It almost didn’t happen. Lee Milligan seriously contemplated texting the CEO in the middle of the night to say he had changed his mind about taking the CIO role at Asante. His doubts were completely understandable; not only did it mean leaving the CMIO position, which is a significant change, but it also meant filling the shoes of his predecessor, who had resigned after more than 20 years at the helm.
If that wasn’t daunting enough, a new CEO had just taken over.
Fortunately, Milligan never sent the text, having decided that the rewards outweighed the risks. But it hasn’t been an easy adjustment. “I had to be more honest with myself than I’ve ever been in my professional career in sizing up what I do well and in what areas I’m lacking,” he said in a recent interview, during which he opened up about how he was able to grasp the CIO responsibilities, what surprised him most during the first 6 months, the goals he has established for his team, and why he never takes metrics at face value.
- Current state assessment – “I didn’t want to throw out things that were working well.”
- Targeted areas of improvement: standardization & processes
- Team building through leadership retreats
- Becoming a high reliability organization – “We’re moving boldly in that direction.”
- Creating an “exceptional customer experience”
- “Honeymoon period” as new CIO
- Shedding the CMIO role
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What I wanted to do was really assess current state, because I really didn’t want to throw out things that were working well – and my predecessor did a number of things really well. I wanted to make sure we weren’t spoiling that.
You’re identifying what you want to work on and what are your objectives. In a well-constructed system, these things roll up into each other.
The approach I try to take with my folks is to create a transparent environment where they’re free to talk about what works and what doesn’t; where we can criticize, but do so respectfully so that we can have an honest conversation.
When you come into a position like this, most people will give you a bit of a grace period. My advice is to take advantage of it.
I needed to get out of the room and let him spread his wings. If he has questions, he can come to me, but people needed to see him as the leader in that space.
Gamble: Do you think it was an advantage that you hadn’t previously been in a CIO role, and were able to come in with a fresh perspective?
Milligan: Absolutely. The arguments had grown stale. Finance could see them a mile away, and so being able to frame that differently was really helpful.
Gamble: Looking back at your first 6 or 7 months, were there certain priorities you wanted to address right away?
Milligan: I had a lot of ideas in the back of my head as to what I wanted to do, and so when it happened, I felt like a kid in a candy store. I thought, ‘Wow, now I have a chance to do some really cool things.’ What I wanted to do was really assess current state, because I really didn’t want to throw out things that were working well — and my predecessor did a number of things really well. I wanted to make sure we weren’t spoiling that.
And so I took some time to meet with all of the individual teams to understand the work they’re doing — what’s working well and what isn’t. From that, a couple of themes bubbled to the surface. The first was we didn’t have great standard work in place. As a result, folks were doing good work, but it wasn’t always standard work, and therefore we didn’t have the level of accountability and transparency that we wanted.
The second theme that bubbled up is, at that time, we actually didn’t have a formal process improvement methodology in place. In other words, if you’re a front-line staff member and you see something that needs improvement, there was no framework in place to make that change. I thought about that quite a bit, and ultimately proposed changing our organizational structure so we could begin to do some of this work. I appointed a director of innovation for Asante ITS; he’s actually our former manager of data analytics.
He’s tasked with leading us through the development of an internal process improvement methodology and framework. We’re using what are called OKRs. I know a number of folks across the country are getting into that space, including Ed Marx at Cleveland Clinic. It stands for Objectives & Key Results. Basically, you’re identifying what you want to work on and what are your objectives. In a well-constructed system, these things roll up into each other.
We’ve been on this journey now for about six months to develop OKRs so that we can first identify what we can do to improve our processes, and then effectively execute around that and deliver on that objective. It’s been a fantastic journey. For starters, it has definitely rocked the world of leadership within ITS. Some folks were resistant at first, and we had to have some very difficult conversations. But others embraced it right out of the gate.
One thing I’ve done twice now is a leadership retreat. At the first one, which was back in March, we focused on two things. First, we had just received the results of our KLAS Arch Collaborative survey, and we went over those results. The other area of focus was the concept of becoming a high reliability organization (HRO). That was held at Grants Pass in a cabin, which was pretty cool.
For the second retreat, we didn’t have a lot in the budget, so I took the team to a mountain nearby. We hiked for a few hours, and when we were done, I had set some picnic tables, handed out Gatorades and waters, and gave everyone copy of the Harvard Business Review article on the topic of the Toyota Production system.
For the rest of the day, we talked about OKR. Our team is now inundated in OKRs, and we’re moving forward pretty boldly in that direction.
Gamble: By approaching it that way, were you able to identify what the hesitations were?
Milligan: I think it came down to the typical resistance to change, because it rocks their world; it creates instability. I think a lot of people weren’t sure if they’d have a job. And some of the leaders thought, how do I fit into this new paradigm?
The approach I try to take with my folks is to create a transparent environment where they’re free to talk about what works and what doesn’t; where we can criticize, but do so respectfully so that we can have an honest conversation about what needs to happen. I think that concept, as simple as it sounds, was foreign to most folks.
Gamble: Really interesting. And were certain processes implemented to help move the organization in that direction?
Milligan: We struggled a bit with how to set up the OKR framework; you have individual OKRs and team OKRs. We ended up doing team-based OKRs where the directors and I were on one team, and together, we would sink or swim. The managers collectively are a team, so they have to identify things that work across the board for everyone. It forces them to work together in ways that they hadn’t before.
It’s been a really interesting journey.
At the end of the day, I have two main goals I set for the team, and it’s based on the fact that when I first came into the position, I was reading our strategic objectives for the next three years. It was 25 pages long; 8-point font, thousands of words. And when I asked my directors and managers what our strategic initiatives were, nobody could tell me. I’d get some things here and there, but they couldn’t zero in on what we were trying to accomplish.
From a high-level perspective, my team knows very clearly that we have two main objectives. One is to create an exceptional customer experience — not exceptional customer service, but an exceptional customer experience from end to end; from them initially learning about whatever the product is to them navigating that product as part of their healthcare work or journey. That one is really clear to my team.
The second is to become a high reliability organization (HRO). Every single day, my admin puts up a new piece of paper inside my officer posting the number of days since our last unplanned downtime. All of the managers, directors, and supervisors across the system print that out on a daily basis and hang it up. Because how do you know if you’re delivering an exceptional customer experience if the system is down? Now everyone knows; the goal is exceptional customer experience. What we say works, actually works. If they have clarity in those two areas, everything else can be framed up to support that.
Gamble: It certainly makes sense to get that framework in place for process improvement. And so I’m guessing the idea was to get this framework in place before anything else could happen.
Gamble: And as far as the goal of standardized work, is that an ongoing effort?
Milligan: It is. We’re focusing on a few areas that really need attention. One is our image and data transfer process. When we transfer images or data from server A to server B, what does our process look like? How transparent is it? Do we have a procedure and a policy in place? Are we following that procedure and that policy? Are the people who are doing that work accountable to the steps of that procedure? Do we have redundancy in place so we have double and triple checks? Those are the types of questions that weren’t being asked before.
Gamble: Right. Now, looking back at your first six to eight months in the role, obviously you knew the organization well, but when it came to embracing the CIO role, how was the learning curve? Did you have starts and stops?
Milligan: When you come into a position like this, most people will give you a bit of a honeymoon period — a bit of a grace period. My advice is, take advantage of it. If I don’t know what a load balancer is during month one of this job, that’s okay. People expect it. But if two years from now I’m asking, ‘what’s a load balancer,’ I’m not going to look very smart. I don’t mind asking questions. And in fact, when I ask my managers questions through email or at meetings, it shows them I’m listening, that I care, and that I’m trying to understand.
Gamble: You came from the CMIO role. In a lot of ways I’m sure it’s beneficially having that knowledge and understanding the clinicians and their workflow, but can it also be a challenge transitioning to the CIO position?
Milligan: Yes, that piece is huge. In fact, one thing I did in the beginning was to make a list of CIOs across the country whom I respect. I made a list of 16 CIOs and reached out to all of them. Believe it or not, all of them got back to me almost immediately; within two weeks, I had spoken with all 16 of them.
Looking back now at that time, I was nervous; I was new to the role. I reached out for help, and everybody stepped up. It was incredible. Ed Marx stepped up, as did John Halamka, but one person who was really able to help with this particular scenario was Michael Pfeffer, who went from the CMIO role to the CIO role at UCLA Health. He taught me that you need to shed the CMIO piece as quickly as possible, and described a very confusing world where the folks with whom you interact don’t know when to come to you. And so gaining clarity around that for everyone — not just yourself — is really important.
I did hire a medical director of informatics to backfill my position. His name is Peter Canning; he’s a physician builder who has also programmed Xcode. Years ago, he built what was, at the time, the best emergency department ultrasound app. He’s a really terrific guy, great to work with. He’s smart, hardworking, and logical — I couldn’t ask for a better replacement. When we started interacting more and going to meetings together, I noticed that folks would defer to me with questions. I realized, based on that experience and Dr. Pfeffer’s advice, that I needed to be out of the room. I needed to get out of the room and let him spread his wings. If he has questions, he can come to me, but people needed to see him as the leader in that space. And so I pulled back from those meetings, and it’s gone very well.
Gamble: Has it been difficult to shed that, especially having been in the physician leadership role for a long time?
Milligan: People still tend to come to me with their issues around workflow or if smart text doesn’t work, but I’m able to direct them to the right people, and that’s been effective.