My first year as chief of staff.

April 20, 2003.

I arrived for my first day on the job as chief of staff at a new hospital in a new city. I was coming from the Department of Veterans Affairs (VA) and thought I was familiar with the system. Or was I? Who knew what challenges awaited me as the new chief of staff? I certainly had no idea of what all lay ahead ...

Figuring things out

My first month on the job consisted of a wide variety of "how-do-you-do's" with staff who were supposed to tell me about their jobs. It truly takes a community to run a medical center. This was my chance not only to learn the formal organizational structure but also the informal structure.

Not only did I get to know the true power brokers, but also whom to go to with a problem, or to whom I needed to apologize for making yet another mistake. After a while, I lost all sense of self-consciousness for asking questions. I was slowly being absorbed into the culture of the organization, an important transitional step for any new executive. And all the while I knew that people were thinking, "He sure isn't like ... [my predecessor]."

Yet it is people who make things happen. Having gone from a few people working for me to knowing everyone in the whole hospital system that our two campuses encompass was a baptism for me. What was being chief of staff after all?

First, it means serving as the liaison for the medical staff with the rest of the staff. This included talking up the chain, talking down the chain and talking all around the chain of command. It includes serving as the listening ear for all kinds of people, many who really didn't know where to go with their problems.

I also learned how far a smile and a kind word go. Most people are longing for encouragement and an expression of commendation that says they have been noticed. I'm still working on how to best give people the praise and affirmation they deserve, but I wanted to be remembered for the positive after I left, not the negative.

It also helped to have other chiefs of staff as friends to go to, particularly when I had questions about what I ought to do. Their mentorship helped me through some really difficult situations.

My secretary leaves

I had been at my new job for just a month when my secretary popped in with news. She had accepted another position in Florida! I tactfully asked if she was sure that this was something she wanted to do. She reassured me that it was.

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With only a month until her actual departure, we set about trying to put her house in order. A good secretary, I found out, is only a heartbeat away from a health care executive and I really needed someone to keep me on task to know where to be and when to be there.

Suddenly, we needed to plan for her successor. While no one is truly indispensable, sometimes his or her knowledge is. Unfortunately, we lost a lot of information when she left, like several of the electronic files that we later needed. (One year later, for example, my new secretary was finally able to come up with a file plan based on her predecessor's filing and all the files I brought with me from my old job.)

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Other questions I faced: When did I have to be somewhere? Where was it? Where were the minutes from the last meeting?

On the other hand, we were able to come up with a reasonable plan to keep the office in business until we could hire a replacement, something that took three months. I learned that hiring (like firing) in the federal government is extremely slow (it took us roughly a month to advertise the position the first time).

With a lot of flexibility and people chipping in, we were able to make things happen. In addition, I wouldn't trade my current secretary for any in the world! The keys are staying on focus, knowing what the most important things in the day are and having a healthy sense of humor.

Recruiting 101--Two vacancies and a stroke

A special challenge awaiting me was recruiting. No one had prepared me for this difficult task. I arrived finding the chief of surgery position vacant, so getting a new qualified applicant was going to be a challenge.

Add that my chief of geriatrics and extended care resigned for personal reasons at the end of July. Now I was in the middle of a full blown recruiting war for chiefs (not to mention providers!)

My first experience interviewing candidates for chief of surgery taught me that I needed to be a bit more inquisitive. The first candidate brought an impressive dossier, and it wasn't until he arrived for his personal interview that we found out he had been forced to resign his hospital privileges at two previous hospitals.

What would I find out about the rest? Even as I write, this position remains vacant, silent testimony to the fact that qualified chiefs of surgery willing to work full time on governmental salaries are hard to find.

Searching for a chief of geriatrics and extended care was a bit less intimidating. First of all, it hadn't been vacant forever. Secondly, it seemed like we got a greater number of qualified applicants. One came to see us on the advice of the university. Golly, I thought, this was going to be easy.

Then it happened, we found the applicant we wanted and we got stuck in a bidding war, and ultimately lost. This taught me to never undervalue a worthwhile employee. We seem to be on the verge of filling this vacancy, but I now know nothing is final until the ink is dry on the paper.

Just as we were working ourselves to cover all the other vacancies, the chief of pathology had a stroke. While we all prayed for his healing, we had the good fortune to uncover an internist-pathologist who rose to be our acting chief of pathology. So, I learned to look around in the organization for people who are able to rise to the top when you need it the most.

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JCAHO survey

I had come here with several missions, but number one on my horizon was pulling the clinical staff together for our impending Joint Commission on Accreditation of Healthcare Organizations' survey. I knew my arrival was timed about five months prior to our scheduled triennial survey.

Our facility, like many other institutions, had undergone a mock JCAHO survey about a month prior to my arrival and we were just beginning to digest its findings. I found optimism was not high and we were at risk for getting at least one repeat Type I recommendation.

I visualized my office as an information hub for clinical staff to address any problems they foresaw with the impending visit. Fortunately, the staff was justifiably interested in the outcome.

We would end up having five different surveys on two campuses over five days, so it was a gargantuan task getting everyone ready. There were times when we did nothing but drill and make contingency plans. The visibility factor here was key--people needed to know that I was committed to a successful process.

We had innumerable committees dedicated to solving particular systems problems and I learned to work through and with them to arrive at solutions. We learned to work with each other. I was absorbed in policies and in reading the many CMH manuals in my office.

D-day came on September 8th. We had a whole complement of surveyors. I felt as though we had done our best to prepare. I chose to shadow the physician surveyor and add comments when necessary. That helped me understand the process from the other side as well.

The results? We were rewarded with survey scores of 97, 99, 99, and 99. Not bad for a week's work. I learned that a team of people could multiply the efforts of an individual when the team members get a vision for accomplishing a clearly stated goal.

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The university

I had come to this position hoping to parlay my previous academic experience in an affiliated institution into a faculty appointment, despite the absence of a formal affiliation agreement with the university at our hospital.

I knocked on a lot of doors and asked a lot of questions. Would they be willing to accept a transplanted Mid-Atlantic associate professor? To what extent would office politics be involved? And then there is the town-gown debate.

Patience and persistence were on my side. First, I made sure that my medical director was behind me. Then, I used every possible contact and asked the same questions over and over again. What did I have to offer? I knew how to train residents and students and I was comfortable giving medical lectures. Finally the day came when I was given an appointment to speak with the dean of the medical school. I mustered all the courage I had as I walked into his office.

It turned out, of course, that he was a human just like the rest of us and pretty much asked me the same questions that I had asked him before. I stressed it wouldn't cost the university anything for my services, as I was going to be a volunteer faculty. I asked for his help with the promotions committee (you tend to get what you ask for and nothing if you don't ask for anything).

I started almost immediately after that mentoring students and seeing patients at the affiliated VA hospital. I wanted to make the point that my side of the offer was legitimate. Four months later (nine months after I started), I received my letter indicating my faculty appointment as a volunteer associate professor of medicine. Persistence paid off.

Performance measures

No one likes being graded on the plethora of activities used to score the performance of administrators. The menu seems vast and, at times, endless. In our hospital director's contract was a list of 20 domains of performance, with seemingly infinite subpoints under each domain.

We are also given a four-page tabular performance grid each month that compares our performance with that of other centers in our network. One of my enduring tasks was to be grilled on how we were doing on this "dashboard" and figure out reasons why we were not meeting desired levels on certain of these measures.

These seemed to involve problems that people had already spent hours and days trying to resolve. For example, one was the percentage of patients with blood pressures above 140/90 mmHg. How was I going to get a patient to control his own blood pressure?

Another issue was getting patients with appropriate risk factors for hepatitis C serologically tested for antibodies to the virus. Again, how would I get patients to go and get the testing? Furthermore, if another VA facility in our network was able to do better than we were, why couldn't we bring our scores up?

In addition, there were now four sites involved, since we have two main campuses as well as two outpatient clinics established away from our campuses. Each of these outpatient clinics is run by outside contractors.

We continue to struggle through several of these issues, largely dedicated to persuading patients to take enough interest in their own health care to participate in preventative care. Yet staff issues did surface as we talked about these areas, and we together formulated plans on how to do our best to get as many as possible of our patients to comply.

For example, we had people showing up for fasting lab testing who had not taken their antihypertensive medications, and of course their blood pressures were high on testing.

This was also my first exposure to borrowing from other administrators. The VA family, I learned, is very willing to allow people to borrow ideas and methods from each other. Some of these might not be applicable, but why not try?

A year later we are better off and moving in the right direction.

My AA retires

Hoping to become a certified physician executive, I decided to attend ACPE's tutorial for certification, a rigorous weeklong program to evaluate your medical management skills.

In the middle of the tutorial, I received the following e-mail: "I have decided to retire and today is my last day. It has been a pleasure working with you."

My heart sank as I read it, and of course I ran to my cell phone to try in vain to reach my administrative assistant. This was the person who had been with me through the thick and thin of the last 10 months. He had been my right hand man and my conscience. He had told me what to do and more importantly what not to do. How could he leave?

I am still wondering the "why" of his leaving suddenly as he did without my being able to talk with him. We hadn't really discussed it (although I knew he was eligible to retire at any time). Had he left while I was gone so that he wouldn't have to explain his decision to me?

I searched for answers to questions like this. In some ways, this hurt the very worst of any would I had received so far. I resolved to forgive him and to go on as best I could. After all, I was truly grateful for his faithful service during the time that we had been together.

Perhaps the greatest impact of his departure was that I did not have a detailed job description for his position, precisely because I never anticipated his leaving so abruptly. This meant that I had to dedicate a disproportionate amount of my time to piecing it together without any assistance from him, the one person who could have helped.

I am still smarting from the lesson that I should never assume that someone would not leave abruptly and I am working to organize my life so that I will always know what the job duties of the next person entail. Through it all, I have made new friends inside human resources, and learned a bit more about navigating the personnel maze.

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Bed restructuring

One of my initial interviews for this position focused on the plan for an internal restructuring that included closure of acute medical beds at one of our two campuses. Change, of course, is inevitable, and yet resistance to change is equally inevitable. With that in mind, I supported our administration's decision to close a six-bed subacute medical unit.

In the sometimes highly charged political environment in which we live, I quickly became the object of scorn for those physicians who disagreed with the decision to close these beds.

You might have even thought we were closing the whole hospital. (Nothing could be further from the truth. We have 75 active psychiatry beds and 145 long-term care beds.) We were given a step-by-step process to go through prior to suspending the use of these medical beds on the one campus.

At the same time, the U.S. Secretary of Veterans Affairs established a commission whose job would be to make recommendations on the most efficient use of VA bed space into the 21st century. Based on Medicare beneficiary guidelines and anticipated service population, a model constructed to determine the projected number of hospital beds in 2012 and 2022.

A commission held hearings around the country and the recommendation was made to close the hospital beds at the other campus because the need for beds projected by this formula had not met the minimum established to keep our acute medical unit open at the other campus.

This led to a six-month misunderstanding in the media and in our customers, who circulated the rumor that the VA at that campus would "close." In fact, it was a matter of setting the record straight, that when the secretary concurred with the commission's report, we would turn this campus primarily into an ambulatory care facility.

All of this gave me the opportunity to explain the clinical and administrative niceties of a suspension and a closure to a number of people. I learned that a chief of staff is, first and foremost, a salesman--sometimes for better, sometimes for worse. It's the fine art of persuasion that counts.

One year later

Can it really be that 365 days have passed since I came here as chief of staff? Sometimes I wonder where the time went. There was so much to learn when I came, so many problems to tackle, so many people to meet.

The challenge of thinking, often on your feet, as well as a commitment to make things better, are what makes the job both challenging and rewarding. I am looking forward to the time when I start mentoring another new chief of staff in the VA, advising him or her how to weather circumstances and do an even better job than I have.

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I would tell anyone who is thinking of taking the plunge to go ahead and do it--you do learn as you go.

By Marc Wooten, MD, MBA, CPE 

Marc Wooten, MD, MBA, CPE, is chief of staff of VA Northern Indiana Health Care System. He can be reached at [e-mail]. The views expressed in this article are not those of the Department of Veterans Affairs or of the United States.