Health and healthcare have been important topics of public conversation for decades, and the focus will undoubtedly increase as the US approaches the 2020 election. Much of the public debate and news coverage centers on topics like the future of Obama Care, various single payer or Medicare-for-All proposals, surprise billing, the unaffordability of prescription drugs and biologics, and the continuing consolidation of healthcare insurers and providers.
All these issues are important, but none of them capture what needs to change as completely as the “Quadruple Aim.”  It describes four critical needs:
- Improving the individual patient experience
- Improving health of the population
- Reducing the per capita cost of healthcare
- Helping caregivers find joy and meaning in their work.
People look to us, as experts in the provision of healthcare, for informed guidance on what needs to change and how to do it. So, it will be important that we focus on the big picture before getting lost in the “how.” That’s because the change prescribed by the Quadruple Aim will not happen just through legislation, regulatory action, mergers and acquisitions, consolidation, or disruptive innovation. Change that accomplishes those four goals will require us to realign the focus of our care, engage individual patients and populations in new ways, and better align the financial incentives of caregivers, payers, patients, and populations with optimal health and healthcare outcomes.
That kind of profound restructuring will require leaders with deep expertise in finance, managing organizational complexity, change leadership, and firsthand experience and expertise in the science and culture of healthcare at the front lines.
That means we must bring together leaders at the intersection of operational, financial, and clinical expertise who have the skills to create a compelling vision of how change can lead to better outcomes for all, who can chart a course through the complex journey to the accomplishment of the Quadruple Aim, and who can hold a steady helm through choppy seas while creating a culture of positive energy rather than fear and uncertainty at the front line.
Even a team of individuals with those skills won’t succeed in transforming healthcare unless it is bonded together by personal and professional trust. And trust seems to be a quality in short supply these days. In healthcare, there’s some evidence that differences in professional training and enculturation of administrators and physicians may further impair the development of trust.
Peter Angood, MD, in a 2012 article in Trustee Magazine titled “Changing Demographics, Competencies, and Physician Leadership,”  observed that medical training tends to create a physician mindset of individual expertise, prescribing and expecting compliance, focusing on short term results in episodes of care, following procedures as individuals or small teams, and expecting to receive thanks from patients and respect and trust from colleagues.
In contrast, Angood observes that organizational leaders succeed by leading through collaboration and influence more than from authority, focusing on long-term results, changing complex processes over time, working in large groups that cross boundaries with competing objectives, sharing responsibility with other experts, managing resistance, and working with some people who, from time to time, might accuse you of being a “suit.”
Others have been even more explicit in describing a trust gap between physicians and healthcare administrators. In an Advisory Board 2000 Executive Survey,  CEO’s were asked to indicate what they cared about, and what they thought physicians cared about. At the same time, physicians were asked what was important to them, and what they thought was important to CEO’s. Here’s a summary of the study’s findings:
While this study is nearly 20 years old, I think many of its points are still very relevant, and as I’ve shared it with various groups around the country, other clinical and operational healthcare leaders tend to agree that it describes viewpoints that still profoundly affect our work. The transformation of healthcare will require leaders who can bridge this chasm of trust within our organizations.
When you think of a leader you admire, who comes to mind? Often these days, people seem attracted to leaders who have acquired great wealth, power, and/or celebrity status; or who are outspoken and enjoy confrontation; or who have been successful in disruptive innovation. But think of some people you admire who have successfully led others through difficult times or profound change. What traits contributed to their ability to lead in those situations? Were those measures their greatest strengths?
At the Intermountain Healthcare Leadership Institute, we think that trust is the most needed leadership skill for our times. Trust, the combination of competence and character, requires deliberate daily focus and action, and takes a long time to develop. Trust is essential to successful collaboration between the clinical, financial, and operational leaders who must redesign healthcare and engage payers and patients in sharing responsibility for optimal outcomes. Yet trust is fragile. Trust that has been built over many years can be destroyed very quickly by actions that are, or seem to be, self-serving, unaligned with organizational values, discordant with an organization’s mission, or lacking in integrity.
- The Quadruple Aim: care, health, cost, and meaning in work. R Sikka, JM Morath, L Leap. BMJ Quality and Safety First Online. 2 June 2015.
- Angood P. Changing Demographics, Competencies, and Physician Leadership. Trustee Magazine. 65:10 (2012).
- Health Care Advisory Board. Advisory Board 2000 Executive Survey. The Advisory Board Company, Washington DC (2000). (Unpublished report quoted in Schwartz RW and Pogge C.)
Charles Sorenson, MD, FACS, is President and CEO Emeritus at Intermountain Healthcare and the Founding Director of the Intermountain Healthcare Leadership Institute.