Podcast: CareCulture President's Perspective on Service-Centered Healthcare Culture

Listen to the podcast below to hear CareCulture President Lawrence Bean, MD, FACEP, MBA share the inspiration behind CareCulture's unique, service-oriented approach to transforming emergency departments.

Podcast Transcript

What is CareCulture all about?

First and foremost, we serve each other, we have integrity in what we do. We take ownership of our mistakes and we look at every problem through a lens of, “how can I do something better for the person in front of me.” If you build a culture around that you can adapt to anything else. Everything else is fixed around that. We wanted to build a business around this culture because we believe it is much more lasting. It endures any changes in technology, in environment, in healthcare in general. No matter what happens with Medicare, Medicaid, payers, insurance. None of that matters. What matters is taking care of the patient and taking care of each other, so we have a great place to go work every day.

What inspired you to embrace this culture/philosophy?

Where this all started for me was where I grew up. I grew up somewhere where there was a lot of violence, a lot of drug use, children were turned into adults very young. But the thing that I saw was we were all people and that we all have needs and that sometimes the people who appear the scariest have the biggest needs and that they can be changed through compassion and kindness and it really happens every day and a lot of them are in a lot of pain and seeking comfort.

I knew early on that I wanted to do something with my life that provided comfort to people who were in pain. And relief to people who were suffering and hope to people who were hopeless. And my introduction to that was kind of a divine intervention. A friend of mine had a physician drop off a mission trip that they were doing into the Dominican Republic, he asked me if I had a passport and wanted to go. I discovered something on that trip, a sense of renewal and of purpose and vision that I did not know previously existed. It was serving the people that had need—just like we were doing in the emergency department—but it was so much more need and they had so much less. I couldn’t truly realize how much need they had without seeing it and being a part of it. The gratitude that they, in turn, expressed was like nothing I’d ever seen either. It was very fulfilling on multiple levels, personally gratifying, but also definitely fulfilling that sense of purpose. I came back talking about it non-stop. I immediately went to Eugene (now CEO of CareCulture) since I knew he thought the same way I did about things; he and I went together Armenia and after that [service] became a huge part of our lives. It became integrated into our larger vision.

What inspired you to start CareCulture?

We saw a really high level of burnout amongst ER providers. We saw a lot of unhappiness in clinical interactions…the interactions between providers and nurses, between providers and techs and the rest of the hospital staff. We felt there was something that could be done to change that.

Amazingly, there were days that everything was different. Some days I would be [working in the emergency department] and things would be really rough. I knew I had a good purpose. I knew I was there for the right reason, I knew these were people that needed serving. I knew I was where I should be. But they were rough days. Then, an amazing day would happen right afterword. So, you start asking yourself, “why was yesterday so bad and why was today so great?” You start looking at the people around you and you start seeing patterns develop. One pattern that developed was when Javier was on and when Eugene was on, it was a great day. Over time we figured out what the difference was, why it was so much better when we were with each other. It’s not just our friendship. It’s actually what drew us to each other and the reason we knew we would get along. And that is, this mentality of serving. Of serving each other and serving all the people around us. We hadn’t yet defined what it was that made the days great when we were together. We knew we liked each other, but why did it change the entire environment of the ED? Why was that so much different.

Our EVP (executive vice president) over our ED noticed we had something special when we worked [together]. He had worked side-by-side with us a couple times and knew there was something about our culture. He asked us to go to EDs that were struggling and help them work out some of their problems. We would go to these places and it was always a problem with flow or some technical issue, but we chose to dig and ask “why is this happening?” It was followed by, “I’m doing what’s best for the patient.” And someone else saying, “No. I’M doing what’s best for the patient.” And we sat around and discussed that and said, you know, it’s interesting that that phrase, “I’m doing what’s best for the patient.” Is being used as a weapon against someone else in a disagreement. We’re all there to do what’s best for the patient. The further we dug, [we discovered the issue] was conflict [between] two very well-intentioned people or multiple well-intentioned people over how best to do their job.

Why do you believe in CareCulture’s service-focused approach?

The patient always benefits when you fix [conflicts] during the delivery of care. This finally really turned the corner for us and we knew you have to focus first on serving each other. We know we’re all there for the patient. But if you focus first on serving each other, you can no longer use that as a weapon against each other, we’re all going to do what’s right, and you can have disagreements without beating each other up… It’s changed everything.

We’ve applied this approach at multiple places and every time we did it, it worked. It fixed all these operational metrics…things that were technical seemed to immediately improve when you applied this one philosophy. That philosophy shone through all the other stuff that was going on, all the bad attitudes that might be around…when just a couple of people start serving each other and serving even the people that aren’t serving them, you serve them and your kind to them and that starts to rub off and change the mentality of everyone around you. There’s nothing complex about it. It’s not hard to implement into any healthcare facility. Into any healthcare setting. There’s no barrier to it. It’s just a very human fundamental principle: I’m going to serve the person in front of me to the best of my ability.

You don’t have to solve every little problem that everyone has. You have to teach people to solve their own problems. The way you do it, the core principle behind that: start with asking the question, “how can I serve this person that I am conflict with?” We knew we both came to work today to heal this patient, to make their lives better. Why are we in conflict? What can I do to serve this person that will at its core fix this problem between us?

CareCulture is a movement. CareCulture is a group of people who are trying to change the way medicine is practiced. In the hospital specifically, but also everywhere. We are focused on serving each other first and knowing the patient will benefit from the work that we do. The better a team functions, the more efficient and high quality care the patient will receive. So, we focus first on the team and on serving each other and building the team and building each other up and creating an environment where everyone loves coming to work. Every problem within the healthcare team is solved with this solution. We’ve yet to find one that doesn’t get fixed with it.

Why We Believe in Being the In-Network Emergency Department Management Group

Emergency medicine physician staffing firms are increasingly associated with egregious out-of-network billing practices. Not CareCulture Health Partners.

The in-network/out-of-network billing debacle is driven, at least in part, by a dysfunctional system. The current state of emergency medicine billing does not align healthcare facilities, providers, and consumers around patient care. Headlines regarding surprise out-of-network bills from other emergency medicine groups in our industry are ugly. Patients who receive surprise, exorbitant bills want answers. Hospitals, blamed for the exorbitant bills, are left trying to repair community perception and negative patient experience. And clinicians – the front line of the hospital’s community perception – are caught in the controversy, adding to the list of bureaucratic headaches driving physician burn out (all while we face an unprecedented physician shortage).

The tension between payers, providers, and consumers is certainly thick, but it is not impenetrable. The fact is, balance billing is not new. Since the unfunded EMTALA mandate in 1986, emergency departments have been particularly impacted by billing issues. This issue has come to the forefront as patients have become responsible for a larger portion of their healthcare costs.

As our health system changes, we are heeding the call to change along with it. Our mission at CareCulture is to inspire a movement to change the culture in which healthcare is delivered, for the better. We believe that includes empowering clinicians and ensuring they are paid fairly for the services they provide while also fostering a stable, positive patient experience that includes the post-discharge billing process.

That is why we prioritize negotiating in-network rates at all of our sites. It is an integral part of achieving our mission to be a responsible partner dedicated to changing the culture in which healthcare is delivered. Achieving the best outcomes for facilities, providers, payers, and patients, requires that we pursue positive healthcare change to not only empower clinicians and prioritize patient care quality, but also bear more of the financial burden associated with going in network. Doing so engenders more engaged clinician teams, better patient experiences, improved community perception, and reduced variability in patient care—all of which is appealing to both the managed care organizations we negotiate with and the facilities we serve.

Photo by NeONBRAND on Unsplash

The Transformative Power of Clinical Mission Work

Just a few years after completing his residency in emergency medicine, CareCulture Health Partners CEO Dr. Eugene Gicheru felt the burnout so many physicians face seeping into his life. The monotonous cycle was ingrained: wake up, work, do it all again. The gap between his daily grind and a feeling of fulfillment and purpose widened. Even though he had accomplished his personal goal of becoming a physician, he felt there had to be more. He resolved to break the cycle. He always knew that it was possible to cultivate fulfilling harmony between work and life. But how?

Dr. Gicheru knew that emergency medicine would be challenging and that burnout was common. But he was determined to find an outlet that would reinvigorate him, anchor him, and give him a deeper sense of purpose. He found his answer when he began participating in non-profit clinical mission work with colleagues.

In 2010, Dr. Gicheru went on his first medical mission trip to Armenia. That trip, and the many that followed, sparked a lasting passion for service through mission work. Dr. Gicheru traveled about twice a year to serve, and for him, each trip was a rededication for his commitment to serving others. It filled the void. It blended a sense of purpose he could apply interchangeably to work and to life. And, it turned out, the renewed fervor and purpose it gave him was contagious. Today, Dr. Gicheru is able to travel with his wife Laura and 2 sons so they can experience this sense of purpose as a family.

After joining other organization’s trips for years, Dr. Gicheru co-founded his own non-profit, Great Commission Outreach (GCO). GCO’s mission is to provide high quality health care to communities in need locally and across the world. GCO evolved from encouraging the spirit of service by going on short term mission trips to a complex organization that supports communities both in the United States and all over the world. GCO’s domestic arm, Clinic for the Cities, is dedicated to partnering with churches to provide free local community clinics in the United States.

Dr. Gicheru believes all humans eventually search for meaning and  purpose in their lives and for him that purpose was found through service. He enjoys seeing the clinical team members who join him on trips return to their clinical teams with the same renewed enthusiasm for the practice of medicine he experiences. The feeling is often contagious, extending to co-workers and patients and drastically improving the overall team dynamic.

To learn more about the transformative power of clinical mission work, we spoke with a colleague Dr. Gicheru inspired, Jessica Hughes Kisicki, MD, FACEP, about the way clinical mission work has transformed her approach to her life and career. 

What do you find most rewarding about service?

Dr. Hughes Kisicki: Since I was a child, I have always been inclined to help people in need. I know my purpose is to serve people in need and my goal is to do that in all facets of my life. If I see an opportunity to serve someone in need, I seize it. I find it rewarding to share my knowledge, strength, and love with communities in need. It’s an incredible feeling to watch these same communities grow to be self-sustaining and thriving.

Why do you recommend that clinicians participate in non-profit clinical work?

Dr. Hughes Kisicki: I would recommend missions because serving others not only benefits the person you are serving, but also benefits the person serving. It is incredibly fulfilling to give your time, energy, and love to others. You receive far more than you give. If the world is full of servants, our world will be a better place.  

How has service impacted your life at home?

Dr. Hughes Kisicki: Mission work has changed my life. I’ve always valued selflessness and mission work has enhanced my intention to live that value every day. This work has helped me see that every person has struggles and there is always an opportunity to help others. As a mom and emergency department medical director, I strive to be a servant leader in every aspect of my life. I am raising my children to be servants who are selfless and loving.

I have also found that by treating people selflessly, others have become inspired to do the same. In fact, the Guatemala trip in June 2018 will be full of people from my hospital who have become inspired to serve by seeing how we treat people and by hearing our stories. I have learned that serving is what truly matters in life, not material things. 

How has service made you stronger clinical leader?

Dr. Hughes Kisicki: Service has made me a much stronger leader. I have learned to slow down and really listen to people. I have learned that it is important to inspire others to serve and grow. Every single person has a need that you can fulfill at some point, and it is very important to lift other people up. Status and material things are not important, people are. Love and strength can build people up and change their life.

6 Philosophies Forward-Thinking Emergency Departments Share

Emergency departments that embrace the below philosophies benefit from outstanding culture and in turn  high physician retention rates and leading performance metrics.

We are owners, not renters

Successful emergency departments engender a sense of ownership among the team by engaging them in formal and informal meetings, seeking and implementing their feedback, and rewarding their accomplishments.

We are here to serve

Strong emergency departments view all – from medical directors and physicians to nurses and techs – as important members of the team and they prioritize serving their team members so that they may better serve their patients. This means doing the extra thing to make life easier for every person you interact with, every day.

We are accountable

Thriving emergency departments consider every challenge and opportunity and consistently address issues rather than shifting blame or accepting the status quo. That means turning phrases such as, “I can’t do that. It’s not our policy...” and “that’s not my job…” on their heads and replacing them with constructive phrases like, “Let me see what I can do,” and “Let me find someone who can help.”

We are positive

Positivity breeds more positivity. Consistent positive communication across all roles within the emergency department makes it difficult to have a negative interaction with a colleague or a patient, which improves both patient satisfaction and provider burnout and turnover rates.

We communicate with respect

Improved efficiency, quality, and practice culture starts with better face-to-face communication at every interaction, from patient check-in, to patient hand-off, to admission, discharge, or transfer. Every interaction, no matter how high-stress should be positive, constructive, and respectful.

We are innovative   

The definition of insanity applies here: you cannot keep doing the same thing over and over and expect different results. Your ED must evolve to succeed. Part of innovating for the future is considering the department’s impact on the entire continuum of care. Overall, successful emergency departments ask “how can we do it better?” rather than holding on to, “that’s the way we’ve always done it.”

Adopting these philosophies can pay dividends in reduced provider turnover costs due to increased provider satisfaction, increased efficiency due to improved interdisciplinary relations, and more satisfied patients due to kind, respectful interactions and smoother patient transitions. These tenets contribute to a strong program culture, and by building a solid cultural foundation, you set the tone for lasting, tangible increases in patient and clinician satisfaction, positive community reputation, and quality and efficiency performance improvements across the board.

Culture Check Up: How to Assess Your Emergency Department Culture

Whether you are aware of it or not, your emergency department has a unique subculture within your organization. Hopefully the subculture is positive and harmonious. If there are elements of dysfunction begin by assessing your emergency department’s current strengths, weaknesses, and opportunity areas. Outlined below are steps to follow to assure your emergency department team is united and headed in a direction that mutually benefits the providers, staff, hospital or health system, and the patients and community you serve.

1. Identify key stakeholders

When working to assess the culture of the emergency department, it is crucial to include everyone who works within or interfaces with the emergency department in your assessment. This includes:

• Hospital administration

• Hospital leaders and community providers who interface with the emergency department

• Physicians and Advanced Practice Providers

• Nurses and technicians

1. Have face-to-face conversations with key stakeholders

Once you have identified stakeholders, talk with them to clearly understand their vision, needs, and goals. The act of asking for input is itself a great opportunity to promote a culture where everyone feels valued. Start by asking:

• What do you love most about your job?

• What would you change that would make coming to work each day a more positive experience?

• How does/can the emergency department contribute to achieving your goals/meeting your needs?

1. Summarize key challenges and opportunities

A collective review of answers to the questions in the previous section can illuminate core strengths and weaknesses of department culture. After you have this information, natural themes will emerge around which workflows, processes, and training need to be improved to promote a more satisfied staff and in turn safer, more cost-effective, efficient patient care. Your summary should include a full assessment of the following:

• How does the community perceive the emergency department?

• What are the abilities of the current clinical staff?

• What is important to each stakeholder and are priorities aligned?

• Physician turnover, how often are providers leaving and why?

• How are physician relations with APPs, nursing staff, and techs?

• What defines success?

• What is the general attitude among staff?

• Does the clinical staff feel supported?

• Does the clinical staff feel invested?

• What are the primary communication issues within the department?

• Where does efficiency/throughput break down? Why?

10 Traits of Great Clinical Leaders

Your medical director’s leadership sets the tone for the entire emergency department. A medical director who understands both the daily realities of clinical work and the operational and financial realities your hospital faces is critical to the effective development of your emergency department. While leadership is not the focus of medical school, that does not  mean you cannot  find a medical director with leadership experience or develop your current medical director to lead your emergency department.

Essential traits of effective medical directors include:

1. Leads by example (not word alone)

2. Willing to defer credit to team members rather than taking credit

3. Ability to have positive conversations about conflict

4. Ability to communicate department vision, goals, and progress toward achieving those goals

5. Servant leadership mindset (believes he/she works for the team rather than the team working for him/her)

6. Is comfortable leaving their title and ego at the door and working alongside their team in the trenches

7. Willingness to be open and vulnerable with team members

8. Open to receiving and sharing both positive and negative feedback

9. Invested in seeking and acting on the input of every member of the team

10. Positive mindset, views challenges as opportunities to improve

All effective leaders establish trust. The above list includes foundational traits leaders who have the unwavering trust of their team and peers embody. If your emergency department leadership is not trusted, you must resolve that issue with coaching, mentoring, or a leadership change before your department will be able to realize its potential.