Either the federal government or state governments must create health planning functions to oversee the system. Why do we have so few dermatologists with many of them focusing on cosmetics when many citizens cannot get in to have a skin lesion checked? Again, why do we have so many operating rooms per capita and so little access to mental healthcare? Surely, public health experts could plan for better assignment of resources to create a better system for all our people.
As a part of my interview series with leaders in healthcare, I had the pleasure to interview John B. Chessare, MD, MPH. Dr. Chessare is the President and CEO of GBMC HealthCare, in Baltimore, Maryland. Dr. Chessare has been actively involved in designing and managing systems of care in academic medical centers and in community hospitals. A pediatrician, he is a graduate of Boston College, the University of Rome School of Medicine, and the University of Michigan School of Public Health. Dr. Chessare is recognized nationally for his work in utilizing operations management to improve patient flow and to drive out waste in the acute care hospital, as well as for designing safer and more reliable medication delivery systems. His present work is in transforming his organization to be better able to deliver higher value by creating better health, better care, and lower cost with more joy for those providing the care. In September of 2016, the GBMC HealthCare System won the inaugural Patient Safety Award from the American Society for Healthcare Risk Management for its use of Lean Daily Management to drive high reliability.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
As a senior in high school, I decided that becoming a physician would be a great way to spend my life helping others. Later, while studying for my master’s degree in public health, I realized that I could do more to help others by getting involved in leadership to redesign the healthcare system.
Can you share the most interesting story that happened to you since you began leading your company?
The State of Maryland signed a new contract with the Centers for Medicare and Medicaid Innovation to create a more value-driven healthcare system. This contract incentivizes Maryland hospital leaders to redesign care towards the national triple aim of better health and better care at a lower cost. The hospital is now paid a global budget and we can spend the money doing what patients need rather than being driven to sell services that generate profit whether they add to health or not. We can now be focused on driving out waste. Navigating this complex shift challenged us, but I believe we’re now better able to provide the care that our patients need.
Can you tell our readers a bit about why you are an authority in the healthcare field?
I have studied the U.S. healthcare delivery system and that of other countries for four decades. I have practiced medicine and been in leadership positions in both academic medical centers and community hospitals. I have had the good fortune of learning from the likes of Avedis Donabedian, often called the father of quality improvement in healthcare, and Donald Berwick, the preeminent health care thinker of our time. Over the past nine years, I have overseen the design of a community based system of care that is capable of managing the health of a population.
What makes your company stand out? Can you share a story?
Our company is driven by its vision to be the community-based healthcare system that the patient experiences as a “system” and to deliver the care that we would want for our own loved ones to every patient, every time. Our core competency is redesigning care. We are based in Towson, Maryland but have expanded into the city of Baltimore to open a patient-centered medical home at the Helping Up Mission, a residential home serving 500 substance-addicted men. This facility is a stone’s throw from several larger hospitals, but we were asked to serve because of our ability to deliver evidence-based, high value, primary care.
Can you share with our readers about the innovations that you are bringing to and/or see in the healthcare industry? How do you envision that this might disrupt the status quo? Which “pain point” is this trying to address?
The U.S. spends 40% more per capita on healthcare than any other country in the world and leaves approximately 25 million of its citizens uninsured. Our outcomes in acute illness are good but our performance in most chronic diseases is well below average. We have the best trained physicians, nurses, and other clinicians in the world and they work incredibly hard, but our system is poorly designed, and the incentives are misaligned. Our biggest problems are the lack of coordination in the management of chronic disease and the huge waste in care at the end of life. GBMC is bringing the notion of accountability to healthcare through our use of advanced primary care. The status quo has too much invested in hospitals and operating suites because this is where the profit has been historically. We are driving value by working to keep people out of the hospital rather than making money on their stay.
What are your “5 Things I Wish Someone Told Me Before I Started” and why.
1. Start with the Vision
Doctors and nurses go into healthcare because they see it as a great way to spend their lives helping people. Healthcare leaders often miss an opportunity to connect with them and get the clinicians on board with change initiatives because they don’t paint a picture of the future that builds on this innate desire to help people. We have gotten significant traction at GBMC because we start every conversation with our vision phrase: To every patient, every time, we will provide the care that we would want for our own loved ones.
2. Enrollment is critical
I used to think that if I could give a passionate presentation then everyone would fall in line. I now know that the act of enrollment is critical. It requires that every team member be given an opportunity to ask questions about the change. Then, the leader must ask each person to commit to the change. We frequently skip over this act of enrollment and are then surprised that our change initiatives fail.
3. Data are necessary, but they don’t move people to action.
I have often been told that clinicians, especially physicians, need the data to change. This is true, but insufficient. What moves people to action are stories that get to their heart. Clinicians are more likely to see the need for system redesign when they hear that someone did not get what they needed. Pure statistics are less likely to overcome inertia.
4. If you are trying to generate meaningful change, start each meeting with an effective question.
When someone starts a conversation about something that isn’t working, most humans will “pile on” with their own stories related to the broken system. A much better way to start a meeting to generate change is to start it with a question that starts with “how” or “what.” I specifically remember a time when I was Chief Medical Officer at a large academic medical center. I started a meeting with the intention of fixing the problem of incomplete medical records by laying out the issue and some theories about its causes. I had a difficult time refocusing the group after each physician present wanted to tell me how big the problem was and why it was due to someone else’s failings. I now know that I would have been better off framing the meeting with the question “What can we do to reduce the number of incomplete medical records?” Framing the meeting and approaching the problem in this way removes the opportunity for people to spend all their time discussing the problem rather than working on creating solutions.
5. Be unconditionally positive.
Passionate people can get upset easily, but negativity serves no useful purpose. Demonstrations of cynicism slow down meaningful change. When the leader stays positive, people are more likely to want to work with him or her and to generate good ideas and work to implement them.
Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
The U.S. healthcare system is not a “system.” It is not designed to meet the goals of the best health outcomes with the best care experience at the lowest cost. There is no planning function in the U.S., so the pieces of the system do not fit together well. We have not had the discussion in the U.S. about whether healthcare is a right or a privilege. If we were to decide as a country that healthcare was a right, then we would realize that the only way to provide this without spending all of our resources on care was to design an efficient system. There is no country with a perfect healthcare system but there are many countries that provide outcomes as good or better than the U.S. for much lower cost. Germany for example spends 12% of the GDP on healthcare (the U.S. spends 18%), every citizen has insurance, and their outcomes are as good as or better than ours. In the U.S., many people believe that the market will somehow provide what our people need in an efficient way. There is no evidence that this is true. The market is providing a lot of access to what makes significant profit (e.g. surgery, imaging tests) and almost no access to what doesn’t, especially for those with no or poor insurance (e.g. mental health care, primary care, coordinated management of chronic disease).
You are a “healthcare insider”. Can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
1. The first change has started as part of the Affordable Care Act and that is to move away from fee-for-service and to move towards payment for value. We are providing too many services that are not improving health or the healthcare experience. Payers are moving in this direction, but it must move faster.
2. Healthcare organizations, especially the not-for-profits, must focus on their mission, which is generally to improve the health of individuals in their community, and stop acting as if the bottom line is the primary goal. The bottom line is important, but only as a means to an end. Why are we building more operating rooms, which there are too many of already, instead of mental health facilities? The need for mental healthcare far exceeds our current capacity, but this isn’t what we focus on. Healthcare organizations must stop getting bigger without asking if they are getting better. Hospital mergers are not making care less costly, rather mergers generate higher costs.
3. Healthcare leaders must be better trained in design and improvement and they must use these skills. The healthcare experience for most patients is full of non-value-added steps because the systems in place are poorly designed or not designed at all. We must stop using the emergency department as the pathway of least resistance for anything that does not fit elsewhere.
4. Either the federal government or state governments must create health planning functions to oversee the system. Why do we have so few dermatologists with many of them focusing on cosmetics when many citizens cannot get in to have a skin lesion checked? Again, why do we have so many operating rooms per capita and so little access to mental healthcare? Surely, public health experts could plan for better assignment of resources to create a better system for all our people.
5. Dare I say it; the U.S. should study the single-payer system. Healthcare providers don’t care where the check comes from as long as it comes, and patients don’t care who writes the check, if the bill gets paid. Canada spends at least 20% less on administrative costs in their system and their government does not deliver any care. Because of its scale, Medicare spends 94 cents of every dollar on care. Private insurers must spend 85 cents of every dollar on care by legislative mandate.
Thank you! It’s great to suggest changes, but what specific steps would need to be taken to implement your ideas? What can individuals, corporations, communities and leaders do to help?
We need better informed citizens to advocate for a better system. We should start by educating business leaders, whose organizations are currently paying for a lot of care, so that they might demand better systems. Community leaders can help by serving as the conveners to bring providers together to create better local systems.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
My favorite resource is the Institute for Healthcare Improvement and their website: www.ihi.org. Created over 25 years ago, the IHI is the world’s foremost source for healthcare improvement ideas.
How can our readers follow you on social media?
My blog is A Healthy Dialogue and can be found here.