Ingrid Nembhard: Improving Healthcare Organizations to Improve Health

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week we will be speaking with Professor Ingrid Nembhard, but first we like to check in on current health news. What’s got your attention this week, Harlan?

Harlan Krumholz: Yeah, I think I’m reflecting a little bit on this issue of financial toxicity. We’ve talked about it before, but it’s this recognition that within healthcare system, somebody comes in sick, you take care of them. But there’s a whole nother thing that’s going on with people that is usually invisible to most of their clinicians, which has to do with the bills that they receive when they leave, and the out-of-pocket expenses that they incur.

And we’ve been talking about this as a financial toxicity and also as financial complications of care, so that one of the things that happens to people, sometimes people leave with big bills when their credit rating is threatened, when even their housing can be undermined because they have these large bills to pay. Then, their lives can be unraveled in different ways, and downstream it can change people’s lives.

On some Saturdays, as you know, I spend time with the medical students at Yale who have a clinic for people who are without insurance, and it’s one of the best things I do. I mean, I leave there so inspired by the dedication of our medical students who work so hard and diligently and perform so well in the service of trying to provide care with attendings, of course, involved in integrally providing oversight, but that the medical students are spending time really listening to these patients, trying to bring out their stories as well as understanding their health problems.

And then they’ve arranged the clinic so that they can get them referred immediately for mental health services or social workers, and they can make sure that they get access to medications even though they may be expensive. I mean, we have frontline medications that we know are guideline-recommended that often we run out of and people can’t afford. I mean, we have a situation in this country where people can’t afford medications that clearly provide survival benefits, but that they can’t get access.

In this clinic, the medical students have worked really hard to make sure that people get it, but it’s one island of relief within a sea of turmoil and problems. And whenever I’m there, I’m both instilled with a sense of optimism when I see these medical students so terrific and so dedicated. And at the same time, I’m disheartened to see that there is this need for such a clinic in our country.

And then this week, as I tweeted about this, Katie Thomas and Jessica Silver-Greenberg at The New York Times wrote a pair of articles that got a lot of attention. One that was called, “They Were Entitled to Free Care, and Hospitals Hounded Them to Pay.” And another one was “How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits.” And it’s quite a moving set of articles that really illuminate this issue in our country.

Again, this juxtaposition of being in the clinic, reading these articles, it’s not that I’m not thinking about it. We’re writing scholarly pieces about this all the time, about the large number of people who are threatened by this. It turns out to be huge. There’s Medicaid, but it’s often inadequate. And in Connecticut, by the way, one in four people in Connecticut are on Medicaid now. So these are big issues. Right? Some people without insurance still, we haven’t gotten to zero on uninsured. And then among people who are insured, many people are underinsured. And even if it’s not Medicaid, we’ve written articles about how people have insurance from premier insurers, but they end up being handicapped by out-of-pocket costs because it’s underinsurance for what they need, based on what they had to get for their health.

So anyway, Howie, this is very much on my mind, I think as a nation. In my tweet, I said, “Is this really who we want to be in this country? A country that punishes people who are sick, who despite all goodwill and good intentions, just simply cannot keep up with these health bills?” And I think it’s something that demands our attention.

I’ll say one final thing, and I know that we talked to Zack Cooper, and Zack’s doing some really great work where he’s showing these escalating healthcare costs not only are causing individuals, but it also costs jobs in regions. And it has collateral effects, not even on the people who are sick but because rising healthcare costs and how it sucks money out of the entire system that’s available for social services and other things, it can cause income loss or just even loss of jobs as the economy contracts because so much money is going into healthcare. So I just think this does become a major issue for us to pay attention to. And I know this is an area of specialty for you as well.

Howard Forman: Yeah, no, no, no. I share all your concerns about it. And I’ll just point out what the Times did was point out the most egregious, clear-cut examples of abuse. But the system has problems at every level from physician fees, pharmaceutical company charges, right across the board. The insurance industry. It’s like we’ve seen the enemy and it is us.

As you pointed out, the Affordable Care Act reduced the un-insurance problem in this country substantially, but it also may not have caused, but it was completely associated with, a dramatic increase in the under-insurance problem, as you correctly point out. So the Times article just highlights the worst abuses, but there are big problems, and I think we’re just going to keep coming back to them on the podcast. And I hope that we’ll also start to talk about solutions.

Harlan Krumholz: Yep. That’s really important, trying to get to solutions. So, let’s go to our guest, Howie. Take it away.

Howard Forman: Today we welcome Professor Ingrid Nembhard. Ingrid Nembhard is the Fishman Family President’s Distinguished Professor and professor of healthcare management at the Wharton School of the University of Pennsylvania. Before joining the faculty at Wharton, she was faculty in the Yale School of Public Health and Yale School of Management and our Yale School of Public Health Teacher of the Year in 2011.

I was fortunate enough to work with her for over a decade at Yale. She specializes in organizational behavior and learning and healthcare. Her research focuses on improving the quality of care by examining the characteristics of healthcare organizations and their ability to learn and implement new practices.

Currently, she is studying leadership and psychological safety and teams’ organizational learning, how patient feedback drives quality improvement by clinicians and administrators, and more. She received her PhD in health policy and management from Harvard. She received her master’s in health policy and management from Harvard School of Public Health and did her bachelor’s degree with a dual major in ethics, politics, and economics as well as psychology.

So, I want to start off by asking you, many people are in this field of healthcare management, oftentimes coming from either an organizational behavior point of view, an organizational psychology point of view, and you have come from a more pure healthcare management point of view. Can you tell us about how that informs what you’re doing now, and maybe a little bit about how your journey from a psychology major at Yale to the important work that you’re doing now happened?

Ingrid Nembhard: Sure. So first, it’s a pleasure to be with you and Harlan today. It’s really just a delight and a treat for me to be able to do this. It’s interesting. So you mentioned that I had my degree in ethics, politics, and economics, affectionately “EP&E,” and psychology at Yale. And when I graduated, honestly, I didn’t know what to do.

Looking at those specialties, it’s clear that I’m interested in a lot of different things. I couldn’t quite place my finger on what it is I needed to do. The options were investment banking and consulting. At that time, I was supposed to choose one of those two things. That’s what you apparently do when you’re a Yale undergrad. And I knew that wasn’t right for me.

And so I ended up graduating without a job. But I landed in a job a couple months later working for a health insurer. And if it weren’t for that, I wouldn’t actually be in healthcare management today. But when I was working with them, one, I got a glimpse of healthcare and started to understand that healthcare was more than medicine, that there were ethics, politics, economics issues and psychology issues. And for me, it was like, whoa. There’s an industry that’s wrestling with all of these different things.

And so my heart was sort of captivated by the ability to apply those disciplines but also to be in healthcare and sort of be able to have impact in that way. Now within healthcare, you could choose any number of things. You could focus on operations, you could focus on strategy, you could go do the investment banking in healthcare. But for me, I was working in physician contracting, so I was having the opportunity to really talk to physicians, clinicians, hospital administrators, and some of those conversations were about money for sure. But as we were having those conversations, I was really struck by, for me it was, “Wow, there are a ton of organizational issues happening here,” whether we’re talking about innovation or implementation or marketing, any number of things.

But I was starting to be struck by this idea that the organizational side of healthcare really matter to clinical outcomes. And that has been something that has drawn my attention for years and I still think is very relevant. And honestly, I don’t think it gets as much attention as it should. Yet, I think that if we want to improve healthcare, we really must start paying more attention to the way the dynamics happen within healthcare organizations and among healthcare providers.

Howard Forman: Just as a start to give people a little sense of the type of work that you do, first of all, let me just say, when I look at the body of work that you have, it is filled with optimism. It is all about how to move forward, not looking back at what went wrong, but really what we can do to look forward. But can you give us an idea of the type of learnings that you’ve had during the pandemic in terms of what positive lessons have we had from that?

Ingrid Nembhard: So, the pandemic has been really interesting because it showed us how important a lot of organizational things are, like supply chain management, which most people didn’t think anything about. Most people had never heard of PPE or personal protective equipment. The world became much more educated about those kinds of issues.

I think we learned a couple of things from the pandemic. I think we learned, one of the things that I’ve been studying recently is creativity in healthcare. And the pandemic showcased the ability for healthcare professionals and healthcare organizations to be creative. And I think for a while, for many years, we’ve thought of healthcare as being relatively stagnant. There’s sort of the famous number. It takes 17 years for something, for an innovation to actually become evidence-based or become practice. So we think of healthcare as a slow-moving industry, but the pandemic really showcased the ability for healthcare workers to bring the most creative ideas possible for dealing with issues in healthcare.

And for me, you’re right. I perhaps I’m too much of an optimist, but I saw in there the potential to deal with things like social determinants of health to implement new innovations quite quickly. There were so many learnings that I think we can take from that. And so my hope is that we’ll take that example and be able to say, “Okay, healthcare can be creative, and we can take that and start to deal with things like value-based healthcare.” Some of these really tough issues that we’ve been struggling with for many years now, we’d be able to do that.

So I think we saw the creativity of healthcare professionals. I think we also saw something else, and this is biased by what I study. I think we’ve also seen the importance of creating positive work environments for healthcare professionals. And they every single day give their very best for patient care. And I think we had largely forgotten that that is actual work for them, that they’re giving their full selves and lives and they are both providing care, but they’re also doing a technical job and doing that at that pace and that scale is exhausting. And so I think we learned from that, that we have to take care of our healthcare workers. And so much more attention to thinking about how do you make work environments work for healthcare professionals?

And then I think probably the third thing, which is not in my area, but I think is important, is how much operations really matter, those little things like getting supplies into the right space. We’ve seen that. How do you manage triage? How do you manage a surge in demand? Some of those things I don’t think we paid as much attention to. Yes, there were always studies of emergency departments. But now we really saw at a different scale the need to think about operations management and patient flow.

Harlan Krumholz: By the way, I love your optimism. And I think your work is so important in helping us think about how we can improve it. It thinks systematically about the way that we do our work and tries to help us see what we can do better and what changes need to occur.

You wrote that creativity and standardization or complements, not antagonists, in the piece that you wrote about how the pandemic fostered creativity in healthcare. And I found that to be a really interesting take. Standardization and creativity are complements. And it struck me not just because of the point you were making in the pandemic where we needed to implement systems and standards, but also allow for the agility to create creative solutions.

But there’s this tension between what people are talking about with cookie-cutter medicine, as algorithms and rules and measures come into place, and the creativity that’s inherent in a profession that needs to be able to personalize its approach to each individual based on the preferences, values and goals, background history, perspectives, and so forth.

And so maybe could you talk for a minute or two about how you see this yin and yang of standardization and creativity within it? We don’t want people just winging it. On the other hand, we don’t want people just to be widgets in a producing a standardized product and not flexing for the needs of the individual in front of them. So how are you thinking about this tension between these two?

Ingrid Nembhard: Yeah, so I think you actually said it quite nicely. I don’t think of it as a tension. I really do think of it as complementary. So to the extent that we look and we have standards, standards provide us with a threshold to be able to think about how we deviate and give us the baseline that we may then be creative upon that. And on the flip side, we think about creativity as providing the opportunity for us to discover things that we would ultimately want to standardize. And you need both in healthcare. There’s this—

Harlan Krumholz: Can you give an example of where you’ve seen this that really sort of shows this to folks about how this works?

Ingrid Nembhard: Okay. So imagine that we have a standard for care for heart attack, right? And we do. There are certain things. You’re supposed to get an aspirin, and there are certain things you’re supposed to do when somebody is having that kind of clinical experience. We should have that. Nobody wants to use cookie-cutter care, but we should have evidence-based medicine. That should be a threshold by which we provide care to patients.

That said, we might think that there are opportunities to, I’m going to say creatively have that happen. And so when we use the term creative as scholars, we’re talking by definition about something that is both novel and useful. And so maybe that is a new protocol that allows the aspirin or something to be administered to the patient that we hadn’t thought about before. That doesn’t change the fact that the patient needs to get the aspirin, but maybe the way in which we deliver it, the timing, the situation, all of that are areas in which we can explore and be creative. And that might actually lead to improvement. And that would then be the process by which we would then standardize. So I think that they are complementary in that sense.

Harlan Krumholz: Yeah, yeah. They cycle, right? Because if you’re successful, it becomes the next new standard that you’re implementing.

Ingrid Nembhard: Exactly. And with each one of those, we are moving to a better, higher performance for care. Right? There’s no need for us to stay at the initial starting position at that creativity elevates to where we’re going, and that’s where we want to go.

Given the amount of technological development and advancement of knowledge in healthcare, it’s somewhat ridiculous to think that what we were doing in 1990 is what we should be doing in 2025. But it’s the pathway to get there. And that means that we have to embrace the creativity. We have to nurture the ability to people to be novel, not just use of a novel, on top of that.

Harlan Krumholz: Howie, you can go ahead. I’ve got actually two things I want to cover with Ingrid that I’m really curious about with her. One is that she’s done some work and has been thinking about reform of CDC structure. CDC’s been a target of so much criticism.

Of course, it’s hard to do everything when there was so much uncertainty. And I mean, it continues to be a really hard job. I wonder, just Ingrid, if you could just share with the audience some of your thoughts about CDC and where does it need to go? You’re in the midst of such a political maelstrom and you’ve got such difficult policy challenges ahead. What are your thoughts about how they can grow and improve?

Ingrid Nembhard: Yeah. I was really enthusiastic to see that our CDC director decided to take on the large leadership challenge of reforming the CDC. I think there’s sort of a humbling in doing that, but I think it was necessary. I would categorize for the reforms that they’re planning to do there in two categories. And I think some of those are structural changes and some of those are cultural changes. And I think both of those needed to happen in the CDC.

I think about the CDC as being in a really challenging set of circumstances. I mean, the level of uncertainty about how this pandemic would happen was great. We know a lot. I think the management literature has taught us about the challenges of working in ambiguous and uncertain environments. And one of the things that is most important in that situation is to realize that that is the environment that you’re in and to acknowledge that that is the environment that you’re in, and to really take it as a learning opportunity and to present it that way to those who are working. Right?

So there are people within the CDC, I have to imagine, who kind of knew that some of the decisions that were being made may cause confusion for the public. Some of the things that were said were going to cause confusion. But maybe they didn’t raise their hand to speak up. There may be some issues with that. I don’t know. But it sounded like, in some of what I’ve read, that there may have been some of those issues within the CDC to speak up and say something.

I think that the movement to a culture where you are able to speak up about different things that you see happening, that you’re willing to admit the uncertainty, and that people are willing to bring their heads together to talk about, okay, here’s what we know, here’s what we don’t know, how do we go about presenting this to the public in a way that is understandable to them, I think is quite important.

The challenge the CDC has is that we know that it takes a long time to build up trust and a minute to break that trust. And the CDC has lived through that. And so now it’s in that cycle to have to build it up again. Maybe there are 20/20 guessing, but being able to say to the public, very truthfully, “Here’s what we know and here’s what we don’t know,” and pretending we know everything in the early stages is maybe not advisable. And I think they learned that through this process. I do think that the move to opening up the culture of the CDC, thinking about how you rotate people through the CDC, all of those structural changes are a move in the right direction.

I think they need to be prepared that there’s still probably going to be blips, and I think we’re seeing that happen again. But acknowledging those blips. A lot of it will fall on the leaders at the CDC. There are leaders and there are people working in the CDC, and both of those levels have a role to play, but the leaders play a fundamental role in saying, “This is what we know. This is what we don’t know. I need you to come and tell me what the problems are. I need us to come up with a plan. Here’s how we’re going to talk about X and Y issue.”

And I would say it’s probably not a bad idea to bring in a couple more management people to talk about marketing. How do you message publicly? Companies do this all the time in ambiguous situations and their expertise that I think they could be drawing on more. I think there are healthcare management researchers that are available to help them navigate and deal with some of these issues.

Howard Forman: In many ways, it’s like trying to convert a cruise ship into a hospital while it’s at sea. I mean, this is an organization that has a great history behind it, but it’s not used to dealing with a massive crisis of this magnitude and managing its own transitions at the same time, I am curious to know if there is a large literature about managing companies during times of crisis, but this is about managing a company that is in the business of managing crises and managing it during a crisis.

Ingrid Nembhard: I think that’s what was maybe so shocking to many people, is that this was the moment that everybody thought they had been training for. And so in some sense, there were wonderful moves made. And then there were other senses where we wish it had been different. And I’m sure they’ve experienced that, and they’ve felt the political consequences of that over and over again.

I think they’re smarter now. There’s no way they’re not smarter now. There’s no way they didn’t learn from what they have experienced over the last two and a half, almost three years. The challenge will be to take those learnings and standardize some of them, as we were talking about, Harlan. Some of that is to standardize the things that they learned, work, and then also to say, “There are opportunities for doing better,” and start to get creative about how they do that. And sometimes doing a little experimentation is not a bad thing. And I think they’re in that space now where they can do that, and they have the liberty to do that.

Harlan Krumholz: So as we get to the end, I just want to hit on two quick things, maybe just quick impressions of things I know that have been on your mind that you’ve been working on. One of the issues that interests me is how do you foster a safer environment for patients? How do we promote patient safety to a greater extent?

You talk about psychological safety in improving workplace. I know that some of this is about the environment for clinicians, but also that people can be honest about what they see without worrying about retribution. Can you just give us a kind of your quick take on what needs to happen there to help clinicians generally, nurses, doctors, everyone in healthcare, be able to admit mistakes and talk freely about problems so that they can elevate? Is there a way that we can actually get there?

Ingrid Nembhard: Yeah. So this is probably the question people ask me most in life. How are we going to make it psychologically safe? And I like that you drew the connection between patient safety and psychological safety, because I do think that’s fundamentally important. And it is the motivation, I think, in many organizations for thinking more about psychological safety. What if somebody said, “You’re about to administer the wrong medication to that patient”?

And so we think that there is this correlation, right? There is a large evidence-based literature now about the relationship between psychological safety and a number of organizational performance metrics. That patient safety and that psychological safety together, they’re correlated in my mind for sure.

So what do you do to increase psychological safety? There are a number of things you can do. The number one thing the literature would say, and my own research shows us, is that it is really contingent on the behavior of leaders in each organization, whether they are accessible, when people have something to say, whether they invite input. Do they demonstrate their own infallibility to others? Do they demonstrate the behavior of acting up and speaking out? Those are all things that individual leaders can do and actually need to do in order to create more psychologically safe places.

We also have things that organizations need to do, so they need to align psychological safety with their goals. They need to align it in their reward structure. What happens to the person who raises an issue? Do you cheer them? Do you promote them or do you not? Do they suffer consequences? They get the bad hours, they get the night shift. Those kinds of things. We all have seen evidence of things, people suffering negative consequences, for speaking up. So organizations have a role to play to in that regard. They have to provide the infrastructure for people to be able to be safe, and leaders have to be that sort of frontline voice and that frontline opportunity for psychological safety to be cultivated.

Howard Forman: I want to just first of all, thank you for doing this. I want to point out though that you’re at my former institution where I was a MBA student. And it’s remarkable to me to see an institution like Wharton, which was founded on sort of finance and Taylorism, which was operational improvements, very rigorous scientific attention to how we improve processes, embracing the fact that that’s the simple stuff in many ways. And the hard stuff is actually being able to enact change, and that you and others at Penn and at Wharton are leading that effort. So I just want to personally thank you for joining us on the podcast today, and always so thankful that you’ve been a great colleague and friend.

Harlan Krumholz: Yeah. Thanks Ingrid. And by the way, are they still talking about Howie at Penn? I mean, is he a legend there, having—

Ingrid Nembhard: Absolutely. I mean, honestly, some people, believe this or not, tell me that they choose to come here over Yale because they’ve met Howie. And so the place in which Howie trains is the place that they want to go. So it’s been really interesting in that regard. “I could go to Yale, but Howie trained here. So I want to go there and be with you.” Okay. He’s very good advertising for Wharton.

Harlan Krumholz: Thank you so much, Ingrid. It’s great to talk to you.

Howard Forman: Thanks, Ingrid.

Ingrid Nembhard: Thank you guys very much.

Harlan Krumholz: So Howie, that was great. I was so happy that Ingrid could join us and she’s always full of insight. So now we’re going to pivot to this part of the podcast and for you to tell us a little bit about what’s on your mind.

Howard Forman: Yeah. So over the weekend, I think it sort of came to head the protests that are going on in Iran. There are large numbers of people rising up against the autocracy in the authoritarian regime, standing in solidarity with women regarding their desire to wear a hijab or not, or whether to cut their hair or not. Simply put, for their freedom to live their lives as they choose.

Iran, as has long been known, is a repressive society. And you and I both know many, really many physicians and/or scientists both, who have escaped that regime, come to Yale and other places nearby, in order to have the freedom that we in America take for granted very often. And the demonstrations have occurred in dozens of cities, including the capital of Tehran. Iranian authorities in turn have now restricted internet access. They’ve killed dozens. They’ve maimed many more.

They’ve imprisoned at least 17 journalists as of this past weekend. The nominal trigger for the protest was the death at the hands of the “morality police” of Mahsa Amini, a 22-year-old woman accused of not properly wearing her hijab.

So I bring this up. Why in a healthcare podcast, and I bring this up, is I just want to say we take our freedoms for granted. I can say what I want and do what I want on Twitter, on this podcast, in print, and not fear government reprisal for my free speech and for my generally free actions. And while we may not have absolute separation of church and state in the United States, it’s generally assumed. And religion does not restrict our behaviors in other ways, and certainly nowhere near the level of the Iranian people. But it’s worth keeping this in mind.

Over the summer, we have seen our government further restricting women’s rights to abortion. We’ve also seen governors and private groups attempting to stop transgender adolescents from receiving gender-affirming care. These may or may not be motivated by religious beliefs, but they do represent substantial intrusion of government into the private lives of patients and their physicians and families.

We should all stand with the people of Iran during this very difficult time, hoping that they can live freely as we have done historically, but we should also not take our own freedoms for granted, and we should continue to be on the watch for incursions on our freedom.

Harlan Krumholz: Well said. Well said. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale. That’s hmkyale.

Howard Forman: And I’m @thehowie. That’s @ T-H-E-H-O-W-I-E. You can also email us to health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs where you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.