Convocation Valedictory for Quality and Safety

The following special editorial is an edited version of remarks I delivered at the June 2023 Annual Meeting of the American Association for Physician Leadership (AAPL) in Chicago, IL.

I was truly honored to receive the inaugural “Lifetime Achievement Award” from the AAPL and they asked me to prepare a convocation address.

This provided me with a special opportunity to reflect on my three decades of work with AAPL and to give my historical perspective on the evolution of the field of healthcare quality and safety.

The speech has been slightly edited for publication and a modest number of appropriate references have been added for completeness.

I hope you enjoy my very personal reflections and anecdotes.

What an absolute honor and privilege it is for me to be here today. Thank you all for coming. I am truly humbled to be standing here with you.

I'd like to divide my brief comments into four parts. In part one, I will describe “how did I get here” and the beginning of my own leadership journey. In part two, I'll review my three decades of work with AAPL. In part three, I'll try to connect parts one and two, and note some milestones on our collective leadership journey. And finally, in part four, I'll review some very personal take home messages.

Part One, How Did I Get Here?: In Chronologic Order

I grew up in a gilded ghetto on the south shore of Long Island, New York, in a town called Merrick, which was the last exit southbound on the Meadowbrook Parkway before Jones Beach. If you missed Exit 9, you were headed to the beach.

My parents were both college and graduate school educated individuals so learning and getting good grades was a central activity in our home.

My late father was the middle brother of three sons born to non-English speaking European immigrants from pre-World War II Poland. He became fatherless at age five when his father died of pneumonia. He probably had the greatest influence on my vague adolescent notion that I could somehow combine business and medicine.

I mostly had a happy childhood. I went to a large white, mostly Jewish public high school, where it seemed that 1/3 of a class of 660 students wanted to attend an Ivy League college, followed by medical school.

I totally drank the Kool Aid as we say today. But here is where my journey into physician leadership really began. And special thanks to our AAPL colleague, Dr. Art Lazarus(1), for publishing aspects of my story in his great book from 1998 entitled, MD/MBA: Physicians on the New Frontier of Medical Management.

In the fall of 1972, a heck of a long time ago, I read an article in the newspaper(2) where for the very first time, I saw the juxtaposition of the words, “physician leader”. I have a very distinct memory of this moment, now, more than 50 years ago. I shared the article with my dad and he urged me to write a note to the author, Dr. Samuel P. Martin, III, a professor at the Wharton School of Business on the campus of the University of Pennsylvania in Philadelphia.

Of course, as a 17 year old, I promptly told my dad that it was a “stupid idea”. A day or so later, out came my brand new, ready for college, Smith Corona electric typewriter, and I pecked out an admiring note to Dr. Martin.

Well, wouldn't you know it but that son of a gun called me on my home phone line on Long Island? Let's take a moment: back in 1972, no email, no cell phones, my mother probably answered the call from Dr. Martin. In that fateful call, he told me to get on a train and come to the Wharton campus at Penn in Philadelphia. Sometime in the early spring of 1973, just prior to high school graduation, off I went to meet Dr. Martin.

This is a very personal and admittedly corny story, but it led me to the prestigious Leonard Davis Institute on Locust Walk at the epicenter of the nation's foremost school of business, practically adjacent to one of the top five medical schools in America. Most of this I was blissfully unaware of as a high school senior.

Meeting Sam in his office as a high school kid, was truly remarkable. He was six feet four inches tall, a decorated World War II hero in the O. S. S., and had been appointed by the Robert Wood Johnson Foundation to build a national program to produce academic physician leaders. Penn was one of five such sites across the nation, and Sam was the executive director of the Penn program.

That day in 1973, began a 20 year mentor mentee relationship with Sam. He helped me understand the interaction among the broad fields of management, leadership and medicine. He was in retrospect, eerily prescient in predicting where our industry was headed.

Sam even suggested that I should consider majoring in economics as an undergraduate and simultaneously try to fulfill all of the needed pre-medical requirements. Finding a college where I could actually “operationalize” this plan was daunting, and luckily, Vassar in Poughkeepsie, New York, fit the bill.

Of course, the fact that Vassar had just gone coed, and it was the one of the most prestigious girls’ schools in America, didn't hurt either!

While at Vassar, and with advice from Sam, I completed the plan. My senior thesis, written in 1977 in the Department of Economics, was about health maintenance organizations. Literally no one in the entire Economics Department at Vassar even knew what an HMO was.

In those days, we went straight from college to medical school, there was no such thing as a gap year or even a junior year abroad for pre-med nerds like me. I was lucky to get into multiple medical schools and off to the University of Rochester I went. I continued to meet with Sam annually.

While at the University of Rochester, I became active in student government. In retrospect, my grades in the first two years of medical school were so terrible that I probably was running away from further anxiety and embarrassment in the classroom.

In the summer of 1978, after year one of medical school, I was selected by the Department of Community Medicine to travel to Portland, Oregon for three months and to conduct health services research at the Kaiser Permanente Research Center. This was a pivotal moment in my leadership journey, as I got to meet persons who were thinking about population health, although we didn't call it pop health back then!

I returned for the second year of medical school with new enthusiasm, and with hope that I would pass and get to the clinical years. My student government activity included representing Rochester as a delegate of sorts to a regional American Medical Student Association (AMSA) meeting in New York City.

In October of 1978, the fall of year two of medical school, Rochester actually paid for me to fly to New York City to attend an AMSA regional meeting at the Mount Sinai Medical Center in Manhattan.

At that AMSA meeting, while staying in New York City with my college girlfriend in her apartment, I found myself sitting next to a really cute brunette from Brown University. I’m very happy to report that Dr. Esther Nash is also here with me today, 45 years later. More about her shortly.

Part Two, from AAMD to ACPE to AAPL

I first learned about the American Association of Medical Directors (AAMD) as a Robert Wood Johnson Foundation Clinical Scholar at Penn Med School. Luckily, following internship and residency, I was accepted into this fantastic National Leadership Program under Dr. Martin's tutelage on the Penn campus. I finished residency on a Friday in 1984 and that Monday was in summer school at Wharton.

Later that same year at Wharton, I believe that Roger Schenke, one of the founders of AAMD, visited the Wharton campus to talk about physician leadership. I was totally struck by Roger’s presentation. Although many of the faculty thought that he lacked key academic credentials, I was smitten.

I discussed joining the AAMD with other campus leaders, most of whom said it was likely to be a complete waste of time. As a result, I remember traveling to Tampa, using my fellowship resources on Friday, September 20, 1985 to have a private meeting with Roger.

How would you describe Roger Schenke? Well, I was a 29 year old physician oozing ambition, Roger was a tough ex-military non-clinican leader and I made Roger an offer. I told him that I would teach a course on writing research papers for publication, if he would allow me to teach in one or more of the AAMD programs. I added to the offer by saying that if I got a top evaluation, he would then promise to invite me back to future meetings. We shook hands on that deal. I finished my MBA in 1986 and then joined the University of Pennsylvania general internal medicine faculty.

I spent nearly four years on the Penn campus, practicing general medicine, being a junior faculty member at the med school, and I even had the opportunity to teach an intro health management course at Wharton as well. In 1990 I got recruited from Penn to join Jefferson University, just about 25 blocks east of the Penn campus.

The Jefferson Medical College Dean who recruited me, Dr. Joseph Gonnella, just celebrated his 89th birthday with a special ceremony on our campus at Jefferson, not even one month ago.

But here's where the story connects AAMD to the American College of Physician Executives (ACPE) to AAPL. Roger Schenke called me in 1992 after I had spoken at a series of AAMD meetings, and he said, and I'll paraphrase, that “you've got what it takes and I want you to create a four day core course on quality and safety, go recruit whatever faculty you need, and come back to me with the details. And we're going to launch this course in 1993”.

After nearly a year of work with key colleagues, including the late John Coombs, who was then the associate dean at the University of Washington School of Medicine, we launched the now famous course called the Three Faces of Quality. The Three Faces mirrored the Donabedian tripod(3) of structure, process and outcomes. You have to picture what the course was originally like, four days, two full eight hour days and two half days. Each recipient received two gigantic printed binders. We were using 35 millimeter slides. I carried a Kodak slide carousel in my briefcase to these meetings and every night rearranged the slides as necessary for the next day's lecture. Special thanks to a former colleague at ACPE, Mr. Howard Horwitz, who insisted that I make the transition from 35 millimeter slides to a new platform called “PowerPoint”.

Truthfully, the timeframe from 1993 to 1999 was the heyday of the Three Faces of Quality. Typically, we hosted nearly 100 ACPE attendees in a large ballroom. It was exhausting and exhilarating at the same time. I celebrated multiple birthdays while teaching the Three Faces. It was as though the storied La Paloma hotel in Tucson, Arizona, became my special birthday place. And in a crazy way, celebrating birthday 40, 50 and 60 were all part of the history of the Three Faces of Quality. My wife was generally good natured about this and at various times sent a singing cowboy or other crazy visitors who crashed our course for a few minutes. At my 40th birthday, the college wheeled out a gigantic birthday cake in the middle of the class and it was wonderful show of support.

Let's spend a moment further examining the evolution of AAMD to ACPE to AAPL. For example, in 1999, a rocket booster was applied to the Three Faces with the publication of the Institute of Medicine, now the National Academy of Medicine report, To Err Is Human(4). All of a sudden, everybody was interested in adopting the tenets of quality improvement. People like Phil Crosby, and others became household names. In 2001, the publication of Crossing the Quality Chasm(5) provided further evidence that the Three Faces was the way to go to obtain the necessary grounding in quality and safety, especially for rising physician leaders.

Standout memories of that four day course included the 7am voluntary Journal Club, the two case studies with vigorous class participation, and, of course, multiple jokes that I certainly could not tell in today's political environment. I enjoyed every minute of the day’s classroom work and realized that my energy came from being with these amazing emerging leaders from around the country.

In 2006, my first book with ACPE(6) was published entitled Practicing Medicine in the 21st Century. This was an edited volume with contributors from all over the country, including some leading ACPE members. Somewhat ironically, this future-focused book had a picture of a palm pilot on the cover! I remember that we had to hurry up and replace that cover with a Blackberry, not a great move!

Sadly, John Coombs, died in 2009 of a malignant melanoma at age 63. It was a huge loss to me personally, and of course to the college as well. While I was terribly sad about John's passing, 2009 was also a watershed time at Jefferson, where the University created the nation's first College of Population Health, and I was named the Founding Dean. It was an emotional roller coaster.

In 2010, I came to a special ACPE board meeting and presented to Alan Kaplan, who of course is here with us today, about the possibility of Jefferson and our new College of Population Health, becoming a partner with ACPE. The partnership would be focused on our brand new, second in the country, Master's degree in Quality and Safety. Alan and the board thankfully embraced our proposal, and we joined the ranks of other grad schools like Carnegie Mellon and the University of Massachusetts.

By 2012, my second book with ACPE, entitled Healthcare Quality, the Clinicians Primer(7) was published. This book was designed especially for doctors with big print and lots of pictures. It became the de facto textbook for the Three Faces of Quality.

By 2013, it appeared that it was time to break up the band. No one really wanted to spend four days at a hotel where most of the material could really be adapted to two full days. As a result, I was compelled to leave the Three Faces in very capable hands of faculty whom I had trained. I joined what we used to call the PIM, Physician in Management team. My new responsibility, more than a decade ago, was to create and deliver a one day, eight hour overall introduction to the “Fundamentals of Quality and Safety”. This remains my principal responsibility with AAPL today.

In 2019, I voluntarily stepped down from the Deanship of the College of Population Health at Jefferson. I felt strongly that good leaders need to step aside after a decade or more at the helm. It's also true that most Dean's exit in one of two ways. They get fired, or they get carried out feet first. Neither of those exits was appealing to me.

As the only Emeritus Dean still working full time after 33 years on the Jefferson campus, the university president most recently has called me a “unicorn”. Well, I've been called far worse. But a good leadership lesson here is if you're looking to your organization for love and affection, I would strongly urge you instead to buy a dog.

Part Three, Connect the Dots, Milestones on Our Leadership Journey.

In his October 4, 2022 Modern Healthcare editorial(8), our CEO, Dr. Peter Angood, summed up our field well by calling physician leaders, “interface professionals”. I think that's a great label. We are translators. We are bridge builders. We are interpreters. And we promote the true north of the biggest industry in America. The true north is our mission to improve health.

Let's just take a moment. In 1993, there were no Chief Medical Officers or Chief Quality Officers, there was no “fund of knowledge” or agreed upon curriculum for quality and safety.

I believe it's fair to say with the evolution of AAMD to ACPE to AAPL that this organization has led the transformation toward the professional Doctor/Leader. We started with CME credit, and then created the Triple M degree (Masters in Medical Management) and then partnerships with other leading universities, and promulgated the notion of the certified physician executive which is now a well-recognized national credential.

Finally, looking at this evolutionary arc into the future, I think we can see three key accomplishments including 15 collaborating universities, under the auspices of CAHME (the Commission on Accreditation of Healthcare Management Education), who are self-evaluating, and ultimately on a mission to certify and accredit master's degrees in health care quality and safety(9). In 1993, we could only have dreamt about 15 universities offering a master's degree in quality and safety.

Even the ACGME, right here in Chicago, after a decade of struggle, has approved a two-year non-clinical post residency fellowship in what they clumsily call HALM, health administration, leadership and management(10). But this, I believe, is a pivotal event in the evolution of our field, whereby academic medicine is recognizing the importance of additional training in the arena that we believe is so critical to the future.

Finally, with the publication in 2023 of the Fifth Edition of The Healthcare Quality Book(11) by the Health Administration Press, we now have the most widely used graduate level text in our field. It has been my privilege to be one of the editors since the first edition.

Part Four – Take Home Messages

Now, for some personal take home messages. Good teachers always end with some pithy take home messages. And that's what I would like to conclude with now. Back at Wharton, I had many great teachers but Dr. Bill Kissick stands out, because of his aphorism, “always be nice to people on your way up, as you will surely need them on your way down”. All I can say here is “amen”.

Similarly, Chuck Dwyer, who taught at many AAPL events, said, “never expect anyone to engage in a behavior that serves your needs and values unless you give that person adequate reason to do so”.

Another great mentor, the consultant Tom Atchinson, taught me as a leader you cannot over communicate. And of course, Dr. Samuel P. Martin. His recipe for success was process, process, process and then worry about the outcome. All good work is three quarters process and one quarter outcome.

In closing, I want to recognize again some key persons. First, of course, my physician wife, Dr. Esther Nash, who is here with us today. We are blessed with three children and two perfect grandchildren and another one on the way! The entire team at AAPL, with a special thanks to Dr. Angood, Dr. Kaplan and the entire board of directors. Also, thanks to former staff like Howard Horwitz, the late Roger Schenke, and our late colleague, Dr. John Coombs.

But finally, I want to thank each and every one of you. By one estimate, I have taught in person, nearly 6,000 AAPL members over the past three decades. I have had the privilege and honor of being your teacher, your colleague and your fellow traveler on our leadership journey together. This is something that I will always treasure. Thanks again for joining me here today.

References

1. Lazarus, A. MD/MBA: Physicians on the New Frontier of Medical Management
   ACPE, Tampa FL 1988.

2. Despite an extensive search, I cannot locate the exact article from 1972.

3. Ayanian JZ, Markel HM. Donabedian’s Lasting Framework for Health Care Quality
   N Engl J Med 2016;375:205-207.

4. Institute of Medicine Committee on Quality of Health Care in America. Kohn, LT, Corrigan JM, Donaldson MS, et al. To Err is Human: Building a Safer Health System. Washington D.C. National Academy Press 2000.

5. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington D.C. National Academy Press 2000.

6. Nash DB, Skoufalos A, Hartman M, et al. Practicing Medicine in the 21st Century
   ACPE, Tampa FL 2006.

7. Nash DB, Clarke J, Skoufalos A, et al. Health Care Quality: The Clinician’s Primer ACPE, Tampa FL 2012.

8. Angood P. Opinion: As the Industry Evolves, We Need More Physician Leaders. Modern Healthcare October 4, 2022.

9. Oglesby WH, Hall AG, Valenta AL, et al. Accrediting Graduate Programs in Healthcare Quality and Safety. AmJMedQual 2021;36:441-448.

10. Anonymous. ACGME Program Requirements for Graduate Medical Education in Health Care Administration, Leadership and Management. Sept 26, 2021. www.acgme.org.

11. Joshi MS, Ransom SB, Ransom ER and Nash DB. The Healthcare Quality Book (Fifth Edition) Health Administration Press, Chicago, IL 2023.

Posted with permission from American Journal of Medical Quality 38(5): p 213-217, September/October 2023. | DOI: 10.1097/JMQ.0000000000000141