Rae Woods (00:02):
From Advisory Board, we are bringing you a radio advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. In last week's episode, we explored the key questions effective leaders ask themselves amid uncertainty. This week, I want to explore an example of that in action. To do that, I've brought Lisa Carter. She's a leader at Ballad Health in northeastern Tennessee. Ballad Health is actually a somewhat new organization. It debuted in 2018 as the merger between two legacy health systems in the area. Now, the merger was ultimately necessary and successful in avoiding hospital closures in the region. However, it required Ballad's leaders, including Lisa, to navigate through some extraordinarily difficult and complex challenges.

(01:00):
Hey, Lisa, welcome to Radio Advisory.

Lisa Carter (01:02):
Hey, Rae.

Rae Woods (01:03):
Are you ready to have this conversation? It's a hard one.

Lisa Carter (01:07):
This is a hard conversation. I've thought about this quite a bit.

Rae Woods (01:12):
I bet this has been on the top of your mind for many, many years now. Are you sick of having this conversation maybe is the question I should have asked.

Lisa Carter (01:19):
I mean, no, not really. It's brought back a lot of thoughts and memories, some good, some not so good, and so I have relived a few things, but it's a good story. It needs to be told.

Rae Woods (01:43):
I want you to start off by telling our audience what your role is at Ballad Health and maybe what your role was when Ballad was created.

Lisa Carter (01:52):
My role currently in Ballad Health is that I am the regional president within the health system, which encompasses the southern part of our market. Basically it's about nine hospitals that I cover as the regional president. At the time of the merger, and a couple of years prior to that, I was the CEO of Niswonger Children's Hospital, which is the region's children's hospital.

Rae Woods (02:18):
We are mentioning a merger. I just said that Ballad was created and it's a kind of new organization, right? Five years ago.

Lisa Carter (02:26):
2018. As of February, five years old.

Rae Woods (02:31):
Happy anniversary, Ballad. Happy birthday, Ballad.

Lisa Carter (02:32):
Happy birthday, Ballad.

Rae Woods (02:36):
So five years ago, Wellmont Health System and Mountain States Health Alliance, who both serve regions in northeast Tennessee and Southwest Virginia, came together and created a single organization that we now know today as Ballad Health.

Lisa Carter (02:52):
Yes.

Rae Woods (02:52):
Take me back to not just 2018, but prior to that, what was the real reason behind that merger? What were the challenges that both systems were facing that pushed them to ultimately come together?

Lisa Carter (03:05):
Lots of dynamics, obviously weighing down, some of which are still weighing down in areas throughout the country even today. But the area of the country where we're located, northeast Tennessee, Southwest Virginia, had a lot of depressed economic industries. A lot of the area was previous coal mining country, which meant ... I mean, literally we had double-digit population declines in some of our area. We're one of the lowest Medicare wage indexes in the country, couple that with decreased inpatient bed utilization. We were all very, very understanding of the fact that we were over bedded in the region from an inpatient stance, and then we were facing some really, really tough economic challenges ahead of us.

Rae Woods (03:53):
What I'm hearing is that this was perhaps necessary, at least when we look at the economic outlook, the financial outlook for both systems. Continuing at current course and speed operating as two separate organizations in the same region, that just wasn't possible.

Lisa Carter (04:08):
Yeah, it wasn't. I mean, it really wasn't possible and we knew that the possibilities of losing hospitals through closure, at the time there were lots of rural hospitals, still are rural hospitals that are closing, we knew that was a very real possibility. We also knew that if one of the systems looked to a different partner, then that would also most likely mean hospital closures, and it would also mean loss of local jobs wherever the buying organization would've been based. So really the region came together, lots of regional leaders came together and said, "This is our challenge to fix, so let's fix it."

Rae Woods (04:47):
The point that you just made about of all of the options on the table, because continuing at current course and speed was not an option, that the decision to come together as one system was the best decision for the region because we have to keep the facilities open and financially afloat. I know you said that this was something that a lot of regional leaders came together on, but I have to believe that there were naysayers. I have to believe that you had to convince a lot of people that that was true not just within the organizations, but also some state authorities in both Tennessee and Virginia, because you effectively kind of created a monopoly, right? What kind of commitments did you have to make, get people, including state authorities, on board with this?

Lisa Carter (05:35):
Let's not forget the FTC either.

Rae Woods (05:38):
Yeah, absolutely. That little thing.

Lisa Carter (05:43):
Yes, basically the [inaudible 00:05:45] health system has all of the inpatient beds within the region and so throughout the country, there had been a couple of mergers like this that had taken place, but not to this magnitude, not across two states and not as many hospitals obviously, in the mix. What that required was for the leaders of the health system to work with both states, Virginia and Tennessee, through the development of legislation, actual legislation that allowed this merger to actually take place. In Virginia, it's under a cooperative agreement, and in the state of Tennessee, it's under a certificate of public advantage. What that means is we committed substantial dollars back to the communities. Obviously there's verbiage within the merger, commitments about price increases, capitations on charges and pricing, and then also, like I said, substantial commitments, financial commitments to the regions to improve the overall state of health.

Rae Woods (06:47):
Was there a commitment to keeping those facilities open? Because you said one of the benefits of keeping kind of things within the region was the commitment to saying, "We're going to close as little as possible."

Lisa Carter (06:59):
Yes. Were commitments made that we would not be able for a certain time span to not close hospitals. There were only certain services that were carved out in those commitments that we could look at consolidating, and outside of that, even today, we have to have approval from both states to downgrade services at a hospital.

Rae Woods (07:21):
The biggest benefit of this merger is kind of obvious. These health systems are not closing, but what are some of the other benefits, what are some of the other things that you get out of this deep, deep collaboration and the efficiencies that can be gained by coming together as one system as Ballad Health?

Lisa Carter (07:40):
Through those financial commitments that we made, we really were able to stand up programs that ... it's interesting, as I talked to some leaders throughout the country, they always say, "Well, how are you paying for that?" And I just sort of laugh a little bit because normal health systems don't have financial commitments that they have made that they have to spend money on programs that are outside of your normal capital and outside of your normal operations to really stand up community-based programs that support the overall population health of the region and really work to decrease some of those health disparities and social determinants of health that we hear so much about. Those are the things that we've been able to tackle as a health system because we have gained financial support through those efficiencies.

Rae Woods (08:29):
I want to pause on the story thus far because it's actually one that we want leaders in healthcare business to repeat. We want organizations to realize the financial reality in front of them. We want organizations to make big bets, and frankly, we want organizations to look at their assets and decide what makes sense, what makes sense financially, and what makes sense in terms of patient access. But practically speaking, those trade-offs are never easy, even if they are necessary, especially in this moment where health systems are just in this extraordinary fragile place today. One of the trade-offs that I know that you had to make was the difficult decision to close the NICU at Holston Valley Medical Center. Can you talk to us about why Ballad ultimately made that decision?

Lisa Carter (09:21):
Sure, and that's the hardest part to talk about because it was a difficult decision not made lightly. There's only so much we could do operating as two independent systems prior to the merger. So once merger closed, we were able to come together as two groups now into one merged leadership group to really look at all of the financials, look at all of the operational metrics and indicators, and really sit down and think about what do we need to do. So we had one level three NICU within Niswonger Children's Hospital that had seen really declining volumes. I would say a below average size NICU. We ran an average daily census of about 21 or 22.

Rae Woods (10:11):
You were the leader of this hospital at the time of the merger?

Lisa Carter (10:14):
Yes, I was the CEO of the Children's Hospital. Then with the merger through the commitments made, we stood up a children's service line and a strategic service department for women's and children's services, so I was the leader for the system for children's services as well and so that put me in a unique position to be able to look across the system at both hospitals to see how they were operating, to see really what type of care they were providing. I'm a nurse by background and awfully enough, I'm a NICU nurse. I really had firsthand knowledge and had been in that environment for so long. When I started asking questions about the level of service, the level of care, the types of subspecialists, it really became apparent that we had some differences and that both NICUs were really in trouble because both were seeing declining volumes.

(11:13):
We knew we needed to recruit additional pediatric subspecialists to come in and take care of patients, but we didn't have a consolidated volume and really that one center to be able to do that. So after looking at those redundancies, we realized we could have a really, really great service, a great service if we had one service, but if we continue on with two, we're going to get to the point where we're not going to have any. So that was something that we really could not stomach as an organization is fragmenting and diluting that care in two separate places and running the risk of not being able to sustain either service.

Rae Woods (11:59):
You make this decision that is grounded in all these technical realities. It is grounded in the volumes that you're seeing. It's grounded in the economic reality, it's grounded in the financials, it's grounded in what you're seeing in terms of quality and staffing and all of this stuff. And yet, what was the reaction from the community?

Lisa Carter (12:20):
It was less than stellar. It's probably the understatement of the century.

Rae Woods (12:28):
Which is understandable. The emotional reaction when the headline is NICU closing, I'm not sure if that's the actual headline, but I'm coming up with it in my head. NICU closes, boo Ballad Health. That's the feeling that people have because especially because of their deeply held beliefs about the two organizations that now no longer exist because we formed one.

Lisa Carter (12:53):
Yeah, we formed one, and that was a hill to climb, and now we are now taking away services, great services, services that have been in a community for a long time, provided great care to a lot of families, a lot of children, we are now taking that away and moving it to another location. We saw fear creep in of babies are going to die, they'll not make it to Johnson City in time. As a NICU nurse, I knew those fears were unfounded because you stabilize babies for transport, you make sure that they're clinically okay before you put the baby in an ambulance. We also want to make sure we transported moms and so we were working on plans and had plans in place to do all of that safely and effectively but fear was the most powerful emotion that people were reacting with. It probably wasn't until much later that I realized you can't overcome some of those emotions with data. You just can't do it. It does not work, it does not win.

Rae Woods (13:57):
I think those fears played out in a very real way in the form of protests. Protests that lasted quite a long time. How long did those last?

Lisa Carter (14:06):
I believe it was right at a year.

Rae Woods (14:09):
Wow.

Lisa Carter (14:10):
An actual year that we had people who really camped out in front of Holston Valley Medical Center and it really took the city stepping in and making that area not a place where ... because people were literally living there, it wasn't a place that people could live, and so there was a lot of uprising, a lot of social media backlash. The other thing, we talked a lot about the social media pieces and I always would make the statement if they only knew me, if they only really knew me and knew my heart and knew what I wanted to do. But that's the thing, you don't know people. You don't know the leaders. You don't have those emotional connections and relationships with them. So oftentimes people make assumptions that aren't accurate, but that played in very much to the community reaction to what was being done.

(15:06):
It was not being done for the sake of money. I mean, we are a not-for-profit health system. It was not being done for the sake of profits. It really was being done to sustain services in a very rural community.

Rae Woods (16:09):
What about the reaction from staff? Because they know you a little more, some of them at least do. Perhaps they may be more aware of the data, the technical realities and technical solutions in front of you all. What was the reaction from staff?

Lisa Carter (16:36):
The staff at the hospital where the NICU was closing were very upset, very upset. We, again, came at them with what we thought was a great plan, such a great plan of, "You're going to have these options and you're going to have this and you'll have your same seniority and you'll ...", all of the things that we thought they would hold valuable and that just did not pan out to be the case. It was really more actual grief. So we saw people go through all the stages, some of the anger that was not projected appropriately. Lots of things that happened. Really, I look back on it, and I'm probably most upset by the protestors because that left those team members really clinging to hope that something was going to happen through that protest and they never could move forward in those stages of grief because they really, really thought that the protests were going to be effective and that we as leaders were going to change our mind and things were going to happen differently.

(17:45):
We knew that was not going to be the case because we had a full objective understanding as to why these decisions were being made, and so the team members really could not move past thinking that it really was was not going to happen.

Rae Woods (17:59):
That's right. You have this objective that you are working towards that is also deeply, deeply grounded in purpose, and you already said it is impossible for other people to know all of the details behind that that's happening right now, and yet you're facing this backlash. Frankly, even if you weren't facing this backlash, you're already going through an enormous change, change that's associated already with fear and fatigue and loss, and you've got this additional challenge on top of it. Was it challenging for you and, frankly, for your peers to keep that purpose at the center, to keep moving forward as intended?

Lisa Carter (18:42):
It was a challenge mentally to just sustain that level of intensity. The fatigue, probably that word you used, fatigue was the most appropriate word, because it was tiring because it wasn't just a couple of weeks, it was literally months and months of writing and thinking through and trying to come up with solutions and having conversations and really coming under attack. I mean, personal attack. Going before and speaking before community leaders and legislative bodies and public forums and public protests. That was hard because at the end of the day I always said, "I'm a person, I'm a person. I have feelings, I have a family", and all of those things and it was almost sometimes like a surreal experience, if you will, of just you really couldn't believe the way it was playing out in the public.

(19:41):
But back to the statement you said about purpose, I never wavered from that purpose.

Rae Woods (19:47):
How?

Lisa Carter (19:48):
Because I knew with everything in me, and I think honestly, it probably goes back to me being a mom, mom of a NICU baby and a nurse, a NICU nurse, that I knew 100% what this community in this region needed and I knew that they would not get it if we did not follow through with this decision. I mean, our leaders, all of the leaders and the board, everybody was committed to it, but I really feel like my personal connection to it really helped everybody stay the course because at the end of the day, I could go home and know that the purpose was needed and a whole lot of lives would've been impacted negatively had we not moved forward with this.

Rae Woods (20:41):
How do you articulate that purpose to others, especially when you have this real benefit of having a lot of personal connection to it, but we're also talking about an organizational purpose. How do you articulate that to others to bring them along and first of all, make them feel safe in the decision and keep them going forward, especially when there's this huge backlash, especially when your own staff is walking by those protestors on their way to work to execute on these decisions?

Lisa Carter (21:12):
I mean, it was hard. What we found is really, we say it all the time, and you're not afforded the opportunity every time, but really a one-to-one conversation, sitting down one-to-one with someone, hearing them, giving a chance to hear you, those were the times we really could get people to understand. When they could hear the stories, hear my why, I remember sitting down with some of the local newspaper editors and having some off the record conversations, and they always, never failing, at the end, they would say, "Oh, I get it. I really get it." Unfortunately, you can't do that every time. You can't have a lot of those one-on-one conversations, but oftentimes that's what it takes is putting down all of the business fronts, if you will, and just having a very personal connection and conversation with somebody.

Rae Woods (22:08):
What I'm hearing you say is the data is not going to make people feel safe about this decision?

Lisa Carter (22:14):
No.

Rae Woods (22:16):
The data's still necessary. Let's not say that the data's not necessary.

Lisa Carter (22:20):
The data's necessary.

Rae Woods (22:21):
But the data alone isn't going to fix the problem.

Lisa Carter (22:24):
No, no, no. No, no, no. That's the other piece. Even physicians, and we always talk about that with physicians, they always want data and bring data, and they wanted data. We did that with the physicians, and that did not work. There was still that emotional connection. And still today, I mean still today, I see that play out in a lot of scenarios of scientists who are very empirically minded. The data still is not the driving force.

Rae Woods (22:58):
Always. Is there anything that you would do differently looking back on that time when it comes to bringing others along and keeping them centered on purpose such that we can keep moving forward and cut out this very loud noise that is there?

Lisa Carter (23:15):
Obviously now we would've given way more credence to the emotional side of it. We would have led with conversations that talked about how we're keeping babies safe. We would've had some opportunities for one-on-one conversations and also community listening sessions. One of the things that would've been tremendous would've been to bring in parents of NICU graduates at the facility where we closed the NICU and listening to them, and not only listening to them and what fears they would've had, but also then honoring their stories and honoring the journey that they went on in that facility. Those are defining moments in people's lives because the emotions are so high. So giving credits to that and paying honor to them would have been a tremendous step in helping them see the human side of us, but then also understanding why we needed to do what we were doing.

Rae Woods (24:18):
We mentioned that it's been five years since the creation of Ballad Health. Would you say that your organization achieved the goal that you set out to accomplish back in 2018?

Lisa Carter (24:29):
Oh, 100%.

Rae Woods (24:31):
I mean, you're open.

Lisa Carter (24:32):
Absolutely. I mean, we said over and over and over during the pandemic, I cannot even have fathomed being two competing health systems during the pandemic. How we would've shared information, would we have shared information? Everybody came together and I feel like we would have, but the ability for us to react quickly and make changes so quickly, we would've never been able to do that. So that alone is a win for the region and the community. Also, we're living those commitments every single day. I mean, we're opening new programs. We're focused on things that literally fall outside of the realm of inpatient hospitals. I've had the privilege of really standing up programs that reach out to pregnant women, they address their social needs, they address their real needs of food and shelter and clothing and things like that that we never would've done previously. It's not just providing inpatient hospital care to the region. It's really working to make the region a better place to live and work.

Rae Woods (25:48):
Lisa, I wonder if you can share what's changed for you personally as a result of this experience. What's changed about your leadership style and what you bring into extraordinary complex moments in healthcare and in leadership, which we know are, frankly, constant?

Lisa Carter (26:07):
Well, number one, I probably push a lot on communication plans way more than I ever did. I think differently about how people are going to react and we're still making changes. Obviously, healthcare is not out of the woods by far with things that we're going to be faced with the future, and so every single time, I really, really try to think through the human component of that. What will this mean to one person? Not to a group of people, but to one person? How will one person react to this? So we've been able to think through some of those things most recently in some changes that we're making, and how do we honor people and honor a person because leadership is personal, and how we do that matters, and thinking through that has helped as we have tried to communicate some of these upcoming changes we're facing.

Rae Woods (27:06):
Before we wrap this episode, I want to give you a moment to kind of speak directly to our listeners. What advice do you have for them as they navigate their own complex challenges and need to stay true to purpose?

Lisa Carter (27:21):
My biggest piece of advice would be to stay the course. I have also seen decisions that we've tried to make, and we've gone right up to the finish line and we didn't quite cross it, and that's had some detrimental effects, and I see that in a lot of other areas throughout the region, basic things that really need to make some difficult decisions, but for whatever reason, leaders choose to not do that. It's hard. It really is hard to make difficult decisions, but if you know your purpose and you're aligned with that and you're making the decisions for the reasons they need to be made, then you have to see those through. You have to see them through to the finish line and cross over, because that's the only way you get the benefit from it.

Rae Woods (28:14):
Well, Lisa, thank you for all that you do, and thank you for telling your story on Radio Advisory.

Lisa Carter (28:18):
Thank you.

Rae Woods (28:24):
Complexity and uncertainty are constant challenges that all of us will face in healthcare. There's no such thing as going back to the way things were or ever achieving a state of stasis. In fact, that's a pretty dangerous place to be. The role of leaders, which is exactly what Lisa talked about, is to keep pushing organizations forward even in the face of complexity, especially when it gets hard. Remember, as always, we're here to help.

(29:02):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Katy Anderson, Kristin Myers, and Jenny Heipp. The episode was edited by Dan Tayag with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk and Leanne Elston. Thanks for listening.