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The author declares no conflicts of interest.

Visionary Healthcare Leaders Deliver Transformational Change Anthony D. Slonim, FACHE

C O M M E N T A R Y

DOI: 10.1097/HAP.0000000000000078

Anthony D. Slonim, MD, DPH, FACHE, is president and CEO of Renown Health in Reno, Nevada, and professor of medicine, pediatrics, and community health at the University of Nevada, Reno.

As health systems across the United States endure increased pressures on performance in domains such as clin- ical quality, service, and efficiency and take on risk for both quality and financial outcomes, some are challenging themselves in ways that go well beyond these fundamental con- structs. For these organizations, the changes are not merely incremental—they are fully transformational. The changes reflect not only what needs to be done in the here and now but also how these organizations intend to sustain themselves and the work they do for their communities for generations to come.

In this issue of Frontiers of Health Services Management, CEOs Nancy Howell Agee of Carilion Clinic and Gary S. Kaplan of Vir- ginia Mason Health System share case studies of transformational change in their respective organizations and describe how that work has been precedent setting for them, their teams, and their communities. Their feature articles both add value to my personal leadership library and spur further ideas that I am shar- ing here in hopes that they may help others lead their organizations through change.

Transformational Change Defined Anderson and Anderson (2019) highlight two fundamental criteria that distinguish

transformational change from other types of change:

1. In transformational change, the future state is unknown and must emerge as one goes along.

2. In transformational change, the future state is so radically different from the current state that both people and culture must change to achieve the new desired state.

Carilion Clinic, led by Nancy How- ell Agee, and Virginia Mason, led by Gary S. Kaplan, are not-for-profit healthcare systems serving communities on opposite sides of the United States. Despite their geographic separation, the journeys of both organizations share several important sim- ilarities that are also relevant to Renown Health, a not-for-profit healthcare system in Reno, Nevada, which I have led as CEO for the past five years.

The Legacy of Community Service Carilion Clinic and Virginia Mason have had long and significant histories of service. Carilion Clinic, an organization that began in 1900, and Virginia Mason, which began in the 1920s, are significant not simply

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because of their longevity but also because of their meaningful work in helping their communities evolve. Agee’s story about the origin of Carilion Clinic as a small yet critical community resource is noteworthy on this point. Similarly, two enterprising physicians started Virginia Mason with an 80-bed clinic that aimed to provide the fin- est team-based patient care (Bohmer and Ferlins 2008).

When an organization undergoes trans- formational change, its goal frequently is both to honor the past—the foundation on which the organization was built—and to move forward so that it can continue to contribute to the people and communities it serves. At Renown Health, we too have a rich past dating back more than a century. We honor that past by recognizing our history first as a small hospital; then as a county hospital; and now as an integrated network of hospi- tals, a health plan, and medical offices to meet the health and healthcare needs of the communities we serve. For any orga- nization that contemplates transformation, the change is not about doing away with its history but rather building on its history to continue its legacy.

Strategy Is About Choices Both Carilion Clinic and Virginia Mason recognized that transformational change is dependent on strategy, and strategy is all about choices. Organizations perform stra- tegic thinking and create strategic plans to provide focus and direction. An organiza- tion cannot do everything, so the work that goes into a strategic plan helps it choose be- tween alternatives, sequence the work, and define the outcomes to identify and ensure success. Strategic plans can take a number of forms. A binder that is put on a shelf and dusted off every third year for revision is a thing of the past. Nowadays, a thoughtful

approach to planning may involve a single chart with a series of pillars to support detailed operational plans that highlight the organization’s strategic objectives, tac- tics, and outcomes. It is a living document. While strategic thinking and planning are thoughtful and intensive exercises, the scope and pace of transformational change demand that the plan act as a guardrail to keep the organization from getting off track so that the changes emerge as the context matures.

Since 2006, Carilion Clinic has been ad- vancing its vertical integration, leading in quality, and establishing a medical school in partnership with Virginia Tech. I was for- tunate to have witnessed this advancement firsthand for several years as a vice president at Carilion Clinic and to have had my ca- reer shaped by Agee as a mentor. She helped me really understand how to carry out ex- pansive changes for those you serve by staying focused on the people. I found her passion and leadership to be genuine. The people on her team love her because of her unwavering commitment to their success and to the success of their community. As a leader, she helped me appreciate that out- comes are important and that people make all the difference in whether those outcomes are realized. Today’s healthcare leaders are battling intrusion from other industries, fighting provider burnout, helping teams to adapt to constant change, and struggling to achieve more than ever before. Communi- ties, teams, and boards that have leaders like Agee know what transformational leader- ship is all about.

Virginia Mason’s journey of transfor- mation began in 2002. Its ambitious plan to continue to excel in patient safety and quality was limited by the tools available at the time. Fortunately, Kaplan and his team were (and are) innovators. At a time

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C O M M E N T A R Y

when many people were just talking about tapping into engineering principles to improve quality and safety in healthcare, the Virginia Mason team actually did it. They went outside of the healthcare sec- tor and tapped into the Toyota Production System to anchor that long-term approach to patient care. As a lifetime student of qual- ity, I see this as a dramatic undertaking— looking past incremental quality im- provement work to completely transform healthcare delivery through gemba walks and sequential kaisen events identified by frontline workers.

Renown Health embraced a transfor- mational healthcare approach several years before I arrived, thanks in large part to ed- ucation and support from Virginia Mason. Our leadership team consulted with theirs, learned the fundamentals of transforma- tional healthcare from them, and even traveled to Japan with them to learn about this approach at the source. Now, when you walk into a Renown Health auditorium on a Friday afternoon to hear a team report on what it accomplished that week to improve patient care or experience—using data to move their work streams—you cannot help but be overwhelmed with emotion. The commitment of so many people to serving their customers’ needs is truly noteworthy. Sometimes, the customers are patients who experience long wait times, complicated bills, or a hospital-acquired infection; other times, the customers are other departments that depend on the team’s sequenced work to ensure that products in the supply chain are efficiently acquired, inventoried, and de- livered. Whether the customer is internal or external, these transformational healthcare methods work. More important than the tools and methods is the commitment that employees demonstrate in simply wanting to improve their work. Such cultural change

requires deliberate leadership, communica- tion, and lots of time to achieve results. This commitment of time is one of the reasons I am so appreciative of what Kaplan and his team have accomplished.

Values Matter The case studies in both feature articles highlight the important role people play in executing transformational change, and setting a unified direction helps to engage people in the right work. Values were the platform for transformation at both Car- ilion Clinic and Virginia Mason. At Caril- ion Clinic, these values have transcended Agee’s experiences as a patient, nurse, fam- ily member, and leader. At Virginia Mason, Kaplan notes, improving quality and safety while controlling costs in their production system aligns well with their values. Simi- larly, Renown Health’s values (see box) are our north star for guidance in understand- ing what we stand for; they also provide all team members with the same standards and help us improve the consistency of care for our community.

People Matter The CEO provides direction for an organiza- tion, but a CEO’s efforts will be insufficient without entire teams of leaders, physicians, and employees to ensure that the execution

Renown Health’s Values Caring. We are caring and compassionate.

Excellence. We strive for excellence in all that we do.

Integrity. We demonstrate respect and integrity.

Collaboration. We collaborate with our patients, families, physicians, and communities.

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does not fail. Both Agee and Kaplan are first-rate leaders who have transformed their organizations through times of dramatic change, and they represent their organiza- tions well. Nonetheless, like all great leaders, they acknowledge the importance of many other people in their organizations’ journeys in a variety of ways.

Governance and Boards Boards have a vital role in seeing that the healthcare organization is carrying out its mission for the community. Carilion Clinic’s board was instrumental not only in support- ing the necessary transformational change but also in remaining steadfast in its commitment through difficult times. At Virginia Mason, the board was important in the implementa- tion, too. Kaplan emphasizes the significance of board and management alignment, trans- parency, and performance improvement in governance as well as management and clini- cal care delivery.

The Renown Health board also has shown unwavering support for our work while holding the management team ac- countable for outcomes. As a former county hospital, we take our commitment to our community very seriously. Likewise, it is clear that the boards of Carilion Clinic and Virginia Mason are thoughtful about the transformational changes at their organiza- tions to serve their communities in the pres- ent and through the long term.

The Community The community’s needs are important be- cause they are the reason our organizations exist. As healthcare providers have begun to understand their responsibilities for health as well as healthcare, they have acquired sig- nificant knowledge with respect to the impact of social and environmental determinants on

health. We know that healthcare—the services we provide to people who are ill or injured—is only one component of our work. Our greater task has evolved to keep people healthy in mind, body, and spirit so that, hopefully, we have less illness and injury to treat. Renown Health is focused on this intersection of health and healthcare. We serve a community that has historically experienced health outcomes that have been far from world class. How- ever, as Reno continues to move from gam- bling and gaming to technology and logistics, healthcare services needs have changed. We have learned that health depends on a num- ber of factors outside of healthcare, including social, genetic, environmental, and behavioral determinants. If we really want to help to im- prove the health status of our communities, we must address these determinants so that people have access to appropriate screening and prevention services.

Both Carilion Clinic and Virginia Mason have addressed their communities’ needs in many ways. After introducing a series of efforts ranging from the use of community health workers to assist in care coordination to a fresh food prescription program, Carilion Clinic has seen the health status of its community improve. Similarly, at Virginia Mason, Kaplan has identified not only determinants of health but also oppor- tunities for collaboration as Virginia Mason works with local public health agencies and other health systems to assess community health needs.

In Reno, Renown Health has collabo- rated with the local health district and other not-for-profit healthcare systems in per- forming a community health needs assess- ment (Washoe County Health District and Renown Health 2018). The principal learn- ing from these partnerships is that our communities are not homogenous. Instead,

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they tend to comprise a fabric woven of people with different attitudes, beliefs, and behaviors about health and healthcare. If we, as transforming organizations, are going to improve health as well as healthcare, we and our community partners will need to appreciate the diverse perspectives in our communities, amalgamate them into an assessment, and address any gaps in care together. Otherwise, we will fall short of our ultimate goal of effectively serving the health and healthcare needs of those for whom we exist.

Renown Health also offers free genetic testing to those who want to better under- stand the impact of genetics on their health status. To date, more than 50,000 people have participated in the Healthy Nevada Project to determine their risks for illness and dis- ease so that they can modify their behaviors and mitigate the risks. This has also provided an important strategic road map for Renown Health to identify emerging threats to our community’s health and deploy program- ming to address those threats.

A Motivational Marathon I like to think of transformational change as a “motivational marathon.” This kind of change takes time and requires deliberate and directed energy, communication, and planning. All CEOs would agree that this type of change requires a team of people from the boardroom to the front lines of patient care. Maintaining enthusiasm while chang- ing the model and delivering the desired outcomes over a protracted period is hard work that calls for competent and dedicated leadership at all levels. The CEO is an impor- tant cheerleader with the responsibilities for keeping focus, seeing that ample processes and guardrails are in place, ensuring that no people are left behind in the planning, and

accomplishing key milestones and outcomes. One important way to manage all this is to see it through the eyes of the stakeholders we work for and then to course-correct along the way—especially when the going gets tough, because it does.

Physicians and Employees Carilion Clinic based its transformational change on a new model in which physicians and physician leaders coordinate their work to improve the delivery of care. As Agee writes, even with tremendous effort and communication from leaders, employees fre- quently misunderstand new models of care. Carilion Clinic overcame this challenge early on by deploying an electronic health record (EHR) system that provided a shared plat- form for all of its caregivers. In addition, leadership tapped the expertise of clinical advancement and patient safety personnel to drive the organization’s quality improve- ment efforts. The organization used the data in the EHR to provide decision support for care providers, identify emerging trends, and highlight quality outcomes. With the EHR in place, Carilion Clinic was able to participate in new payment models, thanks to leader- ship’s attention to the people who are respon- sible for delivering the care.

Virginia Mason’s transformational efforts have depended on the organization of people into multidisciplinary teams. Kaplan high- lights the importance of teams in meeting customers’ expectations. While he points out that those teams must be free to disrupt and take risks, he also stresses the importance of accountability, responsibility, transparency, and listening as teams go about their work. Listening, in particular, demonstrates re- spect and allows empowerment, which are two elements of a culture’s transformational change.

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Like Carilion Clinic and Virginia Mason, Renown Health regards people as its most valuable asset. All team members at Renown Health come to work each day to make it a better place for our caregivers and our patients. Leadership strives to provide employees and physicians with the tools and technologies that allow them to be their best selves and better team members. All cultures have certain norms, and Renown Health is no different in that regard.

Centering our organization on our val- ues, listening, creating a space for shared decision-making, and providing guidance while allowing people to do their best work are standards that our leaders aspire to each day. When the day is over, the wins are shared wins and are manifest as improvements in the community’s health. If we fall short, we then seize the opportunity to understand our individual and shared responsibilities to improve, and we are accountable for getting it done. The people, cultures, and work that make healthcare different from most indus- tries are the reasons why all of us as health- care leaders are called to our careers despite all of the change that is occurring.

Conclusion The feature articles by Agee and Kaplan pro- vide useful case studies of transformational

change, and I appreciate the authors’ trans- parency in sharing their organizations’ sto- ries. For me, a number of lessons learned will help to inform our work at Renown Health as we continue to advance our work for those we serve. I am hopeful that the themes iden- tified in this commentary will also inspire my peers to consider these concepts and discuss them with their own leadership teams. By no means are these cases comprehensive reviews or step-by-step guides to executing broad- scale change. Organizations contemplating transformative change must start with thor- ough and credible assessments of their own particular environments and then develop an appropriate process for execution.

References Anderson, D., and L. A. Anderson. 2019. “What Is

Transformation, and Why Is It So Hard to Manage?” Change Leader’s Network. Accessed November 3. http://changeleadersnetwork.com/free-resources/ what-is-transformation-and-why-is-it-so-hard-to- manage.

Bohmer, R. M. J., and E. Ferlins. 2008. “Virginia Mason Medical Center.” Harvard Business School Case 606-044. Revised October. www.hbs.edu/faculty/ Pages/item.aspx?num=32725.

Washoe County Health District and Renown Health. 2018. “2018–2020 Washoe County Community Health Needs Assessment: Executive Summary.” Published January. www.washoecounty.us/health/ files/data-publications-reports/2018-2020%20 CHNA%20Executive%20Summary_FINAL.pdf.

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