“Chief experience officers first popped up in healthcare roughly 10 years ago. The role has only increased in strategic importance for healthcare organizations since implementation of the Affordable Care Act, which tied patient satisfaction scores to reimbursement.” Modern Healthcare, May 12, 2018

“As healthcare becomes more focused on improving the patient experience, the need for having someone in charge of that experience appears to be shrinking.” Modern Healthcare, July 29, 2019

What a difference a year makes. The Chief Experience Officer position which was thought of as being crucial to healthcare organizations is now being subjected to critical scrutiny—and about time. The CEO2, as I liked to refer to the position, had a different job description from organization to organization.

I always thought saddling one person with the responsibility for “patient experience” was a way for other managers to escape accountability for results. It is an artificial contrivance but it sure marked your organization as being cool. Unfortunately, healthcare is so prone to falling heads over heels in love with the latest trends that we forget to be critical in assessing new positions and titles and what they signify to others in the organization.

There are now so many positions which carry the adjective “Chief” that a poor Chief Executive Officer gets lost in the shuffle. There’s a Chief for this and a Chief for that. Many of these positions used to carry mundane titles like “Vice President”. Some of them even served a useful purpose.

Modern Healthcare has a chart with 25 different “Chief” positions. Nowhere on the chart is the title “Chief Executive Officer”. If I was still working and not on the beach where things are clearer, I would probably be devastated.

I therefore propose a new title for the CEO: “Chief Chief” or “CC” for short. If the CC is particularly obtuse, he or she could use “BCC” as an abbreviation. Or if you don’t like that, how about “Chief of Chiefs”?

I once proposed that my title should be “King” but soon discovered that no one wanted to be a prince or princess. I also discovered that not everyone appreciated my sense of humor.

The first CEO I worked for once told me in his down home, funny Texas way that all his senior managers were mice trying to become rats. I knew many people at that hospital who agreed with him, especially on the medical staff.

The Chief Experience Officer may be going the way of the dodo bird but take heart, there are new titles gaining life. It is apparently no longer de rigueur to be the Chief Medical Officer. Now the title should be Chief Physician Officer. New chiefs are being born everyday. Use your imagination.

So it is goodbye to the good old CEO2 (born 2009, died 2019). From the point of view of staff, one less Chief is good. Getting the job done is far more important than a title.

The Fox And The Hen House

John Muir Healthcare in Walnut Creek, California, is an organization I have always admired. Blessed with great demographics in terms of the economic status of its community, they have progressed impressively when it comes to clinical services. It always helps in that regard to have great finances.

So I found it curious last week when John Muir made headlines in healthcare as it announced that it would be outsourcing non-clinical IT (why you separate that from clinical IT is puzzling), analytics, revenue cycle management, purchasing and claim management. The press release also said that ambulatory care coordination and utilization management for its physician network would be outsourced.

These activities will be assumed by Optum, a subsidiary of United Healthcare. Five hundred and forty  John Muir employees will  be offered positions with Optum. I am always suspicious of an organization  controlled by a health plan although Optum has claimed in the past that they build a wall between their activities on behalf of customers and their parent. Nevertheless, there is an element of the fox guarding the hen house.

I never had a satisfactory experience during my career in outsourcing integral services to outside firms. My experience was primarily with clinical services with a few non-clinical services as well. Promises that were made were not kept. Eventually, there was an unwinding process which was painful. In light of this, John Muir’s decision is breathtaking.

I wonder what the level of commitment will be by the outsourced staff as time goes by. Working within an organization is different than working outside the organization. If things go wrong, who will suffer the most, the organization which did the outsourcing or the organization assuming these activities as part of a contract? The more such contracts the outside organization has with other health care organizations, the less important the individual health care organization becomes. Optum clearly sees this is as a source of growth and profits.  There’s that fox again.

The services being outsourced are not as glamorous as clinical services but in their way very important to survival of the organization. If revenue cycle management (a fancy way of saying billing and collection) is not properly done, the very financial foundation of an organization is weakened. The same goes for the other functions. Restoring these functions internally would be a mammoth effort with extraordinary risks and expense should outsourcing fail.

I  expect that there are performance standards built into the agreement with Optum.  Again, though, which organization suffers the most if those standards are not met?  Call me old fashion (I have been called much worse) but this type of outsourcing which is on the verge of becoming trendy in healthcare does not seem worth whatever savings may result.

This is either a courageous, well thought out move by John Muir or a foolhardy action born of some unknown problem. Either way, John Muir will have many eyes on it as this outsourcing  progresses.

My advice:  keep your eyes on the fox.

Please Don’t Tell NorthBay

We learned late last week that one of my twin 15 month old grandsons will require surgery this week to correct a semi-urgent problem. It would be considered “minor” surgery for an older child but a bit risky for a child his age. The surgery is scheduled for early this week.

“Minor” surgery is what happens to someone else’s grandchild. It is my grandson and therefore it is major surgery. When you add the modifier “semi-urgent”, that is enough to make grandpa and grandma concerned. We have been preoccupied the past weekend as a result. I was not intending to write a blog entry given all the angst.

In the midst of all this, I was researching whether the name “Passama” might have a meaning in the Catalan language which is spoken along the Spanish/French border. That is a long story in itself. This is what happens when you are on the beach.

Doing this Google search on my name somehow led me to a link that allowed me to access the 600 plus blog entries I wrote for NorthBay Healthcare from 2010-2017. Eureka! I have been trying to find a backdoor to that treasure trove.

I made many predictions in those blog entries, some of which I would just as soon forget. I did find one entry where I talked about the 2016 candidates and their stances on healthcare in general and the Affordable Care Act in particular.

I found that entry interesting. I have not asked NorthBay for permission to reprint it here so don’t tell them I have done so. They may close that backdoor! Most of my career was based on seeking forgiveness when I forgot to get permission. My retirement is going the same way except now I am seeking forgiveness from my wife instead of the board.

I hope you find my thoughts in April 2016 of interest and relevant to today.

Memo to Presidential Candidates

April 07, 2016


The 2016 presidential sweepstakes is remarkable for the continuing absence of any real discussion of health care issues. That’s too bad because there are some serious health policy matters that cannot be ignored during a year of national debate.

When it comes to the Affordable Care Act (aka “Obamacare”), the positions of the two parties are remarkably simplistic.  That says a lot about the character of the candidates.

The Democrats love Obamacare and defend it at every turn. Memo to Democrats:  the Affordable Care Act is a deeply flawed piece of legislation which front loaded the goodies and left the payment for the goodies to occur after the 2016 elections.  

With deep Medicare cuts (a way to fund the Affordable Care Act) beginning in 2017, we will see elders have less access to a physician or care. You can also expect to see steeply rising premiums for Affordable Care Act health plans offered to people who have no insurance. Already that is happening outside of California and it will happen here with Covered California – just a little later.

Republicans hate Obamacare and want to destroy it.  Memo to the Republicans:  You are right that the Affordable Care Act is a mess but simply torpedoing it without a realistic alternative is not a responsible way to act. The reality is that too many people who did not have health insurance now have it and destroying Obamacare results in more uninsured patients not getting the care they need except in already overburdened hospital emergency services. The “hidden tax” of cost shifting will again rear its head, which benefits no one.

There needs to be discussion about changing the Affordable Care Act in meaningful ways. It needs a more secure financial base. We must recognize that “mandating” health plan coverage is viewed by many as overstepping the role of government.  Let’s at least begin the debate.

There is one other issue which has been disgracefully ignored for years at every level of government. It is what we used to call mental health and now goes by the less-threatening term “behavioral health.”

You see the result in the streets. Poorly clothed and fed people talk to themselves or make public nuisances of themselves. Many of the homeless are people with behavioral health issues.

There was a time in the 1960s and 1970s when the federal government had a much more robust role. It formed community mental health centers and funded training for psychiatric and psychological professionals. Those times are long gone.

We see the consequences every day in our two emergency services. It is not unusual for NorthBay’s two hospitals to have four to six patients with behavioral health problems taking up space in our emergency services and taking up acute-care beds while we scramble to find a more appropriate place for them to receive treatment.

They have no medical reason to be in our hospitals. They need care and treatment, but not the kind we provide.

This issue is growing across the nation, a silent epidemic stemming from public policy neglect. Yet not a word about it is being uttered by any candidate of either party.

Memo to all Presidential candidates:  Get real about health care issues.

Beware The Hopper

I apparently did everything wrong as I pursued a career in healthcare. That is the conclusion I must come to after reading–actually listening to—an excellent new book with the intriguing title of “When-The Scientific Secrets of Perfect Timing” by Daniel H. Pink.

According to the book which asserts that timing plays a big part in outcomes, research shows that ambitious people should change their employer every three to five years to maximize their chances for success, however that may be defined. Given that criteria, I failed as I had only two employers in a career of forty-five years–one for 10 years and one for thirty-five years. I feel totally inadequate.

I took this failure one step further. I was always suspicious of candidates for positions on my senior management team who did job hop frequently. If they did it to someone else, they would do it to me.

The few times I did hire someone with such a job history, sure as heck, they left after less than five years. In their minds that must have been good for their careers but it was not good for the organization as far as my retro mind was concerned.

Most of my senior managers hung around for at least ten years. I knew it was important that they have challenges which went beyond their job descriptions to keep them engaged and growing. So strategic planning was a group effort of all senior managers who each had their unique insights to bring to the process. We always used different planning processes to keep all of us interested, including me. Staying and growing in place does not necessarily mean stagnation.

We also later in my tenure developed with the help of outside consultants and inside experts a robust career development and succession planning process for all managers, including senior managers. Just developing that process as well as the ongoing management of it was of particular interest to some of the senior managers.

I also tried to convince senior managers when the opportunity arose to take on new responsibilities which did not necessarily fit within their comfort zones. The kind of senior managers I had for the most part readily accepted that challenge.

Sometimes, though, it was clear that for a senior manager to progress in their career they did need exposure to a different organization. One such senior manager was in a highly specialized job area and he came to me one day after ten years of tenure to tell me he was leaving to become CEO of a small healthcare support business completely out of his area of comfort. He felt he needed to break his mold.

We kept in contact as he spent seven years in that CEO position and then moved back into a hospital as a VP over a variety of services. After three years in that position, a great opportunity became available on my senior management team so I asked him if he would like to come home which he did. He was happy as a VP in that other organization but the lure of coming back was too strong. In his case, this was not job hopping but a thoughtful career development plan.

I believe that it takes more than three to five years to beome effective in a senior management position and that organizations and managers suffer when job hopping occurs. As the book’s title indicates, “When” is important but how long is equally significant.

One final comment about “When”. Late in the book, the author speaks to the power of endings. He offered several examples of endings done right. One was a restaurant which whenever someone spent a certain amount of money gave that customer a card listing three charities. The customer was asked to pick one of the charities so that the restaurant could makes a donation in his name as a mark of appreciation for his patronage.

If you are going to be a job hopper every three to five years, it may be a good idea to keep your endings in mind. Perhaps, a personal note to each of your colleagues thanking them for helping you or a Starbuck’s gift card—anything that indicates your appreciation. Completing that circle is important, particularly for job hoppers.

Baseball, Healthcare and Scads

Last week I was at a retirement ceremony for yet another of the senior managers I worked with before I hit the beach. This person wore many hats and was superb. She was particularly good at strategic planning and the anticipation of trends to help guide the future of NorthBay Healthcare. As far as I am concerned, she was the epitome of out-of-the-box thinking. After thirty-two years of such guidance at NorthBay, she left the organization with grace and great appreciation from those of us who had worked with her.

At the retirement ceremony I discussed with her top assistant in planning, also a long-time staff member, the tremendous amount of data which is now available courtesy of the deservedly maligned electronic health records providers now use. These creations have made the medical record the focus of patient care rather than the patient herself. Work flows have had to bend to accommodate the needs of the record monster.

One huge problem—while the electronic health record is capable of collecting scads (“scads” is a highly technical term meaning “a lot”) of data, it is not very good at regurgitating the information in a useful fashion. That, in turn, has led to the creation of a legion of consultants who for a handsome fee will try to make sense of the information flood. Think of the electronic health record as a shark circling the patient and the data gurus as the pilot fish feeding off the parasites on the shark. Everyone benefits except those whom the sharks are feeding on–the patient, the hospital and the doctor.

I know that seems a harsh judgment, but it was the reality I saw and which was reconfirmed this week when I spoke to the planning assistant. The billions of dollars which providers were incentivized to spend for electronic health records have resulted in much information with no place to go. The electronic health record vendors have gotten rich by selling a product which is a dead end.

It may be that we are asking and expecting too much of the electronic health record at least in its current form. More information can be overwhelming and that could in itself lead to errors.

Baseball teams now use analytics to develop game plans and govern decision making during the course of a game. Some of these baseball geeks can even be found in the dugout during games dodging tobacco spittle from the grizzled manager. However, the data points they use are relatively small in number and are based upon using past tendencies to project future outcomes. Even then, when you get down to the real nitty-gritty (another highly technical term), the team with the best players wins. What comes first, good data or good players and what is more important?

As I pondered this in a disorganized fashion at the retirement ceremony, I thought back to the many decisions this planning vice president and I made over the years and how often we made good decisions with only a little data available to us. Her creativity was just as important as data and led us to do things which the data either was silent on or indicated we should not do. Maybe we had bad data or perhaps intuition and vision still have a role to play in guiding an organization’s future. That vision thing can be very useful.

Like in baseball, data can be useful. Also like in baseball, the healthcare system with the best players wins most often in spite of what the data indicates. That senior manager who retired last week proved that.

What A Deal!

There are weeks when I spend most of my time on the beach (my way of saying being retired) being a grandfather. The past week was one such week.

Instead of thinking deep thoughts about our purportedly wayward healthcare situation and putting the resultant thoughts into writing, I spent more time than usual with my grandchildren.  In many ways, that time spent is more satisfying than the years I spent as a healthcare system CEO.

Still, a few things caught my eye that are worthy of comment.  Kaiser Permanente, whose top management specializes in virtue seeking while spending other people’s money, received criticism this week for sponsoring “Thrive City” at the new home of the Golden State Warriors opening this September in San Francisco. I commented about this two weeks ago in “How Not To Spend Money”.  Normally, when Kaiser does these kinds of things, they escape criticism.  Not this time. About time someone in journalism woke up.

On Sunday the San Francisco Chronicle ran an article based upon some research they did on the amount of money Kaiser was committing to this virtuous project.  Kaiser had been steadfastly ignoring requests for the dollar amount.  According to the Chronicle, it may amount to as much as $295 million over a twenty-year period.  That’s a lot of virtue devoted to a fabulously rich basketball team by a nonprofit health plan. I want some.  Any.

Earlier this year, Kaiser committed to another virtuous project to the tune of $200 million to help with the homeless problem in areas where they have facilities.  The homeless problem is real but is this commitment of resources what the purchasers of Kaiser health insurance want to pay for?  I doubt it.

Keeping on the Kaiser theme, the June 17 issue of “Modern Healthcare” contained a brief item regarding Kaiser’s displeasure with a healthcare system in Honolulu which was planning to bill directly Kaiser patients who used its emergency service now that its contract with Kaiser has expired. The nerve!

The thrivers at Kaiser were upset because, well, just because. Kaiser wants to pay the healthcare system what Kaiser considers an “usual and customary rate” for its members and does not want its members directly billed.  Put another way, Kaiser wants to determine what it should pay when another healthcare system helps it thrive.  Kind of like going into a grocery store and telling them what price you will pay for a loaf of bread.

Sound familiar?  I wrote about a similar situation in California in “Chumps” in February.  I related how NorthBay Healthcare had won a legal judgement against Blue Shield in a similar situation and how NorthBay and other providers in California were proceeding in similar fashion against Kaiser.  Everyone deserves to thrive.

So, let’s sum up the situation. So far this year Kaiser has committed almost half a billion dollars for virtuous actions unrelated to the direct provision of healthcare, sticking that bill to the public and private employers who buy health insurance from them.  At the same time, they expect other providers to subsidize these wonderful endeavors by gratefully accepting what Kaiser wishes to pay for services provided to their members.

What a deal!  This is why being a grandfather makes more sense sometimes than being in healthcare.

P.S.:  The thrivers also announced last week plans to build a new $900 million headquarters in Oakland.  It’s good to be the king or at least a virtuous thriver. That makes almost $1.5 billion dollars in non-healthcare  spending so far this year.  Hope those paying health insurance premiums take note.

What Gives?

“Get your facts first, then you can distort them as you please.”

Mark Twain

I was listening to a travel podcast recently about President Trump’s decision to immediately stop visits to Cuba by Americans. The podcast hosts were very upset and one said that the immediate impact would be on 800,000 passengers who had booked a cruise which included Cuba as part of the itinerary. That caught my notice.

I am not interested in the politics of the decision. I am interested in the cavalier use of statistics to make a point. There is no way that 800,000 cruise ship passengers will be affected by this decision. Given the number of ships calling on Cuba this year and their size, that is a dubious number.

We see this same careless use of statistics in healthcare where the stakes for being wrong far outweighs that of a disappointed passenger. Careless use of statistics means resources may be wrongly deployed to everyone’s detriment.

For instance, take the Institute of Medicine’s 1999 report, “To Err Is Human”. The report was a shocker with its estimate that between 44,000 and 98,000 people a year died in hospitals as the result of medical errors. Even one such death is one too many.

That report resulted in a great deal of concern as it should have. Hospitals and medical professionals made changes in care including things as simple as being more diligent about hand washing between caring for patients. That effort continued as incentives both positive and negative were created by the government and others. No one I knew in healthcare was happy about the idea of patients needlessly suffering or dying.

Fast forward now fourteen years to 2013 when the Journal of Patient Safety published an article estimating that there were between 210,000 and 440,000 hospital deaths due to medical errors. All the efforts to decrease the number of preventable deaths noted by the Institute of Medicine in 1999 seemed to have had no impact at all. It was discouraging. There was a question which should have been asked: What gives?

Two years later in 2015 the Leap Frog organization, which attempts to give hospitals letter grades for quality using a problematic methodology, estimated that there were 205,000 preventable deaths in hospitals. That was followed three years later by another estimate by Leap Frog of 160,000 preventable deaths. Again, I have to ask the question, what gives?

The common thread to all these statistics is this word: “estimate”. That is a word which needs clarification by the people issuing these reports. The words “estimate” and “estimated” could simply be another way of saying we don’t know.

Estimates are not facts; they are guesses. In baseball, no one says that Buster Posey’s batting average is estimated as being .294. Should we not expect a more rigorous committment to facts and statistics in healthcare when dealing with important matters?

When you have a range from 44,000 to 440,000 deaths, you have a lack of preciseness which is troubling. Furthermore, when the estimates increase significantly after a decade of process improvements directed at reducing such deaths, you have to wonder whether the report issuers have their own error problems. Or maybe they are just lousy estimators.

I certainly knew during my career as a healthcare system CEO and a board member of a risk retention company providing professional liability insurance of medical errors which led to needless suffering and/or deaths. There is no defense for any such occurrence and every and all effort should be made to eliminate the errors. There were too many such errors.

We have a problem but we do not know exactly how big a problem it is. We need more than just estimates if we are going to be able to measure how effective we are in reducing preventable deaths to zero. Of equal concern is we don’t know how many faulty “estimates” are being used in other areas of healthcare to drive decision making in important areas. Perhaps there is a need for a report on “To Estimate Is Human”.