Just Say Yes

Podcast Transcript

Brian Bolwell, MD: Beyond Leadership, a Cleveland Clinic podcast at the intersection of leadership and everything else. In this podcast, we will co-mingle with extraordinary thinkers and explore the impact of their ideas and experiences on leadership and management.

Good morning, everybody. Welcome to Beyond Leadership. I am Brian Bolwell, the host of this podcast, and today I'm delighted to welcome Dr. Neil Smith to our podcast. Neil is president of Fairview Hospital here in the Cleveland Clinic Healthcare System, and he and I have known each other for quite a while. Neil, welcome to the podcast.

Neil Smith, DO: Oh, thanks, Brian. Thanks for having me.

Brian Bolwell, MD: Can you share with our listeners a little bit about you, how you started your career as a physician and ultimately became president of Fairview?

Neil Smith, DO: Sure. It was kind of a circuitous route. Real quickly, I went to undergrad in St. Louis at St. Louis University, and I got a job afterwards working at a hospital in St. Louis called the Jewish Hospital. It's now part of Barnes Jewish. And I was taking grad level classes, and I got a job as an orderly in an emergency room. And I worked the third shift from 11:00 at night to 7:00 in the morning. And my major duties were just stocking the rooms and transporting patients here and there. But the emergency room was run by residents, both surgical and medicine residents. And the one thing that residents like more than free food is sleep. And so, we had call rooms off of the emergency room, and it'd be in the middle of the night, and a patient would walk in, and the nurses would put them in the room, and then they didn't want to wake up the residents because they were generally in a pretty surly mood. So, they would say for me to go wake up the residents.

So, I would knock on the door, and they would ask me, "What's going on?" And I'd say, "We've got a patient here." They said, "What are they here for, Neil?" I said, "Well, I don't know." He said, "Well, go back and find out." And the reason they were doing this was to just give them more time to sleep. So, I go back, and I'd come back and talk to the resident, say, "Well, they're here with shortness of breath." "Well, what else about it?" And after a period of time, they would finally come out and talk to the patient and then start ordering tests. But I would listen to them asking questions to the patients, the timing, when did the shortness of breath start? What makes it better, what makes it worse?

And pretty soon I could see that the really good ones could get these patients to tell them exactly what was going on. And I thought that was fascinating. And so, as this went on, I did this for two years, I would see more and more cases come through, and they would actually show me what a chest x-ray looked like that was abnormal, or an EKG, or blood work. And I got fascinated by really the figuring out puzzles of medicine, really, I thought was really interesting. I was told in high school that I wasn't all that good in chemistry or biology. I could never go into medicine. But I realized pretty quickly that even though that has something to do with medicine, really, if you listen to the patient and you like figuring out what's going on and what their problems could be, that's really kind of what it was about. So that inspired me to take more classes and finally apply to med school and get in. But that's kind of how I got started, just being an orderly at an emergency room working the graveyard shift.

Brian Bolwell, MD: I love that story. That's fabulous. I think there's a huge amount to be said for that. But anyway, so what happened then? So, you went to med school?

Neil Smith, DO: Yeah, I went to med school and went through, and then I did an internship. I did residency at a major institution here in Cleveland. I was all set to do internal medicine and do intensive care medicine. And as I was approaching applying for the fellowship, the leader of the residency program pulled me aside and said, "You know, we got a lot of really qualified people who are going into pulmonary fellowships." He says, "But you're really good at communicating with patients in your bedside manner. We really need good internists too. Anybody can work in an intensive care unit, but most of those patients are intubated and not having a lot of patient interactions. We really think your strength is primary care." And I don't know if he was telling me that because he didn't think I had the chops to be an intensivist, but he was right. And sometimes you get to listen to people that know you better than you know yourself.

So, I got out of my residency and applied for a position here at Fairview Hospital, and they set me up, and I started to practice 32 years ago, solo primary care, and my practice continued to grow. And then, really, what happened next, which really kind of changed things. My younger brother was a doc. He worked at an urgent care. They were willing to sell the urgent care. It was a nationally owned urgent care company. And my younger brother wanted me to buy urgent care with him. And I said, "Well, maybe, how are they doing?" He goes, "Well, we're losing about 500,000 dollars a year." I said, "Why the heck would I want to buy that urgent care if you're losing that kind of money?" He goes, "Well, I think there's deferring costs to us." So, I looked at the numbers, and I thought that they were right.

So, I end up buying the urgent care totally to the horror of my wife, who thought that that was going to be it for us when in actuality we worked urgent care and we started turning it around fairly quickly because we cross-trained a lot of personnel and we cut costs, and we did pretty well. And the thing you learn about private practice is, you get paid last. And I think that's a very important message in that when you get paid last after you pay all your expenses, what's left at the end of the month is what you get to bring home.

And so, you got people at home expecting that you're going to pay the mortgage and things like that. So, you'll learn how to do things a little more effectively, cost-effectively, and you're also willing to expand hours and see more patients and do things like that. And it really kind of set me up for my whole philosophy going forward when I became president of Fairview.

Brian Bolwell, MD: Which is?

Neil Smith, DO: Basically, two things. One is, try to do things more cost effectively so we're not buying all the bells and whistles that other people may have decided are going to be well worthwhile. We do well financially at Fairview Hospital. But on the second point is, you got to also understand you got to grow. And if you're not growing, you're dying. And we've been able to then facilitate bringing in new service lines here and maybe getting some money from foundations to bring in these specialized pieces of equipment, and really working with a win-win situation. As you know, Brian, we've worked well with the Taussig Cancer Institute but also a lot of other institutes at Fairview as far as bringing new service lines. We're a large major medical center on the west side, a 500-bed hospital, a tertiary care hospital. And we really provide a lot of care, Cleveland Clinic-quality care, for people that otherwise wouldn't be able to access it.

Brian Bolwell, MD: So, Neil's correct, he and I have worked very closely together for quite a while, and when I was chairman of the Taussig Cancer Institute, and we had a large cancer center there, but we can talk more about that in a bit. So, you opened up this urgent care center to the horror of your family, but you turned it around, and somewhere along the line you got invited to be president of a big hospital. How'd that happen?

Neil Smith, DO: Yeah, well, so people at the hospital, the president at that time realized that maybe I had some business sense. He thought maybe that I was an entrepreneur, not really. I was just trying to make sure I wasn't going to lose money. But he invited me to apply for a position called assistant chief of staff and work with the independent physicians. There were a lot of Cleveland Clinic physicians, independent physicians. And I did that for two years. And then he asked me to run for chief of staff, and I did that, believe it or not, for nine years. And it really was working with the independent physicians and the clinic to find out what we could do. And some of the things we brought in were really expanding our advanced practice providers for the independent physicians. And this really was a win-win win.

And what I mean by that is, these advanced practice providers would work the floors for these independent physicians' patients, and they would round on these patients, they would get them discharged in a timely manner. They would really spend a lot of time on discharge so the patients wouldn't be readmitted back to the hospital because they knew what their follow-up appointments were. The patients loved it because we had a lot of communication, the staff loved it. Also, we could kind of monitor resource consumption. So, we took a flyer on this program, and we expanded it. And I had a lot of naysayers, originally from the Clinic, thinking that this was going to just be good money after bad. But in actuality, not only did the programs pay for themselves, but we made quite a bit of money off of these programs.

And so, as that evolved, there was a position for what they call Chief Medical Officer, and they asked me to be Chief Medical Officer. And I love that position. To be honest with you, I'm not a person that really likes the limelight. We had a really dynamic president at the time, and she could be out there, kind of the face of Fairview, and I could work behind the scenes and get all sorts of things done. But as it may, the Clinic decided that they needed a position leader. And I didn't think that a private practice physician would be even considered for the position. But lo and behold, they asked me to do it, and I actually turned the position down twice because they wanted me to give up my private practice, but they said I didn't have to. So, I did that. And that's been over 10 years now, as I've been president at Fairview.

Brian Bolwell, MD: And you've done extraordinarily well. So obviously, people tend to follow you, and that speaks well of your leadership. And so, this, of course, is a podcast about leadership. You've been seeing a lot of success. What are some of the things you've learned along the way that seemed to be important? And the follow-up question will be: Have there been times when things haven't gotten very well, and you've learned from them and kind of pivoted and discovered some things that maybe you didn't think were important are?

Neil Smith, DO: Well, yes. I would honestly say what has benefited me the most is that being an independent physician, I still see all my patients in the hospital. I have anywhere between 10 and 15 patients a day that I round on, and I still take emergency room calls for unassigned patients. And I don't do that just to say, "Look at me. I'm doing all this hard work." What it really does is it gets me out onto the floors and the different units taking care of patients, and I'm seen as being very accessible because I'm rounding in the hospital pretty much every day of the week, and therefore a lot of discussions and a lot of ideas come up that they don't have to make an appointment with the president of the hospital to put that forth. So, rounding in the hospital, having them know me as a physician and as the president, I think has really benefited me tremendously. And I think that's been really the secret of my successes, that I'm not seen as somebody behind a big desk. I'm just a guy trying to work with the people at Fairview to make things better.

So, I think that's been kind of key. Originally, I had a difficult time with the delay in making decisions. I'm a solo practitioner when I have a decision to make. When we bought the urgent care, that decision was made literally in about 15 minutes. Now, to pick up urgent care through Fairview Hospital, it would take us well over nine months. So, the delay in actually making a decision was very frustrating for me at the beginning, but I've learned to compensate for that, and I've learned that I'm trying to play the long game, so to speak. And so, I've got with that, as Brian well knows, we have a project that we've been working on for seven years now that has yet to even have a shovel in the ground, but we'll eventually get there. So, I have to be patient. I'm Irish, so patience isn't really part of my DNA, but I'm working on it.

Brian Bolwell, MD: Well, I'd like to go back to the benefits that you talked about by being visible and rounding. And I think there's a lot of things that are important in that. So, number one, it's relationship building, and work is ultimately about developing relationships and working with other people. And so that certainly makes that process easier and facilitates it. Secondly, of course, leadership is always about developing trust. And if you're on the floor and you say you're going to do something, you don't do it. You've got a bunch of people who can tell you to your face, "Buddy, you said you're going to do something, and you didn't come through." And there's a certain amount of really, really good use to that to having that sort of truthful feedback. And then finally, something that I've been increasingly interested in is, how do you get things done? How do people get things done?

And one of the things you've got to do to get things done is you've got to know what, in fact, the truth is what's going on. And the best way to know that is to go to the people who are doing whatever the thing is that you're worried about. I remember I've been in the cancer center, if there was an issue with a chemotherapy, something I get to people tell me what the problem was, but I was much better off if I just got out of my office, went down, and talked to the people doing it, and usually I found out something new. So, does all that ring true to you?

Neil Smith, DO: Oh, absolutely. You absolutely nailed it. I'm not good at reading reports, but I can talk to somebody, and they can kind of tell me what needs to be done, and then I just bring along somebody that can facilitate that. And I really do empower my team to act on their own and really go out there. I'm not a micromanager by any means. I'm really the kind of a person that says, "I trust you; you know a lot more about this content than I do. Go right ahead with it."

I can think of very few occasions where I put some trust in something that didn't pan out, but for the most part, it always has. But getting out there, whether it's a facility situation, whether it's an adult protective services situation, if you go out there and you actually talk to people, they already have not only know the problem, but they also have the solution, which is what I like. I said, "I have a lot of people who can tell me problems. I want people around me that can tell me the solution," and I'm just going to say yes. And nine times out of 10, that's going to be the way to do it, and very quick to get things accomplished that way.

Brian Bolwell, MD: You've been very successful, Neil, running a hospital that's academic but yet primarily a community hospital. What are the keys? I mean, so for a hospital president of Fairview Hospital, what are the really important things you do that our listeners who may come from an academic background don't realize?

Neil Smith, DO: Yeah, that's great. We have something here we call the Fairview Family Phenomenon. And really, what that is, Fairview joined the Clinic in the mid '90s, but it was always a good hospital on the west side. When we joined the Clinic, we had a couple of real positive results from that. Number one, we could attract higher-caliber physicians and nurses because the name of the Cleveland Clinic went a long way, but secondly, we could access more resources.

But having said that, we always maintain the Fairview feel to it. And the people that work here really are dedicated to Fairview Hospital. I mean, they work for the Clinic, don't get me wrong, but they are livers here at Fairview Hospital, and they're really proud of the hospital. One of the things that we've been able to accomplish is, there's a Raters and Rankers organization called Vizient, and what Vizient does is break hospitals down into four categories. The largest of the largest, like the Cleveland Clinic, would be category one. We're in the second category, and it's called large, specialized complex care medical centers. And there's over 250 of them in the country that Vizient ranks. And in 2021, Fairview was rated number two in the country, and we were all happy about that, but our quality director says, "Geez, if we tweak a few things, maybe we could be number one." And everybody got behind that. And sure enough, in 2022, we were rated the number one hospital for complex care hospitals in the country, which everybody got behind because they were so proud of where they work. And first of all, it's better for the patients. Obviously, if you're getting number one, you're taking good care. Number two, it's esprit de corps. Everybody was behind it, and we celebrated that ranking, and it's just been a lot of fun, trust me.

Brian Bolwell, MD: So, developing a local culture is really important. So, one of the things you mentioned earlier, you developed a program of APPs for your independent providers, and as an outside observer, one of the things that I've always been impressed with you is your ability to forge relationships with outside providers and make Fairview an attractive place for them to practice. The APP program sounds like one way you did it, but I'm sure there are others.

Neil Smith, DO: Yeah, you kind of have to know their language, so to speak, and know it's important to them. And so, what we do is, there's situations like when you take ED call and you have unassigned patients, how are we going to be able to best manage those patients in the emergency room? They may be there for extended periods of time, and they don't have time to leave their office to come in and do the history and physicals. So, we extend the program there. We're developing what we call an admissions unit, which can really facilitate that and determine if these patients need to be admitted or not. We're working with other places called Neighborhood Family Practice. We'll be more than willing to take on these patients for next-day care. A lot of our patients are admitted just because we're not quite sure they're going to be doing well overnight.

Well, a lot of these ED docs say, "Well, we can guarantee the patient will be seen the next day at a facility." We don't have to admit them, which obviously frees up a lot of beds for us. So, we're working with Neighborhood Family Practice, they're really excited about it. They're actually providing transportation for these patients. It really does work. And you also get these patients registered for government programs. So just having people know who I am in the community and running good ideas by me, I tell you what, I get a lot of credit for everybody else's good ideas, which I always say it's like the rooster taking credit for the sunrise, but I have a lot of people really helping me out.

Brian Bolwell, MD: Well, you mentioned it several times, and the other thing that I think you're very skilled at is community relations in general, not just with physicians but with other members of the community. So, one of the things, and that's kind of one of your roles, is to represent Fairview Hospital to the local community. Tell us a bit about that.

Neil Smith, DO: I live in a community on the west side called Rocky River, and I've grown up there my whole life. And the very first meeting I had as president was with the Mayor of Rocky River, who I knew personally, and she came into my office and said, "Congratulations, we need you to run out space at our community center." And I said, "Well, I don't know. We don't run out space much anymore." She goes, "Well, we really need you to do this, Neil." And I said, "Oh, geez, right out of the box. Here it comes." So, the very next day, I'm at the main campus and I'm talking to the director of the autism center, and we happen to be walking down a long hallway, and it was on the east side of Cleveland. I said, "Have you ever thought about a facility on the west side?" He goes, "I've always wanted, but I couldn't find the space."

All of a sudden, the light came on. I say, "I may have space for you." So, what came of those two meetings very quickly was we arranged for the Cleveland Clinic Children's Hospital Center of Autism and the city of Rocky River to provide an autism center at the community center. Now, first of all, autism, unbeknownst to me, was a really prevalent need in the community. But what the city offered then was, when you drop your children off for their care and their treatment, because it's a lot of treatment, we will provide you access to the Health and Wellness Center so you can work out. We also have what they call the Kids Cove. We have babysitting for your other children that need to be watched. This took off like wildfire. I mean, this was kind of like the state-of-the-art program where the community, the hospital, and the patients all got together, and it was really just serendipitous that it all worked out like that. But it really was something that got me understanding really quickly that if you work with the community, they will really support your hospital.

Brian Bolwell, MD: That's a pretty cool story. Tell us about a time or times when things haven't gone your way and how you manage that. I mean, for me, I say frequently, I have a PhD in making mistakes. So, I've got a huge library of mistakes to draw on, you may not have very much, Neil, but can you think of one?

Neil Smith, DO: Oh, yeah. So, what I had to learn early was that I really had to trust my gut instinct. So, when I first assumed as president, somebody put forth a program that, at first blush, I said, "Boy, that sounds like a dog." And the more I looked at it, it looked like a dog with fleas, but this person had worked on this program. There was a lot of support from nursing that we should do this program. And I kind of acquiesced reluctantly, said, "Okay, but I need to go down to champion this program." And I just didn't feel it. But anyways, as I get done with it, the director at that time, Brian Donley, said, "Geez, Neil, this one looks a little bit sketchy, but if you think it's going to work, we trust you." And I should have just said, "Yes, let's back off on this." But I didn't want to go back to Fairview with my hat in my hand, so I went along with it.

I regret that to this day because it was a bad program, but I needed more guts to say, "I can't be worried about people's feelings when something wasn't quite right. It wasn't quite right." So, I learned quickly from that.

Brian Bolwell, MD: Well, many authors say that the most important virtue for leadership is courage. And I tend to agree with that. I think that there's a lot of times when trusting your gut or following your values, I think that's almost really more important, is trying to do the right thing, and following your values may put you in conflict with some priority. And I agree with you, Neil. I think you're better off sticking to your guns and trying to live your values. And even if it may not be popular at the moment, I think that that becomes a pretty big deal.

Neil Smith, DO: I was going to say that I had my first meeting after I became president with a guy by the name of Dave Bronson, who, he was the one who really championed me for the position. And he said, I'm having my talk with him. And the end of the conversation says, "Neil, you're going to find you're going to do things that you've always done, and it's come easy to you." I said, "Okay, yeah." He goes, "Don't do that. Do the things that are hard, do the things you didn't like."

And as I was driving back to Fairview Hospital, there was a physician leader that for nine years prior was always a problem, but he was a big-name person here, and nobody would touch him. And I called him in the office that day. I said, "We're going to move on from you." And he says, "You can't do that." I said, "Actually, we can, because it wasn't working." I knew it wasn't working, and I got a lot of pushbacks initially, but as you said, the number of people come. I said, "Man, nobody would touch this guy for decades, and you actually did the right thing." I got a lot of street cred with that one. So, I learned pretty quickly that that's what you have to do.

Brian Bolwell, MD: And I do think you get street cred if you do it. And I think you will get respect. You may not always be well liked, but you get a lot of respect, and that's important. So, a little over a year ago, Neil, you and I, along with some of our other leaders, were in Philadelphia. We had the good fortune to spend a week with Wharton Business School, and we had a lot of their faculty give us their views on different parts of leadership. What are one or two of the things you took away from that?

Neil Smith, DO: Well, first of all, thank you for the program. I thought it was phenomenal. And my wife liked it when I wore my University of Pennsylvania gear [both laugh] thinking that I could have gotten in there, which I never could have, by the way, but I thought it was phenomenal. And they had an exercise that I've been trying to put forth to the clinic where we sat down with a group and we're given a budget in where we were going to invest our money, and they put it through the rigors of actually going through it. And which was your best way? What program was going to be the most profitable or best return on investment? And I learned so much during that afternoon that I said, "I need to do this because I'm presented with all sorts of programs here at Fairview Hospital, and I only have so much capital to spend."

I don't know if it's better to do the right heart catheterization program, or setting the right part of the heart, or doing a robotic lung resection. And when you really put it through the rigors of really smart businesspeople, you can kind of find that out. And a lot of times you do things in silos, but they actually put it all together. And I thought it was really something that I thought we could use on an everyday basis here. But just hearing these guys talk and their lectures, they were so bright, and I'm just sitting there saying, "Wow, this is top-notch stuff."

Brian Bolwell, MD: Yeah, it was a lot of fun. I really enjoyed it. I learned a lot. And one of the things that I remember was one of the faculty members really emphasized all of us leaders to try things, just try pilot projects. I mean, do a little experimentation, and not everything needs to be perfect. You don't need perfect data but give something a try and learn from it. And if it works, great, keep doing it. If it isn't, fair enough, learn from that and figure out what you need to get better at. And that was pretty empowering. I thought that was pretty powerful.

Neil Smith, DO: Yeah, I thought it was great. And that you read about how these phenomenal businessmen or entrepreneurs actually became what they became. I remember reading a story about Steve Jobs and how he became where he was. He ended up calling, he's in high school. He called Hewlett from Hewlett Packard directly on the phone and said, "Do you have any extra mainframes or stuff like that I can play with and do in my thing?" And Hewlett was so ballsy that this high school kid would call him. They said, "Not only am I going to send you this stuff, but you're going to come work for me for the summer." And it just opened up things, and it was like, Jobs says, "If you just go out and ask for some stuff, you'd be surprised how far you get." So, I mean, those are the little kind of lessons you learn from people who've been there that were kind of in your position a long time ago, but how did they get there? And you hear a lot of those stories outside of Wharton. It was just a plethora of those kinds of stories.

Brian Bolwell, MD: Yeah, I think that's right. I think the other thing is, if you're given an opportunity, usually it's a good idea to take it. I mean, just see what it's like, try to learn from it. Then, a lot of times, we're asked, "Do you want to take on project X or Y?" And sometimes it seems daunting because of a lot of work, but usually you learn stuff. And so, saying yes to new things is, I think, not always, but usually pretty worthwhile.

Neil Smith, DO: Yeah, my kids would go crazy because that's the one mantra is always say yes. I said, "You're going to spend more time agonizing over whether this is a good decision or a bad decision. Just free yourself with that. Just say yes. You'll figure out as you go along," but you're not going to be the consternation of, "How am I going to pull this off?" Just say yes, you jumped out of the plane. The parachute almost always opens.

Brian Bolwell, MD: I mean, that's a good way to wrap up is just reiterate, just say yes. But I'll ask you, Neil, do you have any closing thoughts that you'd like to share with our audience about your journey as a very successful leader?

Neil Smith, DO: Well, it's been kind of the accidental administrator, so to speak, as you can tell by my story. But I've relished and cherished every bit of it. I think it's really been the highlight of my career is being able to both maintain my private practice and to work with outstanding personnel at the Cleveland Clinic to make Fairview Hospital. As I said, the number one complex care medical center in the country is something to be proud of. So, all I can say is, I really appreciate the opportunity that people have given me and working with you and other leaders. Sometimes you're seen as an independent physician with a little bit of a slanted view, but you guys have always welcomed me tremendously, and we've learned from each other. So, it's been a great, great, great run.

Brian Bolwell, MD: Well, I think you're being very humble, Neil. You've done a very good job, and your accolades are deserved. And certainly, congratulations on the number one ranking. But we got to know each other about five, six years ago when we had these meetings on Friday afternoons that I don't have to go into the details about. But I remember, all of our leaders had to give presentations pretty frequently. And the more I listened to you, the more you made sense. And I think I shared that with you, and that's still true today. So again, congratulations on your success. And for our listeners, this has been a lovely podcast. I hope you enjoyed it, and we certainly hope to have you join us again in future episodes of Beyond Leadership. I hope everybody has a wonderful day.

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