Last time we began to introduce the course and its structure. And today, we're going to follow up with a series of additional questions. Over the past few years, I've increasingly realized how stuck I was in my old ways. And I think health systems can be like that too. It's sort of because the expertise is so specialized. Then you get almost to technocracy, you get the aortic surgeon who's got special expertise, the person who handles the heart lung machine has special expertise. The ER nurse has special expertise, the CFO has expertise. And because it takes like a village, everyone has veto power and unanimity is required. And I think the one of the things that I've learned over the last five years is that it doesn't really have to be that way. If you can show people the way, they can actually see successes, they can see people somehow getting through what seemed like molasses in January, and see some successes and realize that there are these other little paths that they can test. I think that's been great, like my own view is that it's really been like one of the most exciting things is to see the realization in people's eyes. I guess I can try something, that's been really valuable. Absolutely. I think we have clinicians we've worked with who have won eight pilots or eight experiments in 90 days. In fact and in the last cycle of projects, we had a clinician who did nine experiments in 90 days. So a new experiment, a new attempt, a new try, a new direction, every 10 days. And I don't think people thought they could do that. I don't think they thought they could move that fast. They were holding themselves to an extremely high level of evidence, which of course we need before we roll it out as the way we work. But you don't need that kind of vigor to try something, and to get some evidence and to get some data flowing. So, I think there's also these methods of people are in the habit of asking can I? Or can we do this? It's funny when you start to teach things like Well, don't ask "Can we?" ask "How can we?" In other words, assume there's a way. And it's amazing what happens, if you ask "Can I text with my patients?" They'll say,"No" you know the powers that people say "No, you can't." If you say "Well, how can I text my patients?" They'll say "Well, if you can send them I guess you can do these things, right?" So there's always a way to get started. If you only get to work with two patients in one unit for three hours, you can learn something, and you can get more contextual data and you can actually elicit a surprise. And sometimes those surprises get people more excited to take that next step and that next step. And so I think that approach has been really fun to do here at Penn, because I think that the clinical teams we've worked with just take to it. They've been amazing and made progress. It's interesting. Another part of a job I had, I learned that the only way to get things done was never to take no for an answer. And I think one of the things I've learned from you is, never ask a question where no can be the answer. No yes, No questions. So, that's a much more enabling approach in what otherwise be a very complicated organizational culture. So, what do you think are the successes? Can you point to some clear organizational successes or some clear project successes that reveal how this has worked and might be leaving an enduring impact? So, I can think of a number of projects that we've done that I'm extremely proud of. And some of them are things that we led, some of the things that we followed and advised on, and some of them are things that I've just observed that have gone on Penn, the fact that we didn't have anything to do with. When I think about care models for example, just one way of thinking about the world that we're in right now. Shreya Kangovi's impact program would be a great example. I believe she started doing this work at the Robert Wood Johnson Clinical Scholars Program. So she had a little bit of time and I think time is an interesting thing to talk about that we should probably get to. How do you cut off time to do some of this work? So Shreya had some time, she had some insights and some observations about addressing vulnerable populations, about how the health system wasn't really designed for folks and they ended up inappropriately in an emergency room all the time, because primary care and other types of care we delivered just weren't working for them. And it iterated on a program that really has started to show dramatic returns. She's now, has a two dollar return for every dollar invested. Penn has created a center around her work. Her work has been packaged for dissemination, has been looked at by over 800 other institutions now. And it's fundamentally changing an old model like Community Health workers is an old idea. But Shreya observed that the way that they are selected and hired and trained and deployed was sub-optimal that was never evidence based. And so she brought the vigor of academic medicine in getting real evidence in the speed of innovation of rapid cycles, because she was iterating every week of every month, she was changing this program to the point where it really started to perform and now she is spreading it to well beyond Penn's walls. I love stories like that. I think the theme of Safe Motherhood was Adi Hirshberg and Sindhu Srinivas with Katie Maraj and our team. And some of these come out of conceptual models. So, David your work and Kevin Volpe's work on connected health. If we're going to fundamentally get to better outcomes better value, we better see and know about things we never used to see and know about. So that's a big idea. So, our will doesn't stop when you leave the hospital, when you discharge. So, the Innovation center didn't come up with that and you certainly promoted the idea. But when you take an idea like that and you say well, we have a patient population, in this case, new moms, who are at risk for high blood pressure related to their pregnancy. And we know that, if they're going to get in trouble, this is the highest. So postpartum pre-eclampsia being the highest driver, seven day re-admissions and morbidity related to that population. And they get in trouble in their home, when they're outside of our purview. Well, what do you need to know? Well, you need to know their blood pressure. We tried everything right, before we got involved it was walk in clinics that were free and telephone calls and traditional methods of engagement. And so that team just starts to innovate on different modalities and texting and sending them home with a blood pressure cuff, and all of a sudden, it's starting to iterate in very rapid cycles, you're starting to see a mode where you can actually for more than 80 percent of that risk population know their blood pressure, and more importantly not just know it, act on it, adjust the medication, start a medication, prevent the stroke, prevent the re-admission. And you see a program like that, spread beyond walls, going out to Chicago, going down to North Carolina now, and being adopted by other systems. It gets me excited because not only are you seeing a different way of working faster better outcomes but, it's what's exciting about healthcare innovation in the beginning. It's like you're helping people who need help. Right. Shreya's program is fundamentally changing lives. And she in some cases they've been engaging folks who are not even engaged in life, and they're not taking their medications because they're not that concerned whether they're alive or not, and they can re-engage them in life, and all of a sudden they have a better health outcome. Or they have housing insecurity, or food insecurity. And they can handle those problems. In the Safe Motherhood example, you have a new mom, who all of a sudden has a stroke and that changes obviously her life and her family's life. And that doesn't happen. That team I believe now has achieved zero re-admissions so far, and it's a wonderful thing to say I'm working on problems that are so meaningful, that I care and the team cares and everybody cares whether we get it right. And, that's important because when you're trying to do something new in any big organization, I don't care if it's GE, or Johnson and Johnson, or Intuit, Cisco or Penn. Organizations resist new things, they're designed to really optimize a way of working. And so when somebody is trying to do something new, they're going to hit all kinds of obstacles and all kinds of barriers. And the only way to get past them are people who are passionate, who really care. Because people are going to say No. And No and No. You're going to get told no six, seven times. And if you're working on something as an assignment, or something as "Hey, I'm telling you have to go do that" After you get told no three or four times you sort of say I tried, it didn't go well. But when you're looking at things you're really passionate about like, you know they matter, it's a thing that you want to change in the world. And back to your question, what am I excited about? All of the clinicians we work with are working on the thing they're really passionate about and we're trying to enable them. Cory Schreiber a new way of handling miscarriage care. Every single project, they so passionately want this change to happen in the world. The world to be a better place, the patient to be better off, the outcome to be better, the cost to be lower, the caregiver to be unburdened. It's hard not to be excited about working on problems like that. Let me flip the question around a little bit. You just listed a whole bunch of successes, and you described the passion of the people running those projects as being integral to their success. But I would say something else, which is that if you're at some other health system other than Penn, you have tons of passionate people, they have their own goals. But in each of the examples that you listed there, there was also leadership support. So, we have Ralph Muller our CEO, or Kevin Mahoney, the EVP, or Larry Jameson, the Dean. They were fundamentally behind the creation of the innovation center, and they have supported these individual projects, and despite the passion, or required in addition to the passion of the individual clinicians and faculty members has been a kind of air cover and support. So, when I talk to people around the country, that's the question they ask me. How do you get buy-in from your CEO, or your Dean, or whatever? And we had buy-in because they created our center, they had their initial passion to move forward that gave us an incredible leg up. And we trade on that passion and. How are other places going to get there also? Everyone says they want to be innovative, they want to support these activities. But to actually do it and for the leadership to carve out time in their day, cognitive bandwidth, whatever it is, a strategic priorities for this kind of activity, that's not a small undertaking. Absolutely. And you're right to say these things don't happen without leadership support and leadership enablement. In the beginning of any change management, you see this concept, it's often called the burning platform. You need to have this urgent reason to change. And I think people don't change just for the heck of it. The leadership of Penn I think looked out and said, the world we're in is changing. People are talking about value based models, they're talking about new ways of delivering health care, and that change is going to matter. And that we need to be better at that change. And driving change and thinking about how changing environment means we have to change practice. So, that support is absolutely critical. How you engender to create that support if you don't have it is a very very difficult thing. There are ways to do it and that is, the essence of change management. I think that in any large system, there are somewhere this neat things going on. Like somebody is doing something really interesting. And I think celebrating those behaviors you want to see more often is certainly part of it. Shining that spotlight on people already doing good things is critical. I think that finding and creating mechanisms that are sort of self selection, where somebody can raise their hand and say, I want to be part of this new high energy fast moving thing, those can be grant programs or other types of innovation. Project programs, where people can say I want to be part of it. Sometimes those are fourth year medical students, sometimes those are fellows, sometimes those are junior faculty, sometimes those are senior faculty, sometimes those are nurses or dietitians. But you're creating a chance for someone to say I want to get involved. Most times want to do that, 90 percent of the people are so busy they can't. But they're 10 percent of people who are so passionate, they're going to raise their hand and say, I'll stay a little late, I'll come in a little early, I'll do a little extra," at the beginning because it's not yet the way we do things. So, it is extra effort and acknowledging that reality, I think is important. I think having programmatic dollars, we had some money that was given to us that we could actually give some small seed funding to different projects. And you've said this quite often. I think the money was less important than the recognition. Then the start of the advisory work, then the clearing of obstacles. But there was something to the seed funding. Some people said "I don't even know how to get $500 to buy the software that I need to get this license or to have a research assistant sit here for six hours to do something that I need to try." So I think a little bit of money, is absolutely essential. And then the methods that we teach, the methods that you and I have really tried to make standard of learning very fast at very low cost, are critical. Because no matter what, you are going to have lots of tolerance for huge investments that don't go anywhere and don't show anything for a long time. And so by using these fast psycho experimentation methods, what you're doing is saying after a week, or two weeks, or three weeks, I can show something. Maybe it's only on five patients or 10 patients. But something interesting happened. And you start to build momentum and build evidence that way, and get more time and more support by having quick wins. It's this whole theory of small wins and quick wins. I have to produce something quickly that makes other people say "Huh, it's not what I expected or, wow, I didn't think that was possible." And so I think those are important and then leverage. I think one thing that we've done is leverage outside groups, leverage startups, leverage the community, leverage the engineering school, the design school, Wharton, leverage other folks who are also excited about healthcare and solving healthcare problems, and who are willing to put in a little time and energy and effort, and leverage those skills to kind of make yourself look bigger than you really are. And so I think those methods and those techniques also kind of get you off the ground quickly. And it's because really people bet on momentum, they bet on forward motion. So well there's something interesting happening. They'll say, "Well, I want to keep working with you." Well, I think this is a really important introduction to the course, because what you're going to see as you go through the course, are a series of almost quantitative or disciplined methods to move towards the kinds of healthcare goals that we have. But they are always embedded within a social and political and organizational context of change management, working with people, engaging others, harnessing resources. And as is often described in management, the soft stuff is the hard stuff. So it's discipline in part, it's politics and management and leadership in part. And we're going to try to put all of those elements together for you in the course that you're taking. Thanks very much.
