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Becker’s Healthcare Podcast
Leadership, Capacity and the Ambulatory Front Door with Tracy Chu of Scripps Health
00:29:46
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- [00:00]
A
Molly, welcome back to the Beckers Healthcare Podcast. I am Molly Gamble with Beckers, and joining me today is my guest, Tracy Chu. Tracy is the corporate Vice President of Population Health and chief Executive of the ACO at Scripps Health, the nonprofit integrated health system based in San Diego, California. Tracy, welcome to the podcast. I'm so glad to have you here and have you back. Welcome. Thanks for joining me today.
- [00:22]
B
Great. Thank you, Molly, I'm happy to be here.
- [00:25]
A
To start us off, can you share a bit more about your role at Scripps and how your work is spanning this really interesting vantage point dually both the ambulatory space and also value based care?
- [00:38]
B
Yeah, happy to do so. First of all, I've been with Scripps for 20 years. I've had the, you know, the privilege of being in multiple positions through my tenure at Scripps and really have experienced various aspects of the organization. I'd say, you know, the great thing about Scripps is you get kind of a mix of both operations and strategy and whatever you do. And my job in particular really has that, that perfect kind of Venn diagram of strategy and operations. So I have really three distinct responsibilities in my position right now. I am the chief executive of the aco and what that really entails is oversight over our Medicare Shared Savings program as well as our direct to employer relationship that we have specifically with a large employer in San Diego. I also oversee a lot of the overall strategy around population health, which supports a lot of our value based care, our processes, really mapping the inpatient, outpatient and transitional portions of our work, making sure that it just makes sense for the patients. And then my third area is focus on operations. So I am the executive overseeing the Scripps Coastal Medical Group and centers. And that really is about 10 primary care based locations in our ambulatory footprint. So I get the benefit of both that operation side of the house where we're executing and we're taking care of patients every day, as well as the strategy in developing more system wide processes and workflows. Great.
- [02:15]
A
I met with one of your colleagues recently who like you, has this unique blend of operations with her work. The Dr. Sharif, Dr. Gazelle Sharif, Chief Medical and Operations Officer at Scripps. So the system does seem to have this really intentional way of combining a lot of focus areas that in many other organizations are left completely distinct.
- [02:36]
B
Yeah, it's actually probably one of the most effective ways of managing strategy and operations. I think in many organizations what you're going to find is you've got Folks really focused on strategy, developing kind of the overall vision and goals of the system. And then you've got folks, you know, every day working towards operations, making sure that they're executing on the vision and making sure that patient care is being addressed. I think the value of our roles is that we get to kind of bridge those two areas. And what we often see in many organizations too is that the strategy doesn't match operations. Meaning you come up with a great strategy, but can you really execute on it? Does it actually work in the patient care arena? Can you get the stakeholders engaged? Can people really rally around that strategy in a way that is meaningful for them and the patient at Scripps? Because we have a lot of these combined roles where we match the strategy and operations, we are able to, one, make sure that the stakeholders are engaged at the beginning, two, that the strategy that is developed actually works for the operations team. And so my role and the ambulatory side, similar to Dr. Sharif's role on the hospital side, is we get to kind of do both. And that's the benefit of making sure that what we really envision as our long term goals works and is sustainable. I think that is the piece that has made scripts very successful and continues to make us very successful. I mean, execution is key, but making sure you have the right strategy to execute on is also key.
- [04:19]
A
So well said. Executing the right things. I want to talk about this rare and special position you're in and I think increasingly, as you explained to us, valuable one, overseeing the ambulatory primary care clinics and leading the aco, you are overseeing two different aspects of the system that each have their own operational tempos. How are you balancing the long game here of population health with also that daily urgency of clinic operations? What does that look like for you as a leader? What's most important to you in doing that?
- [04:52]
B
I think at the end of the day, leadership, good leadership will stand the test of time and it allows you to balance that long term view with the short term view. And when you talk about good leadership, you're talking about making sure that you have the right teams in place with the right goals and the right kind of key performance metrics that they can work on every day to ensure that what they're doing is value add specific to their area of responsibility. So you've got the team in place, but then on top of that, making sure you have the right daily management system and the right governance structure to support that. I want to make sure as a leader, what I do is I set the right goals for them. I also empower them at their tier, at their appropriate level to do what needs to be done to get the job done. Me getting involved in areas that I really shouldn't be involved in actually slows things up. But at the same time, making sure that I'm available and they know when to engage me, when to bring me in also allows them to move quickly and for us as a team to execute on what we need to do. So I think at the core of this, regardless of whether you're focused on long term or short term issues, staying focused on the people that are doing the work, setting up the team for success, and then as a really good leader, getting out of their way, making sure that you set the right tone and focus, and then giving them everything they need to execute on it, but then not holding that up. And I think doing that regardless of operations versus strategy, you're going to be successful. And that has been, in my mind, the success in every team that I've led. And it doesn't matter which area you're working on, whether it's primary care, whether it's specialty, whether it's, you know, aco, direct to employer, it really makes no difference.
- [06:51]
A
Right. I think it's, you put it so simply, getting out of the way is so important for leaders, but it's also, it's so intentional in what you just described. It's so well designed to be able to get out of the way. And so I think you just had a number of management leadership principles that make a lot of sense because you're overseeing, like you said, that big picture, long game, and then also just the daily things that need to get done to arrive there.
- [07:16]
B
Right? Yeah, that's right.
- [07:18]
A
I want to talk about capacity. I mean, this is a word that we just hear increasingly with more and more concern, I would say in the inpatient side. At Becker's Hospital Review, we report on different issues of wait times, throughput, boarding. And I wanted to talk about this term and this concept in the ambulatory space, the level of concern that it sees in the inpatient space met in ambulatory or what types of metrics, concerns specific issues when it comes to capacity are most carrying over to that realm of the system that maybe just don't always have the headlines matched with it.
- [07:53]
B
Yeah, I think capacity is probably the number one thing that our ambulatory clinic operations team focuses on on a daily basis. I don't think it gets as much media coverage or focus because it's not as acute in the sense that the patients aren't sitting in a bed or sitting in the ED waiting for a bed. And so that level of focus isn't quite as high on the ambulatory side, but it's not. But I will say it's just as important, if not more so. And the reason for that is when you think about the kind of workflow and the patient experience, ambulatory is the front door. And for patients to get access to their primary care clinics, to their specialty visit, if we don't have the capacity to support that, where do they end up? They end up in the hospital. They end up probably in a much more acute situation than they needed to be because they couldn't get access to the preventative or the proactive health care that they needed to avoid that real acute episode. So if you think about ambulatory as that on the continuum, as that front door to maintain that patient's health, and if there is any sort of obstacle or there's any issues for the patient to flow through there, then they are going to end up in the ED or in the hospital. And that's where the cost of healthcare continues to rise, because that's where they're ending and that's the most expensive place to treat them versus the ambulatory environment. So when we think about ambulatory access, we think about third next available, which I think is a standard metric for ambulatory clinics. And what you're doing is you're looking at when's the third next appointment to see that specialty, to see that doctor, et cetera. And the reason why we pick third is because the first two tend to be either no shows or short cancellations. So you're trying to get the average of. If you're looking for the third next available, how long does it take? Is it two weeks? Is it two months? And we generally have standards. Primary care generally has a standard about a week to get in for like routine care and for like same day access. You want to see whether or not you can get in a relatively quick same day, like acute episodes or UTIs or you know, more of the, the basic care. And then for specialty, you look at 14 days for consults and you start to think about how do you, you know, are these patients getting in in a timely way? And if you can't get 50% of your patients in within seven days, then you probably have a capacity issue. And that is where we continue to look to try to balance out our demand and our access and our capacity with our physicians. And we Also try to, you know, employ different mechanisms, bringing in advanced practice clinicians to support some of that work, making sure that the physician's time is really focused on the areas that really need to be focused, trying to do a lot more triaging and more remote care in cases where they may not need to come into the office. So there's many ways to kind of manage to capacity and manage to demand in the amateur environment. But it is one of those things that we continue to wrestle with every day. Covid, I think, was probably the brought that to light more than ever. Because during COVID we had plenty of access, plenty of capacity, right. No one was going to the office, no one was going into the doctors, Everyone was at home. So we opened up our remote access, we opened up our virtual access. And then when Covid started to wane and people were going into the clinics more, all of a sudden we saw all this pent up demand because patients had not come in and a lot of their conditions had gotten worse because they had delayed care since COVID And we started to see our access and our capacity just worsen to the point where we had months, weeks of patients who were trying to get in and couldn't get in because they had delayed care for so long. And I think nationally that has probably occurred. Overall, we've seen a lot of increase in specialty visits in particular areas. Cardiovascular diabetes, chronic diseases that have probably gotten worse since COVID and delayed care. And that has then contributed to access and capacity issues in the hospital. So it is all interlinked. You can't take one issue and just look at it in a vacuum. They're all integrated. And the value at Scripps is we are an integrated system. So we can see it from the beginning to the end. And the continuum is constant on our radar at all times.
- [12:56]
A
You said so much there that I want to. I have a couple follow up questions in mind, Tracy, but, you know, first is a granular question. But when those, when that occurred, when the pent up demand was in place after Covid and people wanted to resume their primary care appointments, their special specialist appointments for chronic conditions, was that appointment time also a bit longer because they hadn't been participating in the routine care as normal. Can you talk about that? I think sometimes we talk about appointments like everyone is the block time and the same. I'm just curious how that also might have been a variable.
- [13:29]
B
Yeah, the appointments got more complex for sure.
- [13:31]
A
Okay.
- [13:32]
B
I think it depends on the appointments, but I also think people, you know, patient's threshold for what they thought was an acute episode had also reduced. So people were coming in for less things that they used to come in for a little cough. They would, you know, they got a little bit more anxious about getting an appointment, but definitely the appointments got longer, they got more complex because there were multiple issues that they were dealing with, many, again, you know, dealing with multiple chronic conditions that had to be addressed. Primary care got hit very hard as well as a lot of the specialties that deal with these chronic conditions. And I think even, you know, the areas of specialties that had more acute situations, like orthopedics, for instance, they also were dealing with a lot of, you know, people who maybe had suffered through an injury or suffered through an acute situation, but dealt with it until they could get back into the clinics. So you can kind of see how it all just played into this spike in patient demand. And then where do a lot of these patients go if they need surgery, if they need procedures? That's where you start to see the demand increase on the hospital side as well.
- [14:53]
A
Right, right. And I think you calling ambulatory the front door to the system. I think I've always heard that about the ed, but I guess I'm appreciating the more that from your seat, by the time a patient presents to the ED with something that could have been treated ambulatory, it's too. That's too late. So I think moving, shifting left and looking further upstream is something that clearly you are doing. Do you feel like that has been returned at the system level? Do you think we appreciate ambulatory even as the front door to the ed, the way we should? Or do you think sometimes it's a little overlooked?
- [15:28]
B
I think it's not so much underappreciated or overlooked. I think it's trying to truly understand on that patient continuum, you know, what drives what, meaning you can create this wide open door to primary care. The challenge to that is that when you do that, then all the downstream areas also get affected and you need to then balance. Do you increase ancillary? Do you increase radiology? Do you increase labor? Because those things go hand in hand with many of the visits in primary care. Do you increase specialty? What specialties do you increase? So, you know, like every organization out there, every healthcare organization, we have resource limitations as well. We can't just hire, you know, all the primary cares we want. We have to be very thoughtful on, you know, what's the right number of primary care doctors? What's the right number of access, you know, how big is that door because we can't overload the system either, because that's just, you know, you're gonna just create bottlenecks downstream all across the board. So it is a constant balancing act that I think we struggle with, and I think most organizations struggle with because, you know, we're. We're here for the patients. We're a community based, you know, healthcare organization. We want to make sure we provide that access, but we can't do it in an unlimited fashion. So I think there is a true understanding at Scripps kind of how they interlink. The question is how best to do that in a way that is really beneficial to the organization, because we also can't do that without being financially sustainable. So it's a constant balance of all these different priorities that we need to do. There is no easy solution. And they're also very much dependent on your local environment and, you know, and your patient population. And all those factors go into how you really balance all the different priorities for an organization.
- [17:33]
A
Very much so. There's some definite tightrope walking happening with what you just described. You know, Tracy, you've led so many other. You've also been involved with the bone marrow transplant clinic, cancer centers, large scale primary care. As you've helped us just better appreciate through your description of your current work, are there any through lines, regardless of setting or specialty of operational excellence, that have really come to help you better identify when things are going really well and maybe when there's room for improvement? You just outlined the constant balancing act is one dimension of your work that seems you need to be a leader who is comfortable with some ambiguity and some gray. But what else comes to mind when it comes to operational excellence that you've seen firsthand? It's really stayed with you. Now, whatever setting you might find yourself in.
- [18:24]
B
I've really embraced lean management and tier management. And what I mean by that is, and I kind of alluded to this earlier, is when you set up the right structure and you set up the right governance structure in the management system for your teams to work within, it allows you to really execute very quickly and also to keep an eye on the things that might be bubbling up to the surface that aren't on your radar today, but they might be. So if you have those lines of communication from the front lines, we call them the most valuable tier, which is the frontline physicians and staff, to our tier one leaders, which are really our supervisors, our leads, and then you've got tier two, which is our management, our managers, our site managers, and then you kind of move up the chain to the various tiers, all the way up to the CEO level. And Chris Van Gorder, as long as you have all those kind of those tiers clearly outlined and you've got appropriate catch balls is what we call them, which is just really that back and forth conversation that happens between each tier on a daily basis. Then you're able to pick up on those whisper warnings, as my boss calls it, of the things that you may or may not be aware of, but they're just bubbling to the surface. And because of that, you've got kind of that operational resiliency, flexibility, ability to really to adjust to whatever's happening on that day while still staying true to your core principles, to your core performance metrics. So we've got at Scripps, organizational objectives that we work towards every year, but beyond that, we also manage all the various fires that happen on a day to day basis. And so you're constantly, again, balancing the fires with the organizational objectives. Having that catch ball between the various tiers is probably one of those core principles that for me specifically allows me to stay connected to the front lines, but also stay focused on my job and what I'm supposed to do at my tier. And I think that's what is probably kind of as a pull through something that regardless of your specialty area, regardless of your area of focus, regardless of whether you're operations versus strategy versus support systems, it doesn't matter. You just need to make sure your teams are well placed to do what they need to do and know what their value is to the organization. I think that's just a truism in any organization, in any company, regardless of whether it's healthcare or not.
- [21:10]
A
Yeah. What's a sign of a whisper warning versus something that might just be noise or a side note or a miscellaneous observation? How do you identify those whisper warnings?
- [21:24]
B
Yeah, like for instance, we may have a situation at one of our clinics where we're starting to see their metrics start to drop across the board, or we start to see maybe some more complaints than normal coming from the front lines. And we may start to hear things like, you know, the words, certain key phrases. You might hear things like, oh, unfair, or that's not right, or I've been taught and as operators or as leaders, you know, you're kind of in, you're key to hearing those phrases and going, okay, I've heard way too many of those in the last, you know, two weeks or something. And now I need to dig into this this is a whisper warning that something's going on there that we might need to dig into. Is there leadership changes? Is there issues with the team dynamics? Are there morale issues? What's going on? And so those whisper warnings get triggered and everyone is encouraged to kind of talk about these whisper warnings a little bit, to say, okay, I'm hearing something. I'm not really sure if it's anything yet, but let's keep an eye on it because it just doesn't feel right. And if we can encourage that, then it's not. And you encourage that without reacting. Because if the team feels like, oh, I can't bring this up because then I might get in trouble or I might get too, you know, my boss might focus on me too much, then they're not going to bring these items up. But if they feel comfortable sharing those and they feel comfortable digging into it without you as a leader overreacting to it, then you can stay in front of it a little bit more. It's that proactive management that we want to continue to support with our teams. But proactive management just doesn't happen overnight. You have to create a safe environment. You have to create an environment where people feel like they can share these items so that those whisper warnings can bubble up a little bit faster versus that retrospective. Oh, I wish we would have known. Why didn't someone tell us? You should have mentioned this earlier. We try to avoid those at all costs.
- [23:39]
A
Right, that's such a great point. Instead of telling people to be better proactive managers, they the best encouragement you can do to elicit that type of behavior is how you receive their concerns, what they're hearing, how you react to all like, like you said, I'm not sure if it's anything yet, but I'm just trying to understand or learn more about X, Y, Z and exercise some restraint in your reaction.
- [24:03]
B
That is probably one of the hardest things as leaders to do is to have that self control, you know, that emotional self control, not to overreact. Because, you know, at my level I don't get the day to day, you know, nuances in the clinics as much as I used to. You know, when I was a frontline leader, that was easy. I could pick up on those nuances every day and I didn't have to worry about it at my level. Now I have to trust my team to be able to message that. But if they just mention something like, oh, doctor, so and so got upset with me and I, my reaction is, well, what are you talking about? Why didn't you talk to him? Why aren't you digging into this? What happened and what did you do? If my reaction is, you know, too strong, then they're going to think about it. You know, they're going to hesitate the next time they want to bring something up to me, or I'll go and talk to him, or I jump into their business and I start to intrude in their tear, and all of a sudden, you know, I get involved when I shouldn't, and they're like, oh, I'm not doing that again. I am not bringing that up to her again because she went way overboard. You know, my reaction is key to how I want them to behave. It's, you know, what is the saying, you know, every. Every action gets a equal or.
- [25:19]
A
Yes, what is that now?
- [25:22]
B
Now I'm driving a blank. Oh, it's going to drive me crazy. You're gonna have to.
- [25:24]
A
Every. Every action, for every action, there is an equal and opposite reaction.
- [25:29]
B
Exactly. That's. Exactly. And. And because of that, I think as leaders, we don't realize that for our action, we're going to get that equal reaction back from our team. So we just have to be very careful as leaders to restrain from that and let them just almost speak their mind without us getting involved. We're problem solvers, right? Leaders tend to be problem solvers. You bring me an issue, I want to jump in and solve that problem for you. Oftentimes that's the worst thing. You know, many times they're bringing that issue to you because they just need to hear it. They need to brainstorm, they need to maybe talk about it. And you need to ask questions, probing questions, but give them that space versus just jumping in and solving it for them, because that is probably going to cause them to hesitate the next time they want to bring up something because they don't want you always to solve their problem. And if they do, then you're not really creating the right team environment. Right. If you're solving everyone's problem, then what would be the point in having your management team there if you're solving everyone's problem for them? You know, we need to help support their problem solving, but we also need to do it in a way that is supportive and safe and that creates that. That place that allows for not just the whisper warnings, but also, you know, sharing the good news and the recognition and the celebrations and being able to really get a sense of being in tune with what's happening on the front lines without having to be on the front lines every day.
- [27:07]
A
Right. And I should make clear for listeners, I googled Newton's third law of motion and found the answer for Tracy. I did not have that recited, but it's, that's so applicable to what you just described. Tracy, this conversation, I mean, it's helped me better appreciate aspects of operations. It's better help me appreciate your dual lens into the system. Also just good management. How much of good management is intentional restraint, supporting the team, but also helping them find their own answers. And sometimes when they come to you with this dilemma, they likely already know the best way forward. They just want to talk it out or get validation, like you said. Tracy, is there anything we didn't cover, anything else that you want to leave our listeners with before we wind down?
- [27:51]
B
I think the only thing, and it has kind of transitioned a little bit to a leadership conversation, which I think generally happens when you talk about healthcare issues and the problems to solve today is, you know, when it comes to leadership, I would always, I always tell my team to be a lifelong learner, to be a student of leadership. And the better you become a leader, the better your teams are and the better your organization is and the better the healthcare industry is going to be as a result of it. So it feels sometimes very self serving to only focus on yourself as a leader and the improvement you make as a leader. But the truth is the more you do that, the more it actually gives back tenfold on your team, their results, their execution, your organization's results and execution, etc. So very similar to again the same analogy that the airlines always say, which is put your mask on first, your air mask first, before helping others. Take care of yourself first in many ways because if you do that, you're going to have the ability to take care of others. And I think that's one of the truisms. I kind of, it's a core principle of mine that I continue to focus on and it has definitely helped me and my team be able to execute and support scripts.
- [29:14]
A
Listeners, thank you so much for Tracy, first of all, for that ending on that note. And listeners, once again, this is Tracy Chu. Tracy is the corporate vice president, Population Health and chief executive of the ACO at Scripps Health. Traci, I think I'm just left with more evidence that there is something special and in the water at Scripps Health when it comes to leadership and management, from Chris Van Gorder on down. So I want to thank you so much for joining me and spending some time with me today.
- [29:38]
B
Thank you so much. It was pleasure and anytime. I happy to be back.