Infinite ROI: The Culture of Walnut Hill Medical Center

When we sought out hospitals with strong reputations for innovative healthcare IT, Walnut Hill Medical Center in Dallas was at the top of our list. After all, when it opened last year, Forbes named it The Hospital that Steve Jobs Would Have Built. We knew it had to possess a treasure trove of practices relative to dealing with the most complicated information management systems, cumbersome electronic medical records and daunting population health goals. While our investigation unearthed an abundance of cutting-edge approaches at Walnut Hill, what we found to be most impressive was that the organization is clearly built on culture, not technology. Regardless of the latest high-tech advances or the newest government regulations to meet, Walnut Hill adamantly places the needs of its patients squarely in the center of all its decision making. This keen attention to patient-centered approaches goes way beyond impacting its use of technology as it also serves as the organization’s chief criteria for selecting employees, working with government officials and finding vendor partners.

Below is the record of my conversation with Walnut Hill’s new Chief Information Officer, Aaron Miri, and Dr. Rich Guerra, a cardiologist and a key, long-term contributor to the organization’s patient-centered culture. 

(Editor’s note: To hear audio excerpts of this interview, click on the media player buttons that run throughout this article.)

Free: Mr. Miri, you are relatively new to Walnut Hill Medical Center. Will you please provide a bit of your background as well as why you felt the organization was a good fit for you as a Chief Information Officer (CIO)?

Miri: I started off my career, actually, in tele-communications as a software developer, and, wanted to do something a whole lot more meaningful, so I have been in healthcare now for the past 15 years, and have enjoyed every single moment of it.

What attracted me to come to Walnut Hill was their commitment to making the patient the center of their universe. They have a tremendous track record when it comes to using technology as an enabler to patient-centered care because they see technology as a tool that is used for good. A lot of other hospitals that I considered had wonderful people, but I noticed how the patient was missing from some of their considerations regarding the use of technology. This seems very counter-intuitive to me given that the patient is the real reason why we have all joined healthcare in the first place.

My job, every single day, is to make sure that we are leveraging the tools – the technology tools, the data sets and every other tool that our caregivers are utilizing – to the best of our ability to help us to achieve our shared goal of helping our patients and their families. 

Our industry is going through many challenges, and many times technology is not used to its fullest potential. This is done not out of malice, however. Our industry is just encountering a tremendous period of change. The rate of that change, quite honestly, can make people paranoid and concerned. However, those who see these changes as an opportunity to really make a difference in the lives of patients gravitate toward environments like Walnut Hill.

I truly believe our organization is a perfect example of a disruptor who understands how to leverage that rate of change for good, and to leverage change for the patient. Our patients satisfaction scores, our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results and all of the other various ways that we have sampled and surveyed our patient population, all point to Walnut Hill’s success in this area. The fact that our Emergency Department (ED) has a greater than 95 percent satisfaction rate, and in some cases that score is closer to 99 percent, shows me that our hospital is very special. Show me another organization where the community feels as though their ED is a place that they have to go to whenever they are ill. It’s not just the general community that feels this way. We have surgeons on staff who have brought their mothers to receive care here at Walnut Hill. Anyone in our industry knows, that says something. That says a lot.

Free: Dr. Guerra, you have been a long-standing member of the Walnut Hill community. Will you also provide a bit of information regarding your background, as well as some of your thoughts about the culture of Walnut Hill?

Guerra: I am an interventional cardiologist at North Texas Heart Center (NTHC) . I’m a founding member of the Walnut Hill Medical Center (WHMC) Development Board and currently a member of the WHMC Executive Board.

NTHC is one of Walnut Hill’s founding cardiology groups. Along with other prominent Dallas cardiology and surgery groups, its members have been heavily involved in the conception, design and operations of our hosptial.

My background is based on technology. I grew up writing code for McIntosh computers, Newton and Apple iOS devices. As a physician, I have always been struck by the potential of transforming healthcare using technology within the service of our patients.

I also like to learn things, how things work. When I did things in medicine, how does the body work from the molecular level, to the physiology, to the clinical aspects, but, also how organizations work. That led to sort of trying to rethink how an organization like a hospital might work. How do you make something that’s unlike what has come before? How do you change the orientation to the point where it does something, maybe, a little bit different?

When developing Walnut Hill, we set out from the start trying to think outside of the box a little bit, bringing concepts from outside of healthcare – the business world, the retail world and the hospitality industry. The common theme we found from the most successful organizations within these fields was they always put the customer at the center of their thinking. We knew that was the mindset we wanted here.

Free: It is obvious from my conversations with other members of Walnut Hill that you have found a great deal of success in terms of establishing strong patient-centered culture.

Miri: You are right about that. I can tell you as a new member of Walnut Hill that everything we do is looked at from the perspective of our patients in terms of what kind of benefit or value a certain action may bring to their lives. Will it make their lives better? Will it enrich their lives in some way? If the answers to these questions are in the affirmative, then we know are heading in the right direction. That is our first step.

Guerra: I’m glad to hear you feel that way. What I have been doing here at Walnut Hill is trying to orient the organization toward that specific patient-oriented culture, and we strive everyday to maintain a patient and family-centered culture, a culture of collaboration and partnership. Our thinking is that as a group we are far stronger than if we took the traditional, more silo, approach that often dominates healthcare.

We think of Walnut Hill as a start-up company where we are an incubator for ideas and concepts. When we see benefits to our patients, we move fairly quickly on them. We don’t have to run things up the flagpole, or call Nashville, or deal with multiple layers of bureaucracy. Our leadership is here and they are very active each day. Without that level of constant involvement at all levels of our organization, we would not have been able to create the caring environment that our patients and staff enjoy today.

For the last year and a half, every two weeks at our new employee orientation, I give a presentation of how we got here. How the hospital originated and how it evolved into an organization dedicated to partnership and collaboration to deliver high-quality, innovative healthcare.

We try to impress upon everyone here that we are partners in this pursuit, no matter where they work within our organization. We want to generate a sense of ownership and collaboration in our efforts. That’s our call to action and our people embrace it. We move forward together. We build collaborations among ourselves that we extend out to our patients and their families, the community around us, lay and medical. We are a people business. We work very hard, and we have fun at the same time. That’s what I’m all about.

Miri: You know, as Peter Drucker says, “Culture eats strategy for breakfast,” right? So, let’s agree that time spent on culture is infinite ROI. Infinite.

Free: That seemed to be Walnut Hill’s thinking from the very beginning which is unusual. Most people say, “Let’s get some equipment. Let’s hire some staff. Let’s open the doors and move patients in and out.”

Guerra: That approach never seemed right to us. Honestly, that seems like a recipe for disaster. In the beginning it’s vital that you ask the questions, “Which organizations outside your field are successful at creating a positive feeling in their customers? How are they so successful at creating such a positive experience? What sort of customer service are they providing?” Those are very simple questions that have specific answers.

If you look at some of the most successful businesses from industries outside healthcare such as Ritz-Carlton, Disney or Apple and you ask, “What ties them together? What do they have in common?” The answer is: They put their customers at the center of everything that they do. They are people businesses. What’s medicine? It’s a people business. They use different commodities and provide different services, but they are constantly seeking relationships and partnerships with their customers.

The other commonality of these businesses is that they all have a single vision that every level of their organization works to achieve. They have a company-wide culture and set of common practices that permeates everything that they do.

By duplicating the mindsets of those successful organizations here at Walnut Hill, it’s what makes us different from other healthcare organizations.

Free: Given its reputation as one of the most advanced healthcare IT environments in the world, many may think it’s odd that we haven’t mentioned a specific technology or tech-related issue when discussing Walnut Hill’s IT strategy. 

Guerra: Aaron and I both like to think in terms of technology when it comes to care. We can talk tech all day, but our goal is to create the highest level of patient-centered care possible, and we understand that technology is just a single tool. We are more concerned about the people and the mindsets behind those tools. The people here at Walnut Hill are very special and not for the technology they use. They are special because they all see the patient as special, and our patients take notice. 

One of the things that I am most proud of is how picky we are of choosing people. We do not hire anybody here at Walnut Hill at all. We have never hired anybody. We select them. We choose them. Everyone here is screened with a personality profile as part of the application process. We start with that. We ask the questions, “Who has the highest aptitude for service, for compassion, for working in teams, for appreciating diversity and collaboration?” We start with that group of people, and then ask the question, “Who in this group is qualified for this particular role?”

Even though we may need someone for a position, we will wait until we find the right person for that position. We have learned that we get far better results if we are patient with this process rather than simply trying to find somebody to occupy a position on our team that, maybe in the end, turns out to be a bad fit. We have screened over 11,000 applications to select, not hire, about 350 people. We have a 3.2 percent or 3.3 percent acceptance rate. To put that into perspective, it’s easier to be selected by Harvard University than is to be selected by Walnut Hill. 

We also make sure that our technology fits in line with this overall ethos. We always try to demonstrate to our patients how the technology that we have selected is so important to their needs. Whether it’s our interactivity systems, the communication tools that we provide to our staff to share information, or even equipment most our patients never see, all of our technologies are chosen as strictly as our employees, and the questions we ask ourselves before selecting a certain technology are purposefully similar in nature as well: “Which technology provides the highest level of service? Which technology most effectively enhances the experience of our patients? Which technology encourages our staff to work in teams? Which technology provides the highest possible level of collaboration within our organization?” 

Free: Increased patient engagement is a common goal in healthcare today. However, few organizations share common mindsets regarding the evolving roles and responsibilities of patients regarding how they should take more responsibility for their own care. How would you describe Walnut Hill’s perspective on patient engagement and what role does your technology play in achieving your patient-engagement goals?  

Guerra: Engagement is critically important. While we understand that, to achieve it we often have to break away from some of the more paternalistic approaches from the past. We can’t do as much for them as we can educate them to help themselves. We want to give them the resources and knowledge that they need to take care of themselves. We want them to learn how to avoid more problems in the future, and we understand how critical it is for their long-term health that we give them that knowledge in clear and meaningful ways.

From a patient’s perspective, and from IT, I think of it as: empowerment, ownership [and] communication. From our perspective, I would think of it in terms of: management, advocacy and engagement. From our perspective, management means, as a clinician, once I have finished taking care of a patient at a hospital, when they go home, how do I keep them out of the hospital? How do I keep them out of heart failure? How can I interact with them remotely to prevent readmission?

Advocacy comes from the things that we do within the management that I just described. We say to our patients, “Have you had a follow-up appointment? We haven’t seen you in a while. We need to see you back in two weeks. We want to make sure that you have the knowledge of where to go for help if something should change.” We make sure that our technology is aimed at achieving this level of advocacy for patients. 

From a patient’s perspective, empowerment is learning how to do all of those things. We want to give them the resources that they need to prevent more problems in the future. We give them a device. We give them access to a portal. We give them a list of contacts. We give them the information that they need to understand what is going on in their own bodies. We want to give all the information needed to understand what their choices are with they come to our hospital, or if they go to a different facility.

Ownership comes from that. You become the owner of your own destiny. You need ownership of your data. Your health information is not only your medicine and your treatments, but your own body. It’s your own physiology. That’s where wearables and similar tech coming out appears to be very useful and very exciting. Apple is rolling out their HealthKit and the ResearchKit which will allow us to have the management and communication which, as I mentioned, are core components in terms of the patient’s perspective. They need to be able to say, “I am in trouble. I have a question. I need more resources. I need more help.” If the right technologies are selected, then these issues can be properly addressed.

Miri: I have to agree. I spoke a lot about this point at [Healthcare Information and Management Systems Society] HIMSS with the [Office of the National Coordinator for Health Information Technology] ONC and others.

In terms of patient engagement, it’s about preparing the patient emotionally. It’s about making an investment in their care plan, and it’s about making an investment in their own well-being. We need to make sure that throughout their stay, from admissions to discharge and beyond, our patients feel supported. We need to make sure that they feel that we have their back. Some CIOs choose technologies that make this task easier, but some actually make the job even more difficult by using IT that does not truly consider the patient’s emotional needs.  

When I look across the industry, there are so many times you see phenomenal leaders get bogged down with all the stuff coming down: regulatory change, ICD-10, Meaningful Use and blah, blah, blah. That’s all great and dandy, and I’m not debating that. That’s all wonderful. But, what is healthcare? Healthcare is feeling.

Healthcare is coming home after an 18-hour shift in the neonatal intensive care unit (NICU) for 25 years and saying, “Golly. My feet hurt, but you know what? I really helped some sick babies today.” That’s healthcare. Yes, many other things are revolving around, but that’s healthcare. We have to understand that the patient is probably coming to us scared, but we want to make sure they leave happy and that they leave well.

Many clinicians ask, “How can I use this technology to help my patient, who is scared on my table in the need of cardiac care, feel better and to feel secure?” Outside of Walnut Hill, sometimes I see little consideration being made in this area. I would like the healthcare industry, as a whole, to go back and start thinking about the roots of healthcare: instilling compassion and providing a sense of security. 

The technology tools that we put into the hands of our caregivers at Walnut Hill are enabling that feeling of security that our patients need, and we are always looking for new technologies, or new applications of current technologies, to help us with this goal.  

Free: You alluded to the impacts that government regulations often make upon the decision making of CIOs. What is your approach to dealing with such impacts? 

Miri: It’s actually funny that you ask this question because I’m going to be speaking with the ONC very soon.

Number one, you cannot be adversarial when dealing with the government or any government officials. You cannot choose vendor partners that take adversarial stances against regulation either. You must also realize that if there ever is a misunderstanding when speaking with the government, it is your job as a caregiver, as a provider, as a hospital, as an entity delivering services that you educate, as well as listen. That way the misunderstanding has the best chance of being resolved and it should not as often in the future. 

I have personally become very active on the advocacy front. I am the Vice Chair for the Public Policy Committee at HIMSS. I am the incoming Chair for this upcoming year. I do a lot of personal work with the ONC around healthcare IT efforts because I believe that there is an education and awareness effort that must be made as a hand-in-hand partnership.

From my perspective as a CIO, what I would say to other hospital leaders is: “Let’s speak first to listen, and make sure that we understand how we can together get to goals,” because nobody, at the end of the day, wants to see a detriment to patient care. And, I think if you articulate the conversation appropriately, and you are educating, as well as articulating your point, that everybody will listen.

Guerra: You hit the nail on the head. I think the key concept is partnership. As a clinician on the ground, you often fall into kind of adversarial role, faced with things that may not necessarily make sense on the ground where you’re actually taking care of the patient. I think if there is any pain point, it would be that.

That being said, you have to realize two things when considering the role of the government. The first thing is that people want to do right. Oftentimes clinicians only think about what they want to get accomplished. Often times some say that the government only thinks of the things that they want to get accomplished. We need a venue where these two perspectives can come together to get their ultimate shared goals accomplished which is to improve patient care. If we can appreciate that we share the same mindsets of trying to improve the lives of patients, that would be a good starting point when dealing with government officials and their rules and regulations.

This is where I echo the importance of education coming from the clinicians side and aimed at the government side so that both parties can have a better understanding of one another’s perspectives. I can only imagine how impactful it would be for a government official if a clinician came to them without any hostility and stated, “Here are the tools that I need to accomplish my job. Here are the standards that we have found to make the biggest improvements in patient care. Here’s the way we take care of our patients. Here are our workflows. Here are some of the survey samples that we have received from our patients to explain how they feel about technology within their care. Here are some of my feelings about how we are using technology to improve patient care. Let’s share your perspectives on technology and your best practices so that we might be able to develop a more unified strategy when dealing with healthcare IT.”

This openness for mutual education is really the only real approach that will get us to where we both want to go. Both sides have to make stronger attempts to understand the goals and the struggles that the others face. 

Miri: I absolutely agree, and what’s interesting is that when I spoke with Dr. Karen DeSalvo at HIMSS, one of the first things that she asked me was, “Aaron, how is it going? How is your hospital? How are you doing in Dallas?” Again, she’s asking questions rather than restating what she had just given as a keynote. I found her eagerness to make a personal connection with me and my facility to be very encouraging.

I believe the leadership at the major government organizations are seeking first to understand what matches up to the question, “How can we find that middle ground? How can we come to that compromise to get your goals?” They know that there are things we obviously have to work through, but they are trying to find ways to work with us to get healthcare right. You can see the tide is starting to change a bit which is immensely rewarding to watch.

Guerra: That change will be huge.

We talk about our electronic medical record (EMR) and how it impacts upon the clinicians. Generally, these comments are negative in the sense that it draws many away from the care of our patients which is counter to our mission. So learning and understanding the ways of how a clinician works and then changing how an EMR looks and how it’s used, will have a huge impact on not only the patient care, but also on the care of the caregivers. That’s where find the sources of burnout and angst from clinicians. The technology is impacting them, not the government official, and taking them away from their patients. This process is not easy sometimes and I don’t know many doctors who came into healthcare to become experts at technology, but that does not mean that they don’t have a responsibility to make every effort to learn and share their experiences with others, especially the government. Practicing that sort of communication will be the only way that we can ensure that our systems work more effectively.

Free: Let’s close our conversation by addressing the roles vendors play in providing technologies that enable patient-centered care.

Guerra: What I hear repeatedly from vendors is, “Okay, we have a list of functions that have to be implemented. Here is how it is done. Just press this button, then slide the slider, choose the appropriate menu, then open another page, click on these four boxes and then another page opens and then you get it.” That approach by vendors signifies a level of disconnect that is always striking to me. That kind of thinking is just for filling a list of items. It is not an approach that asks questions about how people actually use technology. Some vendors don’t think about how clinicians will use their technologies, how patients will use it, how the staff will use it. It impacts all of their lives.

It always boils down, in my mind, to the question: How does this affect the lives of the people within our system? How are people interacting with it? How are people using it as a tool? Is it a useful tool to achieve our goal of improving lives?

So, to a vendor I ask, “Come to us with your thought processes of how will this make the lives of our patients better? How will it make the lives of our staff better? How will it make us more effective caregivers by delivering something that is more personalized, more humanized in everything that we do.”

Miri: If I am speaking to a group of vendors or outside participants for Walnut Hill, the most important thing I would say is, “To be our partner and not be a vendor. You are participating in our mission together with us. You need to believe in what we are trying to achieve, and that the patient is the center of the universe and everything revolves around it. Otherwise, there is a place a couple blocks down you can go to, and go be at, and enjoy that time.”