Joey Wahler (Host): It's a challenge in this era of healthcare disruption, so we're discussing leading like an entrepreneur. Our guest is Dr. Boykin Robinson. He's Chief Executive Officer of Core Clinical Partners and an ACHE fellow. Core Clinical Partners is one of ACHE's premier corporate partners. Our premier corporate partners supporting ACHE's vision and mission to advance healthcare leadership excellence. For more information on Core Clinical Partners, please visit the corporate partners page at ache.org.

This is The Healthcare Executive Podcast from the American College of Healthcare Executives. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Robinson. You've been a previous guest here, so welcome back.

Boykin Robinson, MD, MBA, FACHE: Thanks. Great to be here.

Host: Great to have you aboard. Appreciate the time. So starting with the big picture here, healthcare leaders, as you know, are dealing with things like financial pressure, workforce challenges, changing expectations, and constant disruption. So that being said, what feels different to you about leadership in healthcare today, and why do you think some of the traditional leadership approaches just aren't sufficient anymore?

Boykin Robinson, MD, MBA, FACHE: Yeah, I think that healthcare leaders are now confronting not just one disruption here and there. They're operating in a state of permanent disruption. It used to be that the problems that came up in healthcare were problems we had seen before. There was a playbook for them. And we were dealing sometimes with a couple at a time maybe, but we knew what to do with each one. We'd get through that, another problem would come up.

It feels like over the last several years, those problems have gotten new, so there's not a playbook. There's new problems we didn't have before. They've been more challenging to deal with, and they're there all the time. And it's some of the same ideas, right? Financial pressures, workforce shortages, new technology. But I think we'd all agree that all of those things are harder to deal with than they used to be. The financial pressures are worse, the workforce shortages are worse, and the new technology's great. But there's so much of it. It's really hard to figure out. What should we put in next? What should we do? What do we do about AI? It's created so many new questions that we don't have any answers for, we don't have experience with. And while all that's happening, expectations for patient quality and patient flow and everything we're doing, that there are rising expectations in the face of all of these problems.

So, I think traditionally we relied more on experience and applying proven solutions to familiar problems. But today, the problems aren't that familiar and they're changing quickly. So, it makes it even more challenging to deal with. And don't get me wrong, experience and operational discipline still matter, but the leaders today also need curiosity, adaptability. And a willingness to challenge yesterday's assumptions and challenge how we've been doing things.

Host: Now, this episode title is Leading Like an Entrepreneur. So, what does that mean to you? And what can healthcare leaders learn from an entrepreneurial mindset, even if they're leading within a larger complex health system?

Boykin Robinson, MD, MBA, FACHE: Yeah. I think when people think about entrepreneurs, they automatically think about Elon Musk or Steve Jobs or, in healthcare unfortunately, Elizabeth Holmes, people who have built companies from scratch. And that's great, and that's what an entrepreneur is. However, the entrepreneurial mindset, You don't have to start a company to have an entrepreneurial mindset. The mindset is really refusing to manage the status quo. It's willingness to take some risk, but not risk like quit your job and go start a new company. Just take some risks in challenging the status quo.

I think a lot of the entrepreneurial mindset comes back to first principle thinking, which is getting to the root of a problem. Instead of just listening to how people have solved some problem over time and we've always done it this way, it's let's get back to the root cause of this problem. Let's break it down to its most basic elements and let's rebuild it and rebuild a solution from those basic elements.

It's harder to do than it sounds like because you've got to ask why multiple times to get to the root cause of the problem. Once you get there and you can really start from a clean whiteboard, you can do some amazing things. And that's what entrepreneurs do, right? They start with nothing. They start with an idea, and they build it into a company. So when you're using an entrepreneurial mindset, again, you're starting with an idea, but this is the idea just to solve a problem within your complex organization. And it could be a small problem, large problem, but you got to get down to the basics.

So, the entrepreneurial mindset is thinking like an owner, staying close to those problems, not being up in the C-suite not understanding what those problems are, but thinking like an owner, being resourceful, asking, "What could we do differently?" So, I talked about entrepreneurs and risk. They do need to be willing to act before every detail is perfectly known, but they don't have to take risks. They just have to then pivot as they continue to learn more and more.

Host: And how do you know when it's time to push for something new versus staying the course?

Boykin Robinson, MD, MBA, FACHE: Yeah. You've got to think about what's actually broken and what needs to be fixed. You shouldn't innovate just to innovate, and you shouldn't be wowed by a new piece of technology or some new process that you heard worked somewhere else. You've got to make sure that solves a problem you have.

So, start by defining what is actually broken, what problem do we need to solve? And one of the ways that I think it's great to find a problem begging for this is if someone says, "Well, we've always done it this way." Because if we've always done it this way, it probably means we haven't iterated on it along the way.

And so, it may not be optimized. And so, that's often a good place to start, is something that doesn't work terribly well that people say, "Well, we've always done it that way." That probably is a great place to say, "Well, why?" And then, why and why, and ask several why's till you get to the root of the problem.

Not everything needs to be innovated, not everything needs to be reinvented, and you can only change so many things at once. So, you do need to pick and choose carefully what you're going to innovate on.

Host: Of course, part of all that in being entrepreneurial is being willing to take risks, as you've acknowledged here. So, how do you think about calculated risk as a leader here? Is there a process you use in order to decide when an opportunity is worth pursuing, even when you don't have every answer right now, as you talked about earlier?

Boykin Robinson, MD, MBA, FACHE: Yeah. There is definitely some risk, and it's calculated risk. You can't know every detail. I'm an emergency physician by training. And so, I think this comes naturally to me. in the ER, you can't possibly know everything about every patient. You can't run every test imaginable, and you've got to make decisions, sometimes split-second decisions, without all of the information.

And so, I think I probably had an advantage becoming an entrepreneur because I was an ER doc and I was already comfortable with that uncertainty. But the goal isn't to eliminate uncertainty. In most of life, you can't eliminate it. The goal is to avoid taking risks you don't understand. So when you're thinking about a new process and there is some calculated risk in any new process, of course, there's also risk in doing nothing. So, there's risk in taking on this new process. You have to think about what assumptions about this new process must be true? What are we pretty sure is going to happen on the positive side? What are the potential downsides? Can we, as an organization, handle that downside if it happens in a not necessarily worst-case scenario, but in a bad-case scenario with this new process, can we handle it?

Also, as we're thinking about the level of risk, is the decision reversible? Obviously, there's more risk in an irreversible decision. So is this something we could back off of if it didn't work? Or can we test this on a smaller scale before we make a larger commitment? And again, I think when we think about taking that risk, we can take a lot of that risk away by doing it in small segments.

And so if you're familiar with how the tech industry works, they use a lot of agile thinking where they take a large problem and start solving small pieces of it. And I think that makes a lot of sense in healthcare sometimes. We have some large complex problems in healthcare that if you sit all of the people, all the stakeholders in the room of some large problem, like for instance, take inpatient length of stay. Inpatient length of stay has probably 100 or 200 stakeholders in a hospital setting. There are hospitalists and specialists and nurses and case managers, and they're the people from post-acute, and there's lab and radiology, and there's hospital executives. There's so many people involved in length of stay.

And I think what happens sometimes is a hospital tries to "fix length of stay," and they put together a length of stay committee with a bunch of people in it, and it's just really hard to fix such a large complicated problem at once. But if you take a small piece of that and try to fix small pieces on a small scale, there's less risk because we're not putting in some new process that might disrupt our length of stay. We're just trying to fix this very small part of it. We fix the small part of it, and then we fix another small part of it. And each time, we make sure that we can iterate on our changes. You make a change, you iterate a little bit, you adjust and pivot. This is where you've got to be adaptable.

And again, getting back to that entrepreneurial mindset, you've got to be able to adapt to the changes. And if you take a bunch of these smaller scale changes and pull them all together over some period of time, you make a large dent in the larger problem that honestly you probably wouldn't have made a dent in at all if you had only tried to deal with the larger problem, because you would've felt like there was so much risk in changing at scale. But when you break it into something smaller, the risk goes down. So, use pilots, use defined milestones, clear criteria for expanding, modifying, or stopping the new initiative.

Host: Speaking of the organizational big picture here, moving quickly can be a great thing, of course, but can also create chaos if you're not careful. So, how do you build an organization that can be agile in responding to change without your teams feeling like the ground is constantly shifting underneath them, so to speak?

Boykin Robinson, MD, MBA, FACHE: Yeah, that's definitely a needle to thread. You don't want your teams feeling like they're changing all the time. And agility doesn't mean changing direction every week. People still need consistency around the mission, priorities, values.

One example that comes to my mind is on when we think about patients coming into an emergency department and how we staff for those patients. We spend a lot of time and energy looking at arrival patterns by hour of the day, by day of the week. We look at acuity by hour, what kinds of patients are coming in, so we can build an optimal schedule of physicians and APPs and get the right skill mix in there for the right patients. You know, I always say if your ER schedule on a Monday is the same as your ER schedule on a Saturday, one of them is wrong, because Mondays are always busier in every ER I've ever seen than Saturdays. And so, you should have more staffing on your Monday.

But we have to be careful as we think about being optimizing. Even that word, you can't always optimize everything. You want to work towards optimizing. But if you optimize the schedule exactly, we run our demand capacity models and we figure out this is exactly the schedule we need to hit the patients as well as we possibly can. But then, we realize that we're giving the clinicians a different shift time every single day. This shift starts at 8:00. But tomorrow, the same shift starts at 9:00, and the next day it starts at 10:00. And we've now plunged their lives into chaos, because it's changing all the time. Or possibly even worse, we think, "Oh, you know what would be really cool? What if we looked at our arrivals in real time and we could decide based on how the day is going when to call a certain shift in?"

That makes a ton of sense in the boardroom because we think, "Well, now we won't have extra bodies there when we don't need them. We'll have all the bodies we need when we do need them. We'll make adjustments in real time to our staffing." But then, what did that do to our clinicians? It gave them no consistency at all, even within their day. I've got a 1:00 shift today except, oh, I got called at 11:00. Now, it starts in an hour. I got to drop what I'm doing. Or it doesn't start until 3:00 because they're slower and now I lost two hours. So, there's a lot you have to think through when you're trying to be agile and respond to, say, patient flow, but you gotta also think about your clinicians and clinician wellness.

Whenever you're making these changes, you need to clearly explain what is changing, why it's changing, what does it mean for each team involved? Honestly, unexplained change can create more anxiety than the change itself. So, change is fine. You just have to make sure you're not changing too often, and you need to make sure you're maintaining a consistent rhythm for communication and decision-making so that every adjustment doesn't feel like a surprise.

Host: And Dr. Robinson, when you talk about people, staff, et cetera, how much of that all comes back to culture? What have you learned about creating an environment where those people feel comfortable speaking up, for instance, challenging the way things have always been done and bringing those new ideas to the table?

Boykin Robinson, MD, MBA, FACHE: That's right. If we're going to challenge the way things have always been done, we have to allow everyone to challenge, right? And we have to actively invite disagreement and actively invite people to tell us that they have a better idea. At Core, we do a new employee orientation every month so that the C-suite can at least virtually be face-to-face with all of the new employees.

And one of the things I tell them every month is, "Please, if you see the way we're doing something and you think you might know a better way to do it, or you even just wonder why we do it the way we're doing it, please ask. No one will be offended by that." We want people to come in and give us ideas on better ways to do things, because that's how we're going to continue to iterate and grow.

And you especially need this from the people who are closest to the work. They're going to see problems, and they're going to see the problems with potential solutions before senior leadership can, because they're closer to it. So, people need to be free to challenge a decision while it's being considered.

Disagreement is okay, right? And culturally, disagreement is okay. It needs to be respectful, but disagreement is good. Once the decision is made, though, then everyone is expected to support that decision and execute on it.

One example we had recently, one of our hospitals has a real problem with inpatient boarding. In this particular hospital, we run the ER and the hospitalists are employed, and we were doing all sorts of things in upfront process in the ER to get patients seen, even though sometimes up to three-quarters of the ER was full of inpatient boarders. And so, what it meant was we were taking care of patients further and further out, in a triage or a vertical zone, maybe even in the waiting room. And we had patients in the waiting room who were ready to be admitted, but the hospitalists weren't willing to take care of a patient who didn't have a bed somewhere. And that makes sense. I completely understood their unease with that.

So, we got everybody in a room. There were different opinions on what should happen, and there were strong opinions on what should happen. Hospital leadership, hospitalist, ER docs all together talking about it, disagreeing, healthy disagreement on what should happen. And then, when a decision was made, everyone leaves the room and says, "This is what we're doing and we're okay with it. We're not going to complain. We said our piece, and we were allowed to say our piece. And so now, we can go out and do what the team decided on." I mean, really the strongest cultures combine psychological safety and the ability to feel okay with disagreeing with high expectations. We need to have really high expectations for our employees, and we need to know they're going to support the decisions that were made. One way to do that is to allow them to disagree beforehand while we're making the decision, have a real conversation.

Ultimately, culture is defined by what the leaders encourage, reward, and tolerate, not by what the organization says its values are. We all work hard on making sure our values make sense to us and make sense to our organization and reflect our culture. At the end of the day, the values we have written down are pale in comparison to how the leaders act and how they act with employees on a day-to-day basis

Host: In summary, for the healthcare leader joining us who knows something needs to change but may not know quite where to start, what's the one thing you'd encourage them to do or perhaps even think about differently in order to start leading with more of an entrepreneurial mindset?

Boykin Robinson, MD, MBA, FACHE: I think the first thing you have to do is start by asking: What's a problem we have here in our organization that doesn't have an adequate solution, but that everyone has learned to live with? Because that's a great opportunity to break it down to first principles, start thinking like an owner, thinking like an entrepreneur, and trying to jump in and fix it.

Every organization has lots of examples of, "We've always done it this way." And we need to find those and ask why. Why have we always done it this way? Now, there may be something unfixable. You may ask five whys and find out that, well, there's really nothing we can do about this. That won't be the one to start with. You want to start with one that is fixable or at least is improvable. And in order to do it, you need to get close to the front line, whether that's patients, the clinicians, the employees that are experiencing the problem, not just the executive level version of the problem. You need to really understand it at a deep level, and you really need that in order to get to first principle thinking. That's why you need your frontline employees involved. You need them to feel the psychological safety of being able to ask questions and disagree.

When you're thinking about what to pick first, choose a meaningful problem, right? And a specific problem rather than just some broad transformation initiative. Better to go solve a problem, gain some political capital from solving a meaningful problem, and then move on to more before you do something more broad. It's easier to take one small measurable change, test it, iterate on it, put it on a relatively short timeline so you can iterate and test and tweak and pivot and get to some defined outcome to get you and your team a win. Once you have that win, you can move on to other things.

So, an entrepreneurial mindset, it begins with seeing a problem clearly. Thinking outside the box gets overused. You don't really have to think outside the box. You just have to think outside of the way people have been thinking about this problem before. You don't need some crazy creative. You don't need Steve Jobs to understand how to solve the problem. Entrepreneurial mindset isn't rocket science. It's not even that complicated most of the time. You just have to have the willingness to get to the root of the problem to find the solutions.

Host: Interesting. So you say you don't have to necessarily think outside the box, but just have a different new way of thinking. Well, we trust you're now more familiar with leading like an entrepreneur. Dr. Boykin, interesting stuff indeed. Continued success with all of the above, and thanks so much again.

Boykin Robinson, MD, MBA, FACHE: Thank you.

Host: And a reminder, Core Clinical Partners is one of ACHE's premier corporate partners. Our premier corporate partners supporting ACHE's vision and mission to advance healthcare leadership excellence. For more information on Core Clinical Partners, please visit the corporate partners page at ache.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks so much again for being part of the Healthcare Executive podcast from the American College of Healthcare Executives.