Most CIOs have experienced a major change at one point in their careers. But they’re rarely as drastic as the transition Barbara Riddell made when she went from Tenet Health, a corporation that includes 49 acute care hospitals in 11 states, to Atlantic General Hospital, a relatively small system with a patient output that fluctuates by season. And as Riddell has learned, a smaller organization does not necessarily mean less complexity. In this interview, she talks about having the right team in place to prepare for data exchange, how vendor agreements are like a marriage, and the added pressure that smaller organizations face in getting it right the first time.
- Working with the docs
- Balancing the governance load
- Cultural considerations
- Remembering that silence doesn’t always mean agreement
- Atlantic General absorbs “Hurricane Barb”
- “It’s a much kinder, gentler organization, but not less complicated”
- How to evaluate a potential new position/organization
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They really did come to the table. We had multiple meetings. We’d even arrange to have lunch meetings so that if the only time they could come would be to come by at lunch time and talk to vendors and ask us questions, they could do that. The physicians, the users, and the clinicians all had that opportunity.
There has to be strong a governance process in place so that this works and we don’t get in to a position of analysis paralysis or too much decision-making. At some point, we cut to decision. And we put a couple of processes in place so that we make sure we get a signoff so people don’t finally just give in and agree.
I’ll be in a meeting, and everyone’s very collaborative and very congenial. And they won’t speak up very much. And I’ll think, wow, either I talked too fast and they didn’t understand me, or everybody agrees. And then little by little, the concerns are voiced.
One of the key things I wish I had asked is about the relationship between the board and decisions. Where are financial decisions made? How do you create a new project and how are you budgeting? What kind of a refresh policy have you had for the last 15 years?
I am held to managing to some things that maybe weren’t in place before I got here. So now to come in and try to put new controls in place, I am rocking everybody’s world. But you can’t burn every bridge, and so you have to find a way to assimilate but at the same time, take things up to the next level.
We had some incredible talent there, but people were getting recruited away for incredible positions and opportunities that they just couldn’t pass up. And so you’ve got to invest in your team. You’ve got to give them opportunities to learn. You’ve got to make it fun.
Guerra: Let’s talk about the physicians a little bit. Do you have any employed physicians?
Riddell: We have hospitalists here.
Guerra: How many, approximately?
Riddell: Approximately 15. We’ve got physicians in the ICU and our hospitalists, so a total of probably 15 to 20 docs in the house.
Guerra: How many are referring in independents?
Riddell: Community wide, they’re referring, but then I would say it’s back to those 25 offices.
Guerra: How many physicians in those 25 offices?
Riddell: I have to tell you I’m going to guessing, but I would say we have probably in the neighborhood of about 60 physicians total.
Guerra: Okay so 60 physicians, about 15 employed. So you have to take delivery of the product and you have to roll it out, but you’re going to be doing, I would imagine, ground work and training. What’s your engagement strategy with the physicians? Do you have a two-tier strategy? For example, you have the employed physicians first and then work the independents? How do you plan on rolling out CPOE? And are you doing CPOE and electronic documentation or are you leaving the documentation for later?
Riddell: So it’s a few prongs—we’re doing the ED this fall, and leaving the documentation for later. We’re doing the order entry. Next year, we will be rolling out the documentation and order entry. And so really, one thing I alluded to earlier was that this is a very collaborative environment. We have a chief of surgery, a chief medical officer, a chief of the ED, and then we have a chief hospitalist. And so those four physicians—and also and the chief of medicine that actually sits outside the organization but is part of the organization and definitely refers to the facility—are going to be core to the team. They were key in selecting this product. We actually took three of them to various site visits. And so that’s going to be very key to us in making the decisions.
We’ve already got that medical executive committee set up. They have a department of medicine meeting where they’re already taking order sets. So we already started that process with the ED product. We’re going to review all order sets, bring those back through, and honestly, they’re going to be, from day one, part of the design team. One of our ED docs actually went to build training, so they participate in the build, they participate in the selection, and they will participate in the rollout. It really is their system. And so I think that’s going to be key to us being successful.
And then I think even more important is the kind of support we’ll provide on the back end. We’re looking at hands-on support 24/7 support. We really are kind of coming alongside of the physicians and letting them drive that process.
The department chief in ED has been absolutely instrumental. He’s been at every meeting. He’s part of the design 100 percent, and he gave us one of his doctors who had been very familiar with Allscripts in the past to go to the build team meetings and literally attend training. So it’s got to be a collaborative thing. We’re very small and so they’ve got to be happy. They’ve got to engage in the process. This has to be their project. And we are very much letting them drive that.
Guerra: Let’s talk about collaboration. When we discussed that system selection before, you kind of indicated that it may have been a little too collaborative. You have to balance collaboration with efficiency, right? Making a decision and then bringing in enough people but not too many to the point that it just gets bogged down. So what are your thoughts around balancing that?
Riddell: It’s a balance of that and then it’s also a balance of the culture. The culture here is very collaborative. I went to high school in New Jersey, and I will tell you that being from New Jersey and New York, I will say that the Eastern Shore is a gentler, more collaborative place, maybe because it’s small and we all live together and everybody’s here together and we’re all in it together. But I have to say, it’s a requirement here much more than anywhere I’ve ever been before. By the time we made this decision, there wasn’t a person inside or outside the organization that didn’t know how we were leaning, what the decisions were, and what the time frame was. And I will tell you that even with the meetings I didn’t attend, I would hear about other physician meetings, even in the outpatient or with the affiliated and non-affiliated docs, where they would stand up and update each other.
And so you do have to balance it. But here, I think we have the luxury of being small enough that it is very inclusive, and that works for this environment. It was something for me to adjust to because I come in and I’m the CIO, and I’ve got Meaningful Use hanging over my head. I’ve got a lot of things, plus I’ve got a several months in the summer where I can’t stage a go-live.
So I wanted to really drive the decision. And my CEO had to really kind of coach me and say, ‘Don’t worry. The process works here. It really will work.’ And it did. I mean, they really did come to the table. We had multiple meetings. We’d even arrange to have lunch meetings so that if the only time they could come would be to come by at lunch time and talk to vendors and ask us questions, they could do that. The physicians, the users, and the clinicians all had that opportunity.
We included the revenue cycle folks. We made sure that HIM was at the table. So I think you’d be hard pressed to find somebody who didn’t know what was going on. So in the selection, that became very important. And it’s interesting because as we’re spending these couple of months planning, and going through the workflow meetings, what I am constantly challenged with is that folks want more and more and more information already. And we’re saying, ‘Okay, we’re working on it.’ We’re identifying the team. We’re starting to figure out who’s going to go to training and how do we backfill. We’re making sure we have everything in place. Meanwhile, we’re in the middle of an ED install and go live here shortly. But folks are very excited to know what’s going on; to be part of it.
And so the one good thing is you absolutely have engagement. Everybody participates. You have engagement, but you do have to balance it. So it becomes very important to have a structure. It becomes very important to have a message—a meeting that they can come to weigh in if they have a concern. There has to be strong a governance process in place so that this works and we don’t get in to a position of analysis paralysis or too much decision-making. At some point, we cut to decision. And we put a couple of processes in place so that we make sure we get a signoff so people don’t finally just give in and agree.
Just because collaboration is very important, that is a huge risk for the organization. It’s as very kind community, so very nice, so I wouldn’t want to be one person who hangs back and disagrees when sometimes that’s the canary in the coal mine.
Guerra: I like that.
Riddell: You can actually be too nice.
Guerra: Sure. That was my question.
Riddell: And so we had to have a mechanism where people could finally weigh in one more time and say, ‘Hey, I still have a concern.’ And the way we did that was two-fold. We have a document where they can list key decisions and they can bring forward, ‘Hey, there’s a concern I have and here’s some key decisions that I feel we need to reexamine.’
The other thing we’ve done is right before this go-live, I have one hour of open office time per week with the project manager dedicated to the ED project. So the project manager and I would sit in my office and the first time I thought, ‘Well, we’ll just be sitting here looking at each other.’ They were lined up at the door.
Because it’s a very collaborative community, people don’t want to step on each other in meetings. They may still have a concern they haven’t voiced. And so we had to give them some other venue to bring that get it on a list where we bring it back as an agenda item but where no one person feels like they had stepped on somebody else’s toes.
A lot of times they’re bringing up very good points. This is new to this organization. Implementing systems is fairly new to a lot of these people. So sometimes they don’t want to look stupid or don’t want to feel like, ‘Well, I’m asking a dumb question and maybe you’ve already handled this.’ And so some really good input has come out of those meetings. And then we recycle that back on to the agenda for the next meeting, but we bring a little due diligence with us and say, ‘Okay, you brought up a great point. Let’s go research that or see what we’re doing or let’s revisit how we made that decision and we’ll bring it back for discussion.’ And that’s resolved a lot of issues.
Guerra: That’s very interesting. I was speaking to someone about a health system in Hawaii, and they said, ‘You can’t assume just because no one’s voiced any objections, that there’s no objections.’
Guerra: I thought that was a cultural thing about Hawaii. I didn’t know it could be cultural to somewhere so close.
Riddell: We’re on a little island down here. We’re a little peninsula. And that was something I had to learn about the culture when I first got here. I’ll be in a meeting, and everyone’s very collaborative and very congenial. And they won’t speak up very much. And I’ll think, wow, either I talked too fast and they didn’t understand me, or everybody agrees. And then little by little, the concerns are voiced. You start to realize that you don’t always have full agreement because it’s part of the culture to be very nice and tolerant and kind. And that makes for great teamwork. It makes for a very pleasant work environment. But when we’re making workflow decisions, sometimes we want to give them some other mechanism to raise a concern or raise questions they have.
Guerra: It’s a secret ballot.
Riddell: Right. Secret ballots, passwords, secret decoder rings—those types of things.
Guerra: So, I have to ask. Where are you from in New Jersey? Were you at what high school?
Riddell: I went to high school in Denville.
Guerra: Is that in North Jersey?
Riddell: It’s Northern New Jersey, near Morristown. My dad worked in Palisades Park.
Guerra: I grew up in Ridgefield, which is very close to Palisades Park.
Riddell: Very good. There you go.
Guerra: So I’m asking about it because culturally, we seem very similar and I know that feeling of, ‘Let’s go. What are we doing? Let’s make a decision.’ And when someone wants to have another meeting or reconvene to discuss it again, it can get very frustrating. So it must be a fascinating process for you, and it probably works both ways. You’re slowing down, but I am sure, you are bringing the organization along a little bit faster, just by your nature.
Riddell: I’m driving everybody crazy. I’ve been here 11 months, and I have absolutely had to slow down a little bit. But it’s funny because I wanted just to hit the ground running. I was saying, ‘We’ve got to do this, we’ve got to get this done,’ and marching to a deadline. And then I would turn around and look back and think, ‘Where is everybody?’ My secretary in particular could tell you that I drive everybody crazy. They’ve nicknamed me ‘Hurricane Barb.’ They hadn’t had a hurricane hit in years, and then I come on the scene and we have a hurricane, an earthquake, and a tornado all in one week. And I’m getting credit. So I’m getting a little bit of a complex this way. But yes, it’s funny to suddenly have to say, ‘You’ve got to be kidding me. We’re not moving faster?’
Guerra: Well, I’m not operating off the premise that you’ve made a mistake taking that position because you sound quite happy.
Riddell: I’m very happy, yes.
Guerra: But what advice can you give your colleagues about taking a position or looking at potential position that will mean a big change. In some cases, it may not work. This could have happened and you would not be happy. So is there any advice you can give them on understanding the type of things that you’ve learned since you’ve taken this position?
Riddell: Yes. It was a big change to come from a place as big as Tenet with 46 facilities and being at corporate. And I thought that this would be a lot less complicated. It’s a much kinder, gentler organization, but it’s not less complicated.
One of the key things I wish I had asked is about the relationship between the board and decisions. Where are financial decisions made? How do you create a new project and how are you budgeting? What kind of a refresh policy have you had for the last 15 years? You know, really understanding how they made decisions in IT in the past, because my position is brand new. The board created my position. Prior to me joining the organization, the local IT vendor functioned in this role. So I was the first internal IS person, which comes with its own challenges.
There a lot of local relationships. And so while they made a conscious decision that IT is becoming important enough that we need an internal person, there’s a lot of concern and consideration internally and externally because they don’t want to displace anybody. We still use our local vendor; that relationship still exists. But even 11 months later, there is great concern for what my motive might be around how people will interact with the organization. It’s a complete change in control. We moved the locus of control from external to internal. And believe it or not, even the internal people were upset about that.
So you really have to understand, especially when you’re moving to a completely different culture than you’re coming from, how decisions are made. You have to understand where the money decisions made and how hard it’s going to be to fix the things that need to be fixed if the money had already been allocated or if those budget decisions were made years before you got there.
And then I would say the last thing would be to understand the contracts that are already in place. You feel kind of funny when you’re in an interview saying, ‘Well, can I understand the terms of your agreement?’ But make sure that service level agreements are in place. And make sure that you know what you’re going to be held responsible to manage to and whether it is a doable task.
I’m very happy. I love this organization. I have a great CEO. I love my boss. But I am held to managing to some things that maybe weren’t in place before I got here. So now to come in and try to put new controls in place, I am rocking everybody’s world, which it maybe it needs to be rocked. But you can’t burn every bridge, and so you have to find a way to assimilate but at the same time, take things up to the next level. And that’s been my challenge.
Guerra: And I would imagine it’s very important to be yourself during the interview process and then from there we have to say that the organization knew what they were getting and must have had some appetite for it. Otherwise they would have picked someone who is much slower?
Riddell: Exactly. And that’s what I have to bank on honestly, because there were two other candidates. And from what I understand, both were calmer and quieter, probably more typical of the stereotype folks have for people in IT. And I am sure I looked like a bull in a china shop when I came in for the interview, and I can tell you that I still look like one now. It’s just is my nature. It is how I’m going to function in this role, and it’s how I get things done. I like to have fun while we’re doing it, but I want to do it well. And it’s kind of funny. Now I do have a lot of people moving to my department, and people are seeking me out in organizations. They like what they see and they want to come over and be part of that, which is reaffirming. But, yes, I keep reminding myself that they chose me. They must have known.
Guerra: Right. That’s why you have to be yourself in this process, so then you can go in with confidence as opposed to trying to be what they want, and then you can’t become yourself.
Riddell: Yes. Suddenly you turn into a different butterfly.
Guerra: Well, your education and your resume are incredibly impressive. You spent time at Tenet and Bloomington Hospital, plus you spent a couple of years at McKesson, and you have a BS in Business Management and two Masters: one in Health Administration and one in Nursing. You probably could go anywhere you want. Anywhere where there is an opening, you would have a good shot with your impressive resume.
Riddell: Thank you.
Guerra: I mean you are in high demand. So they did pretty well too, right?
Riddell: Well, I hope so. It’s interesting how you get here. I don’t know if you heard at CHIME, but the one keynote speaker, Clayton Christensen, said, ‘How many of you knew this was where you were going when you started out for your degree?’ And nobody raised their hand. I honestly started out to go into production operation management. I wanted a degree in manufacturing and was going to go wholeheartedly into manufacturing. And just to show that you should never buy whatever stock I pick, the year I graduated from college, they said it was the worst year in 25 years to graduate and in particular, manufacturing had dried out.
So trust me, it is only by literally God’s divine intervention that I am where I am. I think the time that I spent in California in particular was such a blessing, because I ended up on teams that were doing a lot of IT projects. Because of my business background, I was selected for those teams. And I ended up being involved and working on some incredible projects that taught me everything I know about IT. That was an incredible opportunity; it was the period of time that was right around the dot-com boom. We were literally picking up the talent. One of the gentlemen I worked with for the development of SimCity, another guy was involved in developing the radar for the A-10, and I was at a little IT company in California that was privately held. We were picking up talent left and right. And I was the only token nurse, so I was writing requirements, going on sales trips, writing manuals, and implementing systems. And so I just found out that I just absolutely love this and I love what I’m doing, and finding the right organization to be in where you can really make a difference really matters.
Guerra: What kind of team do you have? How many people are under you?
Riddell: I have 14.6 FTEs with my IT vendor.
Guerra: Point six?
Riddell: I’ve got 0.6 of a guy over there. And then in-house I have eight people. I’ve been growing this informatics teams in-house since I got here. We have a PACS administrator in-house, pharmacy, and some key specialties. Today is the first day for the director of surgery to move over to my department and she will be my surgery analyst, and so she’ll handle surgical areas and supplies. And we’ll be putting in the infusion system and several other things. So we’re picking up key people with an IT interest or IT background who have a specific skill set in the house.
Guerra: One of your recommendations on your Linkedin profile said you were very easy to work with and made every day a joy to come to work. And I definitely believe that with the talent shortage out there for these positions—we talked about the pharmacy informaticist position—that you had better make it a joy to work for your top people to come to work. So it looks like you’re ahead of the game. You’re a fun manager and a good manager—these days if you’re not, you’re going to be in big trouble.
Riddell: I absolutely will. And learned that at Tenet, too. We were in Dallas and we had some incredible talent there, but people were getting recruited away for incredible positions and opportunities that they just couldn’t pass up. And so you’ve got to invest in your team. You’ve got to give them opportunities to learn. You’ve got to make it fun. Honestly, if you don’t make it fun, what’s the point? If we’re doing a good job, it doesn’t have to be dreadful. It can actually be something that energizes you. So that’s my goal and my role is to support my team and make sure that they feel like they’ve got the tools they need to do the job right.
Guerra: And we don’t have to worry about any of them getting board.
Riddell: No, not at all.
Guerra: Well, Barbara, that’s all I had for you today. Is there anything else you wanted to add that we didn’t touch on?
Riddell: No. It’s been a pleasure to speak with you and I appreciate the opportunity to share our experience with everybody.
Guerra: Well, thank you so much Barbara. And I’m going to keep your information and ping you in the future because you’ve been a blessing.
Riddell: Thanks, Anthony. I look forward to seeing you at CHIME next time.
Guerra: Absolutely. You have a great day.