Leading Quality

Why Building Leaders May Be the Most Important Quality Improvement Work

• Jason Meadows, MD • Season 1 • Episode 9

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Why This Episode Matters

Healthcare quality work often stalls not because of a lack of methods or data, but because organizations fail to build the leadership and culture needed to sustain improvement. In this episode, Dr. Todd Allen reflects on his journey from frontline emergency medicine to senior quality leadership at Intermountain Healthcare and The Queen’s Health Systems, and how his view of quality evolved from tools and measurement to leadership, trust, and psychological safety. The conversation explores the design and impact of physician leadership development as a core strategy for cultural change—offering a perspective on quality improvement that goes far beyond projects, dashboards, or checklists.

Key Ideas Explored

  • Quality and leadership are inseparable: Sustainable improvement depends on leader behaviors, not just methods.
  • Psychological safety enables learning: Without it, clinicians won’t question assumptions or surface problems.
  • Technical skills aren’t enough: Character determines how tools like finance, strategy, and operations are used.
  • Culture changes through behavior: Daily actions—not slogans—shape how organizations function.
  • Leadership can be measured: Imperfect measurement still supports learning and accountability.

Takeaways for Quality Leaders

  • If improvement fades, examine leadership capability before redesigning projects.
  • Pay attention to whether people feel safe speaking honestly in leadership spaces.
  • Don’t assume leadership will develop on its own—teach it deliberately.
  • Treat skepticism as a signal of missing trust, not resistance.
  • Look for character-based leadership in everyday decisions.
  • Invest in leadership development as a system capability, not a one-off program.

Continue the Conversation

  • Connect with Dr. Todd Allen on LinkedIn
  • This episode may be especially useful for leaders building clinical programs, leadership pipelines, or communities of practice.
  • If this conversation resonated, consider 
    • Rating and commenting on it to help others find it.
    • Sharing it directly with someone interested in for leadership development or shaping culture in your organization.

Resources & Frameworks Referenced

New episodes published every other Thursday at 7AM Eastern Time.

SPEAKER_01:

We wanted purposely to be a safe space for learning and for sharing. Most healthcare organizations don't have that as part of their culture and part of their history. And you know, we all have stories from our background as a nurse speaks up, a pharmacist speaks up, a provider speaks up, and is just beaten down. We needed a space for physicians, especially to ask the hard questions and to say, okay, wait, you said that, but I saw this last week.

SPEAKER_02:

Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C-suite. I'm your host, Jason Meadows. When you look across the field of healthcare quality improvement, there are only a handful of leaders who've lived every layer of the work. Frontline clinical care, system-level transformation, teaching the methodology, and developing the next generation of leaders who will carry it forward. Dr. Todd Allen is one of these people. Todd started his career as an emergency medicine physician in Utah, but very quickly found himself surrounded by giants, clinicians and mentors who pulled him into the world of improvement before he even realized it was happening. His early years at Intermountain Healthcare placed him shoulder to shoulder with people like Dr. Brent James and Dr. Terry Klemmer, and the clinical teams who were rewriting how an entire system approached sepsis, process improvement, and evidence-based care. Those experiences didn't just teach him the methods, they reshaped his understanding of what leadership in healthcare is and what it requires. Fast forward through two decades of progressively larger leadership roles, and Todd eventually stepped into one of the most culturally meaningful and operationally complex roles of his career. Senior Vice President and Chief Quality Officer at the Queen's Health Systems in Honolulu, Hawaii. And Queens holds a special place in my own heart as well. It's where I completed my internal medicine residency and where I first learned what it meant to practice medicine in a mission-driven, community-rooted system. At Queens, Todd helped design and implement the system's physician leadership development program from the ground up and partnered with leaders across the organization to strengthen quality, safety, culture, and clinical program strategy, all grounded in Hawaiian history, identity, and values. What I love about Todd is how deeply he understands that quality improvement is never only about methods and metrics. It is always about people, about character, about humility, accountability, compassion, and the everyday behaviors that shape culture far more than any dashboard ever will. And he's honest about the hard parts, too. The skepticism, the setbacks, the crucial conversations, and the slow but unmistakable cultural shifts that tell you you're on the right path. In today's conversation, we talk through the arc of Todd's career, the leadership lessons he absorbed during Intermountain's early quality movement, the origin story and structure of the Queen's Physician Leadership Development Program, and what he believes the next generation of quality leaders will need as healthcare becomes more complex and technology, including AI, reshapes the landscape. It's a rich, thoughtful, and quietly powerful conversation, and one that left me reflecting long after we stopped recording. Let's dive in. Dr. Todd Allen, welcome to the podcast.

SPEAKER_01:

Thanks, Jason. Appreciate the opportunity to be with you.

SPEAKER_02:

Thanks. And you know, I'm hoping that we can start with just your your backstory and kind of a 20,000-foot view of your career timeline so far.

SPEAKER_01:

Sure. Happy to sort of tell that story. I think it does illustrate a couple of important points that we'll hit later. Came out of residency in about the year 2000, and like a lot of emergency physicians, didn't know exactly what I wanted to do, but was blessed to get a job offer back in my home state of Utah with Intermountain Healthcare in a brand new position, the first academic emergency uh medicine position that Intermountain had ever created for the Director of Research for Trauma and Emergency Services. And they needed that job to meet the research requirements for the American College of Surgeons to be a level one trauma center. They'd sort of had a waiver up until that point, and that wasn't going to work anymore. And not really knowing what to expect, I said yes. You know, I don't know if I was fully qualified a year out of residency. Uh, but I jumped in, and that's I think where I began, slowly began to get my first sort of l important lesson. Uh, because of the importance of that program, I was immediately surrounded by these mentors, these uh professional physician leaders who just weren't going to let me fell. They were ethical, uh, they worked hard, they cared about the community, they cared about the mission, and they kind of wrapped me in their arms and said, you know, um, let's do this together. And looking back on it, you know, just so lucky as a young physician in his first practice place to be put into that environment. And it again, my eyes weren't totally wide open about what was going on at the time, but as the years passed, I began to see what they had done and how important uh that kind of behavior, those sorts of skills were uh for a physician leader. Fast forward, you know, a decade or so, I was invited to come down and join the quality office at Earn Mountain Healthcare and work for the chief quality officer, a physician named Dr. Brent James. His name is pretty seminal in quality in American healthcare, right up there with Paul Batalden, right up there with Don Berwick. And I got to serve as his assistant chief quality officer. It was right on the hills of the ACA, it was right on the hills of the High Tech Act, and he was being called to travel all over the country and help healthcare systems react to that. And so he brought me in, sort of taught me the ropes, and what an experience. It was while I was there, you know, that I developed my, I think, my ability to understand quality from a deming approach or from a total quality approach and began to teach that around the nation, just like uh Dr. James Brent had done. He left the organization in 2017, and I was fortunate to be asked to sort of step into that role that he had as senior director, senior medical director for the healthcare delivery institute, and teach our quality improvement course within Intermountain, lots of attendees from around the world and around the country, and to help lead our clinical programs in delivering quality and safety using principles of process management and quality improvement, lean six sigma analytics, that sort of thing. While I was doing that, approached by the Queen's Health System in Honolulu, Hawaii, which you know, and asked at least to interview for a senior vice president role and a chief quality officer. And the pandemic hit, turned our world here upside down in Utah, just like everybody else. And the family and I had a long discussion. We decided to go for it. And so we jumped over to Hawaii in October of 2020. Same situation, jumps into an organization mission-driven, cares deeply about what they're doing, a remarkable tradition of quality and safety, and got to lead the core quality components, regulatory, clinical risk, infection prevention, data and analytics, but was given other things to do as well. Help develop physician leaders, help lead clinical programs or service lines, and help run the high reliability. And that was just a marvelous five years. Our family and and me grew so much. The five years passed. Uh, daughter graduated from high school, the youngest daughter. And as you know, Jason, you know, time for a transition. So now in that transition period after the Queen's experience, but uh had just what an honor to work with them and what um a privilege to help them develop programs not only around quality and safety, but around leadership that we'll talk about.

SPEAKER_02:

Yeah, and you've you've given a great high-level view. And I'm curious if we can dive a little deeper into what got you excited, what got you engaged in the quality improvement and leadership side of this equation. Since you mentioned you started out as a, you know, in a research type orientation, a lot of clinicians are are working down either a clinical or an academic path. And QI was a kind of a third path that you decided to go down. Tell me a little more about how you, you know, decided to go that way.

SPEAKER_01:

Yeah. I was minding my own business, as it were, you know, as as the research director, and we were doing pretty well. But it was it was the time that sepsis and the recognition, the early treatment and resuscitation of sepsis in that first 24 to 48 hours was gaining national recognition. And uh the leaders of our system, our hospital at LDS Hospital, there with intermounted health care, recognized we weren't doing a great job, uh, especially in the emergency department recognition, again, early resuscitation. And so I was approached by the leader of the critical care community, a physician named Terry Klemmer and Dr. Brent James just before I really knew him. And they essentially said, Hey, Todd, um, this is important. We don't have a clinical leader. We need this kind of special research learning clinical leader to help partner with me, Terry Klemmer, uh, for the Sepsis Initiative. Would you come? I was actually told, will you, you will come to the advanced training program in clinical process and quality improvement that Brent James ran at the time. And you're going to learn the methods of quality improvement brought to health care so that you can then be more effective as a partner with Dr. Klemmer and the nursing team, the pharmacy team, the radiology team, the multidisciplinary teams to help run the sepsis protocol. That was my introduction. Um, it was remarkable to me to take this history of medicine, how medicine got to where it was, the history of process improvement, how it got to where it was, and why it was a perfect time for these two things to sort of come together in a unique application within healthcare. And indeed, Brent had been at the forefront of that along with Betalden and Berwick. I think they were some of the first physician leaders to attend W. Edward Deming's course in quality improvement that he held a couple of times a year in California. So they learned from the master himself and then brought that in, customized it for healthcare. And it took me a while, a couple times around the uh the track, as it were, to sort of understand it, have it make sense in my brain. But when I did, boy, the you know, the shades went up and the light bulbs uh went on, and it was fun. I loved it because of a couple of things. One, it gave you a methodology by which you could improve. It gave you a methodology by which you could measure to actually prove you were improving. And three, you know, it set up an environment where, as I mentioned, multidisciplinary teams could come together and reimagine process engineer healthcare processes that were, that didn't quite work perfectly. Worked pretty darn well when you look at the history of medicine and all the things that medicine has achieved over the century, but didn't work as well as they could. And I love that. I love working with people. I loved um, you know, listening to them and learning from them and gathering ideas from every source. And so that set me down this track. It got cemented a little bit more when I was asked to be the uh medical director for all of all the 22 emergency departments across Intermountain Healthcare. And there, as a team, big team, we got to dive in more to sepsis, to AMI, uh, to heart to stroke, uh, to heart failure, to diabetes, to first trimester bleeding. We did so many things, the febrile infant, just dive in and really try to understand those clinical and operational processes and make them work a little bit better. That was the next big thing. And boy, had another blast, some of the best experiences of my career. And the last thing, of course, was when Brent um asked me to come in as a formal part of his organization and help teach these principles to others. And when you have to teach these principles, you you gotta learn them at a different level. You have to understand them at a different level. And the connectivity between analytic methods and just process improvement methods, the connectivity between leadership and change management, the connectivity between, you know, process maps and leadership, all those sorts of things began to crystallize and, you know, uh converted, as it were, to the importance of these ideas, the trueness of the methodology and the outcomes you could achieve. That's the package I was lucky to be able to take to Queens and bring it, you know, a fresh canvas to folks. And I think this is true, you know, around the world. People are hungry for this. People are hungry for this. They love what they do, they come to work every day full of optimism. And medicine is complex. Modern medicine is amazingly complex, probably the most complex of any of the industries, forgive me for putting it that way on earth, to have a methodology that helps you take a team-based approach to solve, to problem solve and get outcomes better, even personal outcomes of relationship and culture in an organization, to have those outcomes improve. People love that. They're hungry for it. And I loved bringing that to Queens and to build on their remarkable uh tradition, you know, that began all the way back in 1859.

SPEAKER_02:

Yeah, you've said it so well. I mean, it really is something that a lot of us in this in this healthcare quality improvement community are hungry for and really enjoy as part of this work. I know that that uh leadership is also uh has been a big focus for you, both acting as a leader and also teaching leadership. When you look back on your years at Initial Mountain, what experiences most shaped your view of what good leadership looks like?

SPEAKER_01:

Well, what a what a great question. Um, you know, like I think a lot of people, Jason, you know, leadership for me uh appeared a little bit accidentally. And certainly I had to learn line upon line, precept by precept, as it as it were. There were times, um, certainly within Intermountain Healthcare and at Queens where people reached out to me, like a Dr. Wallace or a Dr. James, to say, hey Todd, you're doing okay, but you lack some technical skills, you lack some, you know, some character-based skills. We've talked about that before. Let's send you to a course. Let's do this professional development, leadership development thing with you, either individually or in a group. And they were helpful. I think it was helpful, you know, to learn about finance, to learn about human resources functioning, about how to develop strategy, what strategy is, uh, change management, etc. But the biggest lessons really came either from, and I hate to say this, mistakes that I made, or, you know, more importantly, watching good leaders. And I've been blessed again, I've mentioned some names and been blessed to have many more in my life. And watching and then thinking, how do they do what they do? Why do they do what they do? How did they make a choice in this moment? And how does that choice reflect back on system, on alignment, on character, on values, on integrity? And so a lot of both, you know, a lot of technical um experiences, I could name a few, but a lot of watching and learning and struggling, frankly, in in some moments, uh, where I had to learn, uh, maybe those are you know, some of the biggest lessons where I had to struggle, um, struggle mightily, but then reflect back and learn from those moments and what I and to and take derive lessons that I certainly needed.

SPEAKER_02:

You've also carved out this niche for yourself as someone who who um develops future leaders. Was there a moment when you realized that developing other leaders, not just leading yourself, but developing other leaders would be central to your own role?

SPEAKER_01:

Yeah, I think again, those two moments. One was in teaching the advanced training program in quality and process improvement for intermountain healthcare. We must have spent um about 20% of the course, either directly or indirectly, speaking about leadership and contrasting styles, frankly. You know, you think about the science of process improvement beginning with well, not perfectly beginning, but you know, as taught by Frederick Winslow Taylor, who helped Henry Ford with the Model T factory. And he had a leadership style that was mistrustful of workers, that thought workers were lazy, that thought work workers were dumb, and and what they would only succeed if they followed his instructions exactly. Now, you know, 1910, 1911, a different environment. Uh leadership, you know, theory grew, and this is true in medicine. It's the most true in medicine, I think. The workers we work with every day, no matter uh what division or office they're in, they care, they're smart, they want to do good, and then the system is complex. And so as a leader, you think, okay, how can I make the system work better? So teaching those principles with NATP, and as I mentioned, the inextricable link to quality improvement was the first thing. The second was when I got to Queens and you look around and you say, Boy, what a remarkable organization. As I mentioned, mission-driven, but we don't have a coherent leadership development program. Consequently, uh the clinicians, and we're not taught this often in medical school, not to mention nursing, not to mention pharmacy, all those others need it just as much. We're not taught, we didn't know the technical skills, the finance, the EHR functions, the strategy, but we weren't teaching a model of leadership that would be most effective in the complex environment of medicine. We call it, you know, in addition to the technical skills, character-based leadership. And so seeing that and talking with my boss, the chief physician executive, and putting our heads together, what do we need to develop to ensure that the next generation of leaders are ready to carry on this remarkable legacy of the Queen's health system? And how do we develop clinical leaders? So they understand the technical bits, but they are rooted deeply in the ethics and the mission of the system, uh the character-based leadership, so we can bring them into the room, we can have tough conversations, and we can grow the organization in a way that the community needs to provide health and security in perpetuity, which was part of the mission statement at Queen. So I think those two things, Jason, just teaching and understanding how essential leadership was to process improvement and quality improvement theory, and then two uh seeing the need there at Queens and have needing to think presciently, carefully, thoughtfully about what you would choose to do.

SPEAKER_02:

Yeah, and I think that's where I want to put the majority of our focus today, is on the work you've done at Queens in in leadership development. First, I wonder if you could describe the context of your work at the Queen's Health Systems in Honolulu.

SPEAKER_01:

Yeah. So uh I served as a senior vice president and chief quality officer, and therefore was you know blessed to be in the ex on the executive team and uh and be involved in most of the conversations. What we needed to do, Queens needed to transition from a classic surgical hospital and hospital based care to adding community based care. That's something that Queens hadn't really done. Up until uh recently. So if you're gonna be in the community and if you're gonna run good hospital care, what are the strategies that you need to run in parallel to get that work done? That was the context as quality officer. Now, the burning platform really was about accreditation and regulation and the regulatory environment. Uh, Queens is a complex place. It's a complex physical plant, and it struggled a little bit with accreditation historically. So that was the burning platform along with infection prevention and control, classic quality and safety, urinary catheter associated urinary tract infections, line infections, falls, pressure ulcers, et cetera. Just had to really dive in. The teams were doing great, but there was the cacophony of COVID, you know, running around, and it was really taking the eye off the ball of those habitual, high rely, high, highly reliable processes. We need to prevent that. But the second bit was then as Queens is evolving into this new world, again, who are the dyad leaderships? Who are the dyad leaders that we need to get this done well, strategically, and within alignment? Then how do you prepare those leaders to be able to take that on and to serve uh right alongside you? So that was the main context. Our CEO and our chief physician executive wanted to build a structure called clinical programs. Now just think of clinical programs as service lines, but in addition to service lines providing the clinical service, the leaders of that service line need to own quality and safety, need to own patient and clinician engagement, need to own strategy, and need to own operations, which is obviously implied by the service line. So with service lines plus plus, right? It's a big, big job. How do you get them ready to go? If I can pick a physician leader for the clinical program of cardiovascular services, if I can pick a physician leader for the clinical program of behavioral health, how do I prepare them to succeed? How do I get them matched up with their dyad partner so that they're on the same song sheet and they can really see and measure what they're doing? That was the context. And again, leadership development then permeates through all of it in the same way that I talked about with Intermountain Healthcare. But the focus, well, at least one part of the focus was what structure do we need to build? What services do we as senior leaders need to provide in order to help our chosen clinicians grow? And to help the next generation who will come along, you know, not too far after that. And hence uh what we call the Center for Professional Development and Wellness was born. They had several jobs uh as part of their portfolio, one of which was a dedicated course called Physician Leadership Development, uh, which we launched in 2021.

SPEAKER_02:

No small task as you as I describe it in its entirety. And I want to get a little deeper into that. I wonder if you could walk me through the early days, the early design of that physician leadership development program and what problems you were trying to solve for first. Yeah.

SPEAKER_01:

So a lot, a lot, you know, a lot like any change management model, we we recognized, described, and brought the burning platform to the board and to the executive team to get that buy-in and understand that need. The second bit, you know, building building the coalition. So we started uh by bringing in some leaders, again, often selected ad hoc over the years, at least at the Queen's Health system. And I think this is true of a lot of systems. You know, medical directors just kind of grow up organically, chief of staffs, chiefs of staff get elected, and you know, it just is what it is. But began to build this coalition to help think through it a little bit. About a year's worth of design, looking both internally within the state of Hawaii, you know, out to the University of Hawaii and other organizations, and then externally, what other folks had done. We settled pretty quickly on about six main goals. You know, we wrote once they were finalized, we wrote that down and they that down. They they were one, the physicians uh and the leaders had to have the skills, the technical skills, the tools, and the organizational knowledge to fit within the queen system. Two, this thing had to be evidence-based, incorporate best practices that we see around um the nation um and be measurable. Three, it had to align with the mission, vision, and principles of high reliability. Uh, four, it's you know, about leadership development and succession planning. That's pretty easy. Five was really important. It became a safe space. We wanted it uh purposely to be a safe space for learning and for sharing. Most healthcare organizations don't have that as part of their culture and part of their history. And, you know, we all have stories from our background as a nurse speaks up, a pharmacist speaks up, a provider speaks up, and is just just beaten down. We wanted, we needed a space for physicians especially to ask the hard questions and to say, okay, wait, you said that, but I saw this last week. Square this for me. And last, uh, you know, just building community, beginning to put cohorts together, have them come to learn to understand each other, love each other, uh, care about each other, and and just let that virtuous cycle go. So that was the that was the goals of the organization now or the or of the program. Then, okay, what curriculum, what's the what's the what's the initiatives that you lay out? That was the next steps.

SPEAKER_02:

I've heard you present on this before, and you mentioned earlier in this conversation teaching technical leadership skills. Maybe you can expand a little on what some of those are that you taught, but then also teaching character-based leadership skills. And so I'd like you to kind of expand a little more on what the technical and character-based skills are and how those uh are important.

SPEAKER_01:

Yeah. So we organized, you know, we're in Hawaii, and so we developed uh kind of Hawaiian themes to the stages of our curriculum. The whole course lasted about nine months. We'd meet at least, you know, every month together, uh, some more intently, you know, like kind of like a Friday and a Saturday, uh, and some just a couple of hours. You know, the first the first session was called charting the course. And it, you know, kind of modeled after the old Hawaiian Voyager expedition, so expeditions. Uh so charting the course, and that's where you could sort of come in and you know say, Welcome, here's our goals, we're gonna learn not too much there. The next we called provisioning, and the technical skills and the and the character-based skills that you asked about, Jason, each kind of interwove through the entirety of course. So, really, in provisioning, um, we focused on the book and the techniques of crucial conversations. And I think people can understand that that's both a technical and a character-based exercise right there, right? There's some technical steps in having crucial conversations, you know, knowing that it's important, knowing there's divergent viewpoints, knowing principles are at state. But then how do you exemplify the opportunity for people to sort of come together along the way? So we focus on that. And we focused on self-assessment here too. So this is part of our measurement tool, right? We focused on leading self. Some physicians hadn't ever, some had been a while, uh, you know, do some personal inventories, um, emotional or intelligence quotients and Myers-Briggs tools like that. Same sort of thing. Technically, what do you do as a leader? But you know, mixed into those questionnaires are a lot of, you know, who are you as a as a character, as a person. The next was um called Passing the Breakers, Navigating the Open Seas, and then Land Ho, you know, as you think uh through that a little bit. Passing the breakers was I would come in and we'd really begin to dive into leadership. And it really was if there was a theme to it, it was this uh two themes. One, you have to have integrity, you have to have humility, you have to have compassion and empathy, you have to have forgiveness, you have to have accountability. How do those show up? What are the skills, activities, and behaviors you need to do that? Came from the idea of I want, we're gonna develop together a leadership framework. There's a way that we lead at Queens. There's a methodology. One of my, another one of my mentors, a physician named Jim Reinertsson, a CEO leader, said this to me one day. Um, there is no such thing as improvisational leadership. Um, there's improvisational lots of stuff, right? When I try to fix the house, I'm improvising all the time. It turns out just exactly as you'd expect. Um, but no improvisational leadership. So, what is our framework? What's our way at Queens that we do that? And that was that passing the breakers idea. Okay, we're gonna get out there, we're gonna go through these ways, we're gonna get out there on the open seas. What's our shared uh collective skills, activities, and behaviors by which we do that? Navigating the open seas, we bring in the business people. This is where we teach those technical skills. We'd have someone come in from finance, teach the finance and the PLs. HR would come in, uh, HR functions if you're gonna lead and who do you reach out to and when? What's the what's what does strategy mean? That nebulous uh term and who who in the organization can help us understand strategy. How does Queens develop strategy? There is a strategy template. We built a strategy template at Queens in that office, too. How do you how do you understand that? What does change management look like? We mentioned you know uh Cotter's model of change management, same sort of thing, no improvisational change management. And then what's the organizational structure? So those are the technical things, and that was really that day, and it was an entire day and a half uh so we could get on the same page there. And then finally we ended with Landho, which is uh called leading uh for the future with character. We'd again we'd dive back in and say, okay, and use it, even use case studies and even use practicing. Okay, you're seeing this conflict. What are how how do you approach it now with the framework? And what what are the ethics? What are the what are the character-based skills, integrity, humility, compassion, empathy, forgiveness, um, and accountability that you're gonna bring and how? Um so there was again, you know, uh there was quality improvement theory and methods in there, but that tight tie to leadership and especially ethically based, character-based leadership was really important to us. And so it occupied a major theme in the course that we built for Queens.

SPEAKER_02:

I can imagine that the the structure, the the customization for the Hawaiian context probably went a long way. Was that important to to the success, the the different kind of nautically, nautically themed sections? And then uh yeah, I guess I'll let you answer that question.

SPEAKER_01:

Yeah, you know, I think it was. It's something that I had to learn. Look, you know, I wasn't um from Hawaii, I came in. What I what I this is true for all of us, no matter where we end up. Know the history of the place that you're working at. History matters. Um, and so, you know, as I thought about the history of, as we thought about, I should say, the history of Hawaii, as we thought about uh the king and the queen, queen Emma and King Kamehameha IV, and their leadership uh, you know, that started, I believe, in 1853, at a time when epidemics brought in by Europeans were devastating the native Hawaiian population, that as a queen and king couple, they walked the streets to raise money for a hospital so that Native Hawaiians could have a place to go to get care. And that important mission-driven legacy that continued. I had to learn that. Anybody had to learn that. And the culture of Hawaii is so rich, not just with Native Hawaiians, as you know, but you know, it's a melting pot for so many people around the Pacific Basin to couch it in their language, to couch things in their language, to make it accessible, less technical, to drive some of the cultural resonance. It did turn out to be really important, and really important in a lot of different ways in a lot of different places across the Queen system. So the extrapolatable lesson is every place has its history. As a leader, you have to know that history, you have to be sensitive to that history, you have to tap into that history. Those are cultural currents, and those cultural currents, when you tap into them, will make your job easier, right? Because that's what that's that's what currents do. So wherever you go, do not be a historical. And it turned out to be really important. Thanks for the question, Jason, in this context, because of that deeply meaningful historical context that the Queen's health system found itself in.

SPEAKER_02:

When you started teaching this, I think, you know, all of the students I understand were physicians, and we've all had these very kind of concrete courses that we've gone through in our medical training. We learned anatomy, we learned, you know, physiology, etc. And I I wonder if there was any skepticism that you had to overcome in teaching something that's uh feels a little bit less concrete, maybe, uh, such as leadership. Was that a challenge that you guys had to face?

SPEAKER_01:

Yeah, it was. You know, I think by the time I had left, we had run four cohorts through. I think the first two cohorts, as you might imagine, were the most challenging. There was no history to sort of tap into. When I was able to lead the ATP course Intermountain, gosh, there had already been a 20-year history of that success. And again, just like those currents, easy to tap into. But here it was new. And we we invited that first cohort was about 12 folks, all physician leaders, and some were absolute skeptics that we knew we needed to bring inside the tent as quickly as possible. And so there was a lot of those, you know, the conversations, as I mentioned, the curriculum where there was silence, where there wasn't the ability to speak up, there wasn't the trust. Most of those physicians, right, had been maybe not passed over, but their leadership hadn't been recognized. They had been pushed down a couple of times. And so, you know, a natural tension, a natural, an understandable uh skepticism. There certainly, there certainly was that. I think as we tried to be transparent and even a bit vulnerable. So in those leadership sessions, I would largely, I would largely help lead the class in that conversation, that cohort in the conversation. And I was pretty transparent about my own shortcomings and my own career. And I think that began to resonate uh with them and slow, and was one part, not the whole part, but just one part of beginning to break down some of that skepticism, some of that cynicism. And then by cohort two, you know, got better at it. There was a little bit of positive buzz. And by cohort three and four, uh, you know, I guess another lesson is do your best to design, but then you got to go out into the crucible of fire and get it done. Listen, be flexible, exhibit the same character-based leadership skills you're asking them to, you know, um be humble, learn, listen, uh, forgive, be accountable. And and that will, that will, uh, I said it before, begin, I think, to turn into that virtuous cycle. And we were getting better, and the classes were getting, the cohorts were getting more engaged as the years went on. But absolutely, physicians, especially, right, were a naturally skeptical bunch. And we should be. That's the way it should be. That's how we keep patients safe. We're naturally skeptical. Um, but you didn't have to begin to break that down in other areas.

SPEAKER_02:

Yeah. Another thing that I'm thinking as you're applying the quality improvement lens to this work, and you mentioned the the Myers-Briggs earlier. I I wonder how much you're applying measurements to this process as you're as you're developing leaders, and and how are what have you learned about uh measuring something as intangible as leadership growth?

SPEAKER_01:

Yeah. It's not well, what I what I have learned it's not easy. And two, I think the the most complete measures still aren't out there yet. I liked I liked to think about it from a measuring the individual, that's where Myers-Briggs, the EQI, you know, 2.0 comes in, the Mayo index comes in. But then you also have to measure the system. So how how if we're developing leaders, if these leaders uh are developing a skill set that daily demonstrates accountability, humility, and humility, that should show up in a system level assessment, uh, you know, from the nurses, from the pharmacists, from the environmental services worker, in the what's the culture of this place becoming. So we tried to do both. Obviously, measuring the system culture leadership uh principles is a lagging measure. That takes a little bit to come. So I don't know that we ever got there and could really say there's a clear association between this program and those system level outcomes. Therefore, we rely, you know, on those process measures that you can repeat and repeat more often. So we assessed the whole course and as I mentioned, made modifications based on that assessment, largely through survey and feedback. Two, we assessed each session with objectives and against those objectives as we went through. Three, we did the personality assessments, the Myers-Briggs, and the EQI and the Mayo index, and we did them sequentially so we could see not only from cohort to cohort, but within cohorts, could we demonstrate change over time? And then we tried to measure the success of the course in case-based scenarios or in practice sessions. Were the principles that were being laid out, or were the methods that were being laid out demonstrable in conversations or practice sessions? We didn't get there, it wasn't quite perfect, but we as I mentioned in the beginning, you know, one of our core six principles was to measure as best we can. So, you know, it wasn't just that um my mom thought I was doing great. It's that uh we could demonstrate that we were getting numbers out of it. And we were accountable to those numbers to the board and the executive team and to the leadership team with the clinical program. So we tried hard, but it's a difficult, I think it's a difficult thing to do.

SPEAKER_02:

I can I can imagine it would be. You've mentioned to me before when we've talked about this, that it really felt like as you went through these cohorts that there was a culture shift. Looking back, what story best captures the the cultural shift that the program created?

SPEAKER_01:

Yeah, you know, the idea is that changing culture does take time, but there are tried and true methods to developing culture and and they work. So we had one physician leader who was so important to the organization for so many reasons. Um I'll I'll say the specialty, a critical care physician. And he had had he had struggled, I think, with the Queen's health system historically uh for things from uh events that preceded me, but you know, mattered a lot to him where he felt his opinion wasn't listened to, he felt maybe he wasn't respected or even disrespected. But we needed him as a leader. He had all the intelligence in the world, and people naturally looked at him as a leader, as you as you might imagine. But, you know, he was in those cohorts and in our in our clinical program leadership meetings and would always sit in the back in the corner, kind of lean back on the chair, you know the posture, arms crossed, a scowl on the face, um, and would only make comments in the last five minutes of the meeting and almost always disruptive, where then you know, you then you had to go into kind of triage mode, put band-aids on things. You didn't have enough time in the meeting uh to sort of address it and fix it. After one particularly uh rough meeting, I think we recognized as leaders that we weren't making the progress that we needed to do, and it you know, kind of came to me to have that conversation. Now he by this time had had the framework of the crucial conversation. I, by you know, this time obviously had had the framework of the crucial conversation, and we did. We had to sit down and say, um, how You doing based on what we've talked about, this isn't what our shared these aren't what our shared values are. These aren't what our shared expectations are. What's the next steps? And we, you know, kind of talked, had that hard conversation and talked through it. And I told him, frankly, how much we needed him, and that this this work was was vital to the organization. Well, I think he thought about it for a while, and there wasn't immediate uh 180-degree change. But over the months and over the years, having exemplified the behaviors that we taught in the classroom, or at least tried to exemplify the behaviors and the methods that we taught in the classroom, you could see the posture change. You could see him move up into the meeting rooms. You could see him make eye contact in emote uh during during the meeting. Comments came earlier on and were constructive and projective. And it wasn't me with that conversation that did that. It was the totality of the organization, I think, who had committed to, I've used the term used it before, skills, activities, and behaviors in leadership to help drive culture that slowly began, you know, to morph around. And but that was a it was kind of a canary in the coal mine for me, I guess, in some ways, although on the on the good side, not the bad side. Um uh where you thought, okay, maybe, maybe we're getting a little traction. And I think that was it was buttressed. That was, you know, one story, one person that was particularly important, but particularly challenging. But there's so many other good examples of how perceptibly, whether it was on in rounds, morning rounds, uh, daily safety brief, any of those things where it was very clear that the culture was improving.

SPEAKER_02:

I've often talked to uh medical students and residents when I teach quality improvement about, you know, the hard data that we that we pull from our data analysts, but then also the experiential data that we get uh as we see processes unfolding and and improving. And it sounds like you gathered a lot of really positive experiential data as this culture change was unfolding at Queens.

SPEAKER_01:

Yeah, you know, obviously the uh leadership development program and clinical programs weren't, you know, occurring in a vacuum. There are other initiatives and strategies going on. And I think cumulatively, right, cumulatively, you just began to see each of them perceptively improve, perceptive perceptibly become more safe. And even those safety outcomes the that you talked about, the uh getting back on track with infections and falls and happies and all those sorts of things. So part of the whole picture, but uh I know there was an important contribution from the leadership development course that we talked about, and plus, and it was an important part of the strategy, really, to you know, again, to develop clinical leaders to help lead and and carry the straty carry on the strategy of the Queen's Health System.

SPEAKER_02:

Yeah. So I mean, now that you've had this experience of helping to develop leaders across two major health systems, both in Utah and in Hawaii, what do you think the next generation of quality leaders will need?

SPEAKER_01:

That's well, what a you know, a great question. I think we've all been thinking a lot about that. The world uh is changing uh um around us everywhere we look, uh techno from technology to culture, uh, and it's getting medicine is getting more and more complex. And I mean that in a good way and you know, a more challenging way. Medicine has distinguished itself, you know, I think amongst all professions and industries, uh, just by learning and getting better uh year after after year, you think about technical technologies, you think about medicines, you think about therapies, amazing, right? And now you layer in all this other stuff. So the job of the quality leader uh is getting more challenging right alongside it. I think two, you know, things, um, well, much more than two, um, but the two things that are most important to me. One is that quality leaders actually do need to be grounded in the science of process improvement. There's a methodology there, it works, uh, it's worked over and over again in industry outside of healthcare and within healthcare, and quality leaders really need to understand that science and how it's brought to healthcare. But the second, I think, you know, is what we've just been talking about this whole time. Easy enough to be competent in the technical skills. Uh, easy enough. You have to lay into it a little bit, learn about it, you have to talk to people, partner yourself up with the right folks. But uh, to develop a leadership framework that is rooted in those character-based skills that we've mentioned a couple of different times, I think will be one of the big things. That framework, those two things I think will help you understand. You know, for instance, to use the the term how does artificial intelligence and how does machine learning fit within a particular routine. Just got back from a course where someone thoughtfully said figuring out where and how to use AI uh starts at the same place as any process improvement. You gotta understand the process map, you gotta understand what you're trying to change, what works, what doesn't work, and then think about the tools. AI may be one of them, but think about the tools. And otherwise, if you just throw AI at the world, uh you're gonna end up with some trouble. So I think if you have those two foundational elements, uh everything else will fit in that framework.

SPEAKER_02:

You you mentioned that you've now uh now finished a uh a really rich chapter of your career. And I'm curious what's uh moving forward in the future, what's something that that you're most looking forward to or you're most excited about in healthcare quality improvement?

SPEAKER_01:

Yeah. So, you know, like I said, uh Jason, it's been such a fun conversation with you to even to reflect on my time at Queens. What a wonderful organization you you you know it, and what wonderful people I was able to associate with. You know, it was a long way away from my family, my wife's family, and travel was difficult. And as our youngest, as I mentioned, graduate graduate from high school, I think my wife and I, our family really had to think about, you know, what's the next steps, and that was part of the transition uh from Queens. Uh the first part of it was kind of uh rest and recovery, able to help my daughter graduate from college and get settled in her new college. We had a blast as a family paddling together in Hawaii, doing activities that I just didn't have time to do uh when I was serving as chief quality officer. So now it's time to start turning, as you just described, what's next. And working with uh having conversations with some mission-driven, culturally aligned organization similar to Queens and similar to Intermountain Healthcare. What animates me, um, what I think animates you, knowing you a little bit, right, is the opportunity to bring whatever experience and skill set that I have to an organization who's trying to do good work and needs um uh just like a Queens and Intermountain, you know, needs a leader who cares deeply about the front line, who cares deeply about the clinical processes and all of the things that go into making clinical work successful. That's why we exist, right? We exist for the community, we exist for that patient who reaches out to us in time of need, and we exist for that person who wants to avoid that time of need, you know, that that it's coming down the packs, the the track. So to lean in, to learn to love a third organization, to learn to love people in that third organization, and to walk this walk uh together again one more time is what uh animates me, what's it gets me out of bed in the morning. So just looking for that right opportunity in a place that now that allows us uh to be closer to family as they as my parents enter you know their stages, their next stages and last stages of life, uh and Jen's as well.

SPEAKER_02:

Well, I uh whatever whatever third organization you find, uh, they'll be very lucky to have you and uh really appreciate you taking the time to have this conversation. I also you know really enjoyed speaking with you again. I always enjoy hearing you talk on this topic. And uh thank you so much for for joining me today. If there's anyone out there who wants to reach out to you to learn more, to get in touch, or just to follow your work, how could they best connect with you?

SPEAKER_01:

Uh the best way I think right now is through my LinkedIn page. And uh I'm pretty good at responding to the messages there, and then we can exchange personal uh information uh after that. I love, love, you know, talking with people about what they're learning, what they're challenged by, and just sharing ideas back and forth to see if we can both get a little bit uh get a little bit better. So thank you for that opportunity. And thanks for letting me be with you today. I always love talking with you too. Thanks for the work that you do, and I've really enjoyed the time.

SPEAKER_02:

Thank you again, Dr. Todd Allen, for for showing how building leaders can be the most powerful form of quality improvement, not just improving metrics, but transforming culture itself. Thank you so much. Thank you. Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.bugsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Mellows, edited by Milan Milostafievich, and produced by Thrive Healthcare Improvement. See you next time.

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Jason Meadows, MD

Host
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Todd L. Allen, MD

Guest

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