Innovating Leadership:
Co-Creating Our Future

Resources:

Bill invites physicians and others in the healthcare industry to learn more about the Learn from Every Patient program by emailing him at William.Smoyer@NationwideChildrens.org.

Our host Maureen Metcalf posts a newsletter every week on LinkedIn. You can subscribe here.

Maureen’s latest book is Innovative Leadership & Followership in the Age of AI. You’ll find details about it at https://bit.ly/LeaderInAI, or check out the Kindle version at https://amzn.to/44buVz8. The audiobook version is now available at  https://amzn.to/4dTCleZ.

Her other 10 books are available on Amazon here.

Other episodes you’ll enjoy:

– High-Performance Medicine: Healthcare’s Lessons for Your Elite Teams with Brian Ferguson

– Pets, Purpose, & Power: The Animal Science of Leadership with Rustin Moore

– From Data to Dialogue: Why Leaders Need More than Numbers with Rens van Loon

Guest(s):

Guest(s) Bio:

William Smoyer, MD, is a member of the Section of Nephrology and Hypertension at Nationwide Children’s Hospital, vice president and director for the Center for Clinical and Translational Research at the Abigail Research Institute at Nationwide Children’s Hospital, Robert Kidder chair in Clinical and Translational Research, and a professor of Pediatrics at The Ohio State University College of Medicine. Prior to joining Nationwide Children’s Hospital, he served as both the Pediatric Nephrology Division Director and Fellowship Program Director at the University of Michigan, which also included extensive mentoring of both fellows and junior faculty members regarding career and research program development.

Transcript
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Maureen: [00:00:00] I’m your host, Maureen Metcalf. I am delighted today to welcome Dr. Bill Smoyer. Bill is currently serving as the Vice President for Clinical and Translational Research at the Research Institute at Nationwide Children’s Hospital. 

In an era where we’re facing major changes in our medical system, with medical costs as high as 20% of GDP, Bill is a leader who’s working to address this challenge. Bill will talk to us about some of the changes and a program he’s created to help move us toward some portion of a solution. So Bill, welcome.  

Bill: Thank you very much for having me.  

Maureen: So let’s talk a little bit about your background. What do you do? What is a pediatric nephrologist?  

Bill: Essentially a children’s kidney doctor. 

But I have spent the majority of my career as a, what we would call a physician scientist, so not only providing the care of today, but doing research to try and figure out what the care of tomorrow should look like. The charge when I was hired is to integrate the [00:01:00] clinical care that was taking place in the hospital with the new knowledge that was being generated in the research institute. Quite simply, how are we going to incorporate that knowledge into the everyday delivery of care to patients? 

And that was actually the impetus for the program that I developed.  

Maureen: What is the program that you developed?  

Bill: So this program we have termed Learn from Every Patient. 

So one of the first things that I did was go around and speak to all of the clinical leaders in the hospital. And then, I went and spoke to all of the research leaders in the research institute. And after pulling all of the information that I learned from all of those interviews together, I came to the conclusion that the approach that we had been using was actually not a strategy for the future. 

A much more powerful approach to go forward would be to fully integrate the research into the clinical care so that in fact, the [00:02:00] research became part and parcel of the everyday delivery of care. 

And this is why we gave it the name of Learn from Every Patient. 

Maureen: The title makes intuitive sense, that as leaders in every field, we should be learning from each of our interactions. Yet how do you make that practical? 

Bill: So the reality of our situation in healthcare is that we have developed policies and procedures and in fact laws that separate the provision of clinical care  

from the policies and procedures and laws that govern the research. 

So these two activities are truly separated by these policies and approaches and laws, when in fact, what we really need is to put them back together so that when we are providing care, we are using that as information to better inform how we will improve care in the future.  

Maureen: Of course you’re not using humans as guinea pigs, and then that’s [00:03:00] presumably why they were pulled apart. 

Bill: Well, in part, and there, there were abuses in research studies in the past- mm-hmm. … where patients’ best interests were not protected, and this has led to the evolution of institutional review boards whose sole job is to protect research subjects from studies or investigators or interventions that might offer them more harm than potential benefit. 

The idea of connecting these two processes really was quite simple. In fact, it is what an engineer would call a systems engineering approach. 

It’s very simple, but the reality is that that is not how medicine and research are practiced in the current day. So what was a very simple concept in design turned out to be quite disruptive in its effects on how we practice medicine and how we do research.  

Maureen: You bring up the word disruptive, which is kind of one of the tag words I think we’re facing right now across fields-  

Bill: [00:04:00] mm-hmm. 

Maureen: you also have a passion for leadership. As you’re thinking about how to implement something that’s disruptive, give us a little insight into how you think about leading transformation?  

Bill: Sure. One most important concept is physicians almost always end up on teams, whether it’s a large medical center or a small medical center, inpatient or outpatient, and when physicians end up on teams, they typically will end up in either the leadership group or as the leader of the team. 

What is unfortunate is that historically, we have actually not done a particularly good job at giving leadership training to physicians, even though they end up leading groups, they end up leading clinics, they end up leading hospitals or medical centers. 

So, I think leadership development is a critical developmental skill for physicians because they will almost for sure need those skills as they advance through their career.  

Maureen: And to your point, they [00:05:00] haven’t been traditionally offered in medical schools.  

Bill: No, but that also is changing as people are recognizing that when they put physicians in these roles, that they oftentimes haven’t been given the fundamental theories and skills to be effective in those roles. 

Mm-hmm. They’re smart, they’re accomplished, but those accomplishments aren’t necessarily the leadership skills that they need to be successful in those roles. So I think that the role of the physician appreciating that the physician is oftentimes in a leadership role is important both for them and for their organizations to recognize. 

Mm-hmm. And many, many medical centers now are investing significant resources in physician leadership because of this recognition of the importance of whether they perform well or poorly in those leadership roles.  

Maureen: Let’s go back to the conversation about learning from every patient. Why is the program so important?  

Bill: Healthcare is a significant expense for our country, somewhere [00:06:00] between 18 and 18.5% of our gross domestic product, and its cost to society is going up at a significantly higher rate than inflation. 

So it is already very expensive for our society and its costs are going up at essentially an unaffordable rate. 

Maureen: And then add to that 10,000 baby boomers a day retiring. So the population’s aging, the generation behind us is smaller, and I’m assuming cost will continue to go up because of advancements.  

Bill: You make a very important point. It’s not that advancements are not taking place. 

We have enormous numbers of advancements, but most all of those advancements in order to incent companies, people, to develop those advancements, they are, are interested in having a return on their investment and when they get the return on the investment, those are the fees that they charge. 

So those advances typically, not always, but typically- mm-hmm. … will come at a higher cost to society.  

One good example is that we’re seeing more and more people come [00:07:00] out with monoclonal antibodies, which are very highly targeted to a variety of different diseases, but they are much more expensive than the traditional less specific drugs that we are used to using. 

So much better care, but at a higher cost. The challenge that lies in front of us is to figure out ways to make care better and cheaper at the same time.  

Maureen: Mm-hmm.  

Bill: And this was what was so alluring to me about this systems engineering approach to actually learn from every patient is historically only somewhere between one and 3% of patients in the US are actually involved in clinical trials committed to improving care. 

With this model that we have tested, what happens is we go to 100% of patients. So every patient that receives care is contributing data that enables us to then analyze it, publish it, and use it to improve care. So it greatly amplifies our ability to improve [00:08:00] care.  

Maureen: When you say use data for every interaction, that sounds like the implementation of big data.  

Bill: It is. As hospitals are moving to the electronic health record, there are enormous amounts of data being collected. So historically, however, data was collected in paper charts really for two main purposes. 

One is to make sure that we adequately documented the care that was provided to substantiate or support the billing- mm-hmm. … for that care. And the other was to save it in the case where there might be a legal action being considered. So there it was kind of protective. In our model and where we are moving with medical care in the future, the data now have what I would consider to be a higher purpose. 

We are collecting the data because we intend to use the data from every patient because that patient’s data is gonna be part of what allows us to improve the care of the patient that follows behind them.  

Maureen: Are there legal implications with this? 

Bill: So there are significant and very [00:09:00] complicated issues around the control of data, the ownership of data, the sharing of data, but I should point out that they are all addressable issues. 

There are methods to partially or completely de- identify data-  

Announcer 2: Okay. …  

Bill: so that if you use my data, you could never tell that it was I who contributed the data, and that is one known and proven way to protect patient’s identity while benefiting from the use of the information that we collected in providing their care. 

Maureen: I have friends with various illnesses that they would rather not have made public. But as long as the data can be anonymized, it seems quite beneficial.  

Bill: Absolutely. And, and this is the, the challenge in front of us is that we now have the capacity and in fact are collecting enormous amounts of data. 

The electronic health record collects data on patient care, the laboratory collects digital data on the blood tests, the urine tests. We’re now collecting digital data on the radiology and the other scanning [00:10:00] technologies that are being used. The pharmacy is collecting large amounts of data about the use and dispensing of the various medicines and exactly which minute they were dispensed. 

So we are accumulating enormous amounts of data. The challenge is how to use all of that data to generate information that is useful to improve care.  

Maureen: How do you use the large volume of data that’s collected and turn it into something that’s productive, not just a pile of data. 

Bill: In our pilot program, the Learn From Every Patient Program, the approach that we took was to try and get the physicians interested in helping us collect these data. We also invited the physicians to ask research questions that they thought would improve the care of their patients. 

And in doing that, we actually were able to get the doctors to be interested in changing the way that they provided care rather than resistant to that. And [00:11:00] physicians’ resistance to being told how they need to change the care, has proven to be one of the biggest challenges to the successful implementation of programs like this. 

So our approach was to engage them completely by offering them the opportunity to be part of improving their own patients care. With this model then, care would be provided, we would collect both the clinical and the research data, and all of that would get migrated to a data mart where all of those would exist in conjunction with the laboratory data and the radiology data. 

That offers us the opportunity then to begin to look at, just as you mentioned, things like outcomes, which is treatment A better than treatment B? 

In our Learn from Every Patient model, we then provided those data back to those physicians who had asked for it.  

Maureen: Having worked with enterprise-wide computer system implementation, there is often a great amount of resistance, but [00:12:00] to your point with physicians, I want to practice medicine the way I want to practice medicine, and now you’re putting me on a standardized system that forces specific behaviors and makes me a typist. 

Bill: Yes. There is widespread resistance in general on the part of physicians to being told you have to do something. Most physicians went into medicine and practice medicine and believe that they practice the very best medicine they know how.  

The reality is that not every variation in care is the best. 

The reality is that only one of them is the best, but we have not embedded systems to help us learn which is the best yet. And this model offers us an approach to begin to learn so that we can begin to refine the care that we provide based on continual production of evidence. 

Those data that get analyzed, what we would then call evidence, will get published in the peer reviewed literature, and as a general [00:13:00] rule, peer reviewed publications are the currency of the realm to provide the basis for changes in care. 

This is what we call evidence-based medicine. 

Maureen: The innovations or improvements happen much faster if I’m collecting data from every patient rather than I’m chartering research studies that need to be funded and staffed.  

Bill: In this model, once you have the evidence, then the evidence should be used to make changes in the care. 

So if a patient comes in with disease X- mm-hmm. … and gets care Y, when they come back to see you in a year or two, what you could tell them then- mm-hmm. … that we cannot tell them now is your care will be different- mm-hmm. 

when we see you in two years-  

Maureen: mm-hmm. …  

Bill: and it will be based on evidence. And that is something we cannot offer most patients today is that their care will be based on evidence rather than experience of the physician, the individual physician [00:14:00] providing care for them. So this embeds the learning into the care. 

Maureen: And the learning across a massive system of patients, not the learning from each unique physician that may or may not see five patients of a certain variety-  

Bill: Yes. …  

Maureen: in a year.  

Bill: So depending on how widely a, a system like this is implemented, that would set the parameters around the learning. In our pilot program, we chose children who had cerebral palsy and were receiving care with one diagnosis at one center. 

So our vision is to expand what we learned with that program- mm-hmm. … at that medical center to other programs at the same medical center, but also to analogous programs, providing care for children with those same diagnoses at other medical centers. So, 

Maureen: To clarify the, the name of the hospital is Nationwide Children’s, but it’s named after Nationwide Insurance, not a designation of the physical location being national. 

Bill: But it is one of the largest children’s [00:15:00] hospitals and research institutes in the country. So it has proven to be fertile ground for doing a pilot program like this. So what we are hoping to do now is this, this pilot program was quite successful. It did show that we could reduce hospitalizations, reduce ER visits, reduce urgent care visits, and at the same time, it actually reduced the total health system charges. 

So at least in this pilot program, we were able to improve care, and it reduced the total health system charges by about 25% that year.  

Maureen: That’s significant.  

Bill: Yes.  

Maureen: Better outcomes and 25% reduction in cost. 

Bill: Yes. We have been pleased with the pilot program results and we are now exploring a number of opportunities with other hospitals and other health systems who might be willing to try some of this apparently disruptive innovation in their hospitals and health systems. 

Maureen: So if I were to think about scaling this, that [00:16:00] would really mean like an NIH dealing with every variation of health issue across scale, so either national or global.  

Bill: Yeah. So in our model, what would happen is that this would happen across clinical programs or diseases- that then would spread to other institutions that were taking care of the same groups of patients.  

Maureen: Mm-hmm..  

Bill: And then with that learning at that institution, the knowledge of how to implement the system could be spread to patients with other diagnosis. So it will likely be an evolutionary process. So I think the idea of just dropping it in and implementing it in one fell swoop is unlikely to be successful. 

In fact- Bad.. But most physicians are not especially interested in having you tell them to change care unless you provide them evidence.  

But on the flip side, most physicians, if you offer them a realistic opportunity to participate in a meaningful way in the improvement in care, most of them will be [00:17:00] very happy to participate in, in a project like that. 

Maureen: There’s no reason that, that the data collection wouldn’t happen around the globe.  

Bill: No, there’s no reason that it couldn’t, but there are reasons that it may not. One of the challenges both within our own country and certainly between countries is the standardization of data, the nomenclature that is used. 

A few years ago when a colleague of mine did a search, there were nine different definitions for what it meant to be a child. Okay. So if you can’t define the patient population it, it makes it very hard to merge-  

Maureen: mm-hmm.. …  

Bill: data collected from populations. 

So these are all solvable problems, but these are challenges that would exist.  

Maureen: At one point, just a silly story, we were implementing in Germany, rolling out a system that was started in the US, and we had selected the wrong character set. 

So the umlaut wasn’t one of the characters, and one recommendation was just don’t use it. That’d be like not using [00:18:00] the O. We run into all kinds of complications and data definition being significant in every system I’ve been involved with.  

Bill: Your example makes a very good point. 

It’s oftentimes nothing fancy- … But it, it is critically important, particularly with electronic systems that we match things exactly so that the data are in fact shareable, so that the data are equally interpretable. But they are all very solvable challenges. 

Mm-hmm. So we don’t need new technology, we need new vision and leadership to commit to solving these problems.  

Maureen: We need new vision and leadership to do this. We know how to implement these systems. 

My experience has been on the corporate side, and it’s hard. On the medical side, a mistake has implications on people’s lives. It has to be done right, but it’s doable. These are things we know how to do. They’re just hard.  

Bill: Yes. [00:19:00] So the stakes are high in medicine, but it is not only our industry where there are very high stakes. 

There are many industries where there are high stakes and precision and accuracy and low failure rates are critical. So I just wanna emphasize again, these are solvable problems. What we need is people and organizations with the vision and the commitment to solve them, that see that this is one of the things that I hope would be considered the innovative aspect of our pilot program, which is we have moved now from a state where we were publishing opinions and editorials about the importance of doing things like creating learning health systems, to now we have an example. 

It’s just one example. It’s just at one program, it’s just in one disease. But once you have an example, then the entire concept that it’s not doable dissolves. And then the question becomes a matter of commitment and will and leadership.  

Maureen: Vision, will, and leadership [00:20:00] and commitment. So how do we implement this? You’ve said it’s one piece of evidence that this is possible, and it’s evidence that something can completely disrupt some parts of how we deliver medicine. 

That seems like a really big deal, and yet I can see a lot of people saying, “I hope I retire before this is done, because it’s gonna change the way I do my work, the work I love doing.”  

Bill: Yes. So the reality in the context of what we’ve been talking about, the challenges of the enormous expenses of healthcare, that the expenses are going up way higher than the rate of inflation. Providing care the way we have been is not sustainable. So the opportunity here is, can we capitalize on things that we have now that we didn’t? Now we have access to data and the question is, can we use it to improve care? I think the answer is unequivocally yes. 

The challenge, however, is how can [00:21:00] we improve care and reduce the costs of providing care? And that is essentially a burning platform that we have right now in healthcare is we need to find ways to reduce the amount of money that our country spends on providing care for our citizens. So the innovation that we hope we’ve provided an example of is that it is not impossible to improve care and reduce costs at the same time. 

It is possible to make care better and more affordable together. And this, this is, we hope, is something that will change the conversation from if we can do it to how and whether we are willing to make the commitment to do it. But the reality is that the practice of medicine will have to change and that will require people with vision and leadership to not just accept it, but to embrace it for the opportunities that are there. 

As I oftentimes like to say, in all [00:22:00] chaos, there lies opportunity. So change is upon us, but that has created opportunities we never had in the past. 

Maureen: So as a citizen and someone who’s aging, who pays insurance, this seems like good news because at some point we’ll be on Medicare and the country budgets for that and it’s a large part of our national debt, which is also increasing. 

So it seems like, while those are big numbers, it does impact our tax burden-  

Bill: And indeed, the Center for Medicare and Medicaid Services has expressed interest and we have been out to talk with them about this model because they are a payer for some hundred million of our citizens and they are very interested in innovative approaches to control the cost of healthcare. 

In fact, we now have a Center for Medicare and Medicaid Innovation, which is an entire group of people dedicated to seeking out innovative strategies to [00:23:00] control costs. 

Maureen: So a third of our population is on Medicare or Medicaid? 

Bill: Roughly.  

Maureen: And that will likely increase as the population ages and lifespan continues to grow.  

Bill: Potentially, if we can afford it.  

Maureen: If we can afford it is a really politically charged question.  

Bill: It is. And so much of the politics swirling around healthcare, as charged as it has been, it has been largely about how to distribute the monies that are currently being put forward for the provision of healthcare. 

We have not yet begun to address what I think is the larger challenge, which is how to reduce those costs. Redistributing them does not solve the problem that they are continuing to rise.  

Maureen: All of that leads to a catastrophic equation if we don’t have a way to pay for it. 

Bill: Correct.  

Maureen: And make it more efficient.  

Bill: Yes. So either less people will get care or people will get less- Less care. Less care. And, you know, of course, no one is interested in [00:24:00] saving money on healthcare if we have to provide worse care. So the, the challenge here, and again, I, I see this as a leadership opportunity, is to envision different models of healthcare that could allow us to achieve this aim. 

Maureen: Envision different models of healthcare, just letting that sink in. My dad was in the military, so we went to military hospitals and we were cared for. There are lots of people in the world who didn’t have that experience and who have not lived to their average life expectancy rate because they didn’t have care. 

So this helps make care available for a broader portion of the population at a reduced cost and better care.  

Bill: Well, I think it’s safe to say that if we can control the costs better, that would give us more options- it doesn’t answer the question about how it will be distributed, but it does create options. 

Mm-hmm. Right now, we’re facing a very difficult options because we [00:25:00] are facing continually rising costs that are significantly higher than the inflation rate, and we’re gonna need to make some changes. So we can wait until they are critical, or we can try and come up with innovative solutions and pilot them- mm-hmm. Just as we have tried to do in our program. So there are other approaches to pilot similar sorts of things, but these are the ideas that we will need to be searching for and maybe implementing many of them and measuring them, expanding them, seeing which ones can successfully scale up or not. But what we desperately need is more people to be coming up with the vision and taking the risks of introducing new approaches that might meet both of these needs, improving care and reducing costs at the same time. 

Maureen: So it sounds like a burning platform. It sounds like a no-brainer also. Here is an opportunity, not easy, but proven results in a small pilot that [00:26:00] will move us forward. What’s the biggest barrier you’re seeing?  

Bill: In the healthcare industry, it is relatively difficult to make changes. 

Change does not come easy in our industry.  

And part of it, is what we’ve talked about because there are high risks for failure when the system fails, but it is also in part because the people that provide the care, the physicians are used to being leaders of their teams, and they’ve been well trained, they may have been mentored by a particular mentor or a particular group of mentors, and they believe that they are providing the best care. 

So until someone can explain to them or prove to them that there are better ways to provide care, they’re not going to be interested in changing. I do believe that physicians will be willing to change, but we need to make it clear how they can participate in being part of the change and how they too will benefit. 

And as I’ve alluded to earlier, I think [00:27:00] that they will believe that they benefit if you can convince them that their patients will directly benefit because that after all is why most of us went into medicine.  

Maureen: Good, super smart people wanting to help improve the health quality of their patients. 

Bill: Yes.  

Maureen: So hopefully we have people listening in the medical practice who would like to learn more about this. How might they do that?  

Bill: So I would be happy to receive emails from anyone that is interested in communicating with me. It’s william.smoyer@nationwidechildrens with an S.org. I’d be happy to have people provide suggestions or continue the discussion. Mm-hmm. 

The question that remains is, could this be used to save more money and improve more care for more patients in the future? So we don’t have the answer to those questions now, but we’re very interested in getting the answers to those questions and those are very testable hypotheses of whether, in fact, it is scalable. 

Maureen: So this is what [00:28:00] research scientists do, right?  

Bill: It is.  

Maureen: One of my clients, one of my favorite statements from her was, “As a researcher, I don’t need to be right. I just need to keep learning.”  

Bill: Yes.  

Maureen: And it sounds like this is a beautiful foundation upon which to build, to solve some very big problems that we will all personally be impacted by at some point in our lives. 

Bill: It does offer, we hope, very nice opportunities to both save money and improve care in a systematic way. 

Maureen: I want to generalize this a little bit. This type of disruption is happening across all industries, across the globe, and so I talk often about leaders taking on the mind of the scientist. 

So as we listen to Bill , hopefully what you’re hearing from him is there are brilliant opportunities to solve the problems we face. 

Bill: And our hope with this is that we can systematize the learning so that it [00:29:00] is occurring with all of the data that we collect on all of the patients all of the time.  

Maureen: So thank you to our listeners and thank you so much, Bill.