Successful leadership 

Nurturing a culture that prizes transparency, engagement, performance and accountability

Featuring Chris Van Gorder, MPA/HSA, FACHE
President and CEO of Scripps Health, San Diego, and author of The Front-Line Leader

By Marc B. Miller, MD, MBA, FACPE, FACPM
Advisor at Tyler & Company

When Chris Van Gorder joined Scripps Health as President and CEO at the turn of the century, the nearly bankrupt organization was losing $15 million annually; votes of no confidence epitomized employee and physician sentiment. In 15 years, Van Gorder led Scripps through monumental turnarounds in finance, culture and satisfaction. Today, the $2.6 billion integrated health system plans for campus expansions as well as regional growth.

A former police officer, Van Gorder retired from the force early due to an on-the-job injury. Although his first life-changing experience in the healthcare industry was as a patient, he became a hospital security director and climbed the leadership ladder.

Scripps has been named among the “100 Best Companies to Work For” ranking by Fortune magazine for eight consecutive years and a “great place to work in healthcare” by Becker’s Hospital Review multiple times. These achievements take work, dedication and empowering your front-line staff, says Van Gorder. 

Our most sincere appreciation to Van Gorder for sharing with other healthcare executives and physician leaders some of the secrets  behind Scripps’ success.

Dr. Miller: A central thesis in your book warns that the more complex or large the organization, the easier it is to lose the connection with front-line employees who create value for patients. Of the approaches you’ve taken to maintain that connection, which do you consider the most universal or essential? 

Van Gorder: We’ve realized over time that employees’ fear of asking hard questions and raising concerns diminishes when there is trust and a relationship with management. For example, with Scripps Employee 100 program, several other executives and I meet with front-line, non-management staff members one day each month for six months. We start with introductions, Scripps’ history and career paths, then incorporate presentations throughout that day. By sharing valuable feedback, we can learn where we can change and improve. Concluding with a Q&A session, we found that the quality of questions by front-line employees improved substantially after meeting one time with this set group vs. congregating with many different front-line employees during open forums.  

Nevertheless, it’s extremely important to start somewhere – to begin taking action in building relationships with staff. Over time, efforts will develop into a multi-faceted approach. About 25 percent of my time is spent communicating with staff at all levels via programs targeting front-line employees, middle management, alumni and physicians; my daily market news e-mail that reaches hundreds of employees; and open-staff Q&A forums. 

Dr. Miller: In addition to leading by example, which is very powerful, what other approaches are used to transmit your leadership style and culture to management throughout Scripps’ five hospitals, dozens of clinic sites and 14,000 employees?

Van Gorder: Scripps’ Leadership Academy is a year-long monthly training program geared for middle managers who either have been promoted to that position or are new to the organization. Hundreds of staff members have graduated since this program began nearly 15 years ago. In addition to providing instruction on Scripps’ system and technology, the program offers an ideal platform to explain my expectations of our managers and leaders – their No. 1 job is to be an advocate to their employees. That is, “Take care of them and provide the resources they need to be successful. In turn, they will take care of you.”

Middle managers are the closest to front-line staff; they are the most important thread to realizing the management style we’d like to weave throughout Scripps. Managers make mistakes and improve by listening to their employees. I’m grateful for the front-line staff who trained me to be the person I am today. My key message to them is to help and talk with managers. Chances are that managers will improve when provided feedback from staff who support vs. undermine them. We evaluate management on satisfaction ratings via an employee survey that enjoys a nearly 95-percent participation rate.

During training I also draw a three-legged stool and explain the importance of responsibility, authority and accountability. I add attendees to my daily “market watch” e-mail, which at times concludes with a leadership article from Harvard Business Review. Last but not least, I encourage everyone to see me as a resource and contact me when needed.   

More than 60 organizations have visited Scripps to learn about our horizontal management structure, which shaved $340 million of cost from operations without any layoffs.

Dr. Miller: What special challenges or considerations come to mind when extending that approach to physician leaders and other providers they manage?

Van Gorder: Since Scripps cannot employ physicians in California, they must desire to work with us. As scientists and profound learners, they strive to excel in leadership and management as they do in medicine. Through our Physician Leadership Academy (current class has 80 doctors) and other structures, we have strengthened bonds with this group. What is humbling is coming to Scripps at a time when physician satisfaction was at rock bottom and now disclosing to the board that our biggest challenge is keeping up with doctors! They are advancing as leaders in clinical care lines, as well as elected medical executives in corporate. Although it takes time (15 years in our case), turnaround is possible. We consider physicians our partners and serve them so that they can be successful.

In addition to embracing leadership training, physicians also have asked for assistance in improving patient satisfaction. Reporting to the Chief Medical Officer is an observing physician whose sole role is to work with our physician partners in improving patient relation scores. This offering is very well received. 

Dr. Miller: The term “emotional intelligence” is used a lot. If you had to rank it, how important is EI for a leader?  

Van Gorder: It’s essential. According to Dan Goldman, EI’s framework consists of self-awareness, self-regulation, motivation, empathy and social skills. Those who have mastered these skills generally perform very well as leaders.

Dr. Miller: With the evolution of IT capabilities, dashboards and the like, how have your thoughts on accountability and metrics evolved?

Van Gorder: You can’t manage what you don’t measure. Unfortunately, sometimes we try to measure too much, which results in our chasing insignificant metrics.

Unsuccessful organizations ask their employees to do many things as opposed to focusing them to complete the things that make a difference. While our six pillars consist of many details, they are at the heart of what we consider important and hold our employees accountable for.

By identifying core metrics, we set targets all the way down to the unit level. Our goal is to collectively move dials in the right direction. IT helps in gathering and analyzing mountains of data. Our core metrics are 1) quality, 2) safety, 3) finance and satisfaction among 4) patients, 5) employees and 6) physicians.

In the absence of knowing what you’re supposed to do and measured upon, it’s human nature to fill time with personal interests. To achieve good employee relationship scores, leaders must manage their workforces well. Chances are little (if any) time will remain from trying to move dials.   

Dr. Miller: With Scripps ahead of many other systems when it comes to value-based healthcare, can you give us an update on how “value-by-design” efforts are progressing and lessons learned?

Van Gorder: We are making progress in educating every employee of value by design, a methodology that incorporates Lean processes or the Toyota Production System. By working with front-line employees (since they use processes the most and know their intricacies) we’ve been successful in completing many four- to five-day rapid improvement events. Rapid improvement calls for an intricate review of a process, then a redesign to remove unnecessary or non-value-added steps and variation. We’ve made remarkable enhancements in bringing drugs to the floor as well in the operating room.

It’s a wholesale change of thinking. By empowering our front-line staff with problem solving, morale shoots sky high. And, it frees time for managers to think strategically – something they generally don’t have the bandwidth to do when tasked with fixing issues.   

Our visual management system allows each unit to track its progress in moving its dials across our core metrics. Twice-daily unit huddles bring to light which groups deserve well-earned praise, as well as identify other initiatives needed to facilitate improvements.

Even though they exist, we’re not focusing right now on dollar savings. Instead, we’re setting our sights on getting employees engaged in creating value propositions for patients and exploding this process systemwide. Since returns decrease over time, we continually have to identify new initiatives.

Dr. Miller: The Front-Line Leader describes participation in disaster response for Katrina and in Haiti, which reflects your organization’s ability to successfully wear more than one hat – locally focused and a stakeholder in a larger, national and international community. How do you balance the trade-offs and benefits between taking scarce resources and devoting them beyond local service areas?  

Van Gorder: We are fortunate in that Scripps is a $2.6 billion company and resources used for disaster management are a tiny fraction of the whole. For example, a team of 30 helped with Katrina. Due to logistics, our team to Haiti totaled 18. We have 14,000 employees. E-mailing everyone from Port-au-Prince and being greeted by a massive crowd of Scripps employees when we touched down on U.S. soil are testaments to the tremendous amount of pride that results from helping others. Recently we hosted a domestic physician who completed Ebola work in Africa and provided our staff with grand rounds. These efforts also benefit us in creating extraordinarily well-prepared medical response teams, which are treasured local assets. 

Reach Marc B. Miller, MD, MBA, FACPE, FACPM, Advisor, at mmiller@tylerandco.com or 610-558-6100.

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