence-based care that combines a number of these elements, and you all, you and your wife as philanthropists, got these things started and they really are within the structure of the way that we practice today. One of our participants in our online Q & A mentioned this challenge. Ken Defeden has talked about how can we as nurse leaders tackle issues that staff are not comfortable with, their herbal medicines and a number of other things that bring in these complementary [approaches]. And some may not have evidence, and some may, you know, be snake oil, but some may have real, real merit, and I think you're proving that at your work at Abbott. Can you just comment in a little bit more detail why you've invested in that, and why it's at hospitals where we really deliver our care, those that are on the call? Bill George: Yes. Let me just say I'm a great believer in evidence-based medicine. I think we need to acknowledge, though as a group, we need to be more honest with ourselves and say that half the procedures we're using today in hospitals, many of which have been around for 30, 40, 50 years, are not proven by evidence-based medicine and that, oftentimes, the evidence changes from study to study as we look at it more deeply and we look at individual patient types. And I think we need to treat each person as, each human being as a complex organism, if you will, with many variables. And the idea that we can solve with a single variable, I'm just not a great believer in that. I realize that's the easiest way to do the testing, but people are too complex. And so I think we need to tailor our therapies and our healing for people, particularly on the healing end, from chronic disease, to look at their needs and have them look at all aspects of who they are and try to get healthy in mind, body, and spirit. It may be that their lack of purpose for living becomes the most important thing, or their lack of support, healthcare support in their


life, the lack of belief that they can get through this disease, the fact that they have people, healthcare workers, around them who are helping teach them the techniques they need for good diet, for good nutrition. Their surgeons aren't going to have time to do this. Who's teaching these things? And I think, you know, as Dr. Esther Sternberg at the National Institute of Health said, “Chuck, you know, if stress can make you sick, why do we not believe that the absence of stress can keep you well?” And I really believe that. I think the immune system of the human body is, perhaps, the most powerful healing technique ever seen. Well, what are you doing to enhance the immune system? Through looking at food as medicine and eating healthy food and looking at ways we can strengthen our bodies through various stress reduction, through exercise – get the endorphins flowing. I think we need to do all of the above, that we need to teach people how to do that, not just send them on home and drop them on their heads. And I think that's where the future of healthcare resides, in bringing all these things to bear on patients. It's not about alternatives to what we do. If I have a tumor, if I have prostate cancer, if I have a tumor, I want it out, but then I need to make sure my body gets healthy, that it can ward off whatever those cancer cells in my body were, to make sure that I'm healthy as a person. And so I feel very passionately – we’ve got to make these investments, and that's – of course, philanthropy can help, but there's not a lot of money in them today, but if we're only looking at the bottom line, healthcare is going to go exactly the way it's gone the last 20 years. So, this, to me, is the future of medicine, to look at the whole person. Charles Denham: Bill, these are wonderfully inspiring thoughts that really have direct application to what we do. Now, let's get right into some tactics. It's wonderful that you've got the seven steps to focus on winning up. As you and I were conversing this morning in preparation for this webinar, we talked a little bit about it, and I suggested to you that we really are starting to recognize that our pharmacy directors, our pharmacy leaders, are really people running their own small company within a holding company of other companies that are all slammed together and really operating as silos. Our nursing leaders, our chief nursing officers and nurses who are nurse managers are leading, front-line players who are really running kind of a business within a business and budgets. They have all of the pressures and key issues that are going on now with healthcare reform. We know we are going to move to episode-of-care payment. It's only a matter of time until what we do in the hospital and how we manage and discharge, and how we manage patients on medications, can have a direct impact on readmission rates, which now the hospital will have to warranty or guarantee it or, and eat some of that cost. So, as we start to talk about, and come back to the National Quality Forum Safe Practices, these are clear activities that have enough specificity but enough flexibility to be put into action plans, and calendars, and structures to deliver work. As we look at your seven steps that you have up and we think of these leaders who are on the phone today, can you walk through these steps as we think of a pharmacy leader, just to set the context, Bill? We've been trained that the chains of habit are too light to be felt until they're too heavy to break. Our habit is to play defense, not offense. Our habit is to adapt – have this learned helplessness to say, “Oh, I'm dealing with 10 percent less budget, these guys aren't listening to me, woe is me,” have the pity party and really not lead. And what happens is, instead of trying to put quality touchdowns on the scoreboard by playing offense and throwing the ball and moving the ball up the field, we collapse on the revenue ball and try to hang on to where we are. And now, with healthcare reform, episode-of-care payment, reduced resources, it's not going to pay to play defense, and I think this is why, as I read the manuscript of your book, I thought, “My gosh, this has direct applicability to people leading the pharmacy today, nurses who are leading their troops.” Can you walk us through these, each of these steps and expand a little bit in the remaining time that we have? Thinking of these division leaders and the fact that they can play offense, they still have a budget they can deal with, they can own their problems, they can create that transparency and kind of break those chains of habit. Can you just walk through each step, because I think this has direct applicability to our audience today? Our pharmacy leaders know far more about the adverse events that are occurring all across the hospital, beyond the walls of the pharmacy. But within the walls, they really can lead their teams, as the nurses can. Can you walk through each step? Bill George: Let me just start by saying, Chuck, that no matter what's done at the national level in healthcare, healthcare is always going to be a local business, if you will, a bottom-up business, and it is a competitive business. Let's face it, patients have choices. Are they going to your hospital, or are they going to your clinic, or are they going somewhere else? And I think, in the future, patients are much more


empowered to choose where they go, and I don't think our healthcare reform is ever going to tell them where they have to go. They're going to choose where they go based on where they get the best care and feel like they can be best cared for. We know that 75 percent of all healthcare costs are in chronic disease. How do people learn to become empowered in managing their chronic disease? Are they going to want to go back to your hospital because they were treated so well before? Are they going to say they had a bad experience, and they don't want to go back? So I think we do have to, if you will, win in our local marketplace, and the way to do that is to think through what's going to be required. And I think it's going to be, as my colleague Michael Porter at Harvard says, the competition really should be around quality. We can't just pass the buck on costs and get people off our insurance rolls and think that's going to solve anything. It'll solve nothing. But, you know, how do we get people to focus on quality as the strategy? We want to have the finest-quality healthcare where the patients feel they get the best treated in any hospital in our region. Can you honestly say that about your hospital? Are you striving for that? Jim Collins talks about, you know, big, hairy, audacious goals. Do you have those big, hairy, audacious goals that we will be the best? And, by the way, we will measure that based on quality. We will produce the data. We will share the data. We do this at Medtronic. None of our competitors does it. Put it out there. Here's the data. They pick on us that we made mistakes. Of course we make mistakes. Are you putting the quality, are you putting the safety record of your hospital, your clinic, on the line for anyone to see that you can say, “Look, folks, come here, and you're going to have the best care you can get”? I think at the same time, we've got to shed our weakness. What's our biggest weakness? Rules-based bureaucracy. Something that gets in our way. People who fall back on budgets say, “I can't do it, I can't do it.” That's a weakness for so many organizations. Having weaknesses in our own employees' health, having weaknesses in our safety systems. We've got to get on top of these. Until we can say we have sound systems, that we – the reason we can turn out quality and safety data in our system is that we know, we have the measurements here. Now, what are you doing? What are others doing? Let them figure that out, but I think you need to do that, and then shape the industry around your strengths, you know? I think that winning healthcare organizations in the future are the ones that have the best quality, and I'm a strong believer. The highest quality, lowest cost. Don't let anyone tell you differently. You know, highest quality care does not indicate high-cost care. Now, if you are giving surgery to a 96-year-old patient and putting a Medtronic defibrillator in them, you know, that's high-cost care. That may not be the highest-quality care. The most humane care may be to let them live in a nursing home or in a hospice or at home with all proper in-home care at a lower cost. But I think you need to reshape your market around your strengths. By the way, things are tough, and people say we have no money to make investments. You don't make the investment in the kinds of things we're talking about, I'll tell you, you won't be there when the market really comes out of this crisis, and so they need to make investments now. You need to make the investment. We go on making investments in buildings, equipment. I was at one major center, Mass General, where the doctor looked out the window and said, “I think our CEO has an Oedipus complex.” You know, it's not just the buildings, okay? It's relatively easy to go put a capital drive together and raise money for buildings. Are we raising money for leadership development? Are we raising money for patient care? Are we raising money for proving our quality systems? That's the investment. The Allina Health System put a billion dollars, a billion dollars, in investing in an employee database, excuse me, in a patient information system and has one of the best in the country because he did that. And while we're focusing on the problems, are we keeping our key people focused on winning? Winning means providing the best care with the best systems in town. And then how do we present the image of that? Are we willing to talk about that publicly, to go to the media? The media loves healthcare stories. Give them the stories, give them the positives. Look, there's always going to be negative stories. You can't avoid it. There's always going to be people in your system when they don't get the best care, they're disgruntled. I think the only way to deal with that is put out the positive stories. And then Step No. 7, most important of all, do we have the rigorous execution plan? Are we implementing rigorous execution so we know where we stand? If there's a quality problem, there's a


safety problem, the patient dies, we have a complete review. We don't go into denial. We have all the information out there. We know where the high costs are. We go attack them. We put teams together to go deal with high-cost problems. We know where the quality problems are. We go after those problems. And so I think each of these applies directly to your hospital system or your clinic or your pharmacy. Do we make mistakes in pharmacy? We need to make sure we have the proper systems in place to avoid that and ensure we have compliance among pharmacy leaders, that if patients are actually complying with their drug, then they give them the right drug and they don't take it. Well, Chuck, let me turn it back to you there. Charles Denham: Yes, and so for our nursing leaders and pharmacy leaders, these seven steps really can apply to your little company within the bigger company. And we really need to start thinking that way, that we can really rethink how our pharmacies and how our nursing workforce strategy is developed because many don't have a strategy at all. It's just survive and watch the budget. It's going to take courage and boldness to shed weaknesses and to really take a hard look in the mirror, as Jim Collins would say, rather than look through the window. And these investments, there are investments that you're making in hiring new people every day. The nursing leaders have had a little bit of a break because a number of nurses have come back to work, but we've got this downturn, and we know it. We've got a shortage coming in the future, and so, really, investment is going to be key. And we can't say enough about our pharmacy leaders doing great jobs, but we really know that they can deliver far beyond the walls of the pharmacy. So please, take a hard look at the pharmacy NQF Safe Practice. It's a composite practice that really has tactical elements that are the basis for pharmacy leaders to rally their team around – what they can do for the whole hospital system and really create an image of the pharmacy as a leader within the industry of your hospital system. And this execution-plan issue is absolutely critical because it's going to all be about execution. And as you look at the Safe Practices and the action elements, you'll see that the committee is really focused, and the subject-matter experts have focused on this. What we'd like to do, Bill, is have you address your conclusion slide here, and then we'll be moving to Dr. Angood for some final summary points. Bill George: I'd like to start with what the anthropologist Margaret Mead said, at the bottom of this chart. “Never doubt the power of a small group of people to change the world. Indeed, it is the only thing that ever has.” I think sometimes with healthcare, with it being one sixth of the U.S. economy, that we just feel overwhelmed by the challenges. And I think we can't solve the whole national healthcare problem ourselves. There's no one on this call or no group of us that can do that alone. I think each of us can do what we can do in our group and really set about we're going to make a huge difference. Robert F. Kennedy, in his lifetime, said that few will have the greatness to bend history itself, but each of us can work to change a small portion of events. In the total of all these acts, we have written history of this generation. Well, what's the history of our generation going to be? This crisis may be your defining moment. This may be the year of the opportunity to step up and lead. Are you prepared to do that? You don't have to be the perfect leader. You don't have to have the title. Don't wait until you get a title. Step up and lead right now, right in your own environment. Like Kennedy said, can you change a small portion of events right within your own clinic, your own hospital, your own pharmacy, and make a difference? And while you're doing, stay on course to your true north, no matter how great the pressures or temptations, 'cause I believe that each of us on this call can make an enormous difference in the world. And we're making a difference right in our own local place, and at the end of the day, we can look back and say, you know, I may not have changed the whole world, but I made, really made a difference. In my book, in the conclusion of my book, I have a wonderful quote from a mountain climber, a Scottish mountain climber named W. H. Murray, and Murray says until one is committed, there is always hesitancy, the chance to draw back, always ineffectiveness. The moment one definitely commits oneself, then Providence moves also. All sorts of things occur to help that would never otherwise have occurred. Whatever you can do or dream, or whatever you can do or dream you can, begin it now. Boldness has power, genius, and magic in it. Well, do you have that dream of how you can make a difference? Do you have the power? You have the power right within you, but are you willing to step up and lead and make that difference? Because I think each of us can make a difference in the world, and I just encourage


everyone on this call. Never underestimate what you could do and what you as a small group of people can do to change the world of healthcare because, indeed, you are the only ones who could ever change it and get us out of this crisis. Charles Denham: Thank you, Bill. This has been terrific, and I think that, you know, for those of you who are just starting to get introduced to the National Quality Forum Safe Practices, you will be surprised to find that we have really incorporated values, behaviors. Some of the inspiration that's necessary for transformation is woven throughout the Practices. We started with Jenny Dingman, who is the patient advocate. For those who came on late, Jenny will make some comments at the end. But we really realized that healthcare is a social business, and it is about people. And so as you look at the National Quality Forum Safe Practice for leadership or pharmacy, it does lay out very tactical elements; however, as you read the Leadership Structures and Systems Practice that we introduced this dialogue about it with, all the way through that Practice, attention is paid to inspiring, informing, empowering, and creating cross-connections among pharmacy leaders, nursing leaders, leaders of laboratory, independent physicians, the, physicians within the organization. And that we've recognized that the teamwork is so absolutely critical, and without this kind of inspiration and a broader view and a deeply held view in the values, it's impossible. So, as we now move to introduce Dr. Peter Angood, we want to make sure to remind you that off the website you can access Bill's book. It's a fast read. It provides excellent examples and has real tactics that pharmacy leaders and leaders of any organization can put to work. I also would recommend the Authentic Leadership book that Bill has written. And it is far less a conceptual book than a real tactical checklist and game plan for leaders of any organization. And his True North really delves into this issue of core values and your values as a leader, and I think it leads beautifully into the 7 Lessons ... So, as we turn to Dr. Peter Angood, for those of you who have come on late, we are producing a transcript and audio recording of this webinar, which will be available on safetyleaders.org. Dr. Peter Angood is the Senior Advisor on Patient Safety for the National Quality Forum. He has been the Chief Safety Officer for The Joint Commission and Senior Vice President there. He's a trauma surgeon. He has had academic positions at a number of leading-edge organizations, has numerous publications and, we believe, is a real treasure at the NQF, supported by a terrific staff, without whom we would not be able to be continually updating these Safe Practices that are both timely and harmonized, but actually have a huge impact on the hospitals across the country. Dr. Angood, would you please give us, now, your views? Peter Angood: Well, thanks, Chuck, and thank you for the introduction. This has been just a wonderful hour and a half, so far, listening to Hayley with her perspectives on pharmacy and then having this open conversation with Bill George, who is truly representative of leadership and the high qualities of leadership in this country, if not around the world. So, truly a pleasure, and thank you. I think that as we look at leadership and some overviews within healthcare, we're clearly moving, as Bill was suggesting there, away from a period where there is an expectation of a single or small group of leaders, to bring everyone else along and have them march to their drumbeat. We need to be continuing to move to this newer era of inspiring leadership capabilities within all individuals and promoting the ability of these groups of leaders to work together in teams and to work together in team-based care for patients. And, yes, there will always be silos, and there will always be different disciplines, but part of our challenge, as we go through this healthcare reform and rethinking healthcare, will be to look at ways to cross-over these silos, get the leadership groups within each of those silos communicating and talking and working with one another to look at the collective processes of care so that, indeed, patient care is improved from a quality vantage, improved from a safety vantage, and improved from an efficiency vantage. Unfortunately, healthcare has come out of this long, traditional behavior of professionalism, looking towards physicians for that leadership, and yet the technologies, processes, and interactions of healthcare, including the politics and the finances, have made it all the more complicated. That historical


tradition of professionalism just doesn't work anymore as a paradigm for making healthcare become better. And so this aspiration for individuals to become leaders and then promote cross-disciplinary approaches is clearly the way that we need to move ahead in all of this. Yes, Bill's right, and Chuck's right. This is a social business that starts at the bedside, it starts at the home, it starts with the holding of a hand, but we also have to work through politics and policy and legal structures, et cetera, because that is the infrastructure on which we need to work. Those components do need to be changed, but they also are what we have to work with in this day and age. And I think it is fair to say that several of the lead healthcare organizations in this country are hearing this plea, if you will, for stronger leadership overall. AHRQ within the federal government, the Health and Human Services Department itself and several others, including CMS, within the federal agencies recognize the need for leadership and are demonstrating it through programs like TeamSTEPPS from AHRQ. Organizations like IHI have their Boards on Board program and other different types of programs clearly oriented towards how do you work with leadership, how do you improve leadership, how do you make it penetrate into the organization. The Joint Commission has a set of standards on leadership, and that leadership chapter in the standards from The Joint Commission is really a strong and pivotal chapter in order to try and nudge healthcare organizations along in this quest for stronger leadership. And then, obviously, we here at the National Quality Forum strongly believe leadership is an integral part of all of this through our Safe Practices, and we're beginning to see more of that come through in our Serious Reportable Events program, our Endorsed Measures programs as it relates to patient safety, and you'll see it through the National Priorities Partnership (now a 32-member organization with six strong priorities and with one being a safety priority), where the team-based behaviors, the orientation towards leadership, the cross-disciplinary care will also become present in there. So, what we're building here, then, is not only that social/local business at the bedside, and in the offices, and at the homecare facilities, but also the drive from the top down with the expectation that leadership becomes an integral part of all of this. The sandwich in the middle of that top-down and bottom-up approach, that's, in my mind, where the rubber really meets the road, and that's where we have to have individuals in the healthcare facilities within different organizations and practices taking that leadership strategy and moving towards trying to make things improve at that local level. I like the awareness, the accountability, ability, and the action model that Chuck brought forward in the beginning. It forces us into thinking how to do things, and we have to have some patience in all of this. It's going to take time to create this change, but we don't have to wait for policy. We don't have to wait for tort reform or regulations around reimbursement. These social changes are all activities that can and should begin tomorrow by you in your own organization, and look for how not only to inspire yourself but how to inspire others around you as you tackle the complicated issues overall. I think I'll leave it at that for the moment, other than to make just one closing comment. As you know, leadership is not all about being charismatic and dynamic and, you know, a nice person. You really have to have some knowledgeable substance, some experiences and certainly a strong respect from the community within which you work. And at the end of the day, it's still – as in all industries, all businesses – it’s about the people, how you interact with the people. And, for us, it's about the patients and how we care for the patients and how the patients receive that high quality, high level of safety and efficient care that we would all expect and hope for, for ourselves or for our family members. Chuck, I'll turn it back to you, as you want to close us off. Charles Denham: Well, thank you, Peter, and wonderful thoughts. Peter has a major responsibility and is supported by a terrific staff at the NQF with leadership by Janet Corrigan, and is working with the Serious Reportable Events work, the Safe Practices, coordinating the National Priorities Partnership, of which NQF is a partner. And so we're excited to see what's going to be unfolding over the next 12 to 24 months. In order to bring us to closure here, this webinar really focused on leadership, and I've had the privilege of hearing Bill teach at Harvard because I'm one of the fellows of the Advanced Leadership Initiative. There are a number of lessons that he provides in these books. And we’ve put up for you his book and again, it's always critically important to have transparency. We have no financial relationship with Bill


whatsoever. We will continue to bring forth other resources and assets and connections for our webinar audiences, which we've been doing with TMIT. So, we put this up so that you can access it and get a hold of this. Other books and other content that we found to be very powerful in this area of leadership are Joe Nye's book on leadership. Bill, do you want to take a quick ten seconds, just sort of perspective on Joe's work since you and he had worked with us at Harvard, to help us understand some of the key issues in leadership? Bill George: Well, I think he listed the whole-person leadership and the opposite, command and control, and he talks about soft power and how we can use influence to get things done. And I think the healthcare system is basically one influence. It's not one of command-and-control power. And I think you find the people who have the greatest impact are ones who are wonderful influencers of people and can bring teams of people together. So we're very much on the same page in what I've written in 7 Lessons for Leading in Crisis and what Joe talks about, the use of soft power. Charles Denham: Good. There are some other resources that have really come from this terrific group of leaders and leadership experts. David Gergen, who is the only person who has ever advised four presidents, has written a book, Eyewitness to Power: The Essence of Leadership: Nixon to Clinton, which we frequently cite. That is a terrific book, a terrific and exciting read for those who are contemplating moving up in their hospitals and leadership. Many of the lessons have direct applicability. Rosabeth Moss Kanter has recently written a book that's just being released this week, SuperCorp, which really adds some focus on this values-driven and principled approach. And she describes how great companies out in the marketplace, and some of them are healthcare companies, had a social motive as well as their motive to be a good commercial enterprise. And so what we're finding is that these are not mutually exclusive. Financial performance is intrinsically interlocked with the core mission, and by just focusing on the finances, which we have a tendency to do in healthcare, especially when the squeeze is on the finances, it's so easy to put those values on the back burner. And so we really are pleased, Bill, that you have taken the time to share with us these great insights. Bill, we've had a couple of good questions that are higher-level sort of questions, and they pertain to the entire industry; and one from Marla Miller is about your perspective on the big insurance companies. You are a mover and shaker with many of these big, big companies, and kind of have some insight as to the forces that are at play with your board leadership, and on CNBC, and that kind of thing. Marla asked the question, whether you believe that the insurance companies and PhRMA are going to embrace integrative care and get into the game on healthcare reform and this mind-body-spirit sort of connection. Bill George: Well, so far, in my experience, the big insurers, the bigger the insurer, the less likely they are to come around in this area. They just have not been very progressive. I think it's the employer-based insurers who are going to enforce this, the progressive ones like Safeway, and PepsiCo, and Target, and others who are, and General Mills, who are really looking after their employees' health, who are going to enforce this issue. And I think, I'm a great believer that we need to be looking at insurance cooperatives, not a national health insurance plan. I've seen with group health, the benefits of what they've done has just been fantastic. And I think we just need more of these organizations that are not strictly driven by maximizing the bottom line or maximizing, to be blunt about it, the compensation of the CEO, but can operate as more of a cooperative and get their people more involved and recognize the savings from having people really take, feel empowered about their health. And that's what a lot of these group-health type organizations do, and frankly, that's what they all, the original managed-care organizations [were] supposed to do, but we got away from that. And so I'm not anti-insurance, but I think insurers have got to be brought around, and I think this process in Washington is going the wrong way. It's playing entirely through the major insurance companies. Now, there are progressive insurers like Blue Cross Blue Shield, which do very good work, but I think we as hospitals need to stand up to that because what's happening right now is, frankly, all the money has been ground out of the doctors' compensation and the hospitals. And an awful lot of that has been captured in insurance and administrative costs. And the biggest problem we have with healthcare costs, which we haven't even touched on today, Chuck, is the cost of paperwork. And there's a cost of offensive paperwork on the part of the insurers, which runs 15 percent plus, and then there's the cost of defensive


paperwork on the part of the healthcare systems – the providers. And I think we just need to find a way, electronic means, to eliminate all of the billing and re-billing and all of this and get away from that. And that's what I've put in my plan, and I put it in the Business Week article. Charles Denham: Well, Bill, I've gone to that. Can you give us your seven steps for healthcare reform? Then what I'll do is ask Jenny Dingman to give us the voice of the patient because they should have the last word, and then I'll just address the upcoming webinars. Bill George: In thinking about healthcare coverage for all Americans, which I support, I think we need to start with catastrophic coverage. So what I would favor is self-funded, low-premium, high-deductible catastrophic coverage plans so that even the youngest of people, not youngest, but people in their 20s, who think they’ll never be unhealthy or get in an automobile accident or a motorcycle accident, will have healthcare coverage. And, yes, I think people are going to have to absorb the deductible, and I think these basically can be self-funded plans. Now, I think that I talked about the insurance cooperatives. Now, these should require mandatory portability so people don't fear changing jobs and no limitations for pre-existing conditions. So anyone can get coverage, particularly on the catastrophic side. But, yeah, they should be self-funded, run independently under rules set by the government. And instead of having the billing going back and forth in paperwork, eliminate all the paperwork, do everything electronically, as we did it. We did this at Medtronic. Basically, the first two points of it, we did at Medtronic. Third, lifestyle is critical, and I think we should, the government should spend the money on a national wellness and prevention campaign, much like we did in smoking. Very effective, and I don't think you can eliminate all unhealthy foods, but I think you could focus on sound nutrition, physical fitness, stress management, and reduction of obesity. And we shouldn't be shy about talking about that. Four, the federal government should work with local and state governments to provide community clinics that provide basic service at modest fees. A number of these events set up. Yes, it will take longer, but I think it's a problem long in the making. We're going to take a little while to get out of it. And then I think we put the responsibility for healthy lifestyles back on individuals with support from their caregivers. And then, fifth, quality is absolutely essential, and I think we need to shift from reimbursing procedures, as, Chuck, you said, for procedures, how many stints you put in to paying for outcomes and keeping people healthy. I think this is critical. And then, sixth, I think, is the tort law reform, which I think has to come and I think is absolutely critical when we get to tort reform and so that people don't live in mortal terror of what's going to happen to them if they make a mistake, because people will make mistakes. So, there's no question about that. And I think that's pretty much the plan. I should turn it back over to you, Chuck. Charles Denham: Great. Thank you, Bill. Thank you so much. What I'd like to do is ask Jennifer Dingman to make a closing remark in the voice of the patient. And what I think I'll do is just allow her to have the final word, and I'll ask the speakers to remain in the speaker room so we can do a performance improvement debrief. And I ask all of the participants to please respond in the evaluations. Tell us how to do better, what we need to do to really give you what you need. We have upcoming Safe Practices webinars. On September 17, Dr. Angood's leading us. It'll be terrific and addresses the final chapter of the Safe Practices with a lot of really key issues, a number of HACs, hospital-acquired conditions soon to become healthcare-acquired conditions. Then, October 22, transparency openness and improved safety, Safe Practices 5-8. And November 19, communication and safe information management will address meaningful use, CPOE, bar code, a number of really key issues. And then December 17 the workforce, where we’ll really take a deep dive into this nursing issue and a lot more nursing leadership issues, as well as ICU and the direct caregiver. Jenny, could you close and just give us the voice of the patient? And we'd like to thank everybody for being involved. Jenny? Jennifer Dingman: Yes. Well, all I can say is wow. Professor George, I am so thankful for everything for you said today. It really touched my heart. My heart was jumping for joy. As a patient safety advocate, a lot of my colleagues and I have been carefully watching, and some of us have been involved in the healthcare reform discussion, and very rarely do they talk about quality patient safety issues. And it just made me so happy to hear everything that you said with regard to other types of healthcare to be promoted, alternatives, and things that I hear from our own realm. And I just thoroughly encourage


everyone to support you on that, to get involved in the discussions, because that is the common denominator, to bring everybody together. Thank you, everyone else, for being here and taking your time for me and all of my colleagues and all of the patients in our country, And thank you, Dr. Denham, for what you're doing with these webinars, and God bless you all. Bill George: Thank you. Charles Denham: Thank you, Jenny. And this brings our webinar to a close. Bill, let me thank you personally, again, for just a terrific job. Thanks for writing the books – leading the way for us. Peter, thank you, for your thoughts, you are always terrific, and you have a heavy responsibility on your shoulders. You'll be in our prayers that you can lead us with the new measures, standards, and practices, and Hayley, as always, a terrific job, an unsung hero. And to the teams at the NQF, people whom these participants don't know, and those at TMIT who make all this happen. We just happen to be the voices. Thank you all, and have a good day.

Leadership Lessons for Pharmacy, Nursing, and Hospital...

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