John B. Chessare, MD, FACHE, President and CEO, GBMC HealthCare : Journal of Healthcare Management

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INTERVIEW

John B. Chessare, MD, FACHE, President and CEO, GBMC HealthCare

doi: 10.1097/JHM-D-22-00219
  • Free

As a pediatrician, academician, and hospital executive, John B. Chessare, MD, FACHE, prescribes, teaches, and applies systems thinking to surmount the challenges that U.S. healthcare organizations face. His work as president and CEO at GBMC HealthCare in Baltimore, Maryland, to improve patient flow, limit waste in acute care, and create safer and more reliable delivery is nationally recognized—GBMC received the Malcolm Baldrige National Quality Award in November 2020, and in April 2022, Dr. Chessare received the Harry S. Hertz Leadership Award from the Baldrige Foundation.

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His recent conversation with Eric W. Ford, PhD, editor of the Journal of Healthcare Management, covered his philosophy of sound operations management and is edited here for length, clarity, and format.

Dr. Ford:Tell us about the journey to your current role.

Dr. Chessare: After high school, I was bound for Georgetown University and a career in the U.S. Foreign Service. But as I reflected on my choice, I reconsidered. I instead did pre-med at Boston College and went on to medical school at the University of Rome.

After graduating, I trained in pediatrics at the University of Massachusetts and went to Boston Children's Hospital for my fellowship, where a critical event happened: I was assigned to Don Berwick as my research mentor. When I completed the fellowship, the first paper on my CV was coauthored by Dr. Berwick.

I took my first job as an assistant professor of pediatrics at the Medical College of Ohio because it was proximate to the University of Michigan, where I could get a master's in public health part-time. In the Michigan program, I got exposed to Avedis Donabedian, the father of quality improvement in healthcare. So, I went to graduate school to be better trained as an academic in biostatistics and epidemiology, but I came out with this absolute belief that healthcare could be better. It was just a question of leadership.

Dr. Ford:That's a great story with Berwick and Donabedian. It's kind of like a philosopher saying, “I studied with Socrates and Plato.”

Dr. Chessare: That's exactly the way I feel. I've been so fortunate.

Dr. Ford:What prompted your return to the East Coast?

Dr. Chessare: While a faculty member at the Medical College of Ohio, I became the vice chief of staff at the hospital and associate medical director for the school's HMO. I was also running the general pediatrics practice, I had a specialty practice in developmental pediatrics, I was publishing, and I was overseeing the residents in the continuity clinic. . . . My wonderful wife, Tracey, a dermatologist, said to me, “You're doing too many things.” She was right. With our four young children, we moved back east, where we could live closer to the grandparents and I could really commit to management and leadership.

I pivoted to management at Albany Medical Center, later got the CMO job at Boston Medical Center (BMC), and was the associate dean for clinical affairs at Boston University. BMC is a safety-net hospital, and safety-net hospitals are not known as models of efficiency. But through better design, we dramatically reduced wait times and delays in the emergency department. After a number of years in that role, I decided that I wanted to run an organization, and I got that shot. I left BMC to become president of a Caritas Christi Health Care hospital, and later became vice president for quality and then interim president of the Caritas Christi system. Ultimately the Archdiocese of Boston sold the hospitals to a private equity firm. I moved on to my current job as president of GBMC, which has been a fabulous gift to me and my family.

Dr. Ford:When I teach my classes, I often talk about how great GBMC is as a model healthcare provider. What circumstances shaped that model?

Dr. Chessare: GBMC was started in 1965 with the merger of an ear, eye, nose, and throat specialty hospital and a women's hospital to create a general acute care hospital. GBMC distinguished itself as a very good place to deliver a baby and to go for acute care.

When I arrived in 2010, GBMC's medical staff was incredibly talented in a city that was well-served by acute care facilities. But the world was changing. Americans were spending much more per capita on healthcare than people in any other country in the world, yet they were not anywhere near the best in outcomes in chronic disease, and slipping. Why? The biggest reason was the reimbursement system, which focused on acute care. You could make a lot of money doing a lot of MRIs, but you could lose your shirt if you tried to move upstream and work to keep people out of the hospital through primary care.

When the Affordable Care Act (ACA) took effect in 2010, about 90% of its intent was to move the country from that fee-for-service reimbursement model to fee-for-value. That shift prompted the GBMC board to do something smart: They went off on a visioning retreat and studied the facts. They concluded that, as a not-for-profit corporation, GBMC was there to serve the community—we needed to stop celebrating if we just made some money, paid all the bills, and took care of sick people. We had to do more. We needed to move upstream and do what our friends and neighbors needed in the community. We needed to better manage and ultimately work to prevent chronic diseases.

The retreat resulted in a new vision statement. In four paragraphs, the board essentially said let's reorganize, let's not lose our strength in acute care, let's not lose our strength in being able to deliver babies . . . but let's build up from that.

We created the structure that allows us to be held accountable for the health of our population. At first, some board members scratched their heads about this change, but they could all tell a story of friends or family members with chronic diseases who had not been treated very well. And so, GBMC embraced the concept of the patient-centered medical home.

In those days, we had six or seven primary care offices, open Monday through Friday by appointment. The clinicians told you what to do after leaving the office; from that point on, your care was basically on you. Today with our patient-centered medical home, office hours are extended into the weekends and caregivers commit to being accountable for their patient's health. To do that, you need a robust electronic health record system, and we spent a lot of money on that. We created registries for diseases like diabetes. Before, if you asked me how many patients with diabetes we had, I would have said, “I have no clue.” If you asked how well we were doing with them, I would have said, “Pretty good.” Today, I can get you the exact numbers by going into our reporting system. We got to this place through the commitment to build a system that the patient would experience as a system.

Dr. Ford:Tell us about the GBMC system of care and what makes it unique.

Dr. Chessare: Many companies apply the “system” label to their hospitals but most are not actual systems. They are confederations of hospitals. At GBMC, the patient experiences a true system of care that is designed to meet their healthcare needs at every stage of life.

I learned from local hospice care leaders that healthcare providers like GBMC should push a dialogue about what people want and need in their last months of life and then create a system to deliver that. We need to apply that [patient-centered] mindset starting at childbirth. We then need to keep healthy young people healthy as they age, and for those who develop chronic diseases, we need to maximize their health. To do that, we needed to build a true system of care at GBMC and adopt continuous performance improvement as our business model.

Four or five years into our transformative work, we decided to move faster, so we adopted the Malcolm Baldrige performance excellence criteria. In 2020—8 years after we started to explore the criteria—we were delighted to receive the Baldrige National Quality Award, the first (and to this moment, only) healthcare recipient in Maryland. We were driven by our four-paragraph vision statement and its memorable vision phrase: “To every patient, every time, we will provide the care that we would want for our own loved ones.”

We asked our people at GBMC how they would want the care to be when it is provided to somebody they love. Their responses to that question led us to our aims.

The outcome is the most important aim. The second aim is the best care experience. We don't want inordinate waiting times. We don't want to hear yelling in the hospital. We don't want a dirty exam room. . . . We roll all that up into the best care experience. Our third aim is to not waste our patients' resources, especially in light of the absurd movement in this country to push financial accountability for costly healthcare onto the patient with ridiculously high deductibles. We owe it to the people we're serving to make sure that we don't order laboratory tests and imaging studies if we are not going to use the results to help them get to a better health outcome. We owe it to them to keep them out of the trap of paying for drugs that cost $5,000–$10,000 a month when something that costs $500 will achieve the same outcome.

To this point, you'll recognize our approach's similarity to the triple aim, worded slightly differently. We aim for the best health outcome, with the best care experience, and with the least waste. But we use the term “waste” rather than “cost” because we do not want to confuse our clinicians. If it is costly but can generate the best outcome, do it!

As our fourth aim, we want to be mindful of our calling to serve our patients well at a vulnerable time, and the work should be joyful. We tell our new people at orientation that they will have hard days. Those days, on their way home, they should reflect on just one of the persons they have helped, and then smile. That is the joy.

Those are our four aims. They are nothing more than the definition of the care we want for our own loved ones. That is GBMC in a nutshell.

Dr. Ford:Sounds like you got ahead of the curve. The fourth aim of caregiver well-being reflects the growing recognition of stress and burnout during the pandemic. Can you tell us a little bit more about working in Baltimore and around the community?

Dr. Chessare: Baltimore is your classic example of the haves and the have-nots in the United States of America. There are people like me with excellent access to medical care, while many people in the inner-city have no access to advanced primary care and very few primary care options. They wait to get desperately needed care—not because they want to wait. They wait until they are really acute, and wind up in emergency departments.

This reality prompted us at GBMC to examine our conscience and become a bigger part of the solution. Our predecessor organizations were in the city, so we decided to move back there. That opportunity came when a mission organization that helps men with addictions invited us to provide primary care for the 500 men living at the mission. We couldn't make the deal work for only 500 patients, so we offered instead to open an advanced primary care practice to also serve the neighborhood. Coincidentally, the mission operates in a building that was once one of GBMC's predecessor hospitals. In a sense, we are back where we started.

We intend to move into other neighborhoods. The big impediment still is the reimbursement system. To do primary care correctly and keep people out of the hospital, you need care coordinators and care managers to work alongside the care providers. When you add up all the required resources, it just does not work with the current fee-for-service reimbursement model. Fortunately, since the passage of the ACA, and the creation of the Center for Medicare and Medicaid Innovation, the payment system is slowly changing.

Dr. Ford:Could you share any advice for early careerists? Any books, current or classic, that might benefit them?

Dr. Chessare: My number one suggestion for early careerists is to not lose sight of their dream to make a difference in the lives of people. There were many times in my career when I wondered whether I was getting anywhere and doing the right thing. Today, I am doing exactly what I hoped I could do. Some people go with the financial opportunities in healthcare, and that's not necessarily a bad thing. But I would suggest that they keep reflecting on why they got into healthcare in the first place and try not to deviate from that.

I'm a huge believer in the importance of system design. GBMC has fabulous people; there are fabulous people everywhere in healthcare. But what really differentiates great organizations are the systems in which their people work. We adopted the Baldrige criteria because they force you to ask a series of “how” questions: How do we keep a patient with diabetes out of the emergency department? Once they are there, how do we admit them (or anyone who needs to be hospitalized) to an inpatient unit? How do we assure that the nurses have every medication they need in the moment? It's that system thinking that separates great organizations from typical organizations.

I also ask all young careerists to question the movement toward bigger and bigger hospital companies. The historic impetus for a multihospital company is to leverage insurers for higher reimbursement rates. Yet almost always, when you put a bunch of hospitals into the same company, the cost to the consumer goes up, not down. The economies of scale argument is extremely weak in how mergers happen in healthcare.

For books, I recommend Small Giants: Companies That Choose to Be Great Instead of Big by Bo Burlingham and The Goal: A Process of Ongoing Improvement by Eliyahu M. Goldratt and Jeff Cox.

Dr. Ford:They're sitting on my bookshelf, too. They look a little dated but they're still right.

Dr. Chessare: When I was at BMC, I went to an Institute for Healthcare Improvement National Forum to hear Dr. Berwick. He introduced Dr. Eugene Litvak, a faculty member of Boston University, as the patient flow guru. Later, we started working with Dr. Litvak. At one point I said to him, “Eugene, your work is phenomenal. You need to write a textbook.” He replied, “Didn't you take a course in operations management at the University of Michigan?” I said, “Yes.” He said, “What I'm teaching you is in every textbook of healthcare operations management. The problem is that no one uses it.” He was 100 percent right and to this day, there's still this huge opportunity for improvement in applying the science.

Dr. Ford:As an educator, I frequently talk to alumni who tell me that the things that seemed important in class have turned out to be not so important, while the things that they didn't pick up are things that they are having to learn now.

Dr. Chessare: I think that is a very true sentiment.

© 2022 Foundation of the American College of Healthcare Executives