Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Our guest today is Terry Schulder, author of a new book, Ascent to Excellence: A Blueprint for Healthcare Board and Leadership Success. Terry is a seasoned nurse executive specializing in improving health system quality and operational efficiency with experience across a wide variety of provider settings. Thank you so much for joining us, Terry. It's great to have you on the show.

Thank you for inviting me. I'm happy to be here.

Yes, we're so excited to learn more and to dive right into it. And I want to start first by learning more about you and your journey. Can you tell us more about yourself? I'm curious about what drew you to healthcare executive consulting.

I made so I made the journey from the bedside to the C-suite as a chief quality officer within the same hospital system over several years. And during that time, I fell in love with leadership. And I read every book on leadership and healthcare quality that I could get my hands on. And I also had the advantage of working for an organization that supported professional growth. So I attended conferences and I participated in national collaboratives with other health system leaders. And I learned early on that a common thread among top performing health systems was senior leaders, particularly CEOs and board members, that had a passionate commitment to clinical excellence. So, you know, at that time I was working with Ellen Zoshak, the immediate past president of ACNL, who worked for Truvan Analytics. And together we developed the system strategic plan and tactical improvement, a tactical approach to driving improvement across several clinical and operational metrics, with the ultimate goal of meeting the health system's vision as being recognized as leaders in high-quality care delivery. So the execution of the plan was tremendously successful. In two years, the health system achieved the at the time Truven top 15 health system designation and sustained it for several consecutive years after that. So after a few years, opportunity knocked for me when Baycare, which is a large 16 health system that's headquartered in Clearwater, Florida, was looking for a chief quality officer. Despite saying I would never live in Florida, and also not meeting the medical degree that was required on the job description, I got the opportunity to interview. I shared the successful track record of driving uh health system improvement across the system and made a compelling case for why nurses are ideal for such roles. You know, I highlighted our we're very collaborative, we're collaborative in nature, we're passionate advocates for patients. Um and I think from just nursing innately has a unique ability to navigate process-focused behavioral changes. And we know that that's an absolute requirement in performance improvement. So we saw a tremendous turnaround at Baycare within five years, rising from the bottom quartile to the top 10% of large health systems in the nation for quality and operational efficiency. So the book that you mentioned, Descent to Excellence, my book, culminates in the Baycare case study, taking five essential elements and demonstrating how we put those into action and produced these pretty much astounding results. Um to help health systems and other providers that are struggling to achieve clinical and operational goals.

Wow. Thank you for sharing your journey. There are so many nuggets there that I want to get into. And I do want to first acknowledge how, you know, in your leadership journey, uh, talking about different resources for leadership, there, you know, there are not really a lot of books out there that are really tailored very nicely and relevant to nursing leadership or healthcare leadership. A lot of books are, you know, I find it a little bit hard to find something that relates. So it's really refreshing to see the book that you've written and the tools that you've created that that are very, very much relevant to healthcare leadership, nursing leadership. And I know that with your book and the example that you gave in terms of the amazing results that you found, it sounds like that was um part of the inspiration to write the book. But could you tell us, was there another specific moment or experience that really uh kind of led you to write the book that that you might want to share with our listeners?

Yeah, there is. So I was listening to one of those entrepreneurial business podcasts. Um, and the host recommended was you know, talking with a consultant that was on the line, recommended writing a book about what you know. And I always wanted to write a book on healthcare quality, but I couldn't even get past the first line. I would get stuck on the title of the book and eventually just give up. And the podcast host said, you know, don't get stuck in letting perfection be the enemy of progress. Something I've been preaching to my teams for years. I thought, oh, okay, well, a lesson I needed to learn. Um, so she's, you know, she said, just get your experiences, knowledge, and expertise written down. And so I thought, okay, that's a fantastic idea. And I started writing. And it really wasn't long into my first hours typing that it occurred to me that the tactics to successfully drive improvement that I was writing was the same methodology I used across different provider settings that I had worked. You know, it worked to drive the Ohio system I just talked about as CQO to top decile. It worked to drive Bay Care's quality improvement up 220%. And it worked to shift a home health agency, a company that I worked for across multiple states, um, all the agencies from three and a half to four and a half stars in 18 months. And I didn't start out to write about that. It was just something that kind of evolved as I was writing this down. I was thinking, oh my gosh, this is the exact recipe, uh, basically, that I've used throughout my career. Um, so I then I thought, well, you know, we we I'd love to, I'd love for this to end in Baycare's story because it was so phenomenal, such a phenomenal health system. So I reached out to the the chair of the board at the time, uh Eric Obek, because he, along with, you know, the board was very engaged in clinical excellence and they were really instrumental in the success. And he was on board, pun intended, to write the forward of Ascent to Excellence, which I was so excited about because I wanted, I wanted so much to acknowledge the importance of the board's role in this journey. And so, yeah, so I got him to write the the forward. Um, and then, you know, one of the book's most significant insights lies in recognizing that when boards and executives align realistic goals with the mission, vision, and values of the health system, they incentivize achievement of those goals and really this is important too, effectively communicate the priority of the goals throughout the organization. The chances of those goals resonating with the workforce increase dramatically. And you know, and finally, there's a quote there, there's a quote that I wish I'd included in the book. And um, you know, and I've done that too since I've since I've submitted the book for publication. Oh, I should have added this, I wish I'd added that. So that'll come with the next iteration. Um, but it says the roadmap of moving a metric begins with the leader's unwavering commitment to the destination and to not be further from the truth. You know, I used to tell uh Tommy and Zeno was the CEO of Baycare at the time, and you know, I had the good fortune of meeting meeting with them on a frequent basis, and he would say, you know, what do you need from me? What do you need from me? And I would say, you know, what I need from you is to under is for you to know that whatever you say is important will be important to the rest of this workforce. Whatever you communicate to these to these teams that is important is what they'll believe is important. And I said, So, you know, your communication. And so he started, this wasn't because of this conversation, but he started doing a monthly video that went out to all 30,000 employees. And I ended up doing one specifically to quality. Mine was more fun and recognition. But his uh, but that's what he did. And he'd start off and he'd say, you know, he'd say, I went, if I ask you, if I come up to you in a hallway of one of our hospitals or ambulatory centers and say, What is the most important thing to this organization? I need your answer to be clinical excellence. So, you know, and that's just that that's talk. But they also, the the organization also really walked the walk, um, you know, put their money where the mouth is, so to speak. Um, you know, just it was the most important thing. Um, and really the book dives into those five elements that really are uh essential to goal achievement, whether it's a single measure like reducing nursing turnover or a total system quality transformation. Um, and I really enjoying it, uh, but my desire is to do the work and not write about it, which is why I employ consulting.

And you know, it's so much easier said than done, right? To accomplish these goals, to really be aligned in the mission, to to basically achieve all the of those um pieces that you mentioned. And I do want to even say first that the advice that you received about writing the book is so great because just first writing about what you know, what you've done. I mean, you know, I'm pretty sure you know firsthand, nurses can be very stuck on perfectionism. You know, we are so good at what we do, we want everything to be done perfectly. And this could really be a hindrance to some of the work that we can share with others, including writing a book, doing a poster. And we need so much more of that visibility. So I'm really inspired by your journey and actually putting this on paper, sharing this with others, including our listeners. So I think that there will be so much that they can gain from it. And I am so excited to talk more about what you said, because there are so many things there that I think will be very valuable for uh listeners for this episode. And I first want to talk about, you know, why is it important when it comes to healthcare workers and engagement? Why is it important for healthcare workers to feel engaged? And how does that affect patient care? You know, how does that kind of relate to what you've been writing about? And what are your thoughts on engagement here and how that contributes to the vision and achieving some of these goals?

Well, so some obvious reasons obviously are reduced turnover, quality and safety, positive effects on patient experience. But you know, the the what's not so obvious, um the not so obvious reasons are that a high level of engagement means that the health system leaders have successfully bridged some of those distinct motivators for engagement among the various generations. And it's really not an easy feat. And I thought, you know, and I've been doing a lot of research on this um on this topic specifically, um, you know, the generational differences in healthcare. So 70% of our healthcare workforce are millennials and Gen Xers. And interestingly enough, the average board member, CEO, and C-suite executives are closer to baby boomers than the majority of their workforce. And so when you have the these board members, CEOs, C-suites developing strategy, there's, you know, we have a tendency to develop things through our own lens. Um, and and we've got to be really, we've got to rethink some of this because you know, the you know, the leaders may need to rethink even turnover expectations. So millennials and Gen Xers, based on the research that's out there, are not the baby boomers that value career stability, work ethic, loyalty to their employer. Uh, three to five years is the average time millennials and Gen Xers stay in the same job. And in the book, I talk about the very cohesive team that I worked with many years ago. And most of them stayed in the same ICU for longer than a decade. You know, that's the baby boomers. And they're the youngest of this group. They're turning 60 this year. And you know, that generation values that stability, longevity, and security in their jobs. They're reaching retirement, where the other generations tend to have different, different job-related values. So that, you know, I just I just think that that the impact, it's so important to to have that engagement because you know it it helps align the workforce or helps the goals resonate with the workforce. Um, yeah, very important.

And it sounds like it it really is important because we have to meet the workforce where they are, right? And we have to really think about what's important to them, what are the priorities that they have, and how will that translate to the work that they're doing in the healthcare organization? And given how important employee engagement is, especially for our healthcare workers, what are some ways that we can actually improve employee engagement, especially with these generational differences between our leaders, between our workforce? Can you share some ways that we can improve employee engagement?

Yeah, you know, it was interesting. When I when I had the original drafts of the book, I have a I have so I have kids in healthcare. I have my daughter-in-law as a nurse practitioner. My daughter is a speech language pathologist, and of course, they're um millennials, both of them. And and so I was just, you know, of course I would send drafts to them. Hey, what do you think of this? What do you think of that? And it was really interesting because I I had a lot of focus on thank you notes, rounding, recognition, and reward, what we all have heard of, right? And um, and it was really, it was my daughter, a speech language pathologist, that spoke up and said, Mom, those are all great things, but I don't think they really resonate with with my generation as much as you think. You know, our uh, you know, our our interest is in is in flexibility and transparency and open communication. And so, you know, so I think ways to improve in addition to those traditional, I think this they still have value, absolutely. Um, traditional thank you notes, rounding, recognition, and reward, um, the engagement strategies need to be aligned with what's important to the generations that make up the workforce. You know, there are some common drivers that really that cross that generational spectrum. So professional development, work-life balance, uh, flexibility, and the recognition. But this is interesting. A couple of weeks ago, I was having lunch with the vice president of HR, one of the local uh hospitals, who happens to be a baby boomer. And she was saying there was a group of nurses that were upset because of pay disparities. And she was concerned, she had heard some unionization rumors. And, you know, one big difference is that the millennials and Gen Xers value and expect transparent communication. They value equality and inclusion, equal pay for equal work, where the baby boomer generations are very hush-hush about money. And it's even in, and it was in this this HR, uh, this health system's policy that staff are not supposed to discuss their pay with each other. And you gotta think, you know, who and where did that directive come from? Because if pay is fair and equitable, not equal, but equitable, is there a need to keep it a secret? And if the health system has a fair, equitable methodology for determining pay and communicates this from orientation day one, the need for secrecy around pay, that I would wager for every one of you is not a secret among your teams, wouldn't be necessary. So that's really, I guess, you know, that's probably what I would say the most is to consider, you know, consider it through the lens of that generation that makes up the the health system. And one thing else I want to add that uh that I think is really something for people to consider is integrated clinician role. So I used to be the recipient as a quality leader of eye roles, heavy size, when I would hire a good nurse into a nine to five quality position from the bedside. So we need to rethink ways to keep nurses at the bedside and hybrid roles where a nurse splits time between the side between their bedside role and another role in the organization, like case management or possibly a remote role that offers flexibility that would help satisfy the professional growth that so many so many of us value and and still keep those vital resources at the bedside to a degree. Um so it's just just you know, thinking differently, thinking outside the box.

Right. And I'll I really resonate myself with a lot of what you shared because it, you know, it's really interesting to think that a lot of the policies that some of our organizations might have, including the policy of not talking about money or salary, that could have been born from a generation that's different from ours today. And and I actually have never thought about that, but it makes so much sense. You know, if that was the pervasive idea back in the day, and if the policies haven't changed, it makes sense that that might still be in place today. But but it really sounds like, you know, and and I think that in our changing um and evolving healthcare culture and healthcare works workforce, it really makes sense to rethink how we how we do um healthcare now and how we think about our workforce and what what work actually looks like today. So I think there's a lot of really great takeaways from what you've shared there.

Thank you.

And and I do also like what you shared with with um, I'm glad that you share this actually with your family and and they have been able to share their thoughts. It's, you know, um about what engagement means to them and what recognition means to them, because you know, how how we think of appreciation could really be different from how um our future generations are thinking about it who are coming into the workflow. So it's really, really great to think about it that way as well. And I do want to talk a little bit more about the book, too, because the book um talks about the importance of data integrity and data-driven decision making. And that there's a lot of good points there. And and, you know, there's a natural temptation to get stuck in this analysis paralysis when you collect data, especially for healthcare organizations that just have so much data, maybe even data saturation. So, how can healthcare leaders really simplify their decision making and avoid getting stuck in this analysis mode? What can we learn from that?

Well, I do mention in the book that you know, healthcare is a science, and we are scientists as clinicians. And if you've ever been in a room full of physicians, nurses, and other clinical disciplines discussing an improvement opportunity, there's typically an endless of endless list of potential variables. And and we're problem solvers. We we want to focus on everything, we want to fix everything. We talked about a little bit ago how you know we're kind of perfectionists when it comes to patient care. Um, you know, so so the desire for precision impedes progress. And and it really is an issue in healthcare improvement. So, you know, because we're scientists, we we love the analysis part. Give me data, give me data, let's look at this data. But the the difficulty is acting on the data. That's where you know you keep room and you get involved in in other things. Um, and and there's really a lack of understanding really of what to take that next. Um, you know, how do I, how do I get buy-in? How do I how do I move this forward? And and it really, you know, what it absolutely comes down to is um, you know, although we are problem solvers, we have to focus on those variables that give us the biggest bang for the buck. Um, you know, I start any improvement initiative defining the scope, which includes includes the variable or variables causing 80% of the problem. And you know, the reason this is so challenging for us as clinicians is that 80% is not good enough. Would it be good enough to make 80% of a patient's problems? So um, so yeah, it's it's and then like I say, it's the chat the problem really comes in the uncertainty of uh venturing into that abyss of actions to take following the analysis. You know, we can use great data to diagnose a problem with relative ease, but it is acting on it that poses a challenge for most of us. Um, and I would say this is this is physician, if there are any physicians on the line, forgive me, but physicians tend to proceed with the belief that looking at the data drives behavior change. You know, nurses sometimes believe that the the proceed with the belief that the scorecard will change if we look at it every month. You know, process development and change management is messy, time consuming, and requires really intense dedication and patience. And time is something that most of most of us as leaders lack. Um, you know, time to invest in that process change. Uh so anyway, that's that's one of the things that makes goal achievement challenging. But, you know, the the message in the book is that you know, start off right off the bat looking for 80% of or the 20% that's driving 80% of the problem and and and move on from there. You can always address the rest later.

Mm-hmm. And I really appreciate that because it's so easy to really be stuck in the analysis. And when you see so many different problems that maybe your patients are experiencing, you really do want to tackle each and every one and you want to make it the best experience possible. I mean, I'm guilty of that too, with my nursing background. And and I think I really like what you what the book uh mentions and what you shared because uh looking at the 20% of what's causing, you know, 80% of the challenges that are out there is a really good way to kind of, you know, start with something, right? It's a really good start, especially if that one thing is leading to 80%. 80% of, you know, some of the challenges. That's not bad for, I mean, 80% is pretty good. I know it's not a hundred, but you know, it's pretty good. So I yeah, I I really agree with what you said because, you know, the action could be really hard. I I think, especially for, you know, maybe for nurses who might not be um who might not have as much experience in this world and in, you know, in the quality and process improvement world. And how can we kind of connect those dots a little bit more, you think, um, for people who are newer to this type of thinking?

Well, I I think so part of the the the we we are so data rich, you know, we have so much data. And and and I I think that the the key is like the key is really narrowing that, narrowing it down. Like I say, if you have, if you're looking at readmission reduction, you know, start with the top volume diagnoses that are driving the readmissions. Narrow that down from the top diagnosis to the to the patients that are the that are high risk. You know, everybody has a risk assessment now in the hospital. So, you know, narrow that down to the patients that are high risk. You know, from there, narrow it down even further to diagnoses or comorbidities that have a you know higher mortality. And so you just continually narrow it down until you get to the point where, okay, I can make a difference with this population. And then can you extrapolate that change that you make to the other populations? Um, so really that's it's just about starting someplace, you know, trying to figure out or using data to identify uh the very top priorities or the top opportunities that um that will lead you to the goal you're trying to achieve.

Yes. And as you explained that, I actually was thinking about the assessment process in general. You know, the nursing process has a lot of similarities. We already have a lot of these skills and how, you know, we already know how to assess the situation, think of the recommendation. A lot of this is true too, if, you know, like you're a nurse practitioner and you're looking for differential diagnoses. A lot of that is actually, I think people will be really um interested in seeing that they might already have a lot of these skills that they could transfer over to quality improvement. So I'm I'm really glad that you mentioned that. And, you know, with uh with newer technologies in healthcare all the time, including artificial intelligence, do you foresee any specific challenges with that, you know, kind of adding to all of this data that we have? Or what are your thoughts on AI in that, in that, you know, in terms of data integrity?

I I am so convinced that artificial intelligence is going to be deeply embedded in healthcare that I recently purchased several AI-related web domain names. So how I feel about those is like it's coming. It is absolutely coming. Um, you know, you think about think about radiology. Artificial intelligence could easily and accurately make a diagnosis from an image in nanoseconds. And then you inform that that you know, inform AI with unique individual characteristics like genomics, comorbidities, health disparities. And AI could also generate the best treatment plan and prognosis. I mean, there's a lot to overcome these technology engineers, you know, who are 10 times smarter than me, are gonna have to have to figure out how to overcome some of these legitimate concerns, data privacy, security, biases, um, which can be inherent to artificial intelligence, um, you know, especially for underrepresented populations. And then accountability is a big one. So that's in question. If a clinician or a physician, if clinicians follow the advice of the AI algorithm, who's accountable for the patient outcome? Um, so so I I think that it's yeah, it is making inroads uh into healthcare. And I I don't foresee it going away.

I absolutely agree. I think it will only become more and more integrated into our work. And I mean, it makes sense because it's really being more and more integrated into our society. And and I like that you mentioned the accountability because I know that that's a big topic in your book as well. Talking about cultivating a culture of accountability in healthcare organizations, that was actually one of my favorite topics in the book. And I know that one of the quotes that you mentioned from your colleague was there was a quote that said, say what you know, know what you say. And if asked, be totally transparent about what you don't know. And so, you know, with that all in mind, what does it mean to have a culture of accountability in healthcare and why is that so important?

Well, I, you know, I think that so accountability in healthcare is going to refer to an environment where individuals are responsible for specific tasks or duties and accountable for the outcomes produced by their actions and decisions. You know, I I've had experiences with leaders who said, oh, let's not use accountability, let's call it responsibility. And my my my uh you know, I my response is always the same. Responsibility and accountability are not the same thing. You know, responsibility pertains to duties or tasks assigned to individuals, while accountability refers to the obligation to answer for the outcomes of those responsibilities. Um, you know, responsibility is about what needs to be done, while accountability is about who's answerable for the results. So, you know, while both concepts are very essential in assuring um or ensuring effective performance, um, also, you know, it's very important in the decision making within the organization. And it really can't be overstated. Um, you know, a critical piece of demonstrating accountability is requiring teams at every level to report on progress toward the goals to the next level of leadership. You know, when individuals are accountable for their actions, they're more likely to follow those best practices, communicate effectively, collaborate with others, and strive to meet goals. Uh, you know, one of the things that I mentioned that I do mention in the book around accountability is, you know, if you've ever had to give a report on with bad performance to the next level of leadership is one of the most uncomfortable things on the planet. And and but it but it it's it so so it makes you, you know, it just it just emphasizes the importance of of doing the work, keeping it front of mind if it's priority for the organization, um, and then you know, achieving those, achieving those outcomes and um reporting them up through the organization.

Absolutely. And and I appreciate this a lot because I I do believe that if the more that uh an organization promotes accountability, I actually think the easier some of those conversations might be. You know, if it's an expectation to report out on different things and if that's you know the expectation on different levels, I think that even if those uh the data might not be, you know, as as uh nice of an outcome, it would still be with a culture that really embraces that, I think that they would kind of take that on more openly, right? And I think with without as much, I think kind of shame that could come with a lot of these different reports and you know, different um information that we share.

Yeah, and it can't be punitive. You know, when when you have somebody, when you have a leader that's reporting, say, to the next level of leadership, the responsibility of the next level of leadership is to help that leader, you know, if they're not meeting a goal. All right, let's talk through this. What are what are we missing? What can we help you with? Because, you know, they're like you say, you know, the the hierarchy of the of the leadership chain, so to speak, you know, should be focused on help grow, helping their leaders to achieve their goals. Um, and so, you know, accountability should never be punitive. It should be um, you know, it should be about helping that leader, that next level leader, achieve the goals um, you know, that they're responsible for.

Absolutely. And you know, our listeners do include nurses all the way from bedside nurses to the C-suite level hospital executives. And how can nurses, whatever their role and their leadership level within an organization, set these clear goals and promote this culture of accountability?

I think, you know, team members at every level, regardless of title, um, should have goals that align with the overall goals of the health system. So, that being said, everyone from the bedside of the C-suite should be able to state the goals of the hospital or health system. And engagement's going to suffer if people don't know how their work makes a difference or impacts the organization's success. I know several years ago, and I've seen it, I've actually seen it currently in some healthcare organizations, that individuals will have goals. And so they'll have their own individual goals, which is, you know, I'm going to get my CPHQ next year, I'm going to take a class on coding next year. And while those are those are great goals, those are those personal goals are great goals, you know, how are those goals helping the organization meet its mission and vision? And and if it's if if it's, you know, that so like I say, personal professional goals are great, but when you're looking at waiting, um, those really should be, those personal professional achievement goals should be a smaller part of the weight of the of the goals for the for the staff.

And that's always a great way to, you know, kind of frame it back to the mission and vision of the organization and to always keep that um top of mind because it could be, you know, pretty easy to not consider that when making some of these personal and professional goals. I know that sometimes it could seem so kind of, you know, out there that if it's not always brought into the conversation, it could be kind of out of mind. Um and, you know, it's I can't believe that it's already the end of almost the end of our time here today, but I just wanted to give you the opportunity to share any final thoughts or any final insights to our listeners.

Um yeah, I just want to so I probably say that, you know, when we talk about accountability, I'm gonna I'm gonna kind of focus on that because you cannot have accountability without compassion. And one of the hardest conversations that we have as leaders is when a member of our team is just not meeting expectations. And as long as they're not a behavior problem, um, the most important conversation we can have with them when we identify performance gaps are, you know, it is to review with them, you know, the expectations, uh make sure they're measurable, make sure they're they're set and time stamped and possible outcomes are discussed, including finding employment elsewhere. You know, you got to question is this person just a wrong fit for the role? What's their passion? And how can we as leaders help them find the role that they may excel in? So that's compassionate accountability. You know, you're not a good fit for this, but I'm gonna help you search for other roles you may like even better that you'll excel at. And and and finally, you know, should should people end up leaving, um, check in on them, even if it's just one time. You know, it's really the compassionate and respectful thing a great leader would do. Um, yeah, so that's that's really, you know, I really appreciate uh the opportunity to to share this information today, Charlene. Um, and and I I sure hope it was it was helpful for the listening audience.

Yes, thank you so much, Terry. So much of that resonated. I especially love the that final insight you shared with compassion. I think that there is so much, um, there's so much effects that could come from leading with compassion, having accountability with compassion, and even having self-compassion in all different facets of our journeys in healthcare. So really appreciate you, Terry. Thank you so much for your time today. And we hope to have you back in the future. Anytime. Thank you, Charlene. Our guest today was Terry Schulder, author of the new book Ascent to Excellence: A Blueprint for Healthcare Board and Leadership Success. The book will be available this spring. We'd love to hear your feedback. Email us at socialmedia atacn.org and connect with us on LinkedIn and Facebook at ACNLNurse. And as always, if you like the show, please remember to rate, review, and share. ACNL in Action is presented by the Association of California Nurse Leaders with new episodes on the first Friday of every month. To learn more about the show or ACNL in general, visit us at acnl.org. Thank you for listening.