Near Death Experience to National Model for Vision – The Geisinger Evolution
When Dr. Glenn Steele Jr. moved from Chicago to rural Danville, PA to assume the helm of Geisinger Health System, the organization was in a state of flux. A failed merger had resulted in an exodus of leadership, an entrenched case of change fatigue, low morale and serious concern about the system’s future.
But Steele understood that the health system, with its 100-year legacy of quality and innovation, was well positioned to create new models of care that would directly benefit the residents of Central and Northeastern Pennsylvania and beyond.
Steele seized the opportunity. He disseminated his vision for quality and value, and, in partnership with Geisinger’s Board of Directors, leadership team, physicians and other employees, successfully positioned the system as an invaluable regional resource and one of the country’s most renowned integrated health services organizations.
Here’s his take on executing vision. (Quotes have been lightly edited for clarity.)
Talk about your vision for Geisinger when you arrived.
The best time to articulate and then institute a new vision for an organization is when there is a burning platform. We often referred to Geisinger’s platform as the “divorce” – our merger and then de-merger with Penn State Hershey. I’ve found that organizations that are in a steady state become overconfident and entrenched in the past. After the dysfunctional merger there was a vacuum, an opportunity to capitalize on Geisinger’s operating model (hospitals, clinic and health plan), stable demography, and its long experience with its EHR.
Aside from the post-merger problems, what unique characteristics made Geisinger amenable to the vision you crafted?
The Geisinger model was unique in that it’s both an insurance company and a clinical enterprise. I had this hope or fantasy or supposition that we could take that structure, combine it with our culture and credibility in the market, and create a fundamentally different relationship between the insurance company and provider.
This was the perfect time, the perfect place and perfect cultural/functional demographic and market-based environment to do something radically different. It was an opportunity to change the relationship between payer and provider so that both were using innovation to restructure roles and responsibilities and redesign workflow to provide quality care, improve value, and reduce costs in everything we did. Our approach was to not only push down the price per unit but to also get rid of unnecessary units of care or hurtful units of care. We began to figure out ways to pay for success and get good operational results, which resonated on a national scale.
The other reason for Geisinger’s success is it’s the right-sized organization to do transformational work. It wasn’t so small that it could be ignored. But it wasn’t so big to that it could be infinitely complex.
What about your personal characteristics?
I’m a risk taker. I wouldn’t have moved from Boston to Chicago, and then to rural Pennsylvania without being a risk taker. I’m also more of an entrepreneurial type than usually comes out of academic settings.
I know more about the details of running an operation than most people would have guessed, but I can delegate a lot of the details to the people who actually lead the troops in the various caregiving and insurance areas. So it was top-down as well as a bottom-up. I enjoy human beings, I enjoy interacting with them.
How did you translate your vision into a practical approach to improvement and get buy-in for that process?
We did small experiments. If something worked, great; if not, we moved on. I think we had luck or intentionally good design when we started with services like heart surgery and interventional cardiology. We already had great financial and quality outcomes in those areas, but when we worked with physicians to redesign the care it got even better. Costs were lower and outcomes were better. Once we had some “proof of principles,” the team got increasingly excited. And then we attracted some incredible national publicity that really created momentum. People wanted to be a part of the vision.
You implemented some radical changes. How did you deal with the potential of failure?
Remember that I am a risk-taker so I was willing to try new models, but we tried to be smart about risk. We’d did lots of small experiments, many of which were in areas in which we were already experts.
We also limited our risk by leveraging our structure, culture and demography whenever we were attempting to transform how we financed or provided care. We communicated widely and often, sharing successes, and being open when something didn’t work.
And we’d move on when necessary – no one was punished for trying something new if it didn’t work. We looked at the upside and the downside, and we said, “let’s protect against the downside. Let’s figure out the metrics for intermediate outcomes.” If it looked as if those metrics were moving in the wrong direction, we would stop the experiment. In doing those experiments, we always assumed that 20 to 25 percent of the projects that I was pushing would not work.
We were able to hedge our transformational bets: While we were doing the transformational work with the 50 percent of care given by our own providers and paid for by our own payer, another 50 percent was still paid for by other insurance companies. Even if everything had gone negative on the transformational work that we were doing, we still were building up our ability to increase market share with other payers.
What did you say to the Geisinger staff to bring them into the execution of your new vision?
I knew we had to change the social contracts at Geisinger when I first got there. The morale was terrible. It still had a great culture and pedigree and reasonable financial resources, but it was pretty beaten up after the three-year merger that didn’t work with Penn State Hershey. I knew we were going to have to recruit. I knew we were going to create some “pizazz.”
I can remember standing in front of large gatherings of our clinical and insurance citizenry and basically saying, “We’re going to change the social contract here.” I told them that when we all agreed on our goals and vision, they’d be expected to work harder than ever. I also told them that they’d be prouder about what we were doing here than anything they’ve ever been before. That’s the social contract, I told them, and they were welcome to join us. But if they weren’t willing to get on board, they should not be part of Geisinger. That was a big risk because in those early conversations, I didn’t know we were going to be able to recruit. Thank goodness it worked out … and as the momentum built, we were able to recruit some of the best and brightest clinicians, scientists, and business leaders in the country.
How did you disseminate the vision across the hospitals, outpatient offices and health plan? Explain your approach.
I gathered input and then disseminated our messages and vision by spending countless hours in townhalls and one-on-one meetings across the footprint. Of course, I provided a roadmap and context for the conversations, but I gave our leaders and providers a lot of latitude as to how they could apply our strategic goals to their business units.
I was very respectful of their expertise and we solicited bottom-up, vigorous input. I gave the caregivers as much leeway as possible, so they felt engaged and had ownership of their individual projects. It was top-down and bottom-up.
Talk about your relationship with the board and their role in the change you oversaw. Often with not-for-profit healthcare organization boards you get a lot of community leaders who may not have a deep understanding of healthcare.
You’re right, but from the very start we had some really dynamic, thoughtful community board members. We had ongoing conversations about why we were always talking about creating a national reputation. At the same time, we kept our commitment to the region front and center. Some board members didn’t understand the balance, but others were enthusiastic and aligned.
A few members decided to leave the board, but we were able to bring in some visionary national experts with either insurance or provider backgrounds. Really bright individuals with a deep understanding of healthcare. Changing the board composition could not have occurred without my chairman really standing behind me and getting it done. It wasn’t a revolution where people were removed. We had people who left the board intentionally because they were nervous about the new social contract.
Any final tips for getting everyone involved in a new vision?
You have to be a storyteller. It is absolutely critical. That’s even the case when I was a researcher and an academic clinician. You can’t get grants or donations without being able to tell a good story. Your narration has to be credible to the people you are leading. So, it’s not just recounting facts, it’s including ideas that people can relate to.